In 2007 the American Organization of Nurse Executives (AONE) received a grant from the Robert Wood Johnson Foundation (RWJF) to bring the Transforming Care at the Bedside (TCAB) initiative to 68 hospitals. The goal was to disseminate TCAB to a large group of hospitals using the smallest possible expenditure of resources. Led by the RWJF and the Institute for Healthcare Improvement, the TCAB project originally had four themes: safe and reliable care, vitality and teamwork, patient-centered care, and value-added processes. Transformational leadership was later added as a fifth theme, followed by two additional components from the AONE grant: caring and nurse ownership of practice.
As the work unfolded, it became clear that the leadership skills and talents of TCAB-unit nurse managers were extremely important for the overall success of the initiative. It is the nurse manager who creates an environment that fosters change on the unit. This ability to change, especially with regard to decision making, is now recognized as a core component of TCAB. It is also important for creating the leadership skills of the future nursing workforce.
The nursing shortage is worsening just as the demand for services is increasing. One way to meet this challenge could be to decrease the demands on the available workforce by fundamentally changing the work—that is, by redesigning what nurses do to provide safe, high-quality care. This reform will be successful only if nurses themselves are the ones making decisions to bring about change. TCAB enables nurses at the bedside to reshape, retool, and reform the care that they provide.
Nurse leaders today realize that they will face myriad challenges in the future. The nursing executive can create a vision and strategic direction to guide the delivery of patient care, but one person alone cannot repair old processes and create new ones. Reforming the health care delivery system requires the full commitment of the entire team, from nurses at the bedside to senior nursing leaders. At the midpoint of this hierarchy is the nurse manager, who has the critical role of creating and supporting an environment that fosters the development of leadership skills among bedside nurses.
HOW TCAB CHANGES THE WORK ENVIRONMENT
Using quality improvement methods, nurse managers on TCAB units can teach staff to identify areas for improvement, design and test changes, measure effects, and move new processes through adoption, adaptation, or abandonment. The result is much more than a staff that can implement high-quality improvement projects. Instead, nursing staff members develop core skills that enable them to change the work they do. The change affects the broader health care team and brings all those involved into the redesign. In this way, a team of colleagues collaborates to change the way in which it practices. Staff members gain confidence as they take responsibility for decisions and outcomes. A new way of thinking about practice begins to take shape.
This process is most effective when the nurse manager creates a supportive environment in which nurses can make decisions. The nurse manager transfers authority to the staff members and helps them learn to accept responsibility and accountability.
Early in the TCAB project, some nurse managers expressed concern about going along with proposed changes they disagreed with, especially when they felt the changes were likely to fail. But significant learning takes place when projects don't succeed. Being able to ask the right questions, guide the decision-making process, and translate failures into learning opportunities, rather than providing the "right" answers, have become important new skills for nurse managers. These skills are consistent with those emphasized in leadership models such as servant leadership—in which a leader's primary focus is on serving those who she or he leads—and quality improvement frameworks like the Toyota production system, in which all levels of employees are involved in continuous improvement and learning for the benefit of all.1-3 These leadership models encourage managers to empower front-line teams and allow them to share in the decision-making process.
As nurse managers develop new skills and advance their careers, they retain the knowledge that the person closest to a problem is the one best able to solve it. Likewise, staff nurses know that they are capable of making decisions that affect their work and do not rely solely on those in formal leadership roles. These two insights can change the way that staff and management work together and help create an environment well suited to the difficult task of transforming the care delivery system.
With TCAB, nursing leaders guide staff in becoming decision makers in three specific ways. First, they teach the importance of making data-driven decisions. The quality improvement methodology of rapid-cycle design stresses using measurements to evaluate outcomes. This way, staff nurses quickly learn that having data is the key to success. In rapid-cycle testing, staff members identify targets that will let them know if their goals have been met. For example, if the goal is to increase patient satisfaction with the nurses' call light response, call light frequency before and after the test of change would be compared to evaluate whether patients submitted fewer repeat requests. Second, staff members learn that all decisions take place within a larger system of care—and that decisions made on one unit affect other parts of the system. This brings a systems perspective into the deliberations. Finally, they recognize that collaboration and teamwork are essential for high-quality decision making. The result is a nursing workforce that practices data-driven decision-making skills within the context of a team system. This is the decision-making style that will dominate in the future.
LEADERSHIP TRAITS OF NURSE MANAGERS
What are the special attributes and characteristics of the nurse manager who can successfully lead in this setting? She or he must be willing to surrender control over decision making and support the staff in taking ownership of their practice. To create the right environment, the nurse manager uses coaching and guiding; she or he does not tell the staff what to do. The leadership role is that of a facilitator and mentor, with the leader helping the staff make their own decisions and negotiating to achieve desired outcomes. The nurse manager is the sense maker—the "big picture" person who translates her or his observations for others—and the liaison to colleagues outside the unit. She or he champions the staff in owning their practice and provides them with the opportunity to learn new skills.
As staff members experiment with new ways of working, the nurse manager serves as a role model and helps staff remain comfortable with the ambiguity of the process. The nurse manager supports plans and solutions, even when these are not perfect. Solutions evolve over time, and the nurse manager encourages staff to proceed with action even when they have not envisioned every detail of the plan. The group learns to appreciate diversity of opinion and the possibility that there are multiple paths to solving a problem.
It takes courage for a nurse manager to let go of decision-making responsibilities. The ideal role of the nurse manager is not decision maker but teacher. This means turning authority over to those who are best suited to use it. This competency will be needed in the workforce of the future.
FOSTERING NEW LEADERSHIP ROLES
Many of the nurse leaders participating in the TCAB project have thrived in this environment. They embrace the initiative enthusiastically as an opportunity for professional development.
Nurse managers are also seeking additional leadership experiences, such as the AONE Nurse Manager Fellowship. This yearlong program for 30 outstanding leaders has attracted TCAB-unit nurse managers who want to continue developing their skills. The program incorporates several aspects of leadership, including classes such as "Leading the People," "Managing the Business," and "Creating the Leader Within." The AONE fellows learn that they can be influential at a national level by, for example, presenting papers at national meetings and volunteering for national initiatives, as well as on their units.
In addition, the TCAB project has demonstrated the contributions to be made by nurses in new roles such as the clinical nurse leader, a new master's program developed by the American Association of Colleges of Nursing that, like TCAB, stresses evidence-based practice. The University of South Alabama Medical Center in Mobile has established a dynamic partnership between the nurse manager and the clinical nurse leader, highlighting the potential of this new role.
PART OF A BROADER AGENDA
To improve future health care, the Institute of Medicine urges providers to meet six "Aims for Improvement": safety, timeliness, efficiency, equitability, effectiveness, and patient centeredness.4 The American Hospital Association (AHA) has launched Hospitals in Pursuit of Excellence, a program that's designed to engage, support, and inspire hospital leaders in their ongoing efforts to improve the patient experience and meet these aims while also achieving operational, clinical, and financial excellence. TCAB is an important component of the AHA's strategic plan because it allows the nursing workforce to be bedside decision makers, giving them the capacity to further the program's component goals, such as reducing hospital-acquired infection rates and falls.
As nurses gain skill and confidence in using rapid-cycle redesign to address quality improvement, they can transfer these skills to the larger issues of systemwide reform that will begin to reshape care delivery processes. How will we take waste out of the system? How will we create more effective and efficient processes? As we face greater financial constraints, how can we use our resources to their fullest extent?
As TCAB changes decision-making processes on the unit, it also has the potential to change decision making in the entire health care system. TCAB is creating a culture that respects the ability of those at the bedside to know what must be done to provide the care patients need. This is the culture that will lead to a new, transformative partnership between management and staff. In this culture, "the leadership" includes everyone who is trying to design and deliver care. Redesigned, safe, high-quality care, delivered at a reduced cost to satisfied patients and families in work environments that are professionally challenging and rewarding for nurses—that is the future.