This is the 12th and final article in a series 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.
This is the last in AJN's series on the groundbreaking TCAB initiative, which not only improves patient care, but also keeps nurses excited about bedside nursing.
Amanda 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. She would like to acknowledge Jeanette Ives EricksonMS, RN, FAAN(chief nurse and senior vice president for patient care services), Theresa Gallivan MS, RN (associate chief nurse), and Barbara Blakeney MS, RN (innovations specialist), for their support of the TCAB initiative, and the staff ofWhite 10 for their innovative work.
In the two years that White 10—a 20-bed general medical unit at Massachusetts General Hospital—has participated in the Transforming Care at the Bedside (TCAB) initiative, our nurses have implemented 32 changes that address TCAB's four priorities: patient-centered care, value-added process, safety and reliability, and vitality and teamwork. The first three of these were discussed in prior articles; in this article I describe the changes we've made in promoting vitality and teamwork.
Almost every change we've made as a part of the TCAB initiative has helped to bolster our team's vitality—which has given a great boost to teamwork and overall supportiveness. For example, nurses now participate more actively in presenting patients to physicians ("Nurses Participate in Presenting Patients in Morning Rounds," November 2007), and this has enhanced teamwork among the staff.
In another TCAB change, when nurses were given time to leave the unit for a meal (see "One-Hour, Off-Unit Meal Breaks," January), we discovered increases in trust and teamwork among the staff. Before the change, nurses had cared for patients without relying much on peers, but the change required nurses to work more collaboratively as they took on other nurses' workloads during breaks.
BOOK CLUB: A MISS
One change we made to address vitality and teamwork head-on was the formation of a book club. This idea was generated at one of our "TCAB Tuesday" meetings and was planned relatively quickly. At the meeting the group chose From Silence to Voice: What Nurses Know and Must Communicate to the Public, by Bernice Buresh and Suzanne Gordon. With the help of the hospital's associate chief nurse, we received funding from the nursing department to buy the book for all White 10 nurses. We had intended to meet and discuss a few chapters at a time, hoping that a discussion about a relevant, work-related topic would help us get to know each other better and improve our ability to function as a team.
Within a week, several nurses approached me to discuss the book; it was generating discussion among the staff. But it soon became clear that these informal discussions were the extent of our book club. Despite what appeared to be overwhelming interest in the book and in a White-10 book club, it was difficult to schedule a group discussion. The nurses most interested in the book club worked different shifts. Ultimately, only four of us were able to meet. We had some great discussions but couldn't bring together a larger group.
Staff nurses continue to read and discuss the book. And we hope to adapt this idea and perhaps distribute and discuss a journal article monthly (we currently circulate an article infrequently among the staff) or create a virtual book club that would allow nurses working differing shifts to participate more easily.
MENTORING: A WORK IN PROGRESS
We have worked to encourage nurses to present their ideas about changes we might make on the unit. We held a "TCAB kick-off retreat" at the beginning of this project, in which all 62 members of the White 10 staff—nurses, nursing assistants, unit secretaries, and housekeeping personnel—were taught about TCAB and shown how to brainstorm, build teamwork, and introduce rapid-cycle testing for evaluating changes. But we've hired new staff members since then, and to ensure that they also feel free to suggest and initiate changes, we held a retreat for staff hired since the initiation of TCAB. Held last January, this retreat was a shorter, four-hour version of the original retreat and was facilitated by four senior staff nurses.
One change that promotes teamwork was suggested by Leah Duquette, BSN, RN, a newer nurse. After working on White 10 for about nine months, she approached me about the creation of a unit-based mentoring program for new nurses to follow the broader orientation all new nurses on White 10 participate in. (Our standard eight-week orientation involves the new nurse working closely with a preceptor [a staff nurse] with oversight provided by the unit-based clinical nurse specialist and me, the nursing director.)
Leah, having recently gone through orientation, envisioned a mentoring program that would begin after the formal orientation. I gave her the green light to develop the idea, and she completed a literature review of various mentoring programs and began sharing her thoughts with some of her newer nurse colleagues. She read articles received during orientation and used the Cumulative Index to Nursing and Allied Health Literature (CINAHL), searching the terms "new graduate mentor" and "new graduate support," reading those articles that were most recent (published in the last five years). With the bulk of her research complete, she convened a group of five nurses at her home to discuss how to implement the mentoring program. This four-hour meeting allowed them to develop a needs assessment survey that asked new staff members how well our unit supported newly hired nurses. The survey was given to five nurses who had worked on our unit for six months or less; three responded. They were interested in having a mentor and preferred that this person work on the unit (the survey gave them a choice of having a mentor from outside of White 10).
Based on the discussion at the planning meeting and the survey results, Leah began outlining the details of the mentoring program. We hope that some of our unit nurses will volunteer to be mentors, and we will ask those who are perceived to be particularly nurturing and supportive to participate. Although we may set up a group breakfast at which all of the mentors and those to be mentored can meet, the program will focus on the relationship between the nurse and mentor, with monthly meetings focusing on the clinical, emotional, and professional support a mentor can offer. Leah's next step will be to implement the plan, gather feedback from participants and educate the staff on this new program.
Its development has taken a little longer—four months, so far—than that of other TCAB changes, but its scope is much larger. We're developing a new and complex program for our unit, and the practice of developing and evaluating one is new to Leah. Yet she has diligently prepared for this program, and she has sought additional guidance from our hospital's Norman Knight Nursing Center for Clinical and Professional Development. We hope to see the program put into place by the end of the summer.
PROGRESS DURING TCAB
Some changes have been more successful than others, but as I reflect on our two years of work, I see how significantly staff vitality and teamwork on our unit have blossomed and in turn improved the care we provide. The quality of care has improved, as evidenced by a lower fall rate, less use of restraints, fewer nosocomial infections, and improved patient satisfaction; nursing staff turnover rates have also decreased. We have created an environment that is more conducive to teamwork, and this has prompted the staff to examine the way they practice in a new light. They now take the lead and propose new ways of improving care delivery, effecting real change, and bettering both our patients' and our own experiences.
To view the entire series of TCAB articles, go to ajnonline.com and click on "Collections."