The American Nurses Credentialing Center's (ANCC) Pathway to Excellence® Program recognizes organizations that create positive practice environments for nursing. To achieve Pathway designation, organizations must demonstrate the presence of criteria essential to an ideal nursing practice environment as defined under six standards: shared decision-making, leadership, safety, quality, well-being, and professional development. Elements of performance (EOPs) criteria for each standard are continually assessed by the Commission on Pathway to Excellence (COPE), the governing body of the program, and ANCC Pathway program staff. Typically, the Pathway EOPs are revised every 4 years based on a review of current evidence, best practices, and environmental scans to ensure continuing relevance for addressing issues facing nurses and healthcare organizations.
Development of the 2020 Pathway to Excellence & Pathwayto Excellence in Long-Term Care Application Manual began with a comprehensive literature review to identify potential changes and additions to the EOPs.1 The COPE was instrumental in the review, development, and approval of the final 2020 criteria. (See Table 1.) Members of the COPE represent various specialties and settings, including long-term care, international nursing, academia, research, nursing leadership, advanced practice nurses, clinical nurses, and public consumers.
A concerted effort was made to streamline the criteria in the new manual. Compared with a total of 64 EOPs in the 2016 manual, the criteria in the new manual have been reduced to 53 EOPs. This was accomplished by evaluating each 2016 EOP for its value in practice environment assessment and eliminating those now considered to be commonplace or regulatory. Another convenience the 2020 manual offers is to include the criteria for both the Pathway to Excellence and Pathway to Excellence in Long-Term Care programs in the same volume.
The 2020 manual also introduces a graphic representation of the Pathway framework, depicting the six essential elements for developing positive nursing practice environments. The framework depicts how each element supports the next and how together they enhance the practice environment. In addition, the conceptual framework highlights the infinite cycle and ongoing work required to sustain a positive practice environment. Organizations can use the ANCC Pathway to Excellence framework as a blueprint to foster and sustain a positive practice environment. (See Figure 1.) Its applicability and attainability in an array of settings are attested to by the number and variety of organizations that have achieved Pathway to Excellence designation.
New concepts for 2020 include topics such as the support required when new technology is introduced, strategies for maintaining a positive practice environment during a leadership transition, and nurturing resilience among the healthcare team. These concepts expand on 2016 criteria that relate to leadership development; person-centered care; evidence-based practice (EBP); and advocacy of a workplace culture free of incivility, bullying, and violence.
Shared decision-making gives nurses a voice and is fundamental to the Pathway framework. Nurses should be involved in interprofessional decision-making for all areas that impact their practice.2 Technology implementation in healthcare settings generally has the purpose of improving efficiency, documentation, costs, and/or infection levels. Although the use of these technologies brings the potential promise of improvement, they can also be a source of stress and burnout for nurses and healthcare providers when clinician well-being isn't considered along with the technology implementation.3
The 2020 Pathway manual includes the concept of nurse involvement in the interprofessional shared decision-making process to select and plan implementation of new technologies to give nurse end-users a voice and facilitate a decrease in the stress associated with these technologies.
The CNO and nurse managers drive organizational culture at the hospital and unit levels. Pathway organizations foster shared decision-making and engagement of clinical nurses. Leadership turnover, which has been occurring across the US, has negative implications for workforce stability, staff morale, and patient care.4 For this reason, the Pathway program added an EOP for organizations to have strategies in place for maintaining a positive practice environment in the event of leadership transition. This includes ensuring the CEO's understanding of the value of the Pathway to Excellence framework and its importance during organizational changes.
Organizational retention strategies for nurse leaders at all levels are also highlighted. Lastly, an EOP was added to ensure proper onboarding of nurse managers. Despite the significance of their role, an increasing number of nurse managers express a lack of strong foundational knowledge and leadership experience.5 Nurse managers also report that their orientation is inconsistent or nonexistent as they assume the new role.6 Organizations that invest in leadership competencies demonstrate support for nurse manager professional development and a commitment to their success.
The two new concepts in the 2020 safety standard build on the concept of monitoring concerns related to professional practice behaviors, including promoting a culture free of incivility, bullying, and violence among the healthcare team and safeguarding nurses from abuse by patients or families. For organizations to maintain their current nursing workforce and prepare for the future, it's vital to address these issues to ensure a healthy and respectful practice environment. Incivility, bullying, and workplace violence play a significant role in nurse job dissatisfaction and intent to leave.8 According to the Occupational Safety and Health Administration, 75% of the workplace assaults reported annually occur in hospitals and other healthcare facilities.9 Underreporting has also been associated with lack of reporting policies and/or fear of retaliation.10
Organizations must take a proactive versus reactive approach to violence prevention and mitigation. This includes creating a safety culture bolstered by policies and procedures that minimize the level of workplace violence from patients and families, as well as nurse to nurse or among the healthcare team.11 Both the American Nurses Association and The Joint Commission recommend addressing incivility, bullying, and workplace violence by creating a healthy, supportive practice environment with infrastructures to mitigate the occurrence and effects of violence through policies, awareness, education, reporting, and emphasizing a culture of respect.8,12
Promoting a culture of person- and family-centered care was extended from the Pathway to Excellence in Long-Term Care program to include acute care organizations because the concept applies to patients or residents across the care continuum. Person- and family-centered care is described by the Institute for Healthcare Improvement as “putting the patient and the family at the heart of every decision and empowering them to be genuine partners in their care.”13
In addition, adding an EOP to provide nurses with opportunities to learn about EBP recognizes that healthcare organizations must make a concerted effort to educate clinical nurses on the application of EBP, which positively impacts patient outcomes, quality of care, and healthcare costs.14 Although nurses view EBP positively, they often have insufficient knowledge of the topic. When clinical nurses increase their familiarity with EBP, they're more likely to apply and overcome barriers associated with EBP implementation.15 Increasing nurses' competency in EBP enables them to be drivers toward achieving the National Academy of Medicine's (NAM) 2020 goal of having 90% of clinical decisions be evidence-based.16
Introduced in 2016 in acknowledgment of its impact on job satisfaction and patient safety, the Pathway well-being standard requires organizations to identify and implement strategies that optimize staff well-being.17,18 The 2020 manual delves further into the complexities of well-being by requiring organizations to address the factors associated with staff burnout. Resilience is defined as the “process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.”19 Resilience is compromised when support around a singular adverse event isn't available, and it's further worsened when more pervasive conditions, such as compassion and physical fatigue, are present. To minimize burnout, strategies to enhance staff well-being and strengthen resilience must be part of an organization's strategic planning.
Pathway organizations are required to have strategies in place to address both physical and compassion fatigue experienced not only by nurses, but all healthcare team members. These additions to the Pathway criteria align with the goal of reversing trends in clinician burnout adopted by the NAM Action Collaborative on Clinician Well-Being and Resilience, a network of more than 200 organizations.20
Meaningful recognition, which has been a component of the Pathway framework since the program's inception, may contribute to compassion satisfaction and has been cited in the literature to have a positive impact on job satisfaction and intent to stay.21-23 The new criterion related to meaningful recognition in the well-being standard broadens the scope beyond formal recognition programs and drives organizations to foster a culture of daily recognition. This ensures that nurses are “recognized and ... recognize others for the value each brings to the work of the organization.”24 Creating a culture that involves all healthcare team members in the recognition of others fosters staff ownership of the organizational values associated with creating and maintaining a positive work environment.
Other changes in the revised manual focus on broadening inclusiveness to advance healthcare practice through interprofessional collaboration. Some EOPs under each standard were revised to be more inclusive of other healthcare professionals. In addition, as Pathway's global reach continues to extend, changes have been made to incorporate nonnurse midwives into the nurse survey validation phase of the application process. Nonnurse midwives comprise a large percentage of the healthcare workforce and are an essential part of nursing teams in hospitals outside the US.
In 2019, the Pathway Program Office convened a group of global experts to discuss the benefits and implications of including nonnurse midwives in the application process. Subsequently, the COPE unanimously voted to make that change. This exemplifies the commitment of the COPE and the Pathway Program Office to listen to feedback from the Pathway community, continually assess program requirements, and enact changes to ensure the program's relevance and efficacy in addressing current challenges in the healthcare landscape.
For the betterment of nurses
There are now more than 180 organizations across the care continuum in 34 states, the District of Columbia, and 6 countries outside the US that have achieved Pathway to Excellence designation. This reflects the relevance and attainability of the program's standards in various cultures and settings. The new manual concepts will further contribute to creating positive practice environments for nurses around the world.
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