Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
Currently Skimming:
4 Transformational Leadership and Evidence-Based Management
4 Transformational Leadership and Evidence-Based Management
Pages 108-161
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 108... ...
using knowledge management practices to establish the organization as a "learning organization." These five management practices, which are essential to keeping patients safe, are not applied consistently in the work environments of nurses. The committee concludes that transformational leadership and action by each organization's board of directors and senior and midleve!
|
From page 109... ...
This chapter takes a detailed look at the crucial role of transformational leadership and evidence-based management in accomplishing the changes required in nurses' work environments to improve patient safety. We first discuss transformational leadership as the essential precursor to any change initiative.
|
From page 110... ...
In contrast, transformational leadership occurs when leaders engage with their followers in pursuit of jointly held goals. Their purposes, which may have started out as separate but related (as in the case of transactional leadership)
|
From page 111... ...
In nursing homes, such leadership can come from a facility's owners, administrator, director of nursing, and unit managers. Leadership by these senior organization managers and oversight boards is essential to accomplishing the breadth of organizational change needed to achieve higher levels of patient safety changes in management practices, workforce deployment, work design and flow, and the safety culture of the organization (see Chapter 11.
|
From page 112... ...
In practicing transformational leadership, leaders need to engage managers and staff in an ongoing relationship based on the commonly held goal of patient safety, and communicate with and teach managers and staff about this higher collective purpose. When teaching managers about the actions they can take to minimize threats to patient safety, HCO leaders should underscore the five management practices enumerated earlier that have been found to be consistently associated with successful implementation of change initiatives and with the achievement of safety in organizations with high risk for errors.
|
From page 113... ...
While health care practitioners have been encouraged and supported in the adoption of evidence-based practice, the same support and encouragement has not been widely available to health care managers for multiple reasons: · Organizational research is sometimes esoteric and does not consistently address practical management questions (Axelsson, 1998~. Further, research conducted on health care management is limited compared with management research in other industries.
|
From page 114... ...
HCOs are not immune to these pressures. Concerns have been raised that HCOs, in responding to production and efficiency pressures, may adopt practices that threaten patient safety (Schiff, 2000; SEIU Nurse Alliance, 2001; Thomas et al., 20001.
|
From page 115... ...
. Creating and Sustaining Trust Creating and sustaining trust is the second of the five management practices essential to patient safety.
|
From page 116... ...
116 KEEPING PATIENTS SAFE flows among individuals and from individuals into organization databases, archives, and other records (DeLong and Fahey, 20001. Further, when trust is lacking, participants are less likely to believe what leaders say and to contribute the extra effort, engagement, and knowledge needed to make change successful.
|
From page 117... ...
. Conversely, evidence indicates that change initiatives targeting quality improvement are far less likely to generate support when clinical caregivers believe those changes are motivated by either economic or political considerations (Rousseau and Tijoriwala, 19991.
|
From page 118... ...
as particularly important for successful change implementation: ongoing communication; training; use of mechanisms for measurement, feedback, and redesign; sustained attention; and worker involvement. Ongoing Communication Frequent, ongoing communication through multiple media is a key ingredient of successful organizational change initiatives (Ingersoll et al., iThe human resource side of change tends to be undermanaged as compared with management of the implementation of technological changes (Kimberly and Quinn, 1984)
|
From page 119... ...
This is a sentiment commonly expressed by those unfamiliar with the multiple sources and allocations of revenue that can exist within an institution (Ingersoll et al., 20011. When nurse managers in one 700-plus bed hospital undergoing organizational change were asked to rank the behaviors of health care executives in terms of how supportive those behaviors were to the change management process, respondents ranked frequent communication about the goals and progress of organizational change as the most important behavior (Knox and Irving, 19971.
|
From page 120... ...
hospitals implementing reengineering initiatives in the 1990s found that 2 to 3 years into their reengineering efforts, many had yet to implement a number of their initial plans. Although difficulties arose during the long implementations, the transition from implementation to a sustained, institutionalized process was even more problematic.
|
From page 121... ...
Involving Workers in Work Design and Work Flow Decision Making Evidence indicates that a highly bureaucratic structure, so useful in organizations into the early twentieth century, is inappropriate to many organizations today (Ciborra, 1996; Ilinitch et al., 1996) because both human potential and technology have matured since the beginning of the Industrial Revolution.
|
From page 122... ...
hospitals implementing reengineering initiatives in the l990s found that involving the total organization in the reengineering process was frequently mentioned as an important factor in success and, conversely, that inconsistent involvement was a barrier (Walston and Kimberly, 19971. Nurses working in organizations whose work culture emphasized decentralized decision making reported significantly higher commitment to the organization, empowerment, and job satisfaction and significantly lower intent to leave (Gifford et al., 20021.
|
From page 123... ...
patient needs and practice nursing care appropriate to those needs, that is, their ability to make independent clinical decisions and define the scope of practice in relationship to patients in their care (Kramer and Schmalenberg, 2003; McClure et al., 1983; Scott et al., 19991. Autonomy is a characteristic commonly identified by staff nurses, nurse managers, and chief nurse executives (CNEs)
|
From page 124... ...
autonomy, in which staff nurses, nurse managers, and CNEs take part in hospital policy and decision making about professional practice and patient care (Scott et al., 19991. A review of studies conducted on magnet hospitals reveals that both autonomy and control over nursing practice are consistently identified as magnet characteristics (Scott et al., 19991.
|
From page 125... ...
Other knowledge management organizations, while perhaps not using the scientific method as rigorously as the Toyota System, employ similar methods associated with continuous quality improvement or total quality management. These methods include employing the "plan-do-check-act" cycle; insisting on data, rather than assumptions, for decision making; and using simple statistical analysis tools, such as histograms, Pareto charts, and tests of correlations, to organize data and raw inferences.
|
From page 126... ...
26 KEEPING PATIENTS SAFE pact when they are shared broadly rather than tightly held by a few individuals, and that knowledge must be transferred through multiple, reinforcing channels to create synergy and enhance its absorption and application. A variety of knowledge dissemination mechanisms can promote this transfer, including written, oral, and visual reports; site visits and tours; person
|
From page 127... ...
TRANSFORMATIONAL LEADERSHIP, EVIDENCE-BASED MANAGEMENT 127 net rotations; and education and training programs. Each of these mechanisms, however, can be a cumbersome way to transfer knowledge.
|
From page 128... ...
Time Required to Create ~ Learning Organization The creation of a learning organization first requires an organizational commitment to learning through the establishment of a culture conducive to knowledge creation, sharing, and use a knowledge-friendly culture (DeLong and Fahey, 2000; Garvin, 19931. Yet research on more than 50 companies pursuing knowledge management projects revealed that organinational culture was the major barrier to creating a learning organization (DeLong and Fahey, 20001.
|
From page 129... ...
Learning organizations must identify norms and practices that are barriers to discussing sensitive topics, find and evaluate evidence about the extent to which senior management is perceived as accessible and approachable, and identify the norms and practices within the organization that encourage high frequency of interaction and the expectation of collaborative problem solving. Although the senior executive ultimately must make a decision not everyone will like, the process for engaging and listening to many views on an issue increases the likelihood of a better decision and broader acceptance of the decision once made (DeLong and Fahey, 20001.
|
From page 130... ...
Providing time for thinking, learning, and training For knowledge to be created and adopted, employees must have sufficient time for reflection and analysis to assess current work systems and devise new work processes. Such learning is difficult when employees are harried or rushed; it tends to be displaced by the pressures of the moment.
|
From page 131... ...
UNEVEN APPLICATION OF EVIDENCE-BASED MANAGEMENT PRACTICES IN NURSES' WORK ENVIRONMENTS While some nurses have had firsthand experience with the successful application of the above evidence-based management practices in their workplace, this has not consistently been the case. Concerns about changes in nursing leadership, increased emphasis on production efficiency in response to cost-containment pressures, weakened trust, poor change management, limited involvement in decision making pertaining to work design and work flow, and limited knowledge management are all found in nurses' work environments.
|
From page 132... ...
provide clinical leadership in support of knowledge acquisition and uptake by nursing staff. The senior nurse leadership position in hospitals has not always been an executive-level position.
|
From page 133... ...
Some assert that expanding the CNO role increases senior nurse executives' influence in desirable ways. Others express concern that the expansion of the CNO's areas of responsibility beyond those directly associated with clinical nursing takes attention away from nursing care and hinders the development of strong nursing leadership for nursing practice in the hospital.
|
From page 134... ...
Hospital staff nurses further affirm these findings. An examination of changes in the work environments of nurses in 12 hospitals identified as having characteristics associated with high rates of nurse retention found that from 1986 to 1998, the percentage of nurses reporting "a chief nursing executive equal in power/authority to other top hospital officials" declined from 99 to 69 percent.
|
From page 135... ...
And in the 1997-1998 survey of 29 university teaching hospitals described above, researchers found that as the responsibilities of nurse executives were expanded, consolidation or downsizing of nursing departments occurred in 82 percent of hospitals. Further, nurse manager positions were reduced in 91 percent of the hospitals, and nurse managers' span of control was broadened to include more than one patient care unit.
|
From page 136... ...
facilitate the input of direct-care nursing staff into decision making on the design of work processes and work flow, and (3) provide clinical leadership in support of knowledge acquisition and uptake by nursing staff.
|
From page 137... ...
what mechanisms are used by the HCO to assess the safety of its patient care environment; and (3) what the HCO's overall plan or approach is for ensuring patient safety and whether it has defined objectives, senior-level leadership, and adequate personnel and financial resources.
|
From page 138... ...
The above-cited 1996 qualitative study of the changing role of hospital CNOs in the not-for-profit flagship hospitals of three urban integrated delivery systems found that loss of trust on the part of nursing staff was acutely felt and attributed to changes in the role of the CNO. These changes affected the relationships of CNOs with nurse managers, which were perceived as characterized by a growing distance.
|
From page 139... ...
managers, 31 physicians, 24 staff nurses, and 19 non-nurse staff members at 14 hospitals that had undertaken reengineering initiatives in the past 5 years (Walston and Kimberly, 1997~. The hospitals were selected in collaboration with a consulting firm specializing in hospital reengineering.
|
From page 140... ...
Insufficient Worker Training Walston and Kimberly (1997) found that, as result of reengineering projects, staff nurses and individual unit nurse managers were frequently assigned greater managerial responsibilities without additional training.
|
From page 141... ...
also found that many hospitals that employed cross-training of non-nursing staff to perform patient care activities underestimated the amount of initial training and retraining that was needed. Researchers were told that often after initial, brief training periods (some as short as 3 days)
|
From page 142... ...
At one hospital where the chief nursing officer was the key patron of engineering, each department was directed to develop cost reduction recommendations. Nursing developed a patient-focused plan to incorporate many services, including respiratory therapy, into nursing units, which was projected to save substantial costs.
|
From page 143... ...
The above-cited study of changes in the work environments of nurses in 12 hospitals identified as having characteristics associated with high rates of nurse retention found that from 1986 to 1998, the percentage of nurses reporting "the freedom to make important patient care and work decisions" declined from 98 to 80 percent (Aiken et al., 2000:4631. In a 1998-1999 survey of nurses working in acute care hospitals in Pennsylvania, only 29 percent reported that their administration listened and responded to nurse concerns; 40.6 percent reported that nurses had the opportunity to participate in policy decisions; and 60.5 percent reported being able to participate in developing their own schedules (Aiken et al., 20011.
|
From page 144... ...
These articles are primarily exhortations for the adoption of knowledge management and learning organization practices, as opposed to descriptions of their application. This may be in part because these practices are catalogued under different labels, such as "decision support," "informatics," "continuous quality improvement," or "total quality management." Also, the use of knowledge management and learning organization principles does not apply solely to nursing, but to all health care providers, so it may not be described as a "nursing" practice.
|
From page 145... ...
This finding is significant to improving patient care for several reasons. Problems are relatively frequent and visible, and also carry fewer stigmas than errors; all of these features facilitate an HCO's taking action on a problem to improve patient care and safety.
|
From page 146... ...
Finally, management needs to act on reported problems with second-order solutions so workers will have an incentive to continue to identify these opportunities for learning and improvement (Tucker and Edmondson, 20031. Recommendations to Promote Evidence-Based Management Practices To address the deficiencies discussed above in nurses' work environments with respect to the application of the five management practices introduced in this chapter, the committee offers the following two recommendations: Recommendation 4-2.
|
From page 147... ...
· Engage workers in nonhierarchical decision making and in the design of work processes and work flow. · Establish the organization as a "learning organization." These recommendations are feasible.
|
From page 148... ...
The surveys involved interviews of CNEs, staff nurses, nurse managers, and clinical experts (Kramer, 199Oa,b; Kramer and Schmalenberg, 1988a,b, 1991, 1993; Kramer et al., 19891. In these surveys, eight essential characteristics associated with magnetism were again identified by two-thirds or more of the staff nurses interviewed.
|
From page 149... ...
Involving Workers in Decision Making Autonomy and control over nursing practice recurrently have been identified as strong characteristics possessed by staff nurses, nurse managers, and CNEs in magnet hospitals (Aiken, 2002; Kramer and Schmalenberg, 2002; McClure et al., 1983; Scott et al., 19991. As discussed earlier, a distinction is made between autonomy and control over nursing practice.
|
From page 150... ...
Staff nurses perceived the ANCC magnet hospitals as having greater resources available for patient care; increased time to discuss patient problems with other colleagues; greater involvement in decision making; and strong, visionary CNEs. Stronger magnet characteristics were also evident in the ANCC magnet hospitals when CNEs were interviewed.
|
From page 151... ...
PRHI adapted the principles of the Toyota Production System and implemented practices to manage change, involve workers in decision making about work design and work flow, and become a learning organization to achieve the goal of "perfecting patient care" Weinstein et al., 2002~. PRHI participants have as their goal "delivering patient care on demand, defect free, one by one, immediately, without waste or error, in an environment that is physically, emotionally, and professionally safe" (The Jewish Healthcare Foundation of Pittsburgh, 2002:12~.
|
From page 152... ...
· Lower staff turnover relative to comparable nursing homes in Wisconsin for the same time period. In achieving these benefits, Wellspring has attended to the leadership of these organizations, trusted workers to make decisions about improvements to patient care, created structures and processes to sustain these changes, and instituted practices aimed at supporting members as learning organizations.
|
From page 153... ...
Care resource teams are described as the "main engine" of the patient care improvement activities undertaken by the facilities. These teams are interdisciplinary, nonhierarchical (e.g., nursing assistants may lead a team)
|
From page 154... ...
, led by the University of Washington and codirected by the University of California at Berkeley. CHMR was founded in 1992 by a consortium of HCOs and academic centers to provide a forum for managers, clinicians, and researchers to: · Develop a health care management research agenda in collaboration with corporate members.
|
From page 155... ...
Similar initiatives could address the work environments of nurses and patient safety. The committee concludes that broader use of such collaboratives could hasten the uptake of the evidence-based management practices described in this chapter, and therefore makes the following recommendation: Recommendation 4-4.
|
From page 156... ...
Hospital reorganization and restructuring achieved through merger. Health Care Management Review 27(1)
|
From page 157... ...
2002. A region addresses patient safety.
|
From page 158... ...
2003. Magnet hospital staff nurses describe clinical autonomy.
|
From page 159... ...
2001a. The impact of workplace empowerment, organizational trust on staff nurses' work satisfaction and organizational commitment.
|
From page 160... ...
1999. Review of magnet hospital research: Findings and implications for professional nursing practice.
|
From page 161... ...
When problem solving prevents organizational learning. Journal of Organizational Change Management 15(2)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.