Transformational Leadership and Evidence-Based Management
Creating work environments for nurses that are most conducive to patient safety will require fundamental changes throughout many health care organizations (HCOs)—in the ways work is designed and personnel are deployed, and how the very culture of the organization understands and acts on the science of safety. These changes require leadership capable of transforming not just a physical environment, but also the beliefs and practices of nurses and other health care workers providing care in that environment and those in the HCO who establish the policies and practices that shape the environment—the individuals who constitute the management of the organization.
Behavioral and organizational research on work and workforce effectiveness, health services research, studies of organizational disasters and their evolution, and studies of high-reliability organizations (see Chapter 1) have identified management practices that are consistently associated with successful implementation of change initiatives and achievement of safety in spite of high risk for error. These practices include (1) balancing the tension between production efficiency and reliability (safety), (2) creating and sustaining trust throughout the organization, (3) actively managing the process of change, (4) involving workers in decision making pertaining to work design and work flow, and (5) 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 midlevel manage-
ment are needed to fully secure the advantages of these five management practices. Because HCOs vary in the extent to which they currently employ these practices, as well as in their available resources, collaborations with other HCOs can facilitate more widespread adoption of these practices.
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. We then review in turn the five management practices enumerated above and describe their uneven application in nurses’ work environments. Next, we present several models for evidence-based management in nurses’ work environments. Finally, we examine how evidence-based management collaboratives can be used to stimulate the uptake of health care quality improvement practices. During the course of the discussion, we offer four recommendations (highlighted in bold print) for addressing the deficiencies in nurses’ work environments through enhanced leadership and management practices.
TRANSFORMATIONAL LEADERSHIP: THE ESSENTIAL PRECURSOR
The central function of leadership is to achieve a collective purpose (Burns, 1978). Not surprisingly, leadership has been observed to be the essential precursor to achieving safety in a variety of industries (Carnino, undated), a critical factor in the success of major change initiatives (Baldridge National Quality Program, 2003; Davenport et al., 1998; Heifetz and Laurie, 2001), and key to an organization’s competitive cost position after a change initiative. In a study of hospital reengineering initiatives in U.S. acute care hospitals from 1996 to 1997, only the chief executive officer’s (CEO) involvement in core clinical changes had a statistically significant positive effect on the cost outcomes of reengineering (Walston et al., 2000). The exercise of leadership has also been associated with increased job satisfaction, productivity, and organizational commitment among nurses and other workers in HCOs (Fox et al., 1999; McNeese-Smith, 1995).
In his Pulitzer Prize–winning, seminal study on leadership, James Burns identifies the essential characteristics of leadership (as distinct from the wielding of power) and distinguishes “transactional” leadership from the more potent “transformational” leadership (Burns, 1978). He stresses that leadership, like the exercise of power, is based foremost on a relationship between the leader and follower(s). In contrast to power, however, leadership identifies and responds to—in fact, is inseparable from—the needs and goals of followers as well as those of the leader. Leadership is exercised by engaging and inducing followers to act to further certain goals and pur-
poses “that represent the values and motivations, the wants and needs, the aspirations and expectations of both leaders and followers” (Burns, 1978:19). The genius of leadership lies in the manner in which leaders see, act on, and satisfy followers’ values and motivations as well as their own.
Leadership therefore can be either transaction-based or transformational. Transactional leadership typifies most leader–follower relationships. It involves a “you scratch my back; I’ll scratch yours” exchange of economic, political, or psychological items of value. Each party to the bargain is conscious of the power and attitudes of the other. Their purposes are related and advanced only as long as both parties perceive their individual interests to be furthered by the relationship. The bargainers have no enduring relationship that holds them together; as soon as an item of value is perceived to be at risk, the relationship may break apart (Burns, 1978). This point is illustrated by labor strikes resulting from a change in the terms of work. The compliance of labor with management is based on an acceptable set of transactions; when the transactions are changed, the relationship may not have much to hold it together. Burns notes that in such cases, a leadership act takes place, but it is not one that “binds leader and follower together in a mutual and continuing pursuit of a higher purpose” (Burns, 1978:20). Transactional leadership is not a joint effort of persons with common aims acting for a collective purpose, but “a bargain to aid the individual interests of persons or groups going their separate ways” (Burns, 1978:425).
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), become fused. Such leadership is sometimes described as “el-evating” or “inspiring.” Those who are led feel “elevated by it and often become more active themselves, thereby creating new cadres of leaders” (Burns, 1978:20). Transformational leadership is in essence a relationship of mutual stimulation and elevation that raises the level of human conduct as well as the aspirations of both the leader and those led, and thereby has a transforming effect on both (Burns, 1978).
Transformational leadership is achieved by the specific actions of leaders. First, leaders take the initiative in establishing and making a commitment to relationships with followers. This effort includes the creation of formal, ongoing mechanisms that promote two-way communication and the exchange of information and ideas. On an ongoing basis, leaders play the major role in maintaining and nurturing the relationship with their followers. Burns notes that, most important, leaders seek to gratify followers’ wants, needs, and other motivations as well as their own. Understanding of followers’ wants, needs, and motivations can be secured only through ongoing communication and exchange of information and ideas. Leaders
change and elevate the motives, values, and goals of followers by addressing their followers’ needs and teaching them about their commonly held goals. Doing so may require that leaders modify their own leadership in recognition of followers’ preferences; in anticipation of followers’ responses; or in pursuit of their common motives, values, and goals.
Although a transforming leader plays the major role in achieving the combined purpose of leader and followers, transformational leadership recognizes that leaders and followers are engaged in a common enterprise and thus are dependent on each other. The premise of transformational leadership is that, regardless of the separate interests people may hold, they are presently or potentially united in the pursuit of higher goals. This point is evidenced by the achievement of significant change through the collective or pooled interests of leaders and followers. The effectiveness of leaders and leadership is measured by the extent to which intended change is actually accomplished and human needs and expectations are satisfied (Burns, 1978).
Burns offers reassurance that transformational leadership is far more common than might be thought, given the above discussion. He notes that acts of transformational leadership are not restricted to (and often are not found in) governmental organizations, but are widespread in day-to-day events, such as whenever parents, teachers, politicians, or managers tap into the motivations of children, students, the electorate, or employees in the achievement of a needed change.
In acute care hospitals, individuals in potential transformational leadership roles range from board-level chairmen and directors; to chief executive, operating, nursing, and medical officers; through the hierarchy to unit managers. 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 1).
However, if these individuals rely solely on a traditional, transactional approach to leadership, such substantive changes are likely to be difficult to achieve and sustain, as leaders will need to conduct frequent, ongoing, possibly contradictory renegotiations with workers in response to rapidly changing external forces. In contrast, transformational leadership seeks to engage individuals in the recognition and pursuit of a commonly held goal—in this case, patient safety. For example, individual nurses may desire wide variation in the number of hours they would like to work on a 24-hour or weekly basis. Attempting to secure their commitment to the organization by accommodating all such requests (transactional leadership) despite evidence that extended work hours may be detrimental to patient safety would
likely be both time-intensive and unsuccessful. Instead, transformational leadership would engage nursing staff in a discussion of patient safety and worker fatigue and seek to develop work hour policies and scheduling that would put patient safety first and respond to individual scheduling needs within that construct. Such a discussion could have a transforming effect on both staff and management as knowledge was shared.
A leadership approach that aims to achieve a collective goal rather than a multitude of individual goals and aims to transform all workers—both managers and staff—in pursuit of the higher collective purpose can be the most efficient and effective means of achieving widespread and fundamental organizational change. 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. These management practices also underlie all of the worker deployment, work design, and safety culture practices that are addressed in the remaining chapters of this report.
FIVE ESSENTIAL MANAGEMENT PRACTICES
“The more removed individuals are from … front-line activities…, the greater is their potential danger to the system” (Reason, 1990:174).
As discussed in Chapters 1 and 2, latent work conditions have been documented as posing the greatest risk of errors. Therefore, it should not be surprising that errors often have their primary origins in decisions made by fallible system designers and high-level managerial decision makers (Reason, 1990). The corollary to this statement is that these high-level managerial decision makers have a substantial role to play in error prevention—a role that deserves more attention and support.
The concept of evidence-based practice first emerged in clinical medicine and now suffuses the language, decision making, and standards of care of health care clinicians, managers, policy makers, and researchers throughout the world. Evidence-based clinical practice is defined as the conscientious, explicit, and judicious integration of current best evidence—obtained from systematic research—in making decisions about the care of individual patients (Sackett et al., 1996). The use of systematic research findings for evidence-based practice is also supported and applied in the fields of educa-
tion, criminal justice, and social welfare through the efforts of the international Campbell Collaboration—a sibling of the Cochrane Collaboration that prepares and maintains evidence-based systemic reviews of the effects of health care interventions (The Campbell Collaboration, undated). Evidence-based management, however, is a newer concept—not yet as widely embraced, but just as important (Axelsson, 1998; Hewison, 1997; Kovner et al., 2000; Walshe and Rundall, 2001).
Evidence-based management means that managers, like their clinical practitioner counterparts, should search for, appraise, and apply empirical evidence from management research in their practice. Managers also must be prepared to have their own decisions and actions systematically recorded and evaluated in a way that will further add to the evidence base for effective management practices (Axelsson, 1998).
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. The main funders of research in health care (government agencies and private foundations) have historically not funded management research. When large health systems have funded such research, its findings have often been considered proprietary and the results not widely published. As a result, little empirical evidence has been generated about best health care management practices (Kovner et al., 2000).
The empirical evidence on effective management practices that does exist is difficult to locate. Management literature is poorly indexed for practical applications and is not easily reviewed and synthesized (Walshe and Rundall, 2001).
Many managers are not trained or experienced in the use of such evidence in making management decisions (Kovner et al., 2000). While physicians are trained in a strongly professional model with fairly uniform educational preparation, managers come from a variety of very different professional backgrounds and training. Some management training comes more from long-term practical experience in the workplace, as opposed to formal professional education (Axelsson, 1998; Walshe and Rundall, 2001).
Although many health systems spend millions of dollars on consultants for strategic recommendations based on data, they typically underfund their own data systems designed to support decision making and internal management research (Kovner et al., 2000). A study of 14 U.S. hospitals
implementing reengineering initiatives in the 1990s found that existing operating budgets often were used to measure progress in meeting reengineering goals, but did not contain baseline statistics managers could use for comparative purposes or identification of causes and effects (Walston and Kimberly, 1997).
Some HCOs lack sufficient size and resources to conduct and evaluate applied research (Kovner et al., 2000).
Managers’ decision-making practices are often quite different from those of health care practitioners. While practitioners’ decisions are many in number and made independently, management decisions are often few, large, and made by groups, involving negotiation or compromise and many organizational constraints (Walshe and Rundall, 2001).
For the above reasons, in health care, often “the weapons are ahead of the tactics”—a description used by historian Shelby Foote to characterize military leadership during the U.S. Civil War (Ward et al., 1990). In the case of American health care, the sophisticated medical technology (the weaponry) outclasses the tactics (management) used to organize work and implement change.
Despite the limitations discussed above in the supply of and access to empirical information to guide managerial decision making, there is strong evidence that the management practices enumerated at the beginning of this chapter play a critical role in achieving organizational goals and successfully implementing change within an organization. These five practices are discussed in turn below.
Balancing the Tension Between Efficiency and Reliability
The health care cost-containment pressures of the last two decades (see Chapter 1) have forced HCOs to examine their work processes and undertake work redesign initiatives to deliver care more efficiently. Efficiency frequently calls for conducting production activities in as cost-effective and time-efficient a manner as possible. Organizations in many industries often try to accomplish efficiency by downsizing, outsourcing, and cutting costs. Such efficiency measures can be at odds with safety (Carnino, undated; Cooper, 2000; Spath, 2000). For example, when system failures associated with four large-scale disasters (Three-Mile Island, Chernobyl, the Challenger space shuttle, and the Bhopal chemical plant) were compared, subordination of safety to other performance goals was one of 11 common attributes found (Petersen, 1996). 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., 2000).
For example, one of the practices used by high-reliability organizations to increase safety is to consciously incorporate personnel and equipment redundancy into some aspects of work design. This redundancy creates some slack in the system such that if one component in the work production process fails, a replacement will be available to perform the function. Air traffic controllers, for example, are assigned to radar screening in groups of two. While their job functions are somewhat different, each controller acts as a check on the other (Roberts, 1990). This redundancy and other practices characteristic of high-reliability organizations—such as promoting inter- and intragroup communication, cross-training personnel, and attending to the interdependencies of work production processes—might be viewed by other organizations as “frills” (Roberts and Bea, 2001b) and a hindrance to efficient production. In high-reliability organizations, however, performance reliability (safety) rivals productivity as a dominant organizational goal, and such work components are viewed as essentials rather than frills (Roberts, 1990). Organizations can achieve balance between production efficiency and reliability by balancing and aligning their organizational goals; accountability mechanisms; and reward, incentive, and compensation mechanisms (Roberts and Bea, 2001a).
Creating and Sustaining Trust
Creating and sustaining trust is the second of the five management practices essential to patient safety. Trust has been defined as the willingness to be vulnerable to the intentions of another (Mayer et al., 1995; Rousseau et al., 1998) and is strongest when parties believe each other to be competent and to have one another’s interests at heart. When trust links people and groups to organizations, it generally makes workers willing to contribute their efforts without expecting an immediate payoff, and increases the extent to which leaders can rely on workers to have the organization’s interests at heart (and vice versa). Workers’ trust in organizational leaders has been found to be directly related to positive business outcomes, such as increased sales and profitability, and inversely related to employee turnover (Mayer et al., 1995).
Trust has the added advantage of increasing workers’ capacity for change by reducing the uncertainty and discomfort with change that otherwise impair individual and group adaptability (Coff and Rousseau, 2000; Rousseau, 1995) and increasing workers’ willingness to take risks associated with change (Mayer et al., 1995). Honest and open communication, necessary for successful organizational change, depends on the development of trust throughout the organization (Carnino, undated; DeLong and Fahey, 2000), in part because the level of trust that exists between the organization and its employees greatly influences the amount of knowledge that
flows among individuals and from individuals into organization databases, archives, and other records (DeLong and Fahey, 2000). 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. It is easier to share information, downplay differences, and cooperate when those involved in a change trust each other.
Trust flows two ways—up and down the hierarchies of organizations. Top-down trust is based largely on competence (Rousseau et al., 1998). Leaders are more willing to entrust subordinates with complete information and with the authority to make decisions when they believe those subordinates to be competent and capable of making and carrying out appropriate decisions. It is well established that leaders manage subordinates differently depending on the employees’ perceived competence (Graen et al., 1982; Lowin and Craig, 1968). This is because when hiring, employers put themselves at risk, depending on those they hire to act in ways that help rather than hinder the organization. Employees are hired to act for their employers by making decisions and carrying out responsibilities on the employers’ behalf (Pearce, 2000). Employers cope with this vulnerability by attempting to hire employees they can trust and by managing those they hire in ways that sustain that trust. Top-down trust is reinforced whenever leaders have positive exchanges with their employees. Such exchanges are more likely to occur in long-standing relationships in which both parties have made investments in each other, for example, when leaders have developed subordinates who in turn have worked to understand the leader’s goals and preferred ways of managing and adjusted their behavior accordingly (Huselid, 1995; Miles and Snow, 1984).
Bottom-up trust, on the other hand, is based in part on workers’ perceptions of a manager’s or organization’s ability, benevolence, and integrity (Mayer et al., 1995). An organization’s ability comprises its collective skills, competencies, and expertise. Trust can be fostered by an organization’s strong reputation for competence and capabilities, as well as by members’ ability to directly access the expertise of others within the organization, the collective capabilities of members, their shared knowledge of each other’s expertise, and recognition of “who knows what” based on a history of shared experience (Coff and Rousseau, 2000). Conversely, trust can be damaged by disclosure of failures in competence or by workers’ direct observation of instances in which competence falls short of prior expectations.
Bottom-up trust is also based on benevolence, that is, the extent to which managers and organizations are understood by workers to want to do good (aside from a self-concerned or profit motive) for the person who trusts the entity (the trustor). Benevolence gives rise to an attachment between the entity being trusted (the trustee) and the trustor. An example of such a benevolent relationship is that between a mentor and a protégé. The
mentor wants to be helpful to the protégé, even though there is no extrinsic reward to the mentor for doing so. Benevolence also has been associated with a trustee’s motivation to speak truthfully (Mayer et al., 1995).
The relationship between integrity and trust involves the trustor’s perception that the trustee adheres to a set of principles that the trustor finds acceptable (Mayer et al., 1995). In health care organizations, where many workers have strong professional identifications, trust of leadership by subordinates often reflects the extent to which leadership is committed to the values inherent in the professions of medicine and nursing (Bunderson, 2001; Thompson and Bunderson, in press). 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, 1999). Integrity is assessed by the consistency of a party’s past actions, credible communication about the trustee from other parties, the belief that the party has a strong sense of justice, and the extent to which the party’s actions are consistent with his or her word.
Trust between workers and the organizations in which they work therefore results from the workers’ perceptions of the interplay among the organization’s ability, benevolence, and integrity. Each of these factors exists to a varying degree along a continuum. Although in the best case, high degrees of trust result from high levels of all three factors, meaningful trust can exist with lesser levels of a combination of the three. The degree of trust between parties also is dynamic and evolves over time as the parties interact. The outcomes that result when a trustor takes a risk and places his or her trust in the trustee affect the degree of trust that exists for subsequent potential interactions (Mayer et al., 1995). Mutual trust is enhanced by positive exchanges that have occurred in the past and are expected to continue in the future (Zucker, 1986). Therefore, trust in organizations also depends to a certain extent on the extent of stability in the relationships that make up the organization (e.g., worker to manager, manager to senior executive). In organizations with high turnover, mutual trust is difficult to achieve (Bryman et al., 1987). In firms in which promotions tend to be internal and the employee development system builds organization-specific capabilities, both workers and managers are more likely to possess common knowledge and similar points of view, and managers are more likely to trust workers (Miles and Snow, 1984). Such bases for trust are less common in many contemporary firms, where external mobility and reduced opportunities for within-firm development mean that organization members, leaders, and workers have fewer shared experiences and frames of reference (Leana and Rousseau, 2000).
It is widely evident that over the course of the twentieth century, senior managers in many industries have come to place greater trust in workers
(Miles and Creed, 1995). Employees increasingly have experienced greater discretion and reduced standardization in the way they accomplish their work, coordinated more of their interactions with coworkers and other departments, and reduced their dependence on supervisors for problem solving. At the same time that modern organizational practices presume a higher degree of trustworthiness among workers, however, workers’ trust in management remains highly variable (Freeman and Rogers, 1999). In a large-scale survey of the American workforce, Freeman and Rogers found that workers generally reported levels of loyalty to their employer greater than the degree of trust they placed in their employer to keep its promises to them or other workers. This low level of trust is connected to a widespread sense on the part of American workers that they have little influence over workplace decisions. Where workers exercise greater influence over workplace decisions, they are more likely to trust their managers and act in ways that ease implementation of those decisions. With respect to nursing, higher levels of nurse autonomy and control over nursing practice have been associated with greater trust in management among nurses and greater commitment to their employing HCO (Laschinger et al., 2000, 2001b).
Actively Managing the Process of Change
Actively managing the process of change is essential to patient safety because all organizations have difficulty in navigating major organizational change (Kimberly and Quinn, 1984). HCOs are no exception. Despite their vast experience with introducing new medical technologies, HCOs have a history of ineffective attempts at organizational change and remain prone to poor change implementation (Mintzberg, 1997). A large body of research and other published work offers frameworks, models, and guidance for undertaking change (Baer and Frese, 2003; Goodman, 2001; Parker, 1998; Rousseau and Tijoriwala, 1999; Walston et al., 2000). This work consistently calls attention to five predominantly human resource management practices1 as particularly important for successful change implementation: ongoing communication; training; use of mechanisms for measurement, feedback, and redesign; sustained attention; and worker involvement.
Frequent, ongoing communication through multiple media is a key ingredient of successful organizational change initiatives (Ingersoll et al.,
2001). Such communication is a powerful facilitator of change, whereas poor communication creates significant problems (Rousseau and Tijoriwala, 1999). In its work with more than 200 managers from 32 different countries, the Change Program at the International Institute for Management Development in Lausanne, Switzerland, identified employee acceptance of the need for and nature of a change and its effect on their “personal compact” with the organization as a critical determinant of whether change will be successful (Strebel, 1996).
In the present context, it is essential to have ongoing communication with employees about the goals and mission of the HCO, the reasons for change (including contributing economic and policy factors), and the nature of the change (including changes in employee roles and responsibilities). Soliciting feedback about the change throughout its planning, implementation, and continuance is also necessary (Heifetz and Laurie, 2001; Ingersoll et al., 2001). Studies of HCO redesign, reengineering, and reorganization initiatives identify role conflict and ambiguity as consistent issues in change initiatives; nurses who view their roles as ambiguous have lower job commitment (Ingersoll et al., 2001). Clear communication about changes in employee roles and responsibilities can reduce such ambiguity. Even discussions about how the HCO is financed are recommended. In one study, nurses expressed concern about money being available for construction of new buildings even as staff was being admonished to conserve resources. 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., 2001).
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, 1997). Communication between nurses and nurse managers also has been shown to increase nurses’ commitment to the organization (McNeese-Smith, 1997), which is essential to weathering the stresses of organizational change.
Because change often requires employees to adopt new roles and responsibilities, training is essential to successful change. This need is not always appreciated, however. A study of 14 U.S. hospitals implementing reengineering initiatives in the 1990s found that needs for new knowledge were often underestimated; the result was periods of deteriorated quality and inefficiency (Walston and Kimberly, 1997). Training is especially
needed in such specialized topics as work redesign, knowledge management, error prevention and detection (Spear and Bowen, 1999), and change management itself (Strebel, 1996). In a 1995 survey of nurse leaders in VHA Inc. HCOs and nurse executives and managers belonging to the American Organization of Nurse Executives (AONE), expertise in change management was one of five learning needs reported by the nurse leaders (Gelinas and Manthey, 1997).
Mechanisms for Feedback, Measurement, and Redesign
Few changes in complex organizations work perfectly when first introduced. Virtually all changes require modification over time to achieve optimum results. It is not unusual for organizations, departments, or plants that have implemented innovations most recently to perform worse than those that implemented comparable innovations a year or two before (Macduffie and Pil, 1996). New practices often initially undermine existing routines and competencies and require ongoing learning adjustment, redesign of the change, and supportive efforts to capture the intended benefits of the innovation. Ongoing monitoring, feedback, and redesign are needed to create and sustain effective change (Goodman, 2001; Walston and Kimberly, 1997).
Effective organizational transformations require long periods of time and constant effort. Macduffie and Pil (1996) point out that in the auto industry, plants in the first year following adoption of a new work system struggle with the right mix of incentives, managerial supports, and training needs, and experience coordination difficulties with other units. Those that sustain the change into the second year begin to see cost and quality improvements. The above-cited study of 14 U.S. 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. While most study participants perceived reengineering to be an ongoing change process, and managers realized that continual effort was needed to move reengineering forward, many ended their efforts or decreased them after initial implementation. Without continued attention, the change was not sustained. The hospitals that were able to sustain a change were those that embedded the new initiative within ongoing operations, such as a continuous quality improvement or total quality management process, or established specific, measurable goals and mechanisms to
track their progress. In two cases in which tracking measures were employed, the “established goals and feedback monitors appeared to galvanize the organization to make and maintain changes in these areas” (Walston and Kimberly, 1997:158).
Codifying a change to ensure consistency of application and direction through implementation manuals, guidelines for decision making, and provision of budgetary support has been identified as a critical ingredient in successful and sustained implementation (Walston et al., 2000). Credible commitment to stay with the change over time in the face of personnel changes or economic factors is especially important in organizations with a history of dysfunctional labor–management relations and ineffective change management (Heller, 2003). Such commitment can take the form of public statements and written documents articulating the agreement.
Evidence from multiple studies indicates that change is typically turbulent and difficult for staff members (Ingersoll et al., 2001; Strebel, 1996). Changes often affect worker roles and responsibilities, work group relationships, and resource availability and use. Consequently, a natural human response is to react negatively to the challenges created by change. This negativity can be overcome by actively involving workers in the planning and design of a change and providing them with information about the progress being made in achieving the goals of the redesign (Walston and Kimberly, 1997). The importance of such worker involvement is discussed in greater detail below.
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. Organizational structures that are strongly hierarchical in design with resultant hierarchical decision making are hampered in their ability to respond to situations with high variability (Moorman and Miner, 1998; Quinn, 1992) and are associated with reduced safety (Roberts and Bea, 2001b). Since the 1980s, a worldwide evolution has taken place in the organizing principals of manufacturing, as the mass production system (which itself replaced the old craft system in the early twentieth century) was transformed at the end of the 1900s into the flexible production system (Macduffie and Pil, 1996). This flexible production system was enabled and reinforced by two related forces: managers’ expanded trust in their workers
and an ever-greater reliance on workers as the basis for organizational success (Miles and Creed, 1995).
The relationship between greater reliance on workers and organizational success is being documented across a variety of industries and types of research. Studies of high-reliability organizations show that effective decision making is flexible decision making, pushed to the lowest level commensurate with available knowledge (Bigley and Roberts, 2001; Roberts et al., 1994; Weick and Roberts, 1993). For example, any level of military personnel on an aircraft carrier can call a halt to a flight operation if he or she sees what looks like a dangerous situation (Roberts, 1990). Health services research supports these findings. The above-cited study of 14 U.S. hospitals implementing reengineering initiatives in the 1990s 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, 1997). 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., 2002).
Such high-involvement work systems have been described across a number of industries. They are characterized by shifting more decisions down the organization’s hierarchy to the level of individual workers or teams of workers, increasing worker responsibility for quality control (monitoring safety and taking action to prevent risks to safety or quality), and broadening the knowledge workers possess about the activities of other work groups (e.g., through cross-functional teams). Such work systems promote greater contributions on the part of workers to the value of the organization by releasing underutilized worker competence (Edmondson, 1999; Frese et al., 1999; Ho et al., 1999; MacDuffie, 1995; Parker, 1998). Preconditions for implementing such systems include a relationship of trust between senior leadership and workers (Rousseau and Tijoriwala, 1999) and credible commitment on the part of leadership to persist with implementing high-involvement work systems over time.
In nursing research, this involvement in decision making has been studied under a number of constructs, including shared governance, nursing empowerment, control over nursing practice, and clinical autonomy. These constructs have certain common elements.
Shared governance—“a decentralized approach which gives nurses greater authority and control over their practice and work environment [emphasis added]” (O’May and Buchan, 1999:281)—began to be incorporated into nurse work environments in the late 1970s. The results of these efforts are uncertain because of the lack of a uniform definitional construct,
wide variation in implementation models, infrequent evaluations, and poorly designed evaluation methodologies. “As a result, studies to evaluate shared governance tend to yield mixed results, leave questions as to what has been evaluated, and often produce little opportunity for cross-comparison of results” (O’May and Buchan, 1999:292).
Nursing research on empowerment similarly has not generally included a uniform operational definition of this construct, but has described empowerment in terms of its goal (i.e., “empower nurses to exercise more control over the content and context of their practice” [emphasis added]) and in terms of the resources needed to achieve it (i.e., “the ability to access and mobilize support, information, resources, and opportunities from one’s position in the organization”) (Laschinger and Havens, 1996:27–28). Conger and Kanungo (1988:474) define empowerment as “a process of enhancing feelings of self-efficacy among organizational members through the identification of conditions that foster powerlessness and through their removal by both formal organizational practices and informal techniques of providing efficacy information.” A series of studies of nurses employed at individual Canadian and U.S. hospitals found that perceived empowerment is strongly related to perceptions of autonomy and control over nursing practice (Laschinger and Havens, 1996; Sabiston and Laschinger, 1995). Additional studies in this series found higher levels of organizational trust among nurses reporting greater workplace empowerment (Laschinger et al., 2000, 2001a). Evidence also indicates that organizational structures that foster nurses’ empowerment (combined with strong managers) may be important factors in increasing the organizational commitment of nurses working in nursing facilities (Beaulieu et al., 1997).
Studies of shared governance and empowerment highlight nurses’ control over their practice as a key element. The construct of control of nursing practice has been addressed more explicitly and fully in studies seeking to determine the attributes of hospitals that are rated by their nurses as making them “good place to work” and that do not experience difficulties in attracting and retaining nurses. These hospitals (referred to as “magnet hospitals”) have been the subject of multiple studies. A distinction is made in these studies between control over nursing practice and clinical autonomy. Clinical autonomy refers to nurses’ ability to assess individual 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., 1999). Autonomy is a characteristic commonly identified by staff nurses, nurse managers, and chief nurse executives (CNEs) as important to a magnet hospital (Aiken, 2002; McClure et al., 1983). Control over nursing practice is defined as nurses’ ability to shape not just
the care of an individual, but also the organizational policies and practices to be followed within nursing units and the HCO overall that affect nursing care, as well as to control the resources need to provide that care (Hinshaw, 2002). Control over nursing practice represents an organization-level (as opposed to patient-level) 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., 1999). 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., 1999). Other research suggests that nurses’ autonomy and control over their practice environment are positively associated with their trust in management (Laschinger et al., 2001b).
Creating a Learning Organization
The final evidence-based management practice calls for all HCOs to become learning organizations. The ongoing acquisition and management of knowledge has been identified as one of the intrinsic characteristics of high-performing organizations in postindustrial societies (Quinn, 1992). Economists and business strategists point to how an organization manages its knowledge assets as more important to its competitive advantage in today’s economy than how it manages bureaucratic control of its capital resources (Blackler, 1995; DeLong and Fahey, 2000). Continuous organizational learning also has been documented as playing a central role in the development and maintenance of safety in organizations (Carnino, undated). This point is particularly salient to a high-tech industry such as health care, which is characterized by rapidly accelerating scientific and technologic advances. The Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), cites this growth in health care knowledge, drugs, medical devices, and technologies as one of the four defining attributes of the U.S. health system affecting health care quality.
A learning organization is an organization “skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect new knowledge and insight” (Garvin, 1993:80). Learning organizations do not passively wait for knowledge to present itself, but actively manage the learning process by taking advantage of all sources of knowledge, using systematic experimentation to generate new knowledge internally, and transferring knowledge quickly and efficiently throughout the organization (Garvin, 1993). These processes are used to create better work tools, processes, systems, and structures in order to improve the organization’s production processes (DeLong and Fahey, 2000).
Actively Managing the Learning Process
Taking advantage of all sources of knowledge Learning organizations know that knowledge can come from many sources, including internal flashes of creativity or insight, knowledgeable experts within the organization, external experts, the best practices of other organizations, and other sources. They learn from their own and others’ experiences by reviewing past organizational successes and failures, assessing them systematically, and recording them in a format that employees can easily access (Garvin, 1993). Learning from the experiences and best practices of others is a major factor in the success and sizable cost savings of a number of organizations’ reengineering initiatives (Stewart, 1999), although knowledge gained from failures can often be the most helpful (DeLong and Fahey, 2000). However, knowledge from these sources serves as a starting point only; organizations are expected to test and improve upon it through continual experimentation (DeLong and Fahey, 2000).
Using systematic experimentation to generate new knowledge internally Experimentation is widely recognized as a cornerstone of a learning organization. Experimentation involves the systematic searching for and testing of new knowledge using the scientific method through an ongoing series of small experiments, designed to produce incremental gains in knowledge access (Garvin, 1993). It can be undertaken on existing programs or on planned new demonstration projects. This application of the scientific method in a continuing series of controlled experiments has been identified as the hallmark of the Toyota Production System, which has been widely hailed as a benchmark work system (see Box 4-1). Toyota teaches the scientific method to workers at every level of the organization, thereby creating a “community of scientists” (Spear and Bowen, 1999).
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. These methods help the organization and its employees become more disciplined in their thinking and more attentive to details of work processes and production (Garvin, 1993).
Transferring knowledge quickly and efficiently throughout the organization Learning organizations spread knowledge quickly and efficiently throughout the organization. They know that ideas have the greatest im-
The Toyota Production System (TPS) has long been hailed as the reason for the Toyota Company’s outstanding performance and has been used as a model by many other organizations around the world. In essence, the TPS creates a learning organization by forming a community of scientists among its workers. In the TPS, work processes are studied so intensely that each activity is defined by an exacting set of specifications. This approach allows workers to vary a work process and test the effects of the change on production efficiency and reliability. Toyota’s work specifications thereby serve as sets of hypotheses that can be tested. When making a change, workers use a rigorous problem-solving process that is, in effect, an experimental test of the proposed change using the scientific method. This learning environment is enabled by four signature TPS practices:
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-
An extensive 4-year study of the TPS in more than 40 organizations found that the successful implementation of the above four principles in each organization is guided by a strong, shared vision of the ideal product the company desires to produce and the ideal production system to create that product. This shared vision motivates all employees to make improvements beyond what would be necessary merely to meet current customer needs. This notion of the ideal is not abstract. For Toyota workers, it is one in which the product is defect free; can be delivered one request at a time; can be supplied on demand in the version requested; can be delivered immediately; can be produced without wasting any materials, labor, energy, or other resources; and can be produced in a work environment that is safe physically, emotionally, and professionally for every employee.
To reinforce the learning and improvement process, each plant and major business unit in the Toyota Group employs a number of TPS consultants to help senior managers move their organization toward the ideal. Many of these individuals have received intensive training at Toyota’s Operations Management Consulting Division or the Toyota Supplier Support Center in the United States. Although most companies are auto suppliers, participants also come from other industries, universities, government organizations, and industry associations.
SOURCE: Spear and Bowen (1999).
nel rotations; and education and training programs. Each of these mechanisms, however, can be a cumbersome way to transfer knowledge. Active experience in performing a new activity is much more effective (Garvin, 1993); some research indicates that knowledge is exchanged in direct proportion to the level of face-to-face contact (Davenport et al., 1998). For this
reason, personnel rotations have been identified as one of the most powerful methods of transferring knowledge (Garvin, 1993). It is important to note that such face-to-face knowledge transfers depend on a stable organizational workforce. A relatively stable workforce permits members to hold common understandings of important organizational priorities and processes and adequate information regarding the people and places in the organization where specific knowledge resides (Coff and Rousseau, 2000).
Knowledge management and organizational learning also are found to be more successful when they are supported by information technology (Davenport et al., 1998; Hansen et al., 1999). However, the type and extent of information technology needed vary according to the predominant knowledge management strategy in use. In a study of knowledge management practices at management consulting firms, HCOs, and computer manufacturers, researchers found that organizations that produced relatively standardized products to meet fairly standard needs relied heavily on codified knowledge stored in databases where it could easily be used by anyone in the company (Stewart, 1999). This capability required a heavy investment in information technology. Alternatively, organizations that provided more customized services to address unique problems tended to rely more on person-to-person sharing of knowledge and used information technology primarily to help people communicate (Hansen et al., 1999).
HCOs are likely to provide both standardized and customized services, and must adapt their knowledge management strategies to their settings and particular needs. In all cases, it can be important to avoid overreliance on information technology at the expense of shared personal knowledge through face-to-face contact (Goodman and Darr, 1996).
Time Required to Create a 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, 1993). Yet research on more than 50 companies pursuing knowledge management projects revealed that organizational culture was the major barrier to creating a learning organization (DeLong and Fahey, 2000). This situation will not be remedied overnight; most successful organizational learning and knowledge initiatives are the product of carefully cultivated attitudes, commitments, and management processes that have been built up slowly and steadily over time. The Toyota Production System, discussed earlier (see Box 4-1), is the product of decades of work (Spear and Bowen, 1999).
On the other hand, some changes can be made immediately to foster an environment conducive to learning. These include assessing the existing
knowledge culture within an organization; freeing up employee time for thinking, learning, and training; and aligning incentives to reinforce and facilitate uptake of knowledge management practices.
Assessing the existing knowledge culture within the organization Companies whose cultures are most effective at creating new knowledge and integrating it into the organization have norms and practices that demand broad participation in knowledge gathering and distribution (DeLong and Fahey, 2000). Some organizations, however, favor individual knowledge over group or organizational knowledge. In these organizations, individual knowledge is associated with power, control, and security of one’s position in the organization. When employees believe that sharing what they know poses personal risk and decreases power, the free exchange of knowledge is impeded (Davenport et al., 1998). Before undertaking a knowledge management initiative, therefore, management should assess the culture of its organization to determine existing attitudes toward ownership of knowledge and how those attitudes would be altered by the initiative. Depending on the results of that assessment, management might also need to adopt new behaviors to communicate a shift from valuing individual over collective knowledge. It is necessary as well to make explicit what practices need to change to promote more collaborative use of knowledge (DeLong and Fahey, 2000).
In addition, organizations should examine their internal communication patterns. Communication patterns that make executives accessible and approachable and encourage open and frank dialogue are an essential element of a learning organization. Questioning fundamental beliefs and existing ways of working is difficult for organizational leadership, but is usually a key step in creating new knowledge for the organization. Intense debate on key strategic issues, drawing on extensive and intensive internal and external inputs—sometimes called “constructive confrontation” or “ferocious arguing with one another while remaining friends”—is identified as a key characteristic of cultures that are relatively effective at creating and integrating new knowledge. 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, 2000).
Shared information is enhanced by familiarity, that is, where people know each other and the conditions under which they work. Familiarity can be compromised by status or other differences that suppress interaction (Goodman and Garber, 1988; Goodman and Leyden, 1991). As a result, people from different parts of the organization and different status levels often find it difficult to share knowledge. Such boundaries inhibit the flow of information; they keep individuals and groups isolated and reinforce preconceptions. A solution to this problem is to break down boundaries and stimulate the exchange of ideas between individuals at multiple levels of the organization through formal and informal practices that bring people together for this purpose (DeLong and Fahey, 2000). Conferences, meetings, and project teams that cut across organizational levels promote a fresh flow of ideas and the chance to consider competing perspectives (Garvin, 1993).
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. Only if top management explicitly frees up employee time for this purpose does learning occur with any regularity.
Further, employees must posses the skills to use learning productively. To perform and evaluate experiments, managers and staff members need skills in such areas as statistical methods and experiment design in order to perform and evaluate experiments. These skills are seldom intuitive and must be learned. Such training is often most effective when intact work groups participate in the training together. Training in brainstorming, problem solving, evaluation of experiments, and other core learning skills is essential (Garvin, 1993). All of the organizations managed according to the Toyota Production System, for example, share an overarching belief that people are the most significant corporate asset and that investments in their knowledge and skills are necessary to build competitiveness. They invest heavily in training and in creating among coworkers shared understandings of problem solving and innovation processes (Spear and Bowen, 1999).
Organizations need to create formal programs or events with explicit learning goals in mind. These programs can take a variety of forms, including strategic reviews that examine the changing external environment and the organization’s services, technology, and market position; systems audits that review the performance of the large processes and delivery systems in the organization; internal benchmark reports that compare the organization’s performance with that of other best-practice organizations; the re-
sults of “study missions” in which individuals are dispatched to leading external organizations to better understand their performance and distinctive skills; and symposiums that bring customers, suppliers, outside experts, and internal groups together to share ideas and learn from one another. Each of these activities fosters learning by requiring employees to grapple with new knowledge and consider its implications for the organization (Garvin, 1993).
Aligning incentives to reinforce and facilitate uptake of knowledge management practices Knowledge has been described as being “intimately and inextricably bound with people’s egos and occupations” and therefore as not flowing easily across roles or functional boundaries (Davenport et al., 1998:53). Knowledge is more likely to be transferred effectively when the right incentives are in place (Garvin, 1993). In a study of 31 knowledge management projects at 24 corporations, the motivation to create, share, and use knowledge was found to be a critical success factor for the projects. The researchers concluded that incentives to contribute should be long-term and should be linked to both the general evaluation and compensation structure of the organization (Davenport et al., 1998). Some organizations have used the extent to which employees contribute to the organization’s knowledge repository as a component of employee evaluations and compensation decisions (Davenport et al., 1998). The U.S. Army is one of a growing number of organizations that formally consider knowledge-sharing capabilities when identifying candidates for promotion (DeLong and Fahey, 2000).
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. Each of these barriers to the application of evidence-based management practices in nurses’ work environments is discussed in turn below.
Concerns About Changes in Nursing Leadership
Nursing leadership in hospitals and other HCOs has a key role with respect to the deployment of the nurse workforce in these institutions and overall patient care. This role, however, at least in hospitals, is changing. Evidence suggests that these changes may diminish the ability of hospital nursing leadership to (1) represent nursing staff and management to each other and facilitate their mutual trust, (2) 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.
The senior nurse leadership position in hospitals has not always been an executive-level position. A 1983 national Commission of Nursing report and publications of the American Hospital Association recommended to hospitals that chief nursing officers (CNOs) be regarded as a key component of a hospital’s executive management team.2 Prior to this time, CNOs typically were not involved in strategic planning for the hospital overall; many did not participate in the development of the budget for their own department. Recommendations that nurses be involved in policy development and decision making throughout the organization were important in bringing the CNO position to the executive management team in many hospitals (Clifford, 1998).
This view of the CNO position is consistent with both old and new management concepts. Florence Nightingale, the founder of modern nursing, made major improvements in the education and training of nurses in the latter part of the nineteenth century. She proposed an administrative system for hospitals that included a triad of lay administrator, physician leader, and senior nursing leader. Her model was an important contributor to the development of hospital management systems and was responsible for the introduction of the position of superintendent of nurses to U.S. hospitals. Nightingale asserted that only those trained as nurses were qualified to govern other nurses (Clifford, 1998). This view also is consistent with the more recent management philosophy embodied in the Toyota Production System, which requires that all managers know how to perform the jobs of those they supervise (Spear and Bowen, 1999). Until recently, the CNO was the official leader of a hospital’s nursing staff. Although other administrative responsibilities may have been involved, the primary role of the CNO was the administration and leadership of the nursing service (Clifford, 1998).
In the past two decades, the role of the CNO has continued to expand as a result of service integration and hospital reengineering initiatives. In surveys conducted in 1993 and 1995 of nurse leaders in VHA, Inc. (a nationwide network of community-owned health care systems) and nurse executives and managers who were members of the AONE, 80 percent of all respondents reported changes in their role. Nearly all of these respondents identified expanded responsibilities as a major feature of their role change. The proportion of respondents holding positions whose title included the word “nursing” (e.g., director of nursing or vice president of nursing) declined from 55 to 24 percent, while the proportion holding positions whose title did not explicitly mention nursing (e.g., vice president of patient care, vice president of operations, and chief operating officer) increased from 35 to 53 percent. The new, expanded roles of these hospital nurse leaders included responsibilities for radiology departments, surgery, emergency departments, cardiology, nursing homes, outpatient services, admitting, and infection control units (Gelinas and Manthey, 1997). A more recent, 1997–1998 study of hospital restructuring in 29 university teaching hospitals found that the CNE position had been transformed into a “patient care” executive position in 97 percent of the institutions surveyed (Sovie and Jawad, 2001).
Even as CNOs have increasingly assumed these expanded managerial duties, they also have retained responsibility for managing nursing services. Research is needed on whether the expanded role of the CNO has beneficial or adverse effects on patients (Clifford, 1998). 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. What is agreed upon is that as the roles of nurse leaders have expanded, so have the demands of balancing two, often competing, sets of responsibilities as senior administrative staff and leader of nursing staff. As senior executive, the CNO must help the hospital meet its strategic goals, which are often financially focused. As leader of nursing staff, the CNO is responsible for providing clinical leadership. Concern has also been expressed that the attempt to meet both sets of responsibilities has resulted in the potential loss of a common voice for nursing staff and a weakening of clinical leadership.
Potential Loss of a Common Voice for Nursing
A 1996 qualitative study of the changing role of hospital CNOs in the not-for-profit flagship hospitals of three urban integrated delivery systems chosen by a panel of experts as being “at the forefront of change” found
that at these hospitals, the organizational boundaries of nurse leaders had shifted away from the traditional department of nursing to an organizational structure in which nursing services were unidentifiable and integrated. An expansion of management responsibilities appeared to be taking place in all nursing management roles, in one hospital resulting in the “dismantling of the nursing department.” That is, an identifiable central nursing department was no longer visible in the restructured hospital, as was manifest in the absence of nursing as an organizational element on the hospital organization chart. Moreover, fewer nurse managers, directors, and assistant nurse managers were found at all levels of the hospitals (Clifford, 1998).
This phenomenon has been documented to occur on a more widespread basis. In the previously cited 1993 and 1995 surveys of nurse leaders in VHA, Inc. HCOs and AONE nurse executives and managers, nearly one-third of all respondents indicated that after their redesign initiatives, there would no longer be a separate department of nursing (Gelinas and Manthey, 1997). 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. Those reporting “a director of nursing highly visible and accessible to staff” fell from 89 to 41 percent (Aiken et al., 2000). A more recent, 1998–1999 survey of nurses working in acute care hospitals in Pennsylvania additionally found that 58.3 percent of nurses reported a decrease in the number of nurse managers, and 16.8 percent reported the loss of a CNO without replacement (Aiken et al., 2001). The potential loss of the ability of these nursing leaders to represent staff nurses is articulated in a report on the findings of interviews with executives of 13 VHA, Inc. HCOs conducted in 1992. The nurse authors of the report state:
It was not uncommon to find nursing personnel reporting to non-nurse administrators, and former nurse executives responsible for non-clinical, non-patient care departments…. Nurse executives are fulfilling a variety of roles previously considered strictly administrative, including those of chief operating officer and CEO. In this capacity, it is inappropriate for them to be spokespersons for the nursing profession within their institution—they must be spokespersons for the broad function of patient care. Although this bodes well for improvements in patient care, it also dislocates the strongest voice for professional nursing issues. For the past 20 years or so, nurse executives have been spokespersons for the profession at the institutional, local, state, and national levels, both as individuals and through their organizations and associations. Because of the dramatic role changes underway, the ability of this group to effectively represent the nursing profession may be seriously compromised. The
nursing profession may be well-advised to find leaders from other settings—practice, education, or research. (Gelinas and Manthey, 1995:63)
Weakening of Clinical Leadership
Leadership for the clinical practice of nursing also has been identified as at risk. In the above-cited 1996 qualitative study of the changing role of hospital CNOs in three not-for-profit flagship hospitals, changes in the clinical leadership role of the CNO were found not to have kept pace with the growth and strength of the administrative responsibilities of that role. Similar changes were experienced down the line. The span of control of the midlevel director of nursing increased, and the incumbent had less time to spend with individual unit managers. Unit managers had less ready access to the midlevel director of nursing. They no longer had someone to whom they could readily turn to help them reflect on problems and issues requiring their attention. Similarly, the nurse unit managers’ span of control had increased. Some nurse managers were now responsible for more than one patient care unit as the number of nurse managers in these three hospitals decreased (Clifford, 1998).
These findings echo those of interviews with executives of 13 VHA, Inc. HCOs beginning in 1992. These executives reported that in organizations that had retained a traditional nursing structure, the number of nursing directors and nurse managers had been reduced. Nurse managers were often assigned responsibility for two nursing units, with an expansion in the number of assistants or charge nurses reporting to them at the shift level (Gelinas and Manthey, 1995). These additional duties likely leave the nurse manager with less time to provide clinical supervision or teaching (Norrish and Rundall, 2001).
Interview data from all three flagship hospitals in the 1996 study suggest the need for an ongoing, central locus of clinical leadership within the HCO (Clifford, 1998). 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. Nearly half of the nurse managers were also given additional responsibility for supervising personnel other than nursing staff (e.g., housekeepers, transportation staff, dietary aides). Assistant nurse manager positions were reduced in 68 percent of the hospitals. “The cumulative effect … was a reduction in the direct management support available to patient care staff” (Sovie and Jawad, 2001:591). This effect also is reported in other studies of HCO reorganization of nursing services (Ingersoll et al., 2001).
The committee finds that strong nursing leadership is needed in all HCOs in order to (1) represent nursing staff and management to each other and foster their mutual trust, (2) 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. Recent changes in the responsibilities of senior nurse executives and nursing management in hospitals, in particular, may place these functions at risk. The committee therefore makes the following recommendation:
Recommendation 4-1.3 HCOs should acquire nurse leaders for all levels of management (e.g., at the organization-wide and patient care unit levels) who will:
Participate in executive decisions within the HCO.
Represent nursing staff to organization management and facilitate their mutual trust.
Achieve effective communication between nursing and other clinical leadership.
Facilitate input of direct-care nursing staff into operational decision making and the design of work processes and work flow.
Be provided with organizational resources to support the acquisition, management, and dissemination to nursing staff of the knowledge needed to support their clinical decision making and actions.
Although the committee did not find evidence supporting the use of one particular organizational structure for locating nursing leadership within any one type of HCO or across all HCOs, the intent of this recommendation is to institute (among other management practices) well-prepared clinical nursing leadership at the most senior level of management—e.g., CEO’s direct reports—commensurate with physician leadership within the HCO.
Increased Emphasis on Production Efficiency
Many of the changes in nursing leadership described above were the result of organizational efforts to achieve greater efficiency (Sovie and Jawad, 2001). This increased emphasis on production efficiency (discussed also in Chapter 1) has been a hallmark of the hospital and health care reengineering initiatives of the last two decades (Bazzoli et al., 2002), par-
ticularly with respect to the work of nurses (Norrish and Rundall, 2001). In the 1993 and 1995 surveys of nurse leaders discussed above, although fewer than 17 percent of respondents identified cost reduction as a primary reason for their hospital’s redesign initiative, “reduction of costs” was the criterion employed most frequently to evaluate the outcomes of the initiative (reported by 90 percent of respondents) (Gelinas and Manthey, 1997). Concern that reorganization initiatives have focused on efficiency at the expense of patient quality also are commonly expressed by nursing staff involved in such initiatives (Barry-Walker, 2000; Ingersoll et al., 2001).
Experts in patient safety have identified safeguards that can be used by HCOs to defend against an overemphasis on efficiency at the expense of reliability (patient safety). First, HCO boards of directors should spend as much time overseeing an organization’s patient safety performance as they do dealing with financial goals and performance (Appleby, 2002). They should know (1) how patient safety is addressed in the HCO’s mission statement; (2) 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. The board should also receive regular progress reports on patient safety (Mohr et al., 2002) and review all sentinel events and the organization’s follow-up activities (Appleby, 2002). Further, a member of the HCO’s senior leadership team (excluding risk management) should serve as chief quality and safety officer, comparable to the chief financial officer. Just as the latter individual is in charge of monitoring and strengthening the organization’s financial performance, the chief safety officer should be responsible for patient safety measures and metrics (Appleby, 2002). This responsibility can be met by developing indicators of patient safety and quality that are collected and monitored before and after change initiatives are undertaken (Ingersoll et al., 2001).
Weakened trust has been widely observed by researchers studying and comparing hospitals as part of a national recognition program for hospitals that have achieved high levels of nurse retention (Kramer and Schmalenberg, 1993:62): “As we have visited and studied nursing departments all over the country, we have been struck by the amount of distrust perceived by nurses—not only from physicians but also from nurse managers and administrators.” The researchers contrast this situation with the work environment observed at one hospital (Edward Hospital in suburban Chicago), where high levels of trust were present:
At EH we observed some of the most flagrant disregard for the “on paper” bureaucratic structure that we have ever seen. Repeatedly, when asked how they would handle a situation, nurses told us that it depended on the situation, but that they felt free to ignore the formal structure if the situation demanded it. The perception of openness and trust was almost unbelievable; there was absolutely no reticence to share anything with us—good or bad. “We can say what we think and feel; I know that nothing bad will happen to me if I do.” Nurses talked openly and freely about failures, faults and mishaps, as well as about the positive things in the organization. Not a single nurse asked that any of our interview material be kept confidential. This open and trusting atmosphere is remarkable, especially because of its scarcity. (Kramer and Schmalenberg, 1993:62)
Loss of trust in administration by nursing staff is frequently reported in studies of HCO redesign and reorganization initiatives that have taken place in the last two decades (Decker et al., 2001; Ingersoll et al., 2001). 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. “Whether the change was actual or symbolic did not matter; the distancing was felt.” The nurses needed to trust that someone who understood their practice was advocating at the highest levels of the organization for what they were doing on behalf of patients and families (Clifford, 1998:111).
Other reports of loss of trust during reengineering initiatives are frequently associated with poor communication practices. In a study of major reorganization at two acute care hospitals, loss of a trusting relationship with administration was reported as stemming from a perception (constant across hospitals and nursing units) that information was being withheld and that administrators were not aware of the circumstances that existed at the nursing unit level (Ingersoll et al., 2001). A study of reengineering efforts at 14 U.S. hospitals provides examples of poor communication patterns that reduced employees’ trust in the administration:
Many hospitals promised that there would be no “sacred cows” or areas that would be exempt from reengineering examination. In reality, however, almost every hospital exempted certain areas. One major vendor was also a major donor to the hospital and was excluded. A specialized service area earned too much income to be disturbed and was declared off-limits. A physician was too powerful to be challenged. It seemed that every hospital had some idiosyncratic situation that prevented full participation. The promise of full participation, followed by selective exemptions, resulted in increased cynicism and damaged trust. (Walston and Kimberly, 1997:157)
Honesty with communication is also important … executives would initially communicate through the planning process that quality and employees’ jobs would be protected but, when implementation occurred, employees felt both were affected. One chief financial officer in the final stages of planning his reengineering project told us he did not think that they had been totally honest about what was going to happen as he anticipated a large layoff, but they had not been allowed to even use the words layoff or severance. (Walston and Kimberly, 1997:156)
As a result of these poor communication patterns, trust was low, and employees repeatedly disregarded information. Hospitals reported that employees would regularly discard internal communications and fail to attend informational meetings. Executives would then wonder why letters and speeches to employees were not helping to alleviate concerns and communicate the organization’s direction. This distrust was found to result from the organization’s own actions (Walston and Kimberly, 1997).
Countermeasures to diminished trust include frequent and ongoing communication, involvement of workers in the design and evaluation of change initiatives, and other change management practices as described in the next section. Moreover, regardless of whether an HCO is undertaking a formal redesign or reengineering process, involving nurses in work decisions and providing them with control over caregiving practices by empowering them to make clinical decisions have been linked to greater levels of organizational trust (Laschinger et al., 2000). This observation is discussed in greater detail in the section below on work design and work flow decision making.
Poor Change Management
Very little documentation exists about how HCOs have implemented reengineering and restructuring initiatives. One well-designed study involved intensive interviews with 60 executives, 121 midlevel 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. Although the researchers acknowledge that selecting hospitals that used the same consulting firm may have created bias, they note that they took great care in choosing a sample of hospitals that varied by size, geographic location, and organizational affiliation and ownership. The findings of this study and a few others indicate that the change management practices identified in the previous section (i.e., ongoing communication; worker training; use of mechanisms for measurement, feedback, and redesign; sustained attention; and worker
involvement) are not consistently observed in the reorganization, redesign, and reengineering initiatives undertaken by hospitals. Often these failures are intertwined.
Walston and Kimberly (1997) found that although all redesign initiatives began with planned communication strategies that included special newsletters, employee meetings, forums, and one-to-one meetings between managers and employees, communication was either discontinued or not updated to provide feedback on the status of the project after its initial stages. As communication efforts declined, employees fell back into old routines. Thus, these poor communication practices also reflected a lack of sustained attention to the change initiative. Poor communication from administration to staff throughout reengineering initiatives has also been reported by nurses (Barry-Walker, 2000; Ingersoll et al., 2001) and other workers (Decker et al., 2001) involved in other individual hospital reengineering initiatives.
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. Nurses commented that excellent clinical nurses frequently lacked the management skills necessary to direct and delegate responsibilities to a subordinate team, and that delegation and managerial skills were not routinely taught. At the same time, senior management did not appear to recognize that many of the necessary managerial skills are cognitively learned competencies and should be addressed prior to the assignment of new responsibilities.
This finding is echoed by hospital nurse executives involved in reengineering initiatives who reported needing the following additional knowledge to help them meet the new expectations set for them by their HCO (Gelinas and Manthey, 1997):
Use of clinical pathways and other quality improvement tools to measure and manage outcomes
Understanding of managed care
Understanding of finance, including capitated environments and risk sharing
Change management expertise
The need to train nurse managers in delegation and management skills, strategies for dealing with role change, and the economic and policy factors that contribute to changes has been documented in other studies as well (Ingersoll et al., 2001).
Walston and Kimberly (1997) 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), new workers were assigned patient responsibilities, such as the performance of electrocardiograms and phlebotomies, only to function very inadequately. Much of the rework fell back on nursing staff. The researchers note that training costs are high when comprehensively addressed. One 500-bed hospital spent $700,000 on its training in the first 2 years of its reengineering initiative. This hospital also performed a gap analysis to identify those roles not being performed adequately and to evaluate what additional training was needed. The reviewers concluded that such continual evaluation of training needs is important to the effective implementation of new roles and responsibilities.
Lack of Measurement and Feedback
Walston and Kimberly (1997) observed a lack of measurement and feedback to staff on the progress of reengineering efforts. In many situations, feedback either was not provided at all or if provided, was not well understood. Both managers and employees frequently reported that they rarely heard about the results of reengineering efforts. Although every hospital developed some type of data tracking mechanism, employees typically either lacked access to the data or felt that the availability of the data was inadequate. This inability to record and display the progress of reengineering frequently caused a perception that the outcomes would not be sustained and resulted in diminished efforts to sustain the process.
Walston and Kimberly (1997:153) further found that effective organizational reengineering initiatives require long periods of time and constant effort. “Many hospitals that were two to three years into their engineering effort had yet to implement all of their initial plans. The most simplified plan of any of the hospitals demanded at least a year to analyze, plan, and implement.” During this time, employees expressed concern that the engineering initiative “drifted” and lacked consistency. The transition from initial implementation to sustained operation of the reengineered processes
was most at risk. “Although many hospitals perceived reengineering to be a continual change process that would reorient their organizations, many facilities ended their efforts at least temporarily, after the initial implementation. Without continued and constant efforts, the organizations drifted back to the status quo. A mid-manager from a large teaching hospital reported, ‘The gains are now disappearing as people go back to their old ways of doing things’” (Walston and Kimberly, 1997:160).
Lack of sustained attention is, in part, a function of how an organization codifies a change through formal reporting structures, management tools, and policies and procedures. A 1996–1997 survey of CEOs of U.S. general medical–surgical hospitals located in urban areas and with more than 100 beds found that 40 percent of the 29.4 percent of responding CEOs had not formalized the change process through written manuals, guidelines, budgets, or some combination of the three (Walston et al., 2000).
Low Worker Involvement in Developing Change Initiatives
Walston and Kimberly (1997:157) also found a lack of uniform involvement by organizational departments in HCO reengineering efforts:
Most of the hospitals had a single individual that was the “champion” of reengineering. This was generally a top executive—the chief nursing officer, the chief executive officer, the chief financial officer, or an associate administrator…. 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. When they presented their plan to the hospital’s steering committee for approval, they were informed that they could proceed with their recommendation except for the respiratory therapy component. Respiratory therapy had previously obtained approval from the steering committee without nursing’s knowledge for its own plan that called for laying off a number of part-time respiratory therapists, providing a fixed number of inpatient therapists, ranking all patients according to the severity of their need for respiratory therapy, and providing care to only the sickest patients as far as the fixed hours would allow. Nursing was both astonished and angry, for respiratory therapy was allowed to exempt itself from a coordinated reengineering process and its solution would pass a great amount of work back to nursing services. Variations of this problem occurred in many other hospitals causing inconsistent participation and ineffective implementation.
In addition, limited involvement of nurses (Barry-Walker, 2000) and other health care workers (Decker et al., 2001) has been reported in studies of individual HCO reengineering efforts.
Limited Involvement in Decision Making Pertaining to Work Design and Work Flow
The involvement of nurses in decision making has varied over time and by the hierarchical level of the nurse within the HCO. In the 1970s and 1980s, under the primary care model of nursing practice, hospital nurses had responsibility for clinical nursing care decisions for assigned patients for the patients’ entire hospital stay (see also Chapter 3). Moreover, as a result of some of the health care integration and reengineering initiatives of the 1980s and 1990s, nurses in charge of an 8-hour shift (often called shift “charge nurses”) were elevated to the position of “nurse managers” who functioned—with responsibility 24 hours a day, 7 days a week—as the head of a nursing unit. These nurse managers often were made responsible for hiring personnel, allocating resources, evaluating performance, setting standards of practice, and disciplining staff who did not meet standards or competency expectations (Norrish and Rundall, 2001). This shift in responsibilities coincided with the promotion of “shared-governance” models of nursing practice that promised increased participation of nursing staff and management in operational and policy decision making. As described previously, however, descriptions of shared governance have shown wide variation in the specific decisions made or shared by nurses and managers, which staff are included in the shared-governance decision making, and whether nurses have authority for decisions individually or collectively. Thus, models of shared governance have ranged from minimal, ad hoc, informal participation by some nursing staff in a limited number of decisions to models in which the authority and accountability of professional nurses are codified within the organization, and formal decision-making structures and processes are in place that enable nurses to define and regulate nursing practice and share decisions with administrators regarding the management of resources (Maas and Specht, 2001).
Shared-governance practices waned in the 1990s as reengineering and integration initiatives modified the roles of nursing staff and management. 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., 2000:463). 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., 2001).
Limited Knowledge Management
As discussed earlier, learning organizations take advantage of all sources of knowledge, use systematic experimentation to generate new knowledge internally, and transfer knowledge quickly and efficiently throughout the organization. The little available evidence on knowledge management as practiced in nurses’ work environments indicates very limited use of these practices. A search for “knowledge management” or “learning organization” in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for English-language publications, with no date limitations, yielded but a few articles. 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. However, a similar MEDLINE search for the years 1971–2003 returned only 24 articles with these topics in the title.
Knowledge is available from multiple sources: from internal HCO sources such as total quality management, risk management, and patient and provider experiences with care delivery, as well as from external sources such as research, the professional literature, technology assessment reports, and authoritative practice guidelines. According to Donaldson and Rutledge (1998:6), however, organizational translation of new knowledge from external sources into language and operations familiar to potential users has been “largely ignored in nursing literature.” Six large-scale multifaceted studies of the diffusion and utilization of nursing research undertaken over the past two decades have documented the need to build knowledge utilization infrastructures, expand the capacity of individual nurses to take up new knowledge, and expedite the transmission of new knowledge from external sources to nurses (Donaldson and Rutledge, 1998).
There is also evidence that HCOs do not learn well from internal sources of information. A Harvard Business School study of hospital nurses, their errors, and the extent to which they actively seek to prevent future occurrences of similar errors found that hospitals are not learning from the daily problems and errors encountered by their workers (Tucker and Edmondson, 2003). Twenty-six nurses at nine hospitals were observed for 239 hours, and interviews were conducted with 12 of the nurses at seven sites. Researchers purposely selected hospitals with a reputation for nursing excellence by asking nursing governing boards for referrals to such hospitals and by searching the nursing literature on magnet hospitals. Their goal
was not to employ a representative sample of hospitals, but to assess how excellent nursing hospitals handle service failures. From these observations, common basic patterns of problem-solving behavior across the nine hospitals were identified.
Researchers distinguished two types of process failures: “errors” and “problems.” “Errors” were defined as the execution of a task that was either unnecessary or carried out incorrectly. “Problems” were defined as disruptions of the nurse’s ability to execute a prescribed task because a resource was unavailable at the needed time, location, or condition or in sufficient quantity (e.g., missing supplies, information, or medications), thus preventing the task from being implemented.
Of the 194 observed failures, 86 percent were problems rather than errors. 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. However, researchers found that nurses tended to practice “first-order” problem solving, that is, fixing the immediate problem without communicating that it occurred, investigating why it occurred, or seeking to change its cause. Thus the problem was isolated so that it did not become visible to the hospital as an opportunity to learn how to be more efficient or effective in patient care. Second-order problem solving, in contrast, occurs when a worker, in addition to fixing the problem so the task at hand can be completed, takes action to address the underlying cause. Researchers used lenient criteria—i.e., encompassing any behavior that called attention to the problem—to assess the extent to which second-order problem solving had occurred. Nonetheless, only 7 percent of nurse responses were second-order.
Researchers identified three human resource practices that explained why so few problems had received second-order attention that would have enabled the organization to learn from the problems and correct systemic weaknesses. First, instilling in nurses a strong sense of responsibility for individual vigilance can, as a side effect, encourage such a strong emphasis on independence and self-sufficiency that they see a failure not as a system problem, but as one that can be overcome or withstood through individual competence. The majority of the nurses interviewed commented that they believed their manager expected them to work through daily disruptions on their own. Speaking up about a problem or asking for help was likely to be viewed as a sign of incompetence. Second, staffing levels were so tight, with so little slack in the system, that nurses did not have the time to eliminate underlying causes of problems. Instead, they were “barely able to keep up with the required responsibilities and [were] in essence forced to quickly patch problems so they [could] complete their immediate responsibilities” (Tucker and Edmondson, 2003:9). Finally, removal of front-line managers
and other personnel not involved in direct patient care from daily work activities left workers on their own to resolve problems. At hospitals characterized by second-order problem solving, either nurse managers were a strong presence on the floor, or there was a designated person available to provide guidance and support to nurses (Tucker and Edmondson, 2002). The researchers concluded that “reducing the degree to which managers are available to front-line staff can be a loss for improvement efforts, especially when workers are already overburdened by existing duties” (Tucker and Edmondson, 2003:10).
The researchers identified several countermeasures to first-order problem solving to enable organizational learning. First, managers must be available to staff nurses for at least a portion of all shifts. The researchers observed that the presence of managers increased the likelihood of their being informed of problems occurring on the unit, thus enabling them to investigate and intervene with systemic solutions. Managers also serve as role models for system-level thinking, encouraging nurses to think of second-order solutions. Second, management needs to create a “fair and just” work environment (discussed in Chapter 7) that encourages workers to feel secure in reporting both errors and problems so system performance can be enhanced (Tucker and Edmondson, 2003). Also, if workers are to engage in identification and elimination of systemic problems, this activity should be an explicit part of their job description (Tucker et al., 2002), and they should receive training in its application (Tucker and Edmondson, 2002). 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, 2003).
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. Leaders of HCOs should take action to identify and minimize the potential adverse effects of their decisions on patient safety by:
Educating board members and senior, midlevel, and line managers about the link between management practices and safety.
Emphasizing safety to the same extent as productivity and financial goals in internal management planning and reports, and public reports to stakeholders.
Recommendation 4-3. HCOs should employ management structures and processes throughout the organization that:
Provide ongoing vigilance in balancing efficiency and safety.
Demonstrate trust in workers and promote trust by workers.
Actively manage the process of change.
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. Indeed, they are currently practiced in a number of nursing work environments described in the next section.
MODELS OF EVIDENCE-BASED MANAGEMENT IN NURSES’ WORK ENVIRONMENTS
The five evidence-based management practices described above have been employed successfully in a number of nurse work environments by HCOs acting alone or in collaboration with one another. Examples include magnet hospitals, the Pittsburgh Regional Healthcare Initiative, and the Wellspring model of long-term care.
In the early 1980s, during one of the cyclical nursing shortages, a task force of the American Academy of Nursing undertook a study to identify those hospitals—labeled “magnet hospitals” that had no difficulty in attracting and retaining nurses during such shortages (McClure et al., 1983). Through two decades of research, the characteristics of these magnet hospitals have been articulated and their relationship to nurse and patient outcomes studied.
In the original magnet hospital study, 165 organizations were identified across the country that fit three criteria: (1) nurses saw the hospital as a good place to work; (2) the hospital was able to recruit and retain nurses (as measured by a lower-than-usual turnover rate during a nursing shortage situation); and (3) the hospital was located in a market area that included other hospitals competing for its nurses. Based on a review of the hospitals’ recruitment and retention records as well as other material, 41 organizations were selected as magnet hospitals (McClure et al., 2002). Systematic interviews with the CNE and a selected staff nurse from each organization provided the data for an analysis of the characteristics that attracted and retained nurses in these hospitals. Magnet characteristics were identified in the areas of administration, professional practice, and
professional development. Many of the leadership and management practices cited previously (providing strong leadership, managing change, creating and sustaining trust throughout the organization, involving workers in decision making pertaining to work design and work flow, and establishing the organization as a learning organization) have been documented as present in magnet hospitals.4
In a series of six surveys between 1985 and 2001, Kramer and Schmalenberg refined the original set of magnet characteristics. Their studies included a subset of 16 of the original magnet hospitals, selected by geographic location. The surveys involved interviews of CNEs, staff nurses, nurse managers, and clinical experts (Kramer, 1990a,b; Kramer and Schmalenberg, 1988a,b, 1991, 1993; Kramer et al., 1989). In these surveys, eight essential characteristics associated with magnetism were again identified by two-thirds or more of the staff nurses interviewed. They included working with clinically competent nurses (an essential element of trust), nurse autonomy and accountability, having a supportive nurse manager/supervisor (a component of both leadership and trust), control over nursing practice, and educational support (Kramer and Schmalenberg, 2002).
Two studies have examined patient mortality rates in relation to magnet hospital status. In the late 1980s, 39 magnet hospitals were compared with 195 nonmagnet matched hospitals using Medicare mortality rates. Adjusting for differences in predicted mortality for Medicare patients, the magnet hospitals had a 4.6 percent lower mortality rate, which translates to 0.9 to 9.4 fewer deaths per 1,000 discharges (Aiken et al., 1994). In a second study, patients with AIDS in magnet hospitals and those with AIDS in nonmagnet hospitals with and without designated AIDS units were compared. Patients in the magnet hospitals had a lower chance of dying than those in the nonmagnet hospitals regardless of the existence of designated AIDS units (Aiken et al., 1999). In the early 1990s, the American Nurses’ Association, through the American Nurses’ Credentialing Center (ANCC), established a formal certification program through which hospitals and nursing homes may apply for “magnet status.” The criteria for selection are based on the characteristics originally identified, as well as on specific standards of practice and administration.
In the above studies, the major administrative determinant of magnetism was found to be the quality of leadership from the CNE (Kramer and
Schmalenberg, 1988a,b; McClure et al., 2002). This individual was visible in the organization, took part in policy-level decision making, and set the stage for a decentralized organizational structure and participative management. His/her leadership style conveyed respect for the staff nurses and trust in their ability to provide high-quality patient care. In Kramer and Schmalenberg’s 1989–1990 study comparing magnet and nonmagnet hospital nurses’ perceptions of leadership–management values, staff nurses at magnet hospitals gave significantly more positive responses (p > 0.001) on such items as “Our nursing leaders are visionary, and they communicate and implement ideas, values and goals”; “Potential problems are anticipated and worked on before they become problems”; and “With stable expectations of what must be done to achieve goals, people here are free to experiment and try new things” (Kramer and Schmalenberg, 2002).
Presence of Trust
The presence of trust in the work environment of magnet hospitals was found to be facilitated by the nursing leadership, as discussed above, and also by strong clinical competence among nursing colleagues. Competence was revealed as one of the most essential characteristics of trust, as described earlier in this chapter. Indeed, the clinical competence of nurse colleagues has been identified consistently by staff nurses as a feature of magnet hospitals since 1986, when Kramer and Schmalenberg’s first study surveyed 1,634 staff nurses in 16 of the originally designated magnet hospitals (Kramer and Schmalenberg, 1988a,b). Kramer and Hafner (1989), for example, report that working with clinically competent nurses was associated with positive relationships among coworkers, low turnover, effective nursing, and job retention. The investigators quote staff nurses as saying they could work with fewer staff if they had clinically competent nurses they knew and could trust.
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., 1999). As discussed earlier, a distinction is made between autonomy and control over nursing practice. Autonomy refers to nurses’ control over their work, 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, 2002; McClure et al., 1983; Scott et al., 1999). Control over nursing practice is an organizational level of autonomy, in which staff nurses, nurse managers, and CNEs
participate in all levels of hospital policy decisions about professional practice and patient care (Kramer and Schmalenberg, 2002; Scott et al., 1999). Magnet hospitals score higher on greater autonomy for nurses to act and greater nurse control over resources for patient care (Aiken et al., 1997).
A series of studies comparing the hospitals identified as having magnet characteristics in 1983 (the original magnet hospitals) with hospitals that subsequently received that designation from the ANCC found that the latter hospitals had significantly higher levels of nurse autonomy and control over practice. 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. CNEs in ANCC magnet hospitals (n = 24) viewed autonomy and control over nursing practice as stronger than did CNEs in the original magnet hospitals (n = 24). Three differences among the hospitals were identified as explaining the higher rating of the ANCC hospitals: the latter hospitals had a department of nursing to which nurses were responsible; they were more apt to have a nurse-researcher providing data for decision making; and they regarded nursing as a distinct profession, making a highly valued contribution (Havens, 2001).
Professional development, including teaching students, is consistently cited as an important magnet characteristic in terms of continued learning and career development through formal and informal methods. In the original magnet hospital study (McClure et al., 1983), an essential characteristic identified was professional development, including continuing educational opportunities and support for career development through formal education. A high proportion (92.7 percent) of the directors of nursing held masters or doctoral degrees. In Kramer and Schmalenberg’s 1986 study of a subset of the magnet hospitals, a median of 51 percent of the staff nurses had a BSN or had matriculated in BSN study, compared with a national average of 33–34 percent (Kramer and Schmalenberg, 1988a,b).
This magnet characteristic was identified more recently by Kramer and Schmalenberg as one of the most essential features of magnetism cited by staff nurses. Magnet hospitals use a number of strategies to provide support for education and continuing career development for staff nurses, such as tuition for degree programs, in-service programs, short-term courses, externships for student nurses, and internships for new graduates (Kramer and Schmalenberg, 2002).
Pittsburgh Regional Healthcare Initiative
The Pittsburgh Regional Healthcare Initiative (PRHI) is a coalition, begun in 2000, of 35 hospitals; four major insurers; more than 30 major and small-business health care purchasers; numerous corporate and civic leaders; organized labor; state and federal governments; and academic and research institutions, including Carnegie Mellon University, RAND Corporation, the University of Pittsburgh Center for Health Services Research, and Purdue University (Feinstein, 2002). 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” (Feinstein 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).
PRHI is spearheaded by a “leadership obligation group” comprising hospital and other corporate CEOs charged with keeping the initiative moving forward (Robinet, 2002). It focused initially on two patient safety goals: eliminating medication errors and hospital-acquired infections (Feinstein et al., 2002). Multidisciplinary advisory committees at each PRHI partner facility adopted and use the same incident-reporting system for hospital-acquired infections and medication errors. In a partnership with the U.S. Centers for Disease Control and Prevention (CDC), PRHI hospitals developed a common reporting tool based on CDC’s national Nosocomial Infection Surveillance System—the oldest and most widely used surveillance system for hospital-acquired infections—and a similar standardized web-based error-reporting tool for medication errors. PRHI hospitals share their data with each other, as well as nationally. The data are translated into knowledge that front-line health care workers can use to protect patients (Feinstein, 2002).
PRHI collects data from all participating hospitals, maps them to patient outcomes, and correlates them with processes of care. Based on those findings, its members institute experimental changes in work design to improve patient safety. In this way, PRHI carries out the practice of becoming a learning organization. Groups of people actually performing the work determine the root cause of a problem, experiment with ways to solve the problem using scientific methods, and then measure the results and share what has been learned (Feinstein et al., 2002). PRHI partners empower health care workers to address problems. When a problem is detected, a team of workers designs a solution immediately, employing a set of predesigned principles and scientific methods. Every worker is expected to be-
come a scientist and to contribute to rapid, frequent improvements. PRHI also includes a Center for Shared Learning that coordinates all PRHI improvement efforts.
The Wellspring Alliance
Wellspring Innovative Solutions, Inc. (Wellspring) is a federation of 11 freestanding not-for-profit nursing homes in eastern Wisconsin. Fully operational since 1998, its two-fold purpose is to improve the clinical care provided to residents and to create a better work environment for employees. A 15-month evaluation of the Wellspring model found:
Better patient surveillance by staff.
Improved performance as measured by federal oversight surveyors.
Better quality of life for patients and improved quality of staff–resident interactions.
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.
Leadership and management support is provided by a formal organizing superstructure (The Wellspring Alliance) that, in addition to carrying out several practical functions, such as joint purchasing, provides a forum for collaborative information sharing, education and training, and knowledge dissemination across the facilities. The Alliance functions on many levels, including CEOs; administrators; line staff; and a designated Wellspring coordinator in each facility, whom evaluators identified as arguably the single most important contributor to the successful implementation and sustained operation of the Wellspring model. Coordinators serve as both a formal link between the facility and the Alliance and an informal conduit of information across facilities. These individuals meet and interact at quarterly meetings and training events and help codify lessons learned.
Employee education and training are facilitated by a geriatric nurse practitioner who serves as a primary resource on clinical care, develops staff training modules, provides centralized clinical education and training to staff, and travels to member facilities on a quarterly basis to provide feedback to the facility and reinforce and sustain the adoption of the clinical practices taught in the various modules. Training is cross-disciplinary and targeted to employees as team members. Team members learn collabo-
rative problem solving and share responsibility for resident outcomes. Wellspring uses this team training as a way of decreasing the hierarchical relationships that are typical in nursing home staff relationships.
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), voluntary, and self-directing. Teams are expected to identify and develop new work strategies, monitor implementation success, and intervene when problems in implementation arise.
The Wellspring Alliance fosters the evolution of all its member facilities into learning organizations through several practices. One is the sharing of the geriatric nurse practitioner and the facility coordinators to disseminate and nurture the adoption of evidence-based best practices in the care of residents. Another strategy being pursued is having each member facility enter data (e.g., number of incontinent episodes, falls, and weight loss) into a common data set on a quarterly basis (although evaluators found this aspect of the Wellspring model to be most problematic and least well implemented). A data analyst aggregates the data, prepares analytic reports, and presents these reports at quarterly meetings. This practice facilitates the systematic transfer of knowledge across facilities and nursing units, through the clinical resource teams, to staff, and the application of that knowledge is sustained through regularly scheduled care resource team meetings in the facility (Stone et al., 2002).
USE OF EVIDENCE-BASED MANAGEMENT COLLABORATIVES TO STIMULATE FURTHER UPTAKE
The PRHI and Wellspring models described above are examples of learning collaboratives in which resources, knowledge, and experiential learning are shared to improve clinical practice. Collaborative approaches have also been used as mechanisms to facilitate the uptake of health care quality improvement practices (Institute for Healthcare Improvement, undated), technology assessment and dissemination (The Health Technology Center [HealthTech], 2003), and strategic marketplace assistance for HCOs (VHA, 2003).
Evidence-based management collaboratives (EBMCs) have been proposed as a means of bringing together managers, consultants, and researchers to improve health care management and thereby organizational performance (Kovner et al., 2000). These collaboratives would consist of a team of managers, researchers, and consultants from a variety of organizations whose aim would be to better understand problems in effective health care management and to develop more effective approaches to managing health systems. EBMCs would provide access to data and partners within an
organization’s network to permit pooling of data and resources for the conduct of research, demonstrations, and evaluations that no single organization could undertake. Estimates are that just 10 percent of the annual consulting budget for a large health system redirected to such a collaborative would be sufficient to finance this capacity. EBMCs could be implemented across several different health systems, in one health system, or both. Organizing across systems that are in competition in specific markets has been identified as difficult; thus, organizing noncompeting organizations and their existing alliances has been proposed as an initial approach.
EBMCs would require (1) a strong commitment to improving health care management through the application of evidence, (2) a willingness to use and share management data from compatible management information systems to track and monitor strategic interventions and organizational performance, (3) an interest in participating in applied research, and (4) an interest in being involved in demonstration projects to improve health system performance. In return, collaborative partners would receive comparative information on current ways of organizing services; access to the collective experiences of other cooperative members; results from applied research projects; and an array of technical assistance on statistical, management, and marketing issues (Kovner et al., 2000).
A critical partner in these endeavors would be a research center, typically university-based, with an interest and capacity in applied research on health systems and performance, strategic initiatives, and related management and financial issues. The academic partner could provide expertise in data analysis, survey design, program evaluation, and professional education. In addition to serving its collaborative members, the EBMC could assist in disseminating its findings to a broader community of HCOs through peer-reviewed journals, and in training new evidence-based managers and health services researchers (Kovner et al., 2000).
The prototype EBMC is the Center for Health Management Research (CHMR), 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.
Undertake research, development, and evaluation projects in pursuit of that agenda.
Disseminate research findings and successful management practices of other HCOs and other industries to its members.
Now involving 17 academic centers with graduate programs in health services administration (personal communication, T. Rundall, University of California, Berkeley, May 2003), CHMR is sponsored by the National Science Foundation (NSF) under its Industry/University Collaborative Research Centers program. It is the only one of the 50 NSF Collaborative Research Centers to receive this designation for the field of health services administration (Center for Health Management Research, 2003). CHMR is also supported by its 10 member health systems, which provide financial resources, collaborate on setting research priorities, and allow researchers to collect data at their various facilities. These members are thereby able to develop and implement a research agenda focused on their defined interests and needs. By serving as the primary sites for CHMR research, member institutions also are able to develop, test, and evaluate management practices, as well as other innovations and new technologies. CHMR practices are disseminated to entities not part of the collaboration through published reports and journal papers. Studies are designed with the transferability of research findings in mind. Other activities include commissioning papers to review and synthesize research findings on selected topics, conducting roundtable discussions on management topics, and holding dissemination conferences where members receive oral and written presentations from researchers (Walshe and Rundall, 2001).
CHMR has undertaken a wide range of research projects to enable evidence-based managerial decision making in its member health systems. By design, its corporate members are integrated delivery systems, and the overarching theme of its research projects has been the strategies, structures, processes, and performance of such systems. One recent research project addressed mechanisms for building more effective relationships between the HCO members and physicians (Walshe and Rundall, 2001). 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. Professional associations, philanthropic organizations, and other organizational leaders within the health care industry should sponsor collaboratives that incorporate multiple academic and other research-based organizations to support HCOs in the identification and adoption of evidence-based management practices.
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