Lacey, Susan R. PhD, RN, FAAN; McEniry, Mary MSW; Cox, Karen S. RN, PhD, FAAN; Olney, Adrienne BS, MS
Healthcare industry challenges are complex and multifaceted, with one of the most important challenges being the current and future shortage of RNs. Experts may debate the specific numbers related to the shortage, but what is not in debate is that the projected shortage will significantly outpace demand in the next 10 to 15 years.1-9 To address these issues, the nursing community and, indeed, communities at large must forge partnerships and create sustainable strategies in our efforts to combat what has been characterized in the literature as the "perfect storm."10 This issue has now extended far beyond a debate within the nursing profession to include those in public policy and to groups that advocate for the importance of patient outcomes and the safety of our nation's citizens.7
There are many ways to address this shortage, most of which would fall into 2 categories: (1) expanding the pipeline to increase more students in nursing programs and (2) improving the work environments of nurses to increase retention. There is, however, a third and more contemporary approach that has begun to emerge. This approach uses innovation and improvement of nursing processes at the point of care. It is with all 3 approaches that we stand our best chance of not only having enough nurses in the workforce, but also creating professional practice environments that lead to improved patient outcomes coupled with improved organizational outcomes, such as recruitment and retention. We must respond to this challenge with resources and a collective sense of purpose. With this in mind, 2 healthcare foundations in the Greater Kansas City region, formed in 2003, had similar missions: to provide leadership and funding in the area of improving healthcare access and quality for the uninsured and underserved. The Health Care Foundation of Greater Kansas City (HCF)11 and the REACH Healthcare Foundation (REACH),12 both not-for-profits, serve a bistate, 6-county region that surrounds the Greater Kansas City area. In their first year, they engaged nursing leaders to determine ways in which they could support nurses in both the areas of education and service.
As the nursing shortage increased, these foundations understood that support of the nursing community was essential to successfully meet their unique missions related to access and quality for all citizens. In response, a Nursing Workforce Shortage Advisory Board was established in 2005 with members from healthcare, business, and industry. They commissioned a comprehensive environmental scan of the available workforce in terms of numbers of students who matriculate through regional schools of nursing and faculty characteristics, as well as the potential consumer needs for healthcare goods and services. Based on the findings of this report, a special program area was created to fund nursing initiatives with special priorities in the areas of increasing the pipeline, matriculation of students, and diversity of both students and faculty. In the initial year of pilot grants, the 2 foundations awarded $500,000 for 7 innovative projects to address these priority areas (Table 1). These projects are in progress, and a second-round funding is forthcoming with the same foci.
Building a Network of Nurse Champions
The boards of both HCF and REACH were so enthusiastic about the initial grants that they were determined to sponsor an additional level of support to secure an adequate and competent nursing workforce. To do so, program officers sought new opportunities and partnerships to leverage the expertise of regional nursing leaders with national contacts. They engaged 2 Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows (ENF) from the Greater Kansas City area to discuss innovative ways to address nursing issues, both of whom had published widely in nursing workforce quality and work environment improvements. The ENF program requires a leadership project that must be completed within 3 years. Funds for this project are available to the participant as well as funding for professional development for the fellow. There was a natural fit to partner with the current fellow and create new approaches to complex nursing issues within the region. In addition they sought consultation from the executive director of the Mississippi Office for Nursing Workforce, Ms Wanda Jones. This state workforce center has been very successful in obtaining external funding for innovative programs that spanned the state and had secured one of the highly prestigious Partners Investing in Nursing's Future (PIN) grants in the previous year.
It was determined that what was lacking in the region was the need for a significant presence and central catalyst champion nursing issues and provision of leadership, coordination, and funding for these nursing projects. It was also apparent that the Kansas City region had a rich history of working together on tough nursing and healthcare issues through the RWJF Colleagues in Caring grant period, which spanned 1998-2002. However, after that funding period, no entity assumed leadership for this work. Finally, it was recognized that there were 31 state workforce centers in the United States, but neither Missouri nor Kansas had such formal centers.13
Based on the environmental scan, an extensive search of the literature and a summary of national workforce issues in nursing, the boards of HCF and REACH believed the best way to serve the community was by doing 3 things: (1) continue to fund innovation pilot projects for regional nursing initiatives, (2) examine nursing issues through a more comprehensive, systems lens, and (3) lead change in new and innovative ways. Therefore, it was determined that the most important way to create a new vision that could translate our efforts into meaningful, sustained, and comprehensive change in our region was to establish the Bi-State Nursing Workforce Innovation Center of Greater Kansas City. The Institute of Medicine's Six Aims for Improving Healthcare Organizations, patient safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability, are the touchstones for the center and its programs.5 This framework provides a powerful, yet succinct way to structure the work conducted by the center. Equally important, this provides a sustained focus, making innovation central to the work coupled with the expectation that deliverables are based on translating this innovation through nurses to consumers.
Launching the Center-Regional Collaboration at Its Best
During late 2007 and early 2008, regional stakeholders were engaged in how this new Bi-State Nursing Workforce Innovation Center would be launched and what the inaugural programs would encompass. These stakeholders included nurse executives from area hospitals; the senior vice president of the Kansas City Metropolitan Healthcare Council, who works with the chief operating officers (COOs) of healthcare systems in the area; leaders from schools of nursing (deans, chairs); and the business community throughout Kansas and Missouri. The intent was to create a clear vision for the center with enthusiasm and support to transcend proprietary issues that could derail its success. These successful meetings provided a new level of excitement about the possibilities of what a center using innovation as its core mission could do for the region and beyond.
On August 13, 2008, the Bi-State Nursing Workforce Innovation Center was launched with a press conference. Funding for the center started with $250,838 cash and $78,339 in-kind from HCF, $105,000 from REACH, $40,000 from Children's Mercy Hospitals and Clinics, $24,000 in-kind from the University of Missouri, Kansas City (UMKC) School of Nursing (SON), and finally $250,000 from the RWJF and Northwest Foundations in the form of a Partners Investing in Nursing's Future (PIN) grant submitted in early 2008. The center is housed in the UMKC SON building with state-of-the-art technology for classroom and simulation space, which will be invaluable for programs in the future.
The inaugural programs for the center are focused on (1) work environment assessments, (2) improving patient outcomes by implementing point-of-care change projects led by staff nurses, and (3) sharing the findings for translation to other settings at the first Nursing Workforce Innovation Conference to be held in September 2010. Hospitals for the first 2 programs were selected by reviewing competitive applications.
Work Environment Assessments
Three regional hospitals have been selected for work environment assessments, funding for an improvement project ($20,000), and technical support from the center staff. Request for proposals included why the organization believes it would benefit from such an assessment and its commitment to make measurable improvements once provided the results of this assessment. Priority was given to hospitals that serve large numbers of the uninsured and underinsured. The Individual Workload Perception Scale-Revised (IWPS-R) is a 29-item, Likert scale instrument that measures manager, unit, and peer support; workload perception; intent to stay; and overall satisfaction.14 Currently, more than 8,000 staff nurses from 15 states across the United States have completed this survey. This provides rich benchmarking for those selected for this program. This repository is housed at a local children's hospital, a partner with the center, and has a full-time database manager and certified clinical research coordinator. More than 10 published articles have been conducted using this database over the past 8 years.15-24 Hospitals have used their findings to make substantial improvements in their organizations and to get the overall pulse of the nursing departments. Information on the IWPS-R can be found in Table 2.
After institutional review board approval is obtained, staff nurses will be asked to log onto a secure Web site to complete the survey and a set of demographic items. These data are automatically collected in an Excel program that is transferred to the SPSS25 for analysis. A comprehensive customized report will be provided to the hospital, and details will be shared throughout the organization from staff nurses to senior executives. No individual survey data will be shared with anyone at the site. In the case of less than 10 respondents from a particular unit, their data will be added to a closely matched unit in terms of the types of patients served.
The center staff will work with the site to create reasonable and achievable innovations that target the area in need of improvement. The project funds will be provided to the hospital to implement these changes. After 9 to 12 months, the IWPS-R will be given again to determine if improvements were made. Technical support will be provided throughout the implementation phase to help the organization be successful with their project. Support will also be provided in how to sustain these improvements once initiated. The fact that the center has the full support of the local chief executive officers, COOs and chief nursing officers (CNOs) will be powerful as we seek to find ways to address these complicated issues in the nurses' work environment that meets the needs of all involved from the board room to the bedside, particularly in these times of economic uncertainty.
Clinical Scene Investigator Academy
The second inaugural program is the Clinical Scene Investigator (CSI) Academy. Seven hospitals were selected to participate. Each hospital chose between 2 and 4 nurses to lead the program in their unit, and the inaugural CSI class now totals 25 nurses. In this program, staff nurses learn how to lead unit-based change for a particular patient outcome in need of improvement. The recommended outcomes were either one of the new Centers for Medicaid and Medicare Services never events26 or a National Database of Nursing Quality Indicators.27 Two hospitals with unique needs chose to target other outcomes; however, the CNOs described the need in terms of how it will ultimately impact nursing departments and professional practice (Table 3). The overall goal of this program is to create sustainable process change that improves the selected outcome at the unit level. The long-term goals are to sustain the improvements over time and to determine how to spread the improved process throughout the organization with appropriate modifications.
Staff nurses will be provided 76 hours of didactic content on leadership, project management, and innovation theory. Each participating hospital has enrolled 2-4 staff nurse CSIs for this program, which started in January 2009. This team will partner with a senior leader in their organization to make sure that there are resources and adequate time to conduct the change project. Each organization who has CSI participants will receive $10,000 to support the change project, which will take place over a year. In addition, we have engaged successful nurse executives to provide external coaching who are not based at the hospital where they work. This provides a fresh approach to troubleshoot issues that may ensue as the CSIs progress through the program. This uses a similar approach to the RWJ Foundation and the Institute of Healthcare Improvement28 Translating Care at the Bedside (TCAB).29 In fact, parts of the TCAB tool kit, available on their Web site, will be used for the curriculum. The goal is not to dictate any one methodology for practice change, but to work within the current infrastructure to leverage innovation.
One unique aspect of the education is that we will have panels of consumers who will discuss what they would like to see change in the healthcare industry and specifically in nursing units. We believe that creating a patient-centered environment can be done only by fully and authentically engaging the actual patients who seek care within our region.
Nursing Workforce Innovation Conference-A Regional Workshop for Change
In fall 2010, the first annual Nursing Workforce Innovation Conference for the region and beyond will be held. The sessions will focus on the results of both the workforce assessment projects and the CSI projects. This conference format will not incorporate a typical "show and tell" agenda. Rather, the conference will offer working sessions for hospitals, nurses, clinics, and other types of traditional and nontraditional healthcare organizations to learn how to conduct similar work in their settings with appropriate modifications. We will have panel discussions and work groups to help participants find ways in which to duplicate or modify the workforce assessments or CSI projects to suit their needs as well as help them network with mentors from the initial recipients of the inaugural programs.
The community at large has been greatly energized by the launch of the center. We are inundated with inquiries from both healthcare organizations and consumers. In addition, our first project beyond our region is with the Missouri Foundation for Health, a large philanthropic foundation that funds healthcare initiatives throughout most of the state of Missouri. We are collecting data from licensed nurses across the state to get the pulse of their perception of their organization using, again, the IWPS-R. These data will provide a rich description of the issues facing nurses and will help create statewide programs to increase retention and improve work environments and satisfaction for staff nurses. This project will be completed in April 2009.
Significant change takes a large investment. The center will continue to seek funding from appropriate sources to continue this work; however, HCF and REACH foundations are committed to helping secure a firm financial future for the center.
During the first year, the foundations and the center's staff are meeting with members of the business community to sponsor future CSI Innovation Academy cohorts and the annual Nursing Innovation Conference. We are making the business case that innovation in healthcare will positively influence their organization's overall health, as well as give them a competitive edge over other regions of the country for recruiting new employees. We will charge nominal registration fees for future CSI Academies and Workforce Environment Assessments as well as registration fees for the annual Nursing Innovation Conference. We will also develop and market tool kits and offer training for hospital-based innovation academies and charge "at cost" fees for work environment assessments and customized reports partnering with the Kansas City Metropolitan Healthcare Council, one of the initial members of the Nursing Advisory Board and is composed of regional COOs.
Although these programs are just under way and no definitive outcomes have been measured, the high level of engagement makes the likelihood of success high. There is a rigorous evaluation plan that uses both formative and summative methods to ensure that each program will be appropriately monitored and altered if problems arise. We believe that this new center will offer the nursing community an entity that is built on established principles of the needs of nurses and consumers while being proactive and responsive to additional waves of change in the healthcare industry. We will also use good peripheral vision30 that seeks to interpret weak signals from diverse sectors on the edge of the healthcare that could impact the industry directly in the near future. The Web site was launched in December 2008 and can be accessed by the public.31
The authors thank members of the Nursing Advisory Board, the current participating hospitals, and Ms Wanda Jones, the executive director of the Mississippi Office of Nursing Workforce.
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© 2009 Lippincott Williams & Wilkins, Inc.