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Department: Pathway to Excellence®

Nursing practice environment and care quality in nursing homes

White, Elizabeth PhD, APRN; Woodford, Erin BSN, RN; Britton, Julie DNP, MSN, RN-BC, GCNS-BC, FGNLA; Newberry, Lynn W. DNP, RN, CEN, NE-BC; Pabico, Christine PhD, RN, NE-BC

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Nursing Management (Springhouse): June 2020 - Volume 51 - Issue 6 - p 9-12
doi: 10.1097/01.NUMA.0000662656.07901.a8
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Patient acuity and care complexity in nursing homes have increased over time, fueling demand for skilled, high-quality nursing care in this setting.1-3 RNs provide vital leadership, surveillance, and care coordination, while licensed practical nurses (LPNs) and certified nursing assistants (CNAs) deliver the majority of direct patient care in nursing homes. Extensive evidence has shown that the ability of these staff members to provide safe and effective care is largely influenced by the organizational environment in which they practice.4

Nursing home leaders face chronic challenges in their capacity to retain an adequate supply of qualified nurses and CNAs with the appropriate qualifications to manage the acute and chronic care needs of this increasingly frail population. Many nursing homes fail to meet staffing levels expected by the Centers for Medicare and Medicaid Services, and this problem is only exacerbated by high staff turnover, which is common across the industry.5-7 High turnover has been consistently linked to poor care quality and generates additional labor costs for training, recruitment, hiring, and productivity loss.8-13 These added costs are particularly problematic for an industry that's heavily dependent on Medicaid for reimbursement and already operates under tight budgetary constraints.14

Staff burnout and job dissatisfaction are key drivers of turnover and pose significant threats to patient safety.15 Nursing home RNs report higher rates of burnout and job dissatisfaction than RNs employed in any other clinical setting, including hospitals.16 Other studies have documented a high prevalence of burnout and missed care among LPNs and CNAs.17-20 Nursing home nurses report often leaving necessary care undone due to a lack of time or resources, and this missed care is strongly linked to burnout and job dissatisfaction.21

The National Academy of Medicine has recognized the practice environment as being fundamental to ensuring clinician well-being and patient safety in healthcare settings.4,15 Adequate staffing is a key component of this and it's the organizational area that's received the most attention in nursing homes. An extensive body of literature has shown consistent linkages between higher staffing and better care quality in nursing homes, with RN staffing typically having the strongest relationship to outcomes.8,22-24

Sufficient staffing is an essential component of safe practice environments, but staffing improvements alone may have limited impact without other organizational elements being present.25 Even under tight budgetary constraints, nursing home leaders can still make evidence-based modifications to organizational processes and culture to improve staff retention and better support their nurses and CNAs to deliver safe and effective care. This includes engaging direct care staff in shared decision-making, fostering strong nurse leaders, maintaining evidence-based nursing care standards and active quality assurance programs, providing opportunities for staff advancement and professional growth, and supporting interdisciplinary teamwork.26 These organizational characteristics have been found to be independently associated with better nursing home quality, as well as reduced nurse burnout and job dissatisfaction.27-29

The Pathway to Excellence in Long-Term Care® program

In 2010, the American Nurses Credentialing Center (ANCC) launched the Pathway to Excellence in Long-Term Care® program to recognize long-term-care providers with practice environments that support nursing excellence. The Pathway program provides a framework to help leaders increase nursing staff engagement, develop high-performing teams, and promote a culture of sustained excellence. The Pathway framework includes six standards that represent the essential elements of supportive practice environments: shared decision-making, leadership, safety, quality, well-being, and professional development. (For more information on the Pathway framework, see “Introducing the 2020 Pathway to Excellence® Manual” in the April issue.) Each standard complements and supports the others.

The cornerstone of the framework is shared decision-making, in which nursing home leaders engage their direct care staff members in decisions and organizational processes that impact their practice. This includes operational decisions around cost management, staffing, and purchasing of new products or technology, as well as quality and safety initiatives such as adverse event monitoring and root cause analysis to identify and respond to systemic problems. It also includes nurses and CNAs being involved in nursing home ethics committees to help make challenging patient care decisions.

The director of nursing and nurse managers in Pathway organizations must be competent, accountable, and involved in all levels of the organization. They're expected to integrate employee well-being and resilience into strategic planning and have processes in place to proactively reduce staff burnout and foster work-life balance. Examples of these include flexible scheduling, employee recognition programs, wellness assessments, and support for those who experience work-related adverse events.

The Pathway framework also emphasizes professional development and training, beginning with a positive onboarding experience for nurses and CNAs and continuing with ongoing educational activities. Pathway organizations are expected to conduct needs assessments for new staff members and provide mentoring to orient them to the organization. They're expected to give nursing staff members input into the selection of nonmandatory educational offerings and provide scheduling flexibility for them to attend conferences, participate in professional organizations, or pursue certifications or higher formal education.

Designation process

The Pathway journey begins with nursing home leaders and direct care nursing staff independently completing the Self-Assessment of Organizational Culture tool.30 This exercise helps the organization identify current strengths, serving as a reminder to the entire team about the great things already in place, areas needing improvement, interventions required to close the gap between the current and desired states, and differences between staff members' and leaders' perceptions. This assessment importantly engages direct care staff members from the beginning, building trust and sending the message that their feedback is valued by leadership.

After the initial assessment, organizations then use the Pathway framework as a blueprint to make changes. Within each Pathway standard are Elements of Performance (EOPs) that serve as a guide to what must be in place to meet each standard. Recognizing that each organization differs in resources and infrastructure, the framework isn't meant to be prescriptive. How each EOP is met will be unique to each organization. As organizations work through the standards, they can make use of the Pathway Learning Community, a platform that enables employees at different organizations going through the Pathway process to connect and share best practices, resources, experiences, and strategies.

To attain Pathway designation, organizations must successfully pass two phases: submission of documents to demonstrate the presence of all EOPs within the organization and a nursing staff survey validating the presence of Pathway characteristics within the organization. Nurses at all levels and CNAs are invited to complete the confidential online survey. Passing the survey validation phase requires meeting specified criteria for favorable responses and the rate of participation by eligible respondents. If these two phases are successfully accomplished, ANCC awards the Pathway to Excellence designation to the organization. This recognition serves as a marker of excellence from an external third party and gives nursing staff a voice in the designation process.

Schuylkill Center's Pathway journey

Genesis Healthcare Schuylkill Center, a 190-bed nursing home providing postacute and long-term care in Pottsville, Pa., received Pathway designation in 2018. It's one of over 360 centers in the Genesis Healthcare system. Schuylkill's Director of Nursing Erin Woodford explained why they decided to pursue Pathway designation: “We were seeking validation of the great things we were already doing at the center while challenging ourselves to incorporate new ideas and processes to make us better than we already were.” She also reflected on the importance of recognition across the long-term-care industry more broadly, “Schuylkill Center has always excelled clinically, and we feel we practice with compassion for our residents and employees. Skilled nursing facilities do so many great things, but we aren't very good at getting those positive things out there. Often, all we see regarding our industry is negative [coverage]. Pathway designation provides the opportunity to begin to shift the narrative of our industry through education and visibility.”

The first step for Schuylkill Center's Pathway journey was the introduction of a shared decision-making model. Schuylkill's leaders developed a structure for shared decision-making based on accountability, equity, partnership, and ownership. They introduced the concept of shared decision-making through a series of meetings, facility postings, and education seminars. They found that the nursing staff members were eager to be involved, wanted to have a voice, and valued having an avenue to discuss needs and come together with solutions. They established a volunteer nurse practice council consisting of RNs, LPNs, and CNAs.

The nurse practice council was the steering wheel during Schuylkill's journey to Pathway designation. The council began by completing the self-assessment and then dove into the six practice standards. They determined in which order they would address the standards and introduced changes to existing processes until they agreed each standard had been met. Every 2 weeks the council met to discuss a Pathway standard and evaluate their progress. Some standards were quickly implemented because Schuylkill already had many processes in place congruent with the Pathway framework, whereas others took a significant amount of work. It was the job of the nurse managers, collaboratively with members of the council, to educate the entire staff and promote the benefits and importance of the framework for both resident care and employee satisfaction.

One example of the positive impact of shared decision-making came in response to the nurses' request to have a more flexible schedule. The council formed a team to explore new scheduling patterns. As a group, the nurses decided that 12-hour shifts would increase their personal well-being by allowing them more days off. All nurses were encouraged to provide input via email or a comment box, and team meetings were open to all staff. The team gathered input and suggestions on how to operationalize the new staffing pattern, created a plan, and presented it to the director of nursing. Ultimately, Schuylkill Center adopted the use of 12-hour shifts for those interested and kept traditional shifts for everyone else.

This organizational initiative positively impacted staff members' work-life balance and sense of autonomy. Allowing nurses to work fewer days and have multiple days off in a row led to a decrease in reported stress and burnout. Additionally, staff members were closely involved in the implementation process, allowing them to make changes to the schedule as needed. They were given the opportunity to self-schedule and work together with the full support of nursing leadership.

Return on investment

The Pathway to Excellence program has helped Schuylkill Center in several ways:

  • improved teamwork. Schuylkill's leaders felt they had a strong team to begin with, but the Pathway framework helped their nurse managers and direct care staff members develop a co-ownership of processes that they previously lacked.
  • increased nursing staff autonomy and well-being. The nurse practice council has continued to apply the shared decision-making model to engage staff members in the organizational decisions that affect them. It has also reduced the decision-making burden on the director of nursing.
  • enhanced marketing. Schuylkill Center uses its Pathway designation as a marketing tool for staff and businesses. They've seen an increase in business opportunities, market share, and word-of-mouth referrals from current patients and families as a result of Pathway.

A step toward change

Nursing staff engagement is vital to improving retention and delivering high-quality care in nursing homes. The Pathway to Excellence in Long-Term Care program helps nursing home leaders identify organizational strengths and weaknesses and enact change through shared governance to create practice environments that support staff to provide safe and effective nursing care. Organizations that are interested can take a first step toward change by conducting an organizational culture self-assessment (


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