Brody, Abraham Aizer PhD, RN, GNP-BC; Barnes, Kathi MS, RN, CNS, NEA-BC; Ruble, Cheryl MS, RN, CNS; Sakowski, Julie PhD
The environment where nurses practice influences their ability to provide high-quality, safe patient care and to maintain satisfaction with their position and the profession.1 When nurses practice in a healthy work environment, positive effects on clinical outcomes and on their outlook toward the profession and themselves have been identified.2 Healthy work environments are characterized by a culture of collaboration, communication, accountability, effective shared decision making, and recognition combined with adequate staffing and credible, visible leadership.2,3 Studies demonstrate that nurses working in these organizations have a greater sense of empowerment, have increased job satisfaction, and are more committed to their organization.4-7 The greater sense of empowerment is related to involvement in shared decision making, particularly surrounding the control of professional nursing practice.7 Active involve ment in decisions surrounding practice standards, process improvement (PI), patient care policies, and resources gives nurses control of their practice and the ability to use that control to improve the quality of patient care.4,7,8
Shared governance structure is a strategy to ensure that staff nurses can control their practice and are accountable for quality patient outcomes.4,8 Sharing power over decision-making processes related to nursing practice results in behaviors necessary to achieve improved outcomes for patients and organizational goals.4 One way to share power and enable nurses to have control over their practice is to establish nursing councils with decision-making capacity. Councils can be unit based and/or hospital-wide and can focus on either function or role.5,8 Effective councils accomplish organizational goals through the active participation of staff in the decision-making activities of the council’s work.4 Active participation requires that nurses must want to participate, have access to power, and be effective in achieving outcomes. Councils with these characteristics have been shown to have viability and participation leading to a feeling of greater empowerment and achievement among nurses.4,8
A nurse’s feeling of empowerment positively correlates with intent to stay with an organization.6 Higher intent to stay with an organization supports the retention of qualified nursing staff.9 Nurse empowerment and low turnover have been shown to improve both clinical quality and financial benefits for the organization10 including lower risk adjusted mortality rates and shorter lengths of stay.10 The cost to replace an RN can range from 2 to 3 times the annual salary,5 and the replacement individual may or may not possess an equivalent level of knowledge and skill. By helping to retain qualified staff, investments in establishing structures to involve nurses in decision making and control over practice can be beneficial to the organization.5
This project examines how participation on a nurse-led council impacted council members and how the hospital environment impacted the operations of the councils. Outcomes related to the council members’ experience of work and their perceived leadership growth will be highlighted.
Six hospitals in a nonprofit heath system located in Northern California established staff nurse–led evidence-based practice (EBP) councils in 2007. The councils’ charter was to determine and disseminate EBP, thus improving the quality of patient care in the organizations by enabling direct care nurses to have control of professional nursing practice.
Each council consisted of 5 to 12 bedside nurses with a staff nurse elected as co-chair. A master’s degree–prepared nurse director guided each group. The primary role of the director was to facilitate working with hospital leadership and to help members develop with a goal of assuming full leadership of the council. The director and co-chair jointly performed the leadership functions for the councils in a mentorship model. Decision making and the work of the council were accomplished using a consensus model. Over the study period, the directors transitioned from a mentoring and facilitation role into an advisory role as council members and the co-chairs at each hospital became more comfortable and assumed more responsibilities.
To prepare the council members to be successful in their work, training at the onset was provided in teamwork, EBP, quality and PI methodologies, critique of research, adult learning principles, and the change process. Training included human factors in the work environment and patient safety, professional role, and scope of practice and transforming culture. The co-chairs received additional preparation in conflict management, effective team dynamics, and staff development through coaching and delegation. Annual review sessions were held focusing on change process and conducting literature reviews and additional tools such as use of appreciative inquiry methodology. Each council implemented 5 initiatives sequentially based on needs identified by the council. The council looked at baseline quality performance data, reviewed the literature, and developed or adapted evidence-based protocols that fit in the culture of the organization. Authority was granted to the councils by the chief nurse executive (CNE) of each hospital to independently implement protocols that were budget neutral and had no negative impact on other departments as determined by consultation with department heads. The councils were charged with working with hospital leadership and medical staff to implement proposed changes with the potential to affect others. Multiple modalities were used to educate bedside nurses about changes in practice and policies. Each council was responsible for monitoring the progress of its initiatives and to intervene if quality declined. The councils also worked directly with quality improvement (QI) departments and other departments as necessary, including obtaining data, developing, updating and receiving approval for policies and procedures, and obtaining necessary equipment.
In addition to the hospital-level council, a coordinating council at the system level was formed to share experiences, learn best practices, analyze data, and ensure appropriate oversight of the councils. The coordinating council met biweekly and consisted of the system-wide council director, the individual hospital council directors, council co-chairs (annually), and a data analyst. Quarterly meetings of the coordinating council included the CNE of each hospital and the system CNE. Researchers and guest speakers were invited to meetings as needed. An annual day-long event planned by the system-wide council brought together council members and directors from all hospitals along with other involved parties and internationally known specialists. The purpose was to provide continuing education, leadership development, progress on outcomes of the initiatives, and community and morale building.
This program was qualitatively evaluated using a 3-step process to examine the effects of the council on staff development and satisfaction. First, the principal investigator performed an ethnographic examination of the council process by observing and taking field notes at council meetings and breakout activities of councils over a 3-month period. Over the next 3 months, these notes were coded and grouped into several broad themes based on consistent frequency of occurrence, council member development, interactions with management, operations, and outcomes of practice change using Atlas TI.11
Qualitative analysis using interviews of key stakeholders was used to further explore emerging themes, starting 3 months after completion of the ethnographic analysis. Interviews were performed using a phenomenological approach, requiring the researcher to have a pre-theoretical understanding of experience while simultaneously maintaining an open mind during the exploratory process.12 A purposive sample of council members and directors, unit managers, and CNEs was invited to be interviewed over a 6-month period. All participants agreed to be interviewed. Analysis from the ethnographic observations was used to develop a set of broad open-ended interview questions focusing on the themes. These questions were used as the basis for semistructured interviews that were held individually, digitally recorded, and transcribed verbatim. A set of themes was created based on consistently occurring constructs from the transcripts. Transcripts were reread and grouped into these themes for analysis. All excerpts within a theme were reviewed to ensure consistency and to create a summary.
A 10-question Web-based survey was distributed to all current and previous council members in the third phase. The survey focused on leadership opportunities they have either applied for or obtained since joining the council and satisfaction with and perception of effectiveness of the council. Results of the survey were analyzed using descriptive statistics. The study was approved by the institutional review board of the hospital system.
Qualitative, semistructured interviews were completed with 76 participants (see Table 1). From these interviews, 5 themes were identified related to staff involvement and development and are discussed below.
Quantitatively, 33 current council members and 5 council alumni (57%, n = 67) responded to the survey. Results from the survey are discussed in the leadership growth section.
The most common theme from interviews with all participants was empowerment. Council members believed that the ability to change standards of practice and improve quality of care presented them with an opportunity for workplace empowerment. This led members to feel greater ownership and pride in their work setting. Members focused not only on council initiatives but also on other issues affecting patient safety on their unit or in the hospital. Feeling free to bring issues to risk management through the council was an example of empowerment identified by members.
Meaningfulness was described in 2 ways. First, meaningfulness was identified in discussions about the feeling of council members toward their work on the council and a heightened sense of their impact. Many council members had a significant amount of nursing experience and were at a point in their careers where they could be at risk for burnout. Council members felt that their work on the council provided a sense of meaning to their work. Meaningfulness incited some council members to become more involved at the hospital and assume additional leadership roles. Other council members remarked that without the council and the meaningfulness it provided to their work, they would have retired or changed hospitals. One nurse stated that she continued to work at their hospital despite her 90-minute commute because involvement with the council gave her a sense of meaning and belonging.
The second way meaningfulness was described was in terms of the way bedside nurses were provided in-service education by the councils. Councils were expected to implement interventions related to the initiatives they supported. Their responsibil ity included education of staff regarding any changes in care, whereas education departments performed concurrent education in the hospital on other initia tives. The hospitals varied in the structure of their education department with some hospitals having designated nurse educators responsible to update staff on new practices, policies, procedures, and equipment. Others had educators who were responsible solely for updating policies and procedures and had nurse managers and charge nurses provide the information to staff nurses.
Nurses reported an attitude of indifference towards typical in-service education based on a feeling of unidentified meaningfulness. Nurses were often provided instructions or education for changes in practice without the rationale or evidence for the change being provided. This approach with incomplete communication creates a lack of meaningfulness as to why a change in practice is necessary. Council members, managers, and executives reemphasized the importance of ensuring that bedside nurses were educated regarding why a change in practice was being implemented rather than just telling nurses to do something. As a result, councils focused on providing this key piece of information when educating about practice changes. One council member stated,
Everyone is required to read policies but you need to have people talking to others providing meaningful information. Nurses don’t have time to sit—I read all the time and I read the literature because that’s just what I do. But a lot of people aren’t so inclined. If you can give provide what staff members need to make the best decision for their patients in a way that’s the least time consuming- nurses will be receptive. Just don’t tell staff to go home, “read this, read this, read this, sign this, sign this.”
Other nurses confirmed that bedside nurses were more receptive to proposed changes when they were directly linked to improvements in patient experience and outcomes. Several nurses who initially were not on councils and later became members stated that before council membership, they viewed practice changes differently for 2 reasons: (1) they were told and knew why changes were important to their practice and (2) they were being taught by their peers and not by an administrator or nurse educator who was removed from clinical role.
The experience given to council members accelerated the growth of leadership skills. The experience of having control and responsibility for implementing change is reflected below:
If these nurses weren’t on the council, wouldn’t be doing the things they’re doing. They would probably be doing their staff nurse work and wouldn’t have come into more of a leadership role. Everybody has stepped outside of their comfort zone” (response of a nurse manager).
In the survey given to council members and alumni, 21% (n = 8) of respondents applied for a promotion since joining the council and 85% (n = 7) of those who applied received either advancement on the clinical ladder or a promotion to an administrative or QI position. In addition, 76% (n = 29) of respondents reported assuming additional responsibilities since joining the council, including committee work, educational initiatives, and charge nurse duties.
Leadership growth also occurred among nurse managers, service line directors, and nurse executives supporting the councils. Before the implementation of the staff-led council project, few had experience with receiving input from and giving PI responsibilities to bedside staff. Managers learned and refined skills in facilitation, teamwork, and delegation. The relationship between the councils and unit managers was sometimes strained because of issues of control and role clarification.
Exposure to Performance Improvement
Before their position on the council, few members had experienced any form of PI initiative, and similarly, only a few of the nurse managers or executives had opportunities to work with an empowerment model involving staff nurses. A steep learning curve was identified in addressing PI, and significant issues became apparent including (1) the need to work with administration to budget for the implementation of changes that were not budget neutral in the short term but had long-term benefit and in some cases resource savings and (2) how to partner with unit managers to implement changes. Council members were anxious to implement rapid improvements and did not initially recognize the diplomacy and planning that are necessary to successfully carry forward significant change. Past the initial frustration, improvements were made and council members learned from these challenges for future initiatives.
Over the course of the project, it was observed by all participants that council members had broadened their vision through their work on the council. This vision enhancement was apparent in 2 behaviors: (1) enhanced ability of the staff nurses to look beyond individual patients to the unit and hospital-wide level in terms of appropriate care and the prac tice environment and (2) improved teamwork between departments supporting a focus on the patient. The shift in vision is exemplified by the following statement:
I’m more aware of house-wide outcomes. Sometimes you work in a certain area, you’re focused on your area and you’re unaware of issues on other floors and how we can impact them. I think the councils brought the hospital together. The councils united the staff. Because of the council you’re involved in different committees and meet more people.
Council members consistently expressed an improved perception of empowerment, meaningfulness of work, leadership growth, exposure to performance improvement, and vision. Empowerment in this study was manifested through opportunity, resources, support, information, and formal and informal power.4
Congruent with previous research, this study found that staff nurse empowerment positively impacts job satisfaction, trust in management, labor relations, turnover, and commitment to the organization.6,13 Multiple nurses reported how engagement and a sense of empowerment resulting from their involvement with the councils kept them practicing at the hospital. Incidentally, several labor relation conflicts occurred during this study in 2 of the hospitals that are unionized. The councils not only continued to function throughout the conflicts but also acted as a place where council members could work through these conflicts in a constructive manner and engage management to help solve some non–contract-related issues.
Empowerment of council members enabled them to apply EBP interventions and improve patient outcomes in these facilities. Council members no longer expressed feelings of passivity and powerlessness but felt that they had both the ability and the responsibility to effect change. Quantitative data from the project showed significant improvements in quality outcomes such as ventilator acquired pneumonia. Current and former council members now routinely engage their managers and peers in improving patient safety. The increased leadership and vision created by the councils changed how these staff nurses embody their role responsibilities to their work environment. Nurse managers and executives frequently struggle to engage staff nurses to expand perspective and accountability.14 This project demonstrated the ability of EBP implementation councils to engage nurses and to improve outcomes.
The primary limitation of this study was the self-report nature of the data. No independent measures of professional development and behavioral change were performed to validate the self-reports. Another limitation was the inability to obtain the perspective of the general direct-care nurse population. Although we examined the effects that the council process had on development of council members, we were unable to assess whether other direct-care nurses felt more empowered or took a more direct role in shaping their care environment because of the council. Beyond the limited quantitative survey, this research did not result in extensive quantitative measures of individual council member’s satisfaction with the project or effects on their development. Fourth, although the 6 hospitals included in this study varied in size and structure, all were from a single hospital system, limiting the generalizability of the study.
Implications for Practice
Considering the predicted need for nurses in the next several years because of demographic shifts and work force demands, the ability to empower, engage, satisfy, and thus reduce turnover by keeping nurses in practice has the potential to be a powerful incentive for implementing EBP councils. Staff-led councils have the potential to improve quality outcomes and decrease hospital costs. Hospital executives should strongly consider developing and sanctioning similar councils to support EBP. During implementation, appropri ate training should be provided to council members, managers, and executives for the councils to achieve success.
The authors gratefully acknowledge the support of the Gordon and Betty Irene Moore Foundation who provided the funding to complete this study.
© 2012 Lippincott Williams & Wilkins, Inc.