TL - Transformational Leadership

TL10: Visibility, Accessibility, and Communication. Describe and demonstrate the structure(s) and process(es) by which input from direct-care nurses is used to improve the work environment and patient care.

In 2003, the Institute for Healthcare Improvement in collaboration with the Robert Wood Johnson Foundation created a framework for change on Medical-Surgical units built around improvements in the following:

  1. Safe and reliable care
  2. Vitality and teamwork
  3. Patient centered care
  4. Value added care processes

Transforming Care at the Bedside (TCAB) was developed in phases and was prototyped and pilot tested throughout the country. The purpose of TCAB is to empower nursing staff to implement changes and improve the quality and safety of care. TCAB engages front-line nurses and unit managers in improving care processes. TCAB essentially fosters transformative change. Nursing staff challenges and validates their assumptions and new perspectives are developed. TCAB views staff and family members as full partners when making decisions about their care. Methodologies used in TCAB are “snorkeling” and “deep diving.” Snorkeling means brainstorming ideas and deep diving is taking one of those ideas and focusing on it in detail.

Jersey City Medical Center became a member of TCAB in 2009. The unit chosen to pilot the project was 6 West, a Medical-Surgical Unit. The nursing staff prioritized issues which aimed to improve patient care, increase the time staff spends at the bedside, involve the patients in their care and improve the accountability of the staff. Solutions implemented since 2010 include bringing admission kits closer to the bedside, more efficient use of the dry erase board at the nursing station and the use of order flags and an order rack for charts.

Key to improved outcomes on 6 West is bedside reporting which ensures accountability, heightened awareness, and addresses the quality of care making the time of shift change transparent to both the incoming/outgoing nurse and the patient.

Maintaining open communication and forming working relations to provide optimal patient care is paramount for the success of the unit. TCAB members brainstormed various solutions and prioritized ways to improve communication with the Surgical Department. They established an open-door policy with the Nurse Manager and the Chief of Surgery. The next priority to improve communication is to increase interaction between nursing staff and the entire surgical team, to include each Attending Surgeon and Physicians Assistants. Staff nurses, the Nurse Manager, Clinical Nurse Leader and Charge nurses meet with the team on a monthly basis to review updates or issues on the unit. They review specific cases with the surgeons enumerating potential complications and highlighting ways to minimize or avoid their incidence. Additionally, new staff members are introduced and updates on various services and other projects are presented. This is an excellent example of professional collaboration.

The monthly Coordinating Council meetings with the Chief Nursing Officer, which is another structure/process to receive input from staff nurses, bring together the Council Chairs of the major council structure in the Medical Center. These Chairpersons report on the goals and progress of their respective councils and also describe challenges or barriers which may impede their progress. A recent issue introduced by this group was the barriers which exist on attendance to the various council meetings. Ms. Smith stated that a review of the bylaws of each council should occur and each council can decide what the number of times the council should be attended by each person. She further stated that she would take this to the Nurse Managers meeting for their input Appendix TL10-A. This represents the perfect opportunity for the CNO to provide guidance to this group and/or resources in order to advance their goals.

Additionally, the Shared Governance structure provides an opportunity for staff nurses to provide input to improve patient care, as well as the environment. The Quality and Safety Council has discussed the use of safety huddles Appendix TL10-B. Claudia Garzon-Rivera MSN, RN, CNL, CCRN, Facilitator of the Council, wanted to insure that the safety huddles were being performed at the start of every shift following the prescribed guidelines Appendix TL10-C. One barrier that was mentioned was that communication was lacking with the rest of the care team, i.e., PCTs, Respiratory Therapists and even Physicians. The group determined, under Ms. Garzon’s guidance, that these team members be a part of the huddle to improve communication among team members. The Research Council is also a process whereby nurses input can affect patient care. Janice Kozzi MSN, RN, CNL, Clinical Nurse Leader on 7 West (Medical-Surgical Unit), and a member of the Research Council were instrumental in the participation in a pain study sponsored by NDNQI Appendix TL10-D. Staff Nurses who participated in this study included Laura Alves BSN, RN, Staff nurse in the Post Partum Unit, Kelechi Odimma BSN, RN, and Ogechi Okara BSN, RN both staff nurses from 5 East (Observation Unit), and Astrid Latar BSN, RN a staff nurse from 7 East. The end result was the development of a Pain Care Quality Toolkit Appendix TL10-E.

Surveys are another way that input from direct care nurses is obtained and used by nurse leaders to improve the work environment. Data from surveys are reviewed and unit-based action plans are developed to respond to the needs. For example, in a recent NDNQI nurse satisfaction survey, in response to the question of staffing and resource adequacy, the Intensive Care Unit scored 2.39 versus 2.73 for other teaching hospitals. A segment of the action plan for this unit was to insure that charge nurses were available on each shift that can assist when needed and provide relief to nurses on the unit. A second recommendation was to institute an admission/transport RN for nights so that nurses did not have to leave the unit to transport their patients. These recommendations were instituted and the following survey portrayed an increase of 2.62 in response to the same question.

Another methodology utilized for input from direct care nurses is the Town Hall meetings Appendix TL10-F. These sessions are orchestrated by Rita Smith DNP, RN, NEA-BC, CNO and held quarterly. She normally conducts them on each unit and makes sure that she covers all three shifts. The purpose of these meetings is to keep staff informed of issues occurring in the Medical Center and providing them the opportunity to give feedback, ask questions or express concerns.

Another important way that nurse leaders obtain and use data from direct care nurses is senior leadership rounding. Rita Smith DNP, RN, NEA-BC, CNO participates in these rounds and information/problems are discussed directly with the nursing staff. One of the issues a staff nurse brought-up during rounding was the ongoing lack of sufficient linen on the units. Ms. Smith addressed this directly with the Director responsible and the end result was a change in the company supplying the linen. This rounding is performed on a weekly basis.

One final method used is the unit staff meeting. These meetings are normally conducted monthly and are chaired by the Nurse Manager of the unit. Issues pertaining to the unit or organization-wide issues are discussed and input from staff is received Appendix TL10-G.