This is the seventh in a series of articles from Massachusetts General Hospital in Boston describing one general medical unit's experiences with Transforming Care at the Bedside (TCAB). An initiative begun by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement, TCAB was developed as a way to improve care on medical–surgical units, patients' and family members' experience of care, and teamwork among care team members, and to increase nurse satisfaction and retention. The TCAB philosophy engages all care leaders, but empowers bedside nurses to generate ideas and solutions for change. Mass General is one of 68 hospitals participating in a two-year TCAB initiative led by the American Organization of Nurse Executives and funded with a grant from the RWJF. For more information on TCAB, go to www.rwjf.org/pr/product.jsp?id=31512.
Amanda L. Stefancyk is nursing director of White 10, a general medical unit at Massachusetts General Hospital in Boston.
She also coordinates Transforming Care at the Bedside: firstname.lastname@example.org.
The participation of White 10, a 20-bed general medical unit at Massachusetts General Hospital, in the Transforming Care at the Bedside (TCAB) initiative has encouraged the unit's staff nurses to think about, plan, and enact changes that optimize care delivery. In my work helping to implement these changes, I've witnessed an important byproduct of the initiative: opportunities for nurses to develop leadership skills. The nurses on our unit are more vocal about their practice than they were before, take an active role in identifying problems and developing solutions, are able and willing to assist in managing projects, work more closely with colleagues, and participate in scholarly pursuits; for example, they do research to find the answers to relevant questions, and they create and present posters on TCAB challenges at national conferences. I've seen nurses get on a fast track to formal leadership roles—on the unit and in their careers.
As I reflect on our TCAB accomplishments over the past 18 months, the most impressive changes I've witnessed have been in the nurses themselves.
WITHIN THE UNIT
When we began as Mass General's pilot unit for the TCAB initiative, Erica Tuggey, BSN, RN, was a recent graduate. After 10 months' experience on White 10, she has become more comfortable and confident in her work.
During one of our hour-long "TCAB Tuesday" meetings, Erica became interested in what would become one of our most popular TCAB projects—moving frequently used clinical supplies such as alcohol pads, telemetry leads, and IV tubing to the patient's bedside (see "High-Use Supplies at the Bedside," February). She was one of four nurses who championed this effort, and her dedication was evident: she worked on it at home and came to the unit on her days off, keeping the project on track. Moving these supplies to the bedside proved successful in no small part due to Erica's involvement.
She has told me that she viewed the TCAB initiative— and especially that one project—as a path to greater involvement in the unit's work. "My one-year review was approaching, and I was looking for new challenges and goals I could set for the coming year," she said, adding that she appreciated the chance to build stronger relationships with coworkers. In retrospect, she saw those relationships as a basis for taking on the role of resource (charge) nurse, in which she oversees operations on the unit during her shift, assisting other nurses and patients as needed and facilitating all admissions and discharges. "My transition to resource nurse was relatively easy because I'd already functioned in an unofficial leadership role on the unit," she told me.
THROUGHOUT THE HOSPITAL
Ellen Cellini, BSN, RN, CMSRN, transferred to our general medical unit two years ago after working on a surgical unit for two years. As a strong clinician with a refreshing natural energy and an understanding of the unit's operation, Ellen soon found herself assuming responsibility for various jobs: as the unit's cardiopulmonary resuscitation instructor, as a preceptor on the unit, and as a member of the hospital's Staff Nurse Advisory (SNA) committee, which serves as an integral part of our "Collaborative Governance" structure—an aspect of our facility's professional practice model that includes seven committees comprised of providers from different areas of the hospital.
Ellen's participation in TCAB has also been invaluable to the unit. She's provided suggestions for improvement and useful feedback on all of our projects. Her involvement on our unit has also contributed significantly to her leadership role within the institution. For example, when Ellen became interested in joining the SNA committee, she offered to substitute for our unit's regular representative at a recent meeting, at which the chief nurse raised the topic of TCAB during a discussion of efficiency. Ellen spoke of our unit's many tests of change, particularly our efforts to bring commonly used supplies to the bedside and the time that was saved and the costs that were lowered or maintained. Her experience on our unit boosted her confidence enough to talk with nursing colleagues and leaders about our TCAB work.
BEYOND OUR WALLS
Colleen Pantazelos, BSN, RN, came to our unit as a new nurse the year before we initiated the TCAB program. By the time we introduced it, she was looking for new challenges. Her work on TCAB—she also participated in the supply bin change as well as another project that involved gathering supplies for a patient in isolation—has, according to Colleen, "reenergized me. My job satisfaction increased tremendously."
Subsequently, I invited her to attend two national TCAB meetings sponsored by the American Organization of Nurse Executives. These two-day meetings occur every three to four months and include representatives from all participating TCAB hospitals. More than 200 people usually attend; representatives from each hospital present a poster or give a formal talk describing a best practice. Colleen presented a poster at two of these meetings, illustrating for our fellow staff nurses and leaders some of the changes we'd instituted.
"Before presenting these posters at the TCAB conferences," Colleen said, "my public speaking and presentation skills were mediocre. I've come a long way with both. I was honored to describe our work to a national audience."
UNIT AS A WHOLE
Erica, Ellen, and Colleen aren't the only nurses showing new leadership skills on White 10. Others are strengthening similar skills, and all of the nurses have assumed more responsibility and shown greater independence as a result of their TCAB work. For instance, the staff have taken greater responsibility for leading our Tuesday meetings. The unit's clinical nurse specialist and I are still involved, but typically we speak briefly at the beginning of the meeting, leave the staff nurses to work among themselves, and return at the end to listen to their ideas and plans regarding new changes in practice and to answer any questions. In addition, various staff nurses now step away from their patient assignments on certain days and assume the responsibilities of the resource nurse. They've assumed a more formal leadership position while still working at the bedside.
Having the staff take on the transformation of care on White 10 contributes to greater satisfaction and cooperation among the nurses on our unit. A safety survey we recently conducted revealed that the staff perceive their practice as making a positive contribution to patient safety. We expect similarly positive results from a more recent staff perception survey for which the data are still being compiled. I'll be discussing these data—and our staff nurses' perceptions of the work we're doing on White 10—in an upcoming article in this series.
Next month I'll discuss our unit's pilot project to improve medication administration.