Impact of HWE & NRP on NLRNs Expectations, Transition, - PowerPoint PPT Presentation

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