Impact of HWE & NRP on NLRNs’ Expectations, Transition, Integration and Retention EBP/EBMP -- Sept. 21, 2012
Impact of Healthy Work Environments and Nurse Residency Programs on NLRN Expectations, Retention, Transition and Integration into Clinical Nurse Professional Practice Role 40 Magnet Hospitals Integration Study Transition Study ( divided into 2 studies of 20 hospitals ) HWE Confirmation Study experienced nurses confirm HWE status of clinical unit ( 34 of 40 hospitals submitted sufficient data (unit RR of > 40 %) for continued participation in research program ) (17 of 20 Hospitals participated (17 of 20 Hospitals participated in all transition studies) in all integration studies) 3 Year Retention Study NRP Study (34 hospitals participated) ( 28 of 34 Hospitals participated) Impact of HWE Environment on Integration into Professional 20 Hospitals, 10 from NLRN Transition, Environmental Transition and 10 from Practice Role and into Reality Shock; Identification of Integration studies were Professional Communities; issues/dilemmas that impede selected for site-visits Cultural Values of Unit Professional Role performance Organizational Transformation Study Effective NRP Strategies and Components Study From Chaos to Complexity to Professional Practice
What is a HWE? Permits RN to engage in professional practice FN: scientific alteration of patient’s internal and external environment definition/model most frequently used Theoretical framework for IOM studies (99, 01, 04, 10) Adopted by State Boards of Nursing 18 different Nursing Care Models At least half are based on FN — environment, caring, RBC, FCC, PCC HWE is as it is defined and measured EBP/EBMP -- Sept. 21, 2012
IOM Studies 1999: To Err is Human — 1M injured; 98,000 dying 2001: New Health System for 21 st Century: Health Care organizations are Complex Adaptive Systems 2004: HWE — Improving processes are best strategy! . These also improve patient safety and nurse retention. 2010: Future of Nursing: Leading Change: Expand opportunities to lead; prepare nurses to lead change; reduce scope of practice barriers; Money for NRP EBP/EBMP -- Sept. 21, 2012
S — P — O Structures: physical layout, characteristics (FOM) Measured by absence/presence or degree of Processes: what clinical nurses do; constitute professional practice; Measured by extent to which steps/components of process are operative/present. Outcomes: results — mortality, falls, adverse events, length of stay, nurse retention, job satisfaction. Measured by quantity or by presence/absence of event EBP/EBMP -- Sept. 21, 2012
Academy of Health Challenges: Sources of Clinical Nurse Power Consensus definition: What is a HWE ? Processes inherent in professional nursing practice must be accurately measured Consult clinical nurses on HWE and their practice conditions —“only ones who know” HWE and professional practice processes must be studied at unit level (Buerhaus, Needleman, Mark, 2003) EBP/EBMP -- Sept. 21, 2012
Results of HWE/NRP HWE — measured /EOMII — 8 essential processes Since identified by CN in 2001, same process used by AONE, IOM, AACN etc. HWE is related to all variables Confirmed on 83% of 540 units — 54% VHW E ; 28% HWE NRP — all represented; ½ transition; ½integration Impact related to length of program, rites of passage HWE & NRP — + relationship to 3-yr retention Identified 7 issues/dilemmas of highest concern EBP/EBMP -- Sept. 21, 2012
7 Issues of Highest Concern Delegation Prioritization Making autonomous decisions Collaborative RN-MD relationships Getting my work done Constructive conflict resolution Restoration of self-confidence through feedback EBP/EBMP -- Sept. 21, 2012
7 Management Issues/Skills Same Issues were identified in: 1966-67: Nationwide study of NLRN in 8 large medical centers (Kramer, 1974) 1979: 86 tape recorded New Graduate seminars (Schmalenberg & Kramer, 1979) 2001: metasynthesis of Graduate Nurse Experience surveys (Patterson, 2001) 2008: content of NRPs in 34 MH 2009: Comments on 612 NLRN experience surveys 34 states (Pellico, Brewer & Kovner, 2009) 2009: Largest Preparation-Practice gap (Berkow et al) 2010: 468 NLRN on 191 units at 4 & 8 months EBP/EBMP -- Sept. 21, 2012
Impact of Healthy Work Environments and Nurse Residency Programs on NLRN Expectations, Retention, Transition and Integration into Clinical Nurse Professional Practice Role 40 Magnet Hospitals Integration Study Transition Study ( divided into 2 studies of 20 hospitals ) HWE Confirmation Study experienced nurses confirm HWE status of clinical unit ( 34 of 40 hospitals submitted sufficient data (unit RR of > 40 %) for continued participation in research program ) (17 of 20 Hospitals participated (17 of 20 Hospitals participated in all transition studies) in all integration studies) 3 Year Retention Study NRP Study (34 hospitals participated) ( 28 of 34 Hospitals participated) Impact of HWE Environment on Integration into Professional 20 Hospitals, 10 from NLRN Transition, Environmental Transition and 10 from Practice Role and into Reality Shock; Identification of Integration studies were Professional Communities; issues/dilemmas that impede selected for site-visits Cultural Values of Unit Professional Role performance Organizational Transformation Study Effective NRP Strategies and Components Study From Chaos to Complexity to Professional Practice EBP-EBMP-Sept 21
Evidence-Based Management Practice (EBMP) 1. Develop answerable questions 2. Look for the best external (literature) data 3. Look for best internal (organizational) data 4. Critically appraise evidence for validity, significance and applicability to practice 5. Integrate results of preceding with management expertise, organizational values and setting 6. Evaluate effectiveness of implementing ‘best’ management practice (Adapted from Titler et al, 2001; Levin, 2008) EBP/EBMP -- Sept. 21, 2012
The Questions The Questions: What’s the problem? What are the possible, viable “best “ management practices? EBP/EBMP -- Sept. 21, 2012
Why can’t I get my work done? “2 or more patients need something and I can’t leave one to do what needs to be done for the other.” Responsibility & accountability for care and management of clinical situations for multiple patients, simultaneously (Ebright et al, 2003; Lindberg & Lindberg, 2008; Kramer et al; 2012d). Rapid changes in patient’ condition require “moment to moment vigilance” (P (Pesu sut, 2008) EBP/EBMP -- Sept. 21, 2012
Care Component of Nursing Scientific, humanistic alteration in patient’s internal and external environments so the laws of nature prevail and healing can take place Professional practice environment is an alterable medium in which the structures / conditions and processes of practice are altered to improve quality of patient outcomes. ( IOM, 2004) Nursing is providing the best care possible to each of my patients, based on knowledge that flows from my brain to my fingertips with compassion (RN on Med/Surg unit) EBP/EBMP -- Sept. 21, 2012
Management Component Man anag ageme ement nt co compo mpone nent nt ID c ID coordinati ination and coll llaboration ion wit ith mult multiple ple he healt althc hcare are provi provide ders, s, famil family, y, other other services, serv ices, int intra-dis iscipli iplinary y workers s Seemingly Seemingly un unen ending ding do docu cumen mentati ation on Pr Proc ocuremen urement of of eq equipmen uipment an and d sup suppli plies es In Increased sed technologic logical l deman mands s Meeting n ing needs s of mult f multiple iple patients, ients, same same time ime —”moment to moment” vigilance sut , , 2008 2008 ) ) (Kr Krame mer et al, 2010; Ka Kalisc sch & Beg Begeny, 2005; Pesu EBP/EBMP -- Sept. 21, 2012
Simultaneity Complexities Simult Simultan aneo eous us ne need eds s & & ca care re de dema mand nds s fro from m 2 2 or mo or more re (J (Joe) Simultan Simultaneo eous us de dema mand nds s fo for r ma mana nage geme ment nt of of cli clinic nical al si situa tuati tion ons s (O2 (O2 tanks, s, foo food for for dialysi ysis s patient, rapid resp sponse) ) Prov rovide ide care care to to 1 patient; 1 patient; manage manage clinical clinical situation ituation for or another another Prioritizat rioritization ion vers ersus us s simulta imultaneity neity EBP/EBMP -- Sept. 21, 2012
Sources of Evidence In Intern ternal al Sou Source rces : : In Intervi views/PO s/PO-- --907 nurses nurses (2 ) in 20 in 20 (2009-2010) Mag agne net ho hospit spitals als NLRN RN ske sketch & & confir firmati mation by y 348 N NLRNs RNs Email survey related to hospital’s position on Ca Care mode e models, s, Ca Care Deli e Deliver very y Sy Syst stems ems an and d int intervi view content (l (late 2011-2012) ) Per Person sonal al & & Em Email ail inter ntervi views ews with h cli clinica nical nurses ses of f vari varied experienc ience in no in non-st study y hospit spitals ls i in U US S & & Ca Canada (2 (2011-2012) EBP/EBMP -- Sept. 21, 2012
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