The 261-bed Audie L. Murphy Memorial Veterans Hospital (ALMMVH) is part of the South Texas Veterans Health Care System (STVHCS), one of eight healthcare systems within the Veterans Affairs (VA) Heart of Texas Veterans Integrated Service Network. Today, the STVHCS serves one of the largest primary service areas in the nation, with 96,000 unique veterans in over 40 counties throughout South Texas. More than 1,500 staff members work for the facility's nursing service, with approximately 900 dispositioned to ALMMVH.
ALMMVH started its Pathway journey in November 2015 with an initial gap analysis of 46 nurse leaders, including service line chief nurses, nurse managers, and assistant nurse managers. This online survey allowed for leadership to assess the current culture and identify areas of opportunity to align the organization with the Pathway Elements of Performance (EOPs). In early 2016, nurse leaders, nurse consultants, and clinical nurses collaborated to form six committees focused on each of the six Pathway standards: shared decision-making, leadership, safety, quality, well-being, and professional development. Clinical nurses were involved in the culture shift toward nursing excellence from the beginning stages of the journey.
In 2019, ALMMVH successfully achieved Pathway to Excellence® designation. This culture shift was centered on creating a positive practice environment and establishing a shared governance model for nursing, including activities intended to promote the adoption of a servant leadership framework, enhance the use of evidence-based practice (EBP) at the point of care, and improve nurse satisfaction and engagement rates. The methods described within this article are replicable in other healthcare facilities.
Establishing shared governance
Shared governance was in the infancy stages of implementation when ALMMVH embarked on the Pathway journey. The initial gap analysis indicated 52% (24) of respondents agreed that a shared governance structure demonstrating shared decision-making wasn't in place. Of the 30 clinical units, only 30% (9) had active service/unit-based shared governance councils. There was a lack of consistency and understanding of unit-based council bylaws, roles, and membership to guide the implementation of shared governance as reported by 62.5% (20) of gap analysis respondents.
A nursing service work group created a thorough action plan to establish a unified shared governance approach. Not only did the workgroup review existing literature for effective shared governance models, they also consulted with other VA facilities to identify successful shared governance structures. The STVHCS shared governance model depicts the system for supporting and implementing process changes using shared decision-making. It's comprised of the nursing executive board, Center of Nursing Excellence, nursing committees, and unit-based councils. (See Figure 1.) A standard operating procedure was established to describe the shared governance structure and guidelines, and nursing staff members were systematically educated on the new model before its implementation in July 2016.
The four-tiered shared governance model is founded on the collective unit-based councils comprised of all nursing staff assigned to an individual unit and supported by nurse managers and unit-level nurse educators as needed. Unit-based councils provide a medium to empower and engage nurses in shared decision-making. It's here where ideas affecting the point of care are first initiated. Nurses participate in over 20 hospital-wide committees, empowering them to influence organizational change with interprofessional shared decision-making.
Governing nursing committees account for the second tier of the shared governance model. Each committee is focused on supporting nursing service while aligning with the Pathway standards. The committees facilitate nurses controlling their practice with shared decision-making through documentation policies, initiatives to improve patient outcomes, fostering work-life balance, and creating positive practice environments.
Established as a forum for nurse managers and clinical nurses to proactively address issues impacting nursing practice, quality measures, patient and staff safety, nursing professional development, nursing satisfaction, and employee retention, the Center of Nursing Excellence is the third tier of the model. Nurses are invited to present ideas to their peers and nursing leadership in this setting. Guidance, consultation, and mentorship are provided to those presenting ideas, with referral to specific committees or personnel when necessary for project implementation. Nursing committees and unit-based councils submit quarterly reports, holding clinical nurses accountable for their shared governance activities. Staff initiatives and/or concerns are then reported to the nurse executive board, the fourth tier of the shared governance model.
Servant leadership in action
The implementation of shared governance at ALMMVH was the beginning of the culture transformation within nursing service. The associate director for patient care services, the senior most executive within nursing, further aligned the organization's vision with the Pathway standards through dedication to servant leadership. Key characteristics of servant leadership include “cultivating relationships by listening, being aware and empathetic, and fostering others' growth” and promoting collaboration.1
One of the associate director's first initiatives was to establish open office hours every 2 weeks for any nurse to come and speak with her, no appointment required. She also implemented weekly executive nursing leadership rounds for all clinical areas to foster relationships with clinical nurses. She joined photo ops, extended congratulations for a job well done, and developed a postcard for those she missed on rounds so they could personally reach out to her if needed. Nurses' ideas were shared with all of nursing service via weekly emails. Comments from nurses included, “[This] shows [the associate director] supports everything nurses are striving toward to improve processes for the veterans and nursing staff” and “[The associate director] took time out to visit on the night shift as well, including everyone.”
The associate director encouraged her senior leaders and frontline managers to implement open office hours and unit rounds themselves. She also recognized the significance and value of staff participation in shared governance, EBP initiatives, and professional development, restructuring leadership performance evaluations to measure these components. To encourage staff feedback, responsiveness to the anonymous all-employee survey was also measured in leadership evaluations. This survey is administered to all employees as a measurement tool of employee satisfaction and perceptions of the workplace. It allows leaders to analyze data for strengths and areas for improvement using a “‘big picture’ framework for conceptualizing the employee experience.”2 Leadership can then collaborate with frontline staff to improve the work environment by developing action plans.
To ensure high-level oversight of all facility events, the associate director hosted a daily nursing leadership morning report with all chief nurses and support staff at 7:30 a.m. During this meeting, the leadership team reviewed all pertinent events of the last 24 hours and initiated actions when needed. Additionally, quality management and pharmacy representatives attended once a week to discuss issues impacting clinical nurses. Nurses at all levels were invited to attend this meeting with their chief nurses and encouraged to introduce any issues experienced on the unit. Involving clinical nurses as key stakeholders is critical and fosters ownership as they identify problems and create solutions.3
In addition, the inclusion of the associate director on the VA's joint leadership council in 2016 was instrumental for nursing service representation concerning issues affecting nurses throughout the hospital. The joint leadership council exists within each local VA health system and is comprised of executive leaders such as the medical center director and chief of staff. At council meetings, the associate director spoke with other executive leaders about initiatives to support the Pathway standards, demonstrated nursing's organizational impact, and recognized nursing service as pioneers for quality improvement.
Providing safe, high-quality care
Strong leadership support led to a growing number of EBP projects initiated by clinical nurses, which positively impacted the organization by decreasing the incidence of avoidable adverse events over a 4-year period. (See Figure 2.) For example, nurses affected in-hospital complication metrics by appropriately capturing the high rate of pneumonias in mental health areas, initiating protocol changes for ventilated patients, and introducing cost-saving endotracheal tubes that contributed to a low rate of ventilator-associated events. Improvements to admission documentation also provided a more accurate reflection of the care provided.
Clinical nurses were able to introduce proposals to positively affect their work environment in meaningful ways, such as establishing a hydration station in the ED—a dedicated area at the nurses' station where staff can keep beverages in approved containers close by rather than storing them in the break room—and providing data to support the addition of an RN float pool with 10 full-time equivalents and a nurse aid float pool. Other projects were geared toward improving patient outcomes; for example, RN case managers developed initiatives to improve the length of stay and utilization management for veterans.
Case managers were embedded within each medicine team and provided education on length of stay metrics. They even sparked a competition with weekly prizes and a certificate given to the medicine team with the best length of stay. Subsequently, adjusted length of stay improved to 4.249 days in the first quarter of 2019 compared with a baseline of 4.519. Case managers also launched an initiative to standardize indwelling catheter kits to be compliant with best practices, which led to a decrease in catheter-associated urinary tract infection (CAUTI) rates.
Support for professional development and growth
An essential component of nursing excellence is fundamental support for nurses' professional development. At ALMMVH, this begins with a welcoming and comprehensive orientation process for new employees. Orientation is tailored to the individual nurse, ensuring that learning needs are met and readiness to deliver safe and effective care is achieved. For novice nurses with less than 1 year of experience, a robust 12-month RN transition-to-practice program is available to support the transition into the practice environment. Program participants attend monthly seminars and are provided with a dedicated preceptor throughout their orientation. Since the program's inception in 2013, ALMMVH has seen a retention rate of 96% at 12 months and 82% at 24 months for participants, meeting or exceeding published findings from other nurse residency programs.4
At the onset of the Pathway journey, nursing service obtained the ability to provide continuing nursing education from the Texas Nurses Association. STVHCS has consistently provided 3,500 to 4,500 contact hours of continuing nursing education to RNs and LVNs annually since 2016. Programs not only focus on improving care, but also on developing nurses as emerging leaders, with preceptor and charge nurse courses offered twice a year. Board-certified nurses can maintain their specialty certifications with continuing education provided by the facility. In 2019, STVHCS nurses held over 230 individual specialty certifications, demonstrating a dedication to the nursing profession and commitment to improving patient outcomes.
ALMMVH also supports the National Nursing Education Initiative program, a scholarship awarded to VA nurses seeking baccalaureate and advanced nursing degrees. Over $3 million in scholarships have been awarded to STVHCS nurses to pursue higher education since 1999. This has increased the number of nurses seeking advanced and terminal degrees, with 15.9% of RNs obtaining an MSN (92/579) and 1.2% completing a doctoral degree (7/579). Only 8.8% of RNs hold an associate degree or diploma in nursing (51/579), with 91.2% (528/579) having a BSN or higher. Currently, there are 37 students enrolled in the program seeking a BSN (7), MSN (23), and DNP (6). Thirty-eight nurses have completed the program and are in a service obligation period.
Implementing the Pathway standards has allowed clinical nurses to flourish and thrive at ALMMVH. Nurses practice to the full extent of their education and training, are full partners in the design of healthcare, and participate in overall governance to improve nursing practice. Periodic gap analyses conducted by the organization indicated positive improvement in nursing excellence initiatives. (See Figure 3.) Within 18 months, 97% of clinical units (29) had implemented active unit-based councils. EBP projects initiated by clinical nurses increased 600%. Employee engagement increased, with 82% participation in the 2019 all-employee survey and scores reflecting a steady increase in all measures for nursing service. Overall satisfaction increased from 3.76 in 2015 to 4.15 in 2018. Likewise, organization satisfaction increased from 3.61 in 2015 to 4.03 in 2018. (See Figure 4.)
The VA's scorecard model, known as Strategic Analytics for Improvement and Learning, or SAIL, indicates that RN turnover rates decreased by 24.38%, from 7.34% in 2015 to 5.55% in 2018—almost half the annual turnover rate present across the Veterans Health Administration (9.1%) and lower than national RN turnover rates.5,6 The VA offers opportunities for career development and utilizes cross-training to support career progression, staff development, and retention, including supporting nurses to practice to the full extent of their license; developing emerging roles for nurses; and offering generous nursing education scholarship opportunities, tuition reimbursement programs, and educational opportunities that support virtual or face-to-face continuing education.7
Other instruments used to validate the presence of a positive practice environment for nurses included the VA's Practice Environment Scale of the Nursing Work Index—a national online survey-based tool that measures the practice environment against other VA facilities as reported by nurses using a 1- to 4-point scale for 20 nursing specific questions.8 The 4-point Likert scale ranges from 1 = strongly disagree to 4 = strongly agree; a higher score represents a favorable nursing practice environment. In 2017, 608 nurses rated nursing leadership 3.0 and overall job satisfaction 4.1, with VA average ratings of 2.8 and 3.82, respectively. STVHCS scores were significantly above the VA national average by 0.2 points or more in 2017 (11/11 categories) and 2018 (7/11 categories), indicating high RN satisfaction.
As a facility seeking Pathway designation, ALMMVH had to successfully pass the nurse survey, with clinical nurses confirming the presence of a positive practice environment. The American Nurses Credentialing Center (ANCC) requires that “any nurse (RN, LPN, APRN) in the organization whose nursing practice is under the CNO's oversight is eligible to take the survey, regardless of the nurse's reporting relationships.”9 Stringent guidelines require at least 60% participation, with 21 out of 28 graded items being favorably reported (75% or greater) as existing within the organization by nurse respondents.
When preparing for the survey, we recognized that the terminology used by the VA and ANCC wasn't always interchangeable. For example, the CNO is known at the VA as the associate director for patient care services. The VA refers to nurses providing care directly to veterans as frontline nurses rather than direct care nurses. As such, it was critical to educate our nurses on the terminology differences early on so when it was time for the nurse survey, staff members understood what was being asked. ALMMVH experienced a 65.4% response rate within the first 72 hours of the 21-day survey window. Final participation was 86% (544), with 27 out of the 28 categories scored 75% or higher for favorable responses.
In March 2019, ALMMVH achieved Pathway to Excellence designation, becoming the first VA hospital in Texas to be designated as a Pathway organization and the fifth VA hospital in the nation. For an organization to earn this distinction, it must successfully undergo a thorough review documenting foundational quality initiatives to create a positive work environment as defined by nurses and supported by research. These initiatives must be present in the facility's practices, policies, and culture. Nurses in the organization verify the presence of the Pathway EOPs through participation in a confidential online survey.
Receiving this designation validates the professional satisfaction of nurses at ALMMVH and identifies the facility as having a healthy work environment. Nurses at ALMMVH have become role models for other VA facilities pursuing Pathway designation, and the facility routinely collaborates with the VA's Office of Nursing Services' nursing excellence consortia to share best practices.
The successful transformation of ALMMVH's organizational culture was achieved by aligning it with the Pathway standards and creating a positive practice environment for nurses. Initiatives to support nursing excellence were embraced by clinical nurses and supported by nurse leaders. Not only was this reflected by improvements in nursing satisfaction and retention rates, but it was also validated through the critical element of the Pathway nurse survey.