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

Impact of HWE & NRP

• n 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

(divided into 2 studies of 20 hospitals)

Transition Study Integration Study 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)

NRP Study

(34 hospitals participated) (17 of 20 Hospitals participated in all transition studies)

(17 of 20 Hospitals participated

in all integration studies)

Impact of HWE Environment on NLRN Transition, Environmental Reality Shock; Identification of issues/dilemmas that impede Professional Role performance Integration into Professional Practice Role and into Professional Communities; Cultural Values of Unit

20 Hospitals, 10 from Transition and 10 from Integration studies were selected for site-visits

Organizational Transformation Study Effective NRP Strategies and Components Study From Chaos to Complexity to Professional Practice

3 Year Retention Study (28 of 34 Hospitals participated)

EBP/EBMP -- Sept. 21, 2012

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

IOM Studies

• 1999: To Err is Human—1M injured; 98,000 dying
• 2001: New Health System for 21st 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

• 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

S—P—O

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

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% VHWE; 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

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

(divided into 2 studies of 20 hospitals)

Transition Study Integration Study 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)

NRP Study

(34 hospitals participated) (17 of 20 Hospitals participated in all transition studies)

(17 of 20 Hospitals participated

in all integration studies)

Impact of HWE Environment on NLRN Transition, Environmental Reality Shock; Identification of issues/dilemmas that impede Professional Role performance Integration into Professional Practice Role and into Professional Communities; Cultural Values of Unit

20 Hospitals, 10 from Transition and 10 from Integration studies were selected for site-visits

Organizational Transformation Study Effective NRP Strategies and Components Study From Chaos to Complexity to Professional Practice

3 Year Retention Study (28 of 34 Hospitals participated)

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

• f 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

• ther

serv services, ices, int intra-dis iscipli iplinary y workers s

• Seemingly

Seemingly un unen ending ding do docu cumen mentati ation

• n
• Pr

Proc

• curemen

urement of

• f 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

(Kr Krame mer et al, 2010; Ka Kalisc sch & Beg Begeny, 2005; Pesu sut,

, 2008

2008)

)

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

• r more

re (J

(Joe)

• Simultan

Simultaneo eous us de dema mand nds s fo for r ma mana nage geme ment nt of

• f cli

clinic nical al si situa tuati tion

• ns

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

• r 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

(2009-2010) ) in 20

in 20 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

1 RN RN RN

PT Pt. Pt. Pt. Pt. Pt.

Preceptor

NLRN

Patient Family Chaplain Dietician MD Pharmacist Physical Therapist Respiratory Therapist Social Worker

• Pt. Family

NLRN

Pt. Pt. Pt. Pt. Pt.

MD Patients’ Families

Transition Stage

(Post-hire to 3 months)

Integration Stage

(4 months to 1 year)

Figure 1. Differences in Newly Licensed Registered Nurses' (NLRN) Conceptualization of the Dominant Professional Nurse Practice Role During Transition and Integration Stages of Professional Socialization. Note: The limited shaded area in the precepted-NLRN experience means they have 'some' responsibility (definitely with the family) for answering questions and dealing with

• ther departments etc. but

that the Preceptor "manages" the situation for virtually all five patients-

• that's why the shaded area is small.

EBP/EBMP -- Sept. 21, 2012

Newtonian Science

• Universe is stable, predictable and regular
• Phenomena behave the same as complex machines
• Whole breaks down into parts; whole equals sum of parts—

linear, reductionistic, mechanistic

• Knowledge generation is grounded in observation,

facts, and experiments.

• Observations/interpretations exist independent of the
• bserver
• Dominates medical and nursing practice models
• Nursing education based on linear processes--develop

care plans, implement actions, expect predictable, measurable results or outcomes

EBP/EBMP -- Sept. 21, 2012

Complexity Science

• Universe is not stable, predictable, controllable

and closed in ways that it was thought to be

• Composed of systems; environments and the

structures within them are not discrete

• Systems are not stable; continuously evolve

and self-organize in response to feedback

• Interconnection over fragmentation, networks
• ver hierarchy, influence over control, direction
• ver destination
• New

ewtonian tonian parad paradigm igm is is not not wrong; rong; it jus it just t does does not not explain explain ev every erything thing

EBP/EBMP -- Sept. 21, 2012

Complex Adaptive Systems

• Complex—numerous, diverse parts (agents); many

interactions among agents

• Adaptive—flexible; agents can learn; can change

behavior

• Systems—group of agents or coordinated elements

when taken together, constitute the whole

• Disciplines vary by extent of social and physical systems
• Use of physical laws for social systems can lead to new insights

and creativity via lateral thinking

• Relationship between health and environment
• Systems can be complex or chaotic
• Significant parallels between Chaos and Complexity systems

and systems of work organization

EBP/EBMP -- Sept. 21, 2012

EBP/EBMP -- Sept. 21, 2012

Storm rm—Bath athtub tub Vorte rtexes xes

Properties of Bathtub Vortex

• Attractor (plug in the tub)
• Vortex is in constant motion--dynamic
• Stronger the attractor, the more active

the vortex

• A disturbed vortex reasserts itself
• Closer disturbances are to the

attractor, more dramatic the changes

EBP/EBMP -- Sept. 21, 2012

1 RN RN RN

Patient--Family Chaplain Dietician Physicians Pharmacist Case Manager Physical Therapist Respiratory Therapist Social Worker

NLRN

Pt. Pt. Pt. Pt. Pt.

MD Patients’ Families

• 1. Add patients and “other

services and professionals” to

• ther RN “responsibility circles”.
• 2. Draw a big inclusive circle

around all 4 RN “responsibility circles” to represent the whole unit.

• 3. This big circle needs to

illustrate communication or interactions between RNs and nurse leadership —manager, charge nurses, CNS, APN and NP—with lines going from NM and charge nurses to each of the RN “responsibility circles”.

Suggestions from 348 NLRNs

NLRN Sketch

• Attractor? Good health experience; shared

values of all agents

• Who are the Agents?
• Dynamic systems--constant motion—changes

can occur at any time

• Location of disturbances in relation to attractor:

bad news? pain? cardiac arrest? nose bleed

• Location of disturbances--different for different

patients

EBP/EBMP -- Sept. 21, 2012

EBP/EBMP -- Sept. 21, 2012

RN Professional Responsibility—5 patients

EBP/EBMP -- Sept. 21, 2012

Possible Possible ‘Best’ Practices

• Explain with “stories”, “examples” “scenarios”
• Simultaneous need/demands from one patient—

OR (first use of the word ‘system’)

• NMs Identify priority system for unit patient

population—ABC first, pain-oncology, ER, rehab

(Much external data on prioritization (Nelson et al, 2006))

• NLRN sketch suggests ‘systems’ approach
• Is it

it pos possible tha ible that t both both choic choices es are are correc correct? t?

• Goal: Make a decision without feeling like a

failure as a professional nurse

EBP/EBMP -- Sept. 21, 2012

‘Best’ Management Practice

• Adaptation of Clinical Reasoning model; use

nurse’s story within a system context (Pesut, 2008)

• Ten magnet hospitals
• 8 month NRP class or Coaching session
• Led by the residency facilitator
• Answer 3 questions: What do? How feel? What

do to prevent?

• Participate in discussion as usual
• What learn from experience?

EBP/EBMP -- Sept. 21, 2012

Professional System of Work

• Do whole task—need lengthy, cognitive

development, practice and judgment

• Continual evaluation (research) and up-date
• f knowledge, skill and practice
• Autonomous decision-making for benefit of

client

• Moral, ethical, and legal responsibility and

accountability for all aspects of practice

• Control over the context of practice
• Service and obligation to society

EBP/EBMP -- Sept. 21, 2012

Bureaucratic System of Work

• Worker trained in short period of time to

do part of a whole task--reductionistic

• Values speed, efficiency, accuracy, safety
• -repetitive performance of same task
• Resistance to task is knows and

predictable

• One bureau—responsible to put parts

back together

EBP/EBMP -- Sept. 21, 2012

EBP/EBMP -- Sept. 21, 2012