Organizations that seek Pathway to Excellence® designation have made a commitment to creating a positive practice environment that benefits the organization, patients, and staff. They understand an environment that “empowers nurses and validates their value in the workplace is essential for sustaining a productive and effective workforce.”1 Achieving designation means that healthcare organizations have successfully demonstrated the development and integration of the six Pathway standards throughout the organization: shared decision-making, leadership, safety, quality, well-being, and professional development. However, sustaining a positive practice environment isn't always easy. In fact, within the past 24 months, most unsuccessful Pathway applicants were those seeking redesignation.
This article explores strategies for organizations to identify factors associated with sustainability and illustrates how one currently designated Pathway organization created structures and processes to sustain its positive practice environment throughout two redesignation cycles.
After successfully implementing a transformational shift in how they support their healthcare teams, organizations that haven't been able to sustain the Pathway framework often attribute the cause to executive leadership change. Additionally, half of the organizations that choose not to seek redesignation cite leadership change as the reason. However, other organizations that experience these same setbacks are able to successfully sustain the Pathway framework through multiple redesignations. What are the contributing factors that make some organizations more successful at sustaining the Pathway environment than others? Themes that emerge from the literature on culture and organizational change suggest that distributed leadership and staff buy-in or ownership are keys to sustainability.
Although the literature generally acknowledges that senior leaders play a pivotal role in implementing organizational change, distributed leadership is identified as a key factor for sustaining the change.2,3 Given that changes in senior leadership have been associated with organizational destabilization and disruption, it stands to reason that distributed leadership can mitigate such deleterious effects by diffusing influence throughout the workforce, including to frontline workers who may not readily identify themselves as leaders.4 Distributed leadership results in less fragmented and more complementary leadership channels that flow both horizontally and vertically.3,5,6
Nurse managers are integral players in a distributed leadership framework.2 They're the bidirectional organizational communicators who are tasked with aligning vision to action by operationalizing change initiatives for frontline staff.2,7 This dynamic allows senior leaders to focus on vision and strategic planning while nurse managers “juggle the balancing act between the innovation focus of senior leadership and the operational efficiency required to function in a day-to-day environment.”7 In Pathway organizations, nurse managers contribute specific efforts to sustaining a positive practice environment, including translating Pathway-required processes into policy, incorporating elements of the Pathway standards into nurse job descriptions and performance evaluations, and incentivizing clinical nurses to participate on shared governance committees. Clinical nurses, as influencers within the distributed leadership dynamic, should, in turn, be responsible for assessing the effectiveness of their shared governance structure and recommending improvements as needed.
Once a distributed leadership approach is solidly in place, which should take minimal effort given that many of its principles are embedded in the Pathway standards, the positive practice environment is in a better position to withstand executive leadership transition.
Identified in the literature as another key to sustainability, staff ownership is accomplished by establishing structures and processes that promote staff engagement, accountability, buy-in, communication, and recognition.2,3 Staff engagement occurs when frontline workers are involved in collective storytelling shared in the spirit of organizing, which allows them to “become part of the story through their own actions.”8 The Pathway framework sets a foundation for engaging in collective storytelling. Through open communication channels that underscore what's valued and why, staff members understand the role they play and hold each other accountable.9 However, understanding the importance of staff ownership is only half of the sustainability equation. The other, and more complex, half is operationalizing staff ownership.
A sustainability success story
Midland Memorial Hospital (MMH) received its first Pathway designation in 2011 and has received two subsequent redesignations. Most organizations experience a euphoric atmosphere surrounding the application phase of the Pathway journey; however, this can dissipate until the redesignation process begins anew. The MMH team wanted to maintain the excitement of being a Pathway organization throughout the entire 4-year designation period.
To maintain their momentum, MMH decided it was important to develop multiple structures and activities to keep Pathway in the forefront of clinical nursing staff members' minds. The structures and activities identified as crucial to maintaining a healthy Pathway culture should become a part of the environment regardless of personal biases or the work habits of any single nurse leader. Stated in another way, when a CNO or other nurse leader leaves the organization, the work and culture surrounding Pathway shouldn't leave with him or her. For example, MMH underwent a change in leadership when a long-tenured CNO left the organization for another opportunity. But the Pathway framework was a vital part of the hospital's environment, and the CEO adamantly insisted it remain an integral part of the organizational structure. Additionally, the incoming CNO was a staff member who had participated in the former CNO's succession planning.
If the Pathway culture is based on structure, the surrounding work will continue to thrive and flourish. An environment like this is highly efficient and follows the Donabedian model's organizing concepts of structure, process, and outcomes.10 MMH employed several strategies to create structures that embrace the Pathway environment. Although varied, these structures incorporate communication, recognition, and feedback.
MMH created a recognition team for the sole purpose of promoting and recognizing nursing efforts within the organization. Members include the Pathway program director and Pathway document writers, as well as those whose job it is to promote the recognitions and inspiring stories happening in the organization. The MMH recognition team meets weekly, inviting leaders and education coordinators from different areas to speak about what's going well and the projects, people, and efforts of which they're proud.
The recognition team shares the information they receive in a monthly newsletter and on their Facebook page and records it in an archive to be used as stories in the next Pathway standards document submission. The recognition team also visits all departments to bring the monthly newsletter and Pathway user guides to nurses providing direct care at the bedside. The face-to-face delivery has proven to be especially effective. Recognition team members attend all unit-based council meetings in the various nursing departments and all organization-wide professional governance meetings.
Numerous social media platforms provide easy ways to communicate with many staff members. In addition to an organizational Facebook page, MMH allows each department to have its own closed Facebook page for the department teams to use for communication and recognition.
MMH is an active participant in The DAISY Foundation program for nursing recognition. The DAISY Award for Extraordinary Nurses recognizes nurses for their clinical skill and compassion. MMH displays photographs of its DAISY award recipients on a prominent wall in the organization for 12 months. Additionally, each DAISY award winner is recognized on the organization's and his or her respective department's Facebook pages.
New knowledge council
The new knowledge council (NKC) at MMH focuses solely on exploring innovations, promoting evidence-based practice (EBP), and guiding and archiving unit-based projects. The NKC provides a forum for departments and various teams, including quality management, the Institutional Review Board, the Academy of Inquisitive Thinking, project dissemination, nursing research, and care innovation transformation projects, to meet, review, discuss, plan, implement, and lead cutting edge practices. The NKC meets monthly and is led by an interprofessional team consisting of nursing and ancillary department team members. On a monthly basis, three teams from different departments present their progress on respective projects. The recognition team provides support by organizing the NKC meetings and archiving meeting minutes. Information from the NKC is shared via social media and the monthly Pathway newsletter.
Information about Pathway is presented to all new employees regardless of job title to instill pride in MMH's three consecutive Pathway designations. At the same time, all new employees are introduced to the concepts of professional governance and providing feedback and suggestions for better ways to do their individual jobs. New employees are asked if they've ever wondered “Why do we do it this way?” or “Why don't we do it that way?” at previous jobs. New employees are also told about unit-based council meetings and how to get their voices and ideas heard as the Pathway standards emphasize.
A future strategy for MMH is the Pathway story contest. Hospital staff members will be encouraged to provide their stories related to different Pathway elements of performance (EOP). Once multiple stories have been collected, they'll be presented to the entire nursing staff to select which story best exemplifies the Pathway EOP. Staff members whose stories are chosen will be supported to attend the Pathway to Excellence Conference.
Other strategies already in place include Nurses Week promotions with a project showcase, posters of nurses who attained a new degree or certification during the previous year, and posters highlighting all conference presentations and articles written during the previous year. Nurse residency EBP and research projects are also emphasized during Nurses Week and various other times throughout the year. A story archive was also created. Overall, the approach is to connect as many initiatives as possible to the fact that MMH is designated as a Pathway to Excellence organization.
Efforts to sustain a positive practice environment shouldn't be dependent on a single person, but rather as many people as possible, and should complement the work and structures already in place. When the Pathway framework is brought to the forefront and engrained in an organization through processes and structures centered around a sense of accountability, communication, buy-in, and recognition, staff ownership will take root and allow the work environment to survive the otherwise destabilizing effects of organizational upheaval that occur with changes such as senior leadership turnover. Nurse managers play a key role in operationalizing these structures in ways that instill staff ownership. If done successfully, as demonstrated by MMH, staff members will need to exert little effort to sustain the environment.
1. Pabico C, Cadmus E. Using the Pathway to Excellence framework to create a culture of sustained organizational engagement. Nurse Leader
2. Willis CD, Saul J, Bevan H, et al Sustaining organizational culture change in health systems. J Health Organ Manag
3. Schuller KA, Kash BA, Gamm LD. Studer Group's evidence-based leadership initiatives. J Health Organ Manag
4. Duffield C, Roche MA, Blay N, Thoms D, Stasa H. The consequences of executive turnover. J Res Nurs
5. Forsyth C, Mason B. Shared leadership and group identification in healthcare: the leadership beliefs of clinicians working in interprofessional teams. J Interprof Care
6. Chreim S, Williams BE, Janz L, Dastmalchian A. Change agency in a primary health care context: the case of distributed leadership. Health Care Manage Rev
7. Gutberg J, Berta W. Understanding middle managers' influence in implementing patient safety culture. BMC Health Serv Res
8. Wilson DG. Building bridges for change: how leaders enable collective change in organizations. Dev Learn Organ
10. Berwick D, Fox DM. “Evaluating the quality of medical care”: Donabedian's classic article 50 years later. Milbank Q