Engaged clinical nurses are at the very core of a successful Pathway to Excellence® (PTE) organization. At Adirondack Health (AH), our goal was to combine a solid shared governance model with the PTE framework, resulting in an ideal work environment. One way to achieve this high level of staff commitment is by imbedding a professional practice model that clinical nurses believe in and help develop. This article discusses the necessary steps to prepare, submit documents for, and be successful in maintaining PTE designation, as well as outlining the challenges faced by AH along the journey.
AH has been providing quality healthcare for over a century to our residents and tourists. Our service area extends over 6 million acres of the Adirondack Park of northern New York State. We're located at the top of the state, bordering both Vermont and Canada. AH is comprised of several facilities that span the care continuum: a 95-bed acute care hospital, 5 satellite health centers, 2 EDs, a long-term-care facility, and a state-of-the-art fitness center. In addition to the services that one would expect to find in a rural health setting, AH is unique in that we provide several specialties usually found in a more populated area, such as vascular surgery, bariatric and joint centers of excellence, renal dialysis, pain management, and behavioral health. With approximately 225 nurses and over 900 total employees, AH is the largest private employer in the Adirondack Park.
The American Nurses Credentialing Center's (ANCC) Magnet® and PTE programs provide the framework for organizations committed to quality patient outcomes through an engaged staff and positive work environment. We chose to pursue PTE designation for our rural health system because we felt we had either currently achieved, or were in the process of achieving, the elements necessary to be awarded the designation.1
Creating the structure
There are many integral steps in the process of preparing for PTE designation. The implementation of a professional practice model may be the first step, leading to a robust shared governance structure. If a model is already in place, it's possible that not all clinical nurses are aware of it; this is an excellent time to reinforce the main tenets based on best practice. The hardwiring and adoption of shared governance may consist of a 2- to 3-year journey, depending on the organization, and is by far the step that requires the most attention, patience, and perseverance.
At AH, the nursing leadership team worked alongside clinical nurses to create the current shared governance model. The first 2 years were dedicated to the development of bylaws and charters for our five councils that report to a main governing council: nurse practice, recruitment and retention, professional growth and development, quality assurance performance improvement, and innovation and technology.
The mentors for each council are also members of the nursing leadership team, providing guidance to the council that's led by elected clinical nurses. The main council consists of each council's mentor, chairperson, cochairperson, or recorder and supports the work of the councils. The CNO facilitates the main council meetings and provides support to all council members.
Once this was in place, the next step was to invite all levels of nursing to complete a self-assessment. Nursing leadership completed a formal gap analysis provided by the PTE program and then clinical nursing staff members were surveyed using a mockup of the anticipated PTE survey to verify the validity of the information submitted in the standards. Completing these exercises brought to light that our strengths outweighed our weaknesses and highlighted that AH was on the right path toward designation. Having shared governance firmly established resulted in mostly favorable responses on the gap analysis and mock survey. The areas for improvement were communication across units, staffing, and involving nurses in policies directly related to their practice and practice environment.
Realizing we had some work to do, we involved nursing staff from all levels to be part of the solution. Nurse leaders were guided to include these topics in their staff meetings. This seemed to improve communication and engagement by the time we completed the actual PTE survey.
Sending clinical staff and nursing leadership team members to the PTE conference while preparing for our application was a key factor in gaining confidence in the organization's ability to move forward. Gleaning tips from previously designated organizations about what to do and not to do was vital. Some key staff members also attended the PTE writers' workshop, which was invaluable to the team. The workshop provided clarity on document submission details, as well as insight and guidance from the ANCC PTE team and other organizations that had achieved designation. For example, potential pitfalls when answering the intent portion of each element of performance (EOP) were discussed in detail and there was ample time for individual questions to be answered.
The ANCC recommends appointing a PTE program director to lead the project and this proved to be very beneficial at every milestone of the application process. At AH, the PTE coordinator position is held by the nursing project coordinator, an RN who's had various roles across the organization for many years and believes in the PTE journey for the betterment of nursing practice and the organization. (See Figure 1.) When selecting a PTE program director, it's important to consider certain qualities, such as an individual who's respected by his or her peers, a self-starter, motivated, innovative, creative, organized, and tech savvy.
It's necessary to formulate a steering committee to drive the initiative forward. The steering committee at AH was comprised of nurse leaders and clinical nurses who shared the vision of becoming PTE designated and understood its value. The committee created a 2-year timeline based on readiness and the available resources, as well as the strategic plan and other organizational projects. (See Figure 2.)
Leadership and staff engagement
Explaining the return on investment associated with PTE designation was vital in gaining support from senior leadership and the board of trustees. It's well known that evidence-based practice (EBP) “improves the quality and safety of healthcare, enhances health outcomes, decreases geographic variation in care, and reduces costs.”2 We also know that RNs employed by Magnet or PTE facilities report significantly fewer barriers to EBP than those employed by nondesignated facilities.3 Because the benefits would impact the entire organization in a positive way, the decision was made to incorporate the PTE designation journey into the strategic plan, which provided the necessary financial backing.
Another vital piece of the journey is to engage staff at every level. The ANCC recommends creating a theme to gain alignment and garner interest and enthusiasm. AH is the only full-service healthcare system in the 6 million-acre Adirondack Park, surrounded by spectacular mountains and vistas, so the steering committee chose “peaks” as the central theme. The PTE coordinator used this theme to design bulletin boards centrally located at each of the five AH sites to heighten awareness of the PTE journey. This design included six mountain peaks, representing each of the PTE practice standards, with an envelope at the base of each peak containing several EOPs from which clinical nurses could choose to write a narrative. Each submission from a clinical nurse was rewarded with career ladder points.
Additionally, the steering committee decided that there was a need to highlight nursing careers. Volunteers were interviewed and recorded, sharing their personal stories of what being a nurse means to them in a video called “From the Heart.” In a lighthearted activity to promote staff engagement and create excitement, a music video was developed, including a choreographed dance routine produced throughout multiple departments and disciplines. The PTE coordinator created a newsletter to keep the focus on the journey and sustain staff engagement.
It was also important for nurse leaders in each department to be an active part of and believe in the vision. Nurse leaders embedded PTE into the standing agenda for monthly staff meetings and encouraged clinical staff to take part. Clinical staff members were enlisted to become the “Pathway news crew,” with the mission of keeping all staff appraised of the project's status and needs.
Once we had senior leadership, board member, and staff buy-in and engagement, it was time to tackle the required documentation necessary for designation. “Standard champions” were recruited from across the organization to prepare and assemble the documentation for the PTE standards of shared decision-making, leadership, safety, quality, well-being, and professional development. A total of 64 EOPs were embedded within the standards.
The six standard champions formed the PTE standards committee. The role of the standard champions was to solicit and select appropriate authors and narratives to support the EOPs, as well as any documents or exhibits needed to support the description. The standards committee met monthly to provide updates on their progress and ensure that the submitted EOPs fit the intent as defined in the application manual. Once the standards committee was satisfied the organization had identified all the requirements for designation and were in possession of EOPs to meet all the practice standards, it was time to ensure that the EOPs were coming from one voice.
An editing subcommittee was formed, comprised of four nurses from the standards and steering committees, as well as a nurse educator from the local community college who had worked at AH in the past. It was helpful to have the outside perspective to view the EOPs from a different angle. Once the edits were made and the team was satisfied with the results, it was time for the PTE coordinator to compile the EOPs and format them for final submission.
In hindsight, the hours spent reviewing and revising proved to be priceless as we received a request to make small changes or additions to only 7 out of 64 EOPs after the initial submission. At the writer's workshop, it was made clear that 95% of submissions were returned for edits after initial submission. There was also a requirement to submit an organization demographic form at the same time as the EOPs. To complete this document, we had to work closely with nonnursing departments, such as human resources and finance, because it required specific data, such as turnover rates, average length of patient stay, patient case mix index, and budgeted full-time employees, not readily available to the steering committee.
Once the EOPs and supporting documentation were submitted to the ANCC, we began preparation for the next part of the journey: the staff survey. We took advantage of the document review period to share with the organization, especially the nursing staff at every level, that we were successful in meeting all the EOPs in the PTE standards. Although not all of the EOPs written by the staff were used in the document submission, they were shared among staff across the organization to increase the understanding of initiatives and programs from other departments. Because the survey completion rate had to be 60%, with 75% favorable overall, efforts were made to continually keep staff members involved and well informed to promote engagement in the approaching survey process.
Rarely will nurses turn down an opportunity to enjoy a good cup of coffee and time to interact with their peers. Knowing this, a latte machine was purchased and the leadership team, along with clinical nurse volunteers, staffed the “Pathway café.” The café was set up in a centrally located staff lounge and laptops were made available for staff members to use to complete the survey, all while their beverage of choice was being prepared and served in a PTE mug they could keep. This gave staff members a private place where they could take their time to fill out the survey without distractions. We achieved a 92% completion rate after 21 days. The unanticipated bonus of the Pathway café was the networking and collegiality evident to anyone who entered. To include the four other sites that are up to 40 miles away from the main campus, members of the steering committee took the Pathway café on the road.
In March 2018, we received the call that we achieved PTE designation and in April, our steering committee and a member of the board of trustees attended the PTE conference in Florida to receive our award on behalf of our organization. Upon returning home, the steering committee attended a board meeting where a resolution was passed in recognition of our achievement.
Today we're still “Pathway proud,” continuing to use the PTE framework as a guide in our daily work. Because of the efforts to achieve PTE designation, there's been increased engagement at all levels of the organization. Nursing turnover remains at less than 3% organization-wide and a record number of nurses are pursuing advanced degrees and certification while improving patient outcomes. This aligns with the Future of Nursing report recommendation of increasing the number of BSN-prepared nurses to 80% by 2020.4
Before the PTE journey, nurse well-being initiatives weren't as prevalent as in our organization. The addition of programs and committees to increase work-life balance as a result of PTE designation has been an added bonus that's benefited clinical nurses. We now have many programs to promote wellness, including massage, Reiki, aromatherapy, and a nursing-sponsored 5k run/walk, which were added to the farmers' market co-op and fresh food vending machine for the night shift that was already in place. We also keep the latte machine on stand-by for days when nurses just need a quick pick-me-up. Another benefit of PTE designation has been the emergence of aspiring leaders and significant growth of clinical staff members into new leaders.
Continuing the journey
Knowing that the PTE mission is to guide the positive “transformation of practice environments in multiple settings to build global community healthcare organizations committed to nursing workplace excellence,” we found PTE designation to be a logical step in our process of creating a culture of nursing excellence.5 Nursing staff members and organizational leaders who are committed to providing excellent care and quality outcomes are necessary to achieve PTE designation. Sustaining and hardwiring practices and programs isn't easy; however, we're confident that we'll maintain PTE designation in the future because of our highly engaged staff members who are active in creating new programs. There will be challenges, but the benefits have far outweighed the minor obstacles we faced during our initial designation journey. We encourage all organizations large and small to consider this process. Doing so will strengthen your culture and staff engagement, which will undoubtably result in growth on many levels.
1. Pabico C, Graystone R. Comparing Pathway to Excellence and Magnet Recognition Programs: two roads to nurse engagement and quality outcomes. Am Nurse Today
2. Melnyk B, Gallagher-Ford L, Finout-Ouerholt E. Implementing the Evidence-Based Practice (EBP) Competencies in Healthcare: A Practical Guide to Improving Quality, Safety, and Outcomes
. Indianapolis, IN: Sigma Theta Tau International; 2016.
3. Wilson M, Sleutel M, Newcomb P, et al. Empowering nurses with evidence-based practice environments: surveying Magnet®
, Pathway to Excellence®
, and non-Magnet facilities in one healthcare system. Worldviews Evid Based Nurs
4. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health
. Washington, DC: The National Academies Press; 2011.
5. American Nurses Credentialing Center. 2020 Pathway to Excellence and Pathway to Excellence in Long-Term Care Application Manual
. Silver Spring, MD: American Nurses Credentialing Center; 2020.