Nurse Engagement & Quality: Emory's Journey to Professional Growth

Added on Sep 19, 2019

nurse_patientLyingDownNurse Engagement and Quality: The Journey to Professional Growth for Emory’s Neuroscience ICU
By Whitney M. Fishburn

When the number of beds in Emory University Hospital’s neuroscience intensive care unit increased by one-third, leaders soon realized the necessary focus on recruitment and retention might be eclipsing their usual emphasis on quality, so they knew they had to take action.

“Maintaining a high level of professionalism in the environment of a staffing shortage is very tough,” said Clint Owens, RN, unit director of the neuroscience ICU at the Atlanta-based teaching hospital. “We saw that the added pressure meant we had to be explicit in how we defined professionalism,” he said. To this end, the team developed a clearly stated, objective definition of engagement and tied it to a point-based system for annual performance reviews.

Since linking engagement to performance, the unit has seen significant gains across most nursing quality indicators, an uptick in clinical inquiry and advanced certifications, and increases in its staff engagement and patient experience scores.

Identifying Obstacles to Performance Improvement

After years of needing to divert patients, in 2016 Emory’s neuroscience ICU expanded from 27 to 39 beds. To meet the increased staffing needs, several large cohorts of recent graduates from the university’s nursing program were oriented to the unit. With natural attrition, however, the unit remained in critical staffing mode for more than a year. During this time, leadership on the unit observed a decrease in staff engagement and less of a focus on quality initiatives, as evidenced by a drop in completed improvement projects.

“Engagement can sometimes fall by the wayside in such an environment because the greatest need is to take care of the patients, cover the shifts, and be there for each other,” Owens said.

Redirecting staff toward quality and professionalism through annual performance reviews proved difficult, according to Owens, because the health system’s definition of achievement was subjective and the path to performance excellence was not transparent.

At the same time, acclimating the new hires also posed a challenge. “The journey from just graduating to becoming a neuroscience ICU nurse is one of the most difficult transitions nurses may make in their careers,” said Lauren Paris, the unit’s clinical nurse specialist.

Leadership wanted the new recruits early in their tenure to understand the connection between excellent nursing practice and patient care outcomes, and to participate in building a culture of clinical inquiry, quality improvement, and professionalism. This focus extended to experienced staff as well.

Defining and Implementing the Solution

To meet both challenges and solidify the unit’s individual and collective goals, a unit practice council comprising several bedside nurses collaborated to create an objective definition of engagement that emphasized the collective betterment of the unit, whether through clinical quality, the science of nursing, or promotion of a healthy work environment. As a guide, the council used the American Association of Colleges of Nursing’s statement on healthy work environments, which says an uncomplicated stay driven by a high degree of nursing quality will lead to better patient outcomes and improved patient and family experiences. The council also drew from Emory’s existing performance review structure, which evaluates a nurse’s individual contributions to the unit and to patient care, and the manner in which the nurse executes those tasks.

This new definition of engagement directly correlated with annual performance evaluations through a comprehensive, point-based guideline that weighted unit goals for engagement and quality initiatives with the individual staff member’s personal expectations. Higher point values for unit priorities were used to draw attention to quality initiatives and their importance in overall unit performance. Weighted involvement in committees focusing on specific quality metrics further highlighted the emphasis on quality, as did weighted point values for other unit priorities such as Magnet® certification and quality improvement projects, and the advancement of nursing science.

To ensure buy-in of the revised performance improvement criteria, leadership presented the program in a town hall format that allowed time for staff questions, using the ensuing discussion to emphasize how the revisions gave nurses increased autonomy. By introducing the program in this way, leadership remained consistent with the spirit of shared governance they hoped to cultivate.

The results were nearly immediate, said Paris. “The increased level of autonomy among senior staff encouraged an atmosphere of clinical inquiry that became contagious to new staff.”

This enthusiasm was bidirectional. “Our more seasoned nurses, those who’d never really participated in evidence-based projects before, ended up taking an interest in learning new skills, such as creating a spreadsheet to track progress,” said Paris.

Data Indicate Progress

Between January 2017 and January 2018, the unit’s compliance rate for nurses completing a mandatory quality improvement or performance improvement project rose from 90% to 97%. During that time, the unit also saw an increase in staff members who advanced in the health system’s professional development program, with 20 nurses obtaining specialty certification.

The ICU’s patient experience scores increased 51 percentage points from Q3 2016 to Q3 2018, and the unit performed in the top 10% for all of 2018.

In 2018, pulse surveys of employee engagement were conducted on a continual basis across 18 focus areas, allowing for real-time course correction whenever necessary. Using this feedback, the unit increased its score by four percentage points across the survey’s manager domain spectrum in a nine-month period, which is eight percentage points over the national average. Action planning readiness during that time also improved from 89 to 91. This helped Emory’s overall engagement scores advance from 4.27 to 4.41, moving the organization from the 79th to the 95th percentile.

Data analyses also showed where improvement was still needed. Leadership noted that some of the point determinations allowed nurses to reach higher levels of achievement on their annual performance evaluations, but didn’t result in significant contributions to the unit or align with unit goals. Additionally, some “high achievers” were too focused on certain activities, resulting in lopsided skill development. Adjustments were made going into the second year of the program, yielding the desired increase in a broader range of skills across all personnel and meeting more of the unit’s overall needs.

In 2019, the completion rate on the unit for the mandatory quality or performance improvement project went from 97% to 98.4%, with only two nurses failing to complete their project. “While it isn’t a large improvement, we’re nearing the point where very little improvement is possible, being so close to 100%,” said Paris.

For Q3 2019, the unit’s engagement scores are still above average, but some up-and-down movement suggests a need to revisit the performance point system to see what further adjustments are necessary, according to Paris.

Why the Point System Works

Shifting the focus of nursing in Emory’s neuroscience ICU required an innovative approach to tie together individual staff incentives and overall unit goals. The point system for performance determinations allowed nurses autonomy and provided them with a blueprint for how to reach their professional goals. Once the new system was in place, leadership was able to fine-tune point values to encourage behaviors that aligned with quality initiatives and unit priorities, enabling the team to define engagement in a way that was uniquely relevant to the unit while preserving the overarching integrity of the health system’s performance evaluation guidelines.

The point-based guidelines offered the additional benefit of encouraging advanced certification in specialties relevant to the unit’s patient population, while also increasing the number of nurses who chose to advance in Emory’s professional development model.

“Every one of our nurses wants to do a good job and achieve,” said Owens. “This approach taps into that industry and gives them a vision for what professionalism looks like, how to achieve it, and what we believe are the standard measures of engagement and initiative for how to advance our science outside of patient care. It’s tapping into that industry for all generations on the unit.”

Other units in Emory’s critical care division are currently adopting the process developed on the neuroscience ICU, Owens said. “The highly customizable nature of this program allows it to meet the needs of any unit, even those required to adhere to a more broadly defined institution or system template.”​