Engagement of front-line staff is a critical component when implementing or sustaining quality improvement efforts. While effective quality improvement programs include multiple components, support of staff increases the success of changes. 1 , 2
There are important gaps in understanding how best to engage staff nurses. Transforming Care at the Bedside (TCAB) is intended in part to help fill these gaps. Key TCAB strategies are supporting and training staff nurses and managers in order to empower them to identify the need for change, assess work processes, test new processes, and decide which ones should be maintained.
In the TCAB initiative, the Institute for Healthcare Improvement (IHI) brought hospitals together with a common goal in a "learning and innovation collaborative."3 Such collaboratives have proved to be beneficial for a wide range of goals, including improving diabetic care, chronic condition management, and ED operations.4 In addition, the IHI established a taxonomy for characterizing changes (that is, names for TCAB processes, such as rapid- cycle testing), promoted methods for engaging front-line staff, developed a measurement strategy, provided training and consultation, and established mechanisms for hospitals to exchange ideas and jointly solve problems.5
The Robert Wood Johnson Foundation (RWJF) funded our independent evaluation of TCAB phases 2 and 3. Phase 2 took place from 2004 to 2006 and included 13 hospitals. Ten of those hospitals continued for the next two years in phase 3 (from 2006 to 2008). (See Table 1, "Phases of the TCAB Demonstration Project," in "Overall Effect of TCAB on Initial Participating Hospitals" for a more detailed explanation of the TCAB phases and participants.) We used a variety of methods to collect data, including interviews and surveys of nursing staff and administrators at the participating hospitals, observation of the multifacility collaborative meetings and other selected TCAB meetings and phone calls, and documents and data that hospitals submitted to the IHI as part of their participation in the program. This article includes oral and written comments made by nurse leaders as part of an in-depth qualitative analysis.
Companion papers in this supplement address the overall effects of the TCAB intervention (see "Overall Effect of TCAB on Initial Participating Hospitals") and the ability of the nursing units to implement TCAB processes that were designed to engage front-line staff (see "Participation of Unit Nurses").
We visited all participating hospitals and conducted 150 interviews with nursing administrators, nurse unit managers, front-line nursing staff, and quality improvement personnel in spring and summer 2005 to understand TCAB phase 2 activities, which began in July 2004. Telephone interviews with unit managers about measurement activities took place in spring 2006. All chief nursing officers (CNOs) and unit managers were interviewed by telephone in summer 2006, after phase 2 ended. To gather data on phase 3 activities, which took place from 2006 through 2008, we administered Web-based questionnaires to the CNOs and unit managers when that phase ended. All unit managers and 92% of CNOs responded.
Interviews were recorded and transcribed. Two successive investigators coded quotes and entered them into a spreadsheet. Analytic techniques included descriptive univariate statistics and multireviewer coding and content analysis.
EXPERIENCES OF CNOs
One hospital had two campuses, each with its own CNO. Thus, 14 CNOs participated in phase 2 of TCAB and 11 in phase 3. In all, 55% of the 11 phase 3 CNOs had held their current position for five years or longer. By the sixth year of the initiative, 45% of the CNOs had changed positions, which often made apparent the important role played by the CNO in supporting the TCAB process.
The CNOs carried out a variety of activities as part of the TCAB process (see Table 1). They identified as most important such activities as conducting hospital meetings about TCAB and obtaining assistance with data collection and analysis. They could manage most activities with little difficulty.
Overall, CNOs undertook the following major roles.
Securing hospital commitment. Introducing TCAB into hospital operations required the sustained support of senior leaders over years. When hospitals agreed to participate in the TCAB collaborative, they made a commitment to participate in both the senior leader collaborative and the medical–surgical nursing collaborative. The CNO often took the lead in establishing these relationships with the IHI and sustaining the hospital's involvement with other facilities in the collaboratives.
Organizing leadership teams. Each hospital established a leadership team to guide TCAB and coordinate it with other intrahospital programs. The CNOs were part of these teams, often forming them and serving as chairperson of 55% of them. Another senior hospital leader, such as the chief executive officer, also participated on 64% of the teams. Quality improvement staff served on 82% of the teams, and 55% included patients or their families. The leadership team met at least quarterly, but at 36% of the hospitals it met weekly.
In the final year of the project, all of the TCAB leadership teams were engaged in planning the hospital's TCAB program, reviewing reports from the TCAB units, and reporting to senior leaders. More than half of the teams were also designing tests of change and planning to spread TCAB within the hospital.
Selecting pilot units. Most of the participating hospitals selected one unit to pilot the initiative, although four hospitals selected two units. The CNO authorized selection of the unit and the commitment of resources for TCAB activities. Units in the same hospital or system often differed in how they implemented TCAB and in the results they reported. Thus, success appeared to depend not only on the hospital and its leadership, but also on the unit's manager and staff. One CNO commented, "The manager is key!" Another stated that "continuous support of the unit-level manager is needed from senior leadership."
The units that activated their teams and began tests of change most quickly were the ones that were stable in terms of staffing levels and services offered or had an effective nurse manager who had excellent rapport with the staff. Hospitals that selected a unit that had problems they hoped TCAB would help them address were initially less successful.
Engaging front-line staff. "Involving staff nurses in unit change resulted in a more energized and creative work team, with lower turnover and better relationships," one CNO commented. Another said, "Front-line nurses have the answers—we just need to remember to ask them." Much of the effort to engage front-line staff occurred at the unit level, but CNOs could model and support an effective management style.
Procuring financial resources and establishing staff incentives. An important role of the CNO was to visibly demonstrate her or his ongoing support for TCAB. Several hospitals made modest resources available to support the units" TCAB work. Many sites provided food at presentations and brainstorming sessions and at celebrations marking successes.
Most of the CNOs established incentives to engage staff. At 82% of the hospitals, TCAB participation was acknowledged in performance evaluations. At 73% of hospitals, staff nurses received public recognition of successful innovation results. For example, a story about an innovation might have been posted in the cafeteria or included in the hospital newsletter.
Integrating TCAB into hospital operations. Overwhelmingly, the CNOs reported believing that TCAB had to be fully integrated into hospital operations. They came to believe that TCAB shouldn't be viewed as a temporary project or an add-on that could be abandoned by new leadership.
Comments by several CNOs reflected the importance of this goal. One stated, "TCAB has been ingrained into the DNA of our culture." Another cited a need to "weave TCAB into the fabric of the organization." A third CNO commented, "It needs to become the way we do our work."
The role of the CNO in keeping hospital management informed about the progress of the initiative helped ensure its continuation and support. In their strategic plans, 73% of the hospitals made reference to TCAB, testifying to the institutionalization of the program. By 2008, 73% of the hospitals included information about TCAB in orientation for new nurses.
EXPERIENCES OF UNIT MANAGERS
Most of the managers of the 13 pilot units remained in their positions throughout the project; after six years of involvement, only 15% had been in their positions for two years or less. In all, 61% of unit managers had master's degrees, and the remaining 39% had bachelor's degrees. All were RNs. The units varied in size, the services provided, and the presence of specialty clinicians and physician hospitalists. Change was common on these units. In the last year of TCAB, for example, most of the units experienced significant operational changes, including provision of new services (39%), implementation of new computerized systems (46%), and modification of the unit's physical space with construction (54%).
As key intermediaries between hospital leaders and front-line nursing staff, unit managers were instrumental in organizing TCAB activities at the unit level and coaching their staff to drive the change process forward. Conducting TCAB tests of change within the unit and within the larger hospital environment required them to perform a wide range of activities. Table 2 reports unit managers' assessments of the importance and difficulty of implementing various TCAB activities.
Unit managers emphasized that having the support of hospital leaders was critical for carrying out TCAB processes. As one unit manager stated, "To successfully implement TCAB, you need to have support, understanding, and participation from senior leadership, so this is more than a 'unit' project."
Establishing unit teams. Each unit established a TCAB team, and this was critical to encouraging staff involvement. Team meetings provided opportunities for reviewing ground rules, establishing group decision-making processes, and orienting staff members to TCAB processes such as Plan–Do–Study–Act, the rapid-cycle testing approach to change.
These teams varied considerably among hospitals in their composition and meetings. The unit manager led 62% of the unit TCAB teams. In addition to the unit manager and staff nurses (many from shifts other than the day shift), more than half of the teams included nursing assistants, unit clerks, and quality improvement staff. Pharmacists, physicians, clinicians such as social workers and dietitians, and housekeeping personnel were also on some teams.
Engaging front-line staff. Engaging front-line staff in the TCAB process, which is central to the TCAB philosophy, was achieved with effort. Interviews with unit managers at the end of the first year indicated that while some staff had embraced TCAB with enthusiasm, others were skeptical. A substantial portion of the unit manager's efforts involved building the commitment and capacity of staff to conduct TCAB activities. Unit managers were responsible for structuring TCAB activities, demonstrating commitment to front-line staff participation, giving staff sufficient project time, and ensuring adequate training.
Unit brainstorming sessions, called "snorkels," were held during the early period of TCAB implementation, and 69% of unit managers repeated these snorkels early in phase 3. Modeled after the "deep dive" concept developed by IDEO, an innovation and design firm, snorkels use an energetic, structured style to solicit from unit staff problematic issues that TCAB could address.6 Overall, 67% of unit managers considered the snorkel held at the beginning of a unit's participation to be very or somewhat important to sustaining TCAB, and 46% considered the additional phase 3 snorkels to be very important.
Important methods for engaging staff that unit managers frequently mentioned were having them attend TCAB meetings and getting them involved in selecting tests of change. Nurse involvement in conducting, assessing, or revising tests of change was very or somewhat important according to 60% of unit managers. Staff and team responsibility for making TCAB decisions was common, with 76% of unit managers reporting that their TCAB team or all unit staff (via vote or another formal process) usually decided what tests of change to conduct in phase 3. All unit managers reported that the team or the staff as a whole decided which tests of change to adopt as usual practice.
Every unit manager encouraged staff members to participate in TCAB activities by offering them time away from patient care duties. In addition, 46% of unit managers supported training through hospital-based programs, and 38% provided overtime or additional pay for participation in TCAB meetings or activities. According to 31% of the unit managers, this meant reallocating funds for TCAB work.
Developing staff skills. There was an ongoing need to build staff skills and expertise needed for TCAB work. This included knowledge of quality improvement methods and skills for running meetings, managing projects, measuring outcomes, and using computers, particularly software for graphing results.
Important sources of training were the collaborative meetings and activities, which 80% of unit managers considered to be very important to the program's success. However, relatively few staff nurses attended these multifacility meetings, instead relying upon those who had attended—usually the unit managers—and on print and online materials to orient them to the TCAB process.
Evolving management style. The more engaged staff viewed TCAB as their program. In many cases, this required unit managers to change their management style to give staff nurses more authority for making changes. Unit managers often mentioned that they had developed a participatory style of leadership as a result of the TCAB initiative.
Cultivating staff leaders. This participatory management style meant that managers had to cultivate leaders among the staff nurses. Both CNOs and unit managers indicated that TCAB leaders needed to possess certain traits, including:
- comfort with risk taking
- drive and perseverance
- a tendency to reflect on practice effectiveness
- competence with diversity
- systems thinking, or an ability to see relationships among parts of the whole
- ability to involve clinicians and staff from other departments
- comfort with ambiguity
- self-awareness and initiative for self-development
- partnering skills
- capacity to sustain enthusiasm
As one unit manager explained, successful change requires "vision from the top and passion from the bottom."
The TCAB unit managers cultivated staff nurse leadership in various ways. Nearly all units (92%) had a staff member who became the informal TCAB leader by championing tests of change, communicating information to unit staff, or leading brainstorming sessions. In one hospital, the unit manager was especially proactive, designating "resource nurses" who became experts on and were responsible for innovations and measures in a specific area, such as pressure ulcers.
The efforts to engage staff and support their work with time, training, and resources appeared to be successful. During the first year of TCAB, 31% of the unit managers felt that half the nurses were unsupportive of TCAB. Three years later, only 8% of unit managers reported such lack of support from staff nurses. According to 69% of unit managers, attitudes changed because the staff were able to test their own innovations. Having a positive experience with a test of change or the implementation of an innovation was the main source of attitude change, according to 76% of the unit managers. Encouragement from other staff members, incorporation of TCAB into employee evaluations, and incentives such as release time from work to engage in TCAB activities helped to increase support for the initiative on many units.
BARRIERS TO TCAB
The pilot units encountered many barriers to implementing and sustaining TCAB (see Table 3). Among the major barriers that unit managers identified were insufficient staff time, inadequate staff training, conflicts with competing hospital priorities, uncertainty about TCAB processes, difficulty with problem-solving strategies, insufficient resources, and lack of cooperation from other hospital departments.
Hospitals were carefully selected for this pilot TCAB program. All had strong histories of providing high-quality care and engaging in quality improvement efforts, previous experience with the IHI, and committed leaders who paid to participate in the venture (hospitals paid approximately $54,000 to participate in this collaborative). Key personnel at these facilities were thoroughly trained by and benefited from the IHI's support structure for the program. The effort required major commitments of financial resources and staff energy and attention. These factors resulted in only 10 hospitals participating in both phases 2 and 3, limiting the power of statistical analysis and reducing the generalizability of the findings. Even so, the findings suggest that a well-instituted, complex intervention to engage front-line staff in quality improvement can successfully change work processes and relationships and lead to a more open learning environment.
Although the TCAB process is firmly rooted in engaging front-line nurses, the actions of nurse leaders are critical to its success. Their specific roles differed, but unit managers and CNOs identified similar themes as being vital in implementing TCAB, including the importance of engaging front-line staff, the central role of unit managers, the need for senior leadership's support, and the need to integrate TCAB into hospital operations. Engaging in a management style that ceded some authority to staff nurses, supported the development of new skills in staff members, and fostered more effective problem solving was important for successful implementation of the program.
Nursing leaders responded very positively to questions about what their institutions and they personally had gained from TCAB. One unit manager said, "It was an incredible opportunity that helped bedside nurses improve their skills. It leveled the hierarchy." Another commented, "TCAB has opened my creative mind and made work fun."
CNOs and unit managers reported that TCAB enabled them to
- empower staff with, as one nurse leader said, "a sense of identity and pride, can-do spirit, willingness to innovate, and openness to new possibilities."
- expand staff skills "with the methods and tools that . . . now sustain an effective innovation and testing capacity."
- shift the organizational culture to "a more cohesive and creative environment, willing to test ideas and accept that things may not work."
- improve "interdisciplinary outcomes and patient outcomes."
CNOs pointed out the necessity of integrating TCAB as a fundamental change in the way hospital personnel do their work. As one CNO said, "Don't call it a 'project.' We actually changed the name to 'a new practice model.'"
Although most nurse leaders specified the importance of spreading the TCAB culture throughout their facilities, they recognized the need to reconcile differences across units and to establish throughout the hospital mechanisms for testing and implementing innovations. TCAB spread requires the support, involvement, training, and championship of staff. The 2008 nursing leader participants reported being committed to continuing TCAB teams and participating in TCAB again.
All of the hospitals participating in phases 2 and 3 reported that they intend to maintain their TCAB unit and leadership teams. They all agreed that if they could do it over, they would participate in TCAB again.