Overview of the Quality Improvement Plan
The nursing shortage puts a strain on the present nursing workforce. With unfilled nursing positions on the one hand and a high demand for services on the other, innovative staffing patterns are needed to optimally manage the existing human resource in nursing to effect the best patient outcomes. In the perioperative setting, this was accomplished by permitting nurses from one surgical speciality to float to or cover for nurses in other specialties during times of shortage. However, this proved problematic because the specialisation of nurses prevented them from matching the skills needed in the areas there were floated to.
Thereafter, inadequate nursing skills were identified as a critical factor contributing to several incidents of adverse events in the OR. In other clinical settings, the nurses’ length of experience was associated with rates of adverse events such as falls and pressure ulcers (Dunton et al. 2007). Further, a study comparing new or novice and experienced scrub nurses showed significant differences in performance with the former having a higher likelihood of making mistakes and failing to anticipate the needs of the surgeon (Koh, Park & Wickens, 2014). Nurses augmenting the staff in other specialties would be considered new and inexperienced. As an experienced nursing workforce contributes to the best patient outcomes, providing education and training is an effective strategy in addressing the issue.
A quality improvement (QI) plan for rotational clinical development was therefore developed. A study employing this strategy among new surgical nurses contributed to improved retention and the availability of a group of nurses with broad surgical experience, established working relationships with the staff in multiple specialties, familiarity with different areas of practice, and the ability to transfer skills (Varden 2006: 33). The group was able to provide much needed cross-cover or float work in times of staff shortage. Besides literature support, the QI plan was also informed by multiple stakeholders and data from surveys, incident reports, utilisation reports, training needs analyses, staffing plans, root cause analyses, and brainstorming sessions. It will be implemented and evaluated by a nurse-led multidisciplinary project committee with the involvement of four specialties wherein the volume of patients, and therefore the need for nursing staff, is highest. A pilot will be conducted in a model unit to further improve the project prior to rollout.
The QI project is aligned with the organisation’s mission to achieve excellence in the provision of health care and the strategic goal of enhancing its human resource capabilities to fulfil this mission. The project consists of nursing staff education and training with the provision of mentoring. Education and training address the gaps in knowledge and skills necessary to ensure the effectiveness of a cross-cover or float nurse. Mentorship was the chosen strategy because the role is associated with nurturing, guidance, teaching, coaching, role modelling, supporting, and career development (Weng et al. 2010: 2). It creates a positive work environment conducive to sustained learning that contributes to greater staff commitment, job satisfaction, and retention.
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Achieving Outcomes through Data Management
Data will be collected at baseline, during project monitoring, and after implementation. Comparisons between baseline data, post-implementation data, and project goals permit a quantitative determination of project effectiveness (Hochstuhl & Elwell 2014: 210). A baseline training needs analysis will be conducted by the Clinical Nurse Educator. It will consist of interviews, using a semi-structured interview schedule, with the nurses who have done cross-cover work to determine gaps in knowledge and skills representative of their units of origin. Baseline and post-implementation surveys using an instrument developed by the Clinical Nurse Educator will also be administered by the same to surgeons, and instrument and circulation nurses who have worked with cross-cover nurses to validate and expand the identified training needs.
The findings of the training needs analysis will guide the development of a needs-based and relevant curriculum systematising the learning in each clinical area that will broaden and improve the capacity of the staff. In addition, the curriculum will incorporate the monitoring of progress of each learner. The nurse educator will keep track of attendance of the theoretical component of the training with post-tests to evaluate learning. Progress in the area of skills and knowledge application will be collected by the mentors who work closely with the learners. A log will be created to document the number of hours of training, the skills learned, the learner’s reflections, and mentor feedback. Training milestones will be set and each learner tracked for the achievement of each milestone. Movement of the nurses through these milestones will indicate progress toward achieving individual learning objectives indicative of effective teaching and mentoring strategies.
The nurse manager will also collect data on rostering efficiency to ensure rotational clinical development has no adverse effect on skill mix and staffing levels. Monitoring this data will alert the manager on arising problems so that they can be corrected without significant negative impact on patients and the staff. Moreover, incident reports and theatre utilisation reports will be obtained by the Quality Improvement Officer at baseline, monitoring, and post-implementation as indirect indicators of cross-cover nurses’ skills and staff efficiency. Monthly trends showing an increasing or steady incidence of adverse events and lack of improvement in theatre utilisation would indicate that education and training is ineffective. Using a root-cause analysis, contributory factors to such trends can be determined so that prompt corrective actions are made to ensure project success.
Presenting the trending analysis results in a dashboard assists in project management by serving as a tracking tool. Having an overview of what has been accomplished at particular points in time directs the exercise of leadership and controls to optimize improvement opportunities (Hochstuhl & Elwell 2014: 213). A dashboard also communicates the extent of project progress to the staff. Awareness of how far the organisation is from achieving project goals motivates everyone to further their learning and improve their performance.
Team Performance Management
Part of project management is managing the budget. Actual costs must be compared with the cost estimates to determine if the expenditures are within the budget. Going over the budget is an indicator of a potential problem and requires an investigation. The budget allocates funds for risk management and increasing costs may mean a risk has become an actual problem (Walrath & Augenbroe 2007: 58). One example is a significant number of nurses not reaching their milestones thus increasing the costs of training. Assessment of the problem may show that the issue is attributed to ineffective mentors who may also require further training but this has not been factored into the activities and budget.
Periodic meetings at the committee level are held to monitor the status of the project including the budget. The updates are analysed to determine actual and potential risks that can undermine the success of the project so that troubleshooting can be done for the project to remain on track. Some of the risks include a negative and unforeseen effect on staffing and is being monitored. For instance, the work load of nurses serving as mentors may be too heavy resulting in burnout and increasing the number of sick leaves. There is also risk that surgeons will fail to render their support which can undermine the training process.
There are lessons learnt from the development of the project plan and recommendations during the actual roll out. Resistance is a typical phenomenon during change requiring the adoption of appropriate change management. The literature provides support for the use of a participatory approach which entails open communication and stakeholder involvement in decision making in the planning and implementation of the project. Stakeholders have access to information related to the project and some participated in the data collection and analysis. There are also mechanisms for them to ask questions, voice their concerns, or provide input providing project leaders with valuable information from various perspectives resulting in a well-planned solution to the problem.
The participatory approach was used in this project. During the project planning phase, nurses and other stakeholders were involved in meetings held to assess the problem and formulate a solution. They are also represented in the project committee implementing the project. Stakeholder participation promotes buy-in and common ownership of the project ensuring commitment to the attainment of goals (Borkowski 2009: 381). This was evident in the low resistance to the project noted during implementation and especially among the nursing staff who are the targets of clinical development or are tapped as mentors.
The concept of a force field (Bozak 2003: 81) was also employed in project management. The nurse manager was visible at the start of implementation onwards, building better rapport with the staff, and actively but informally eliciting feedback from them. Together with the RN L1 and L2 representatives, she encouraged the nurses who were very supportive of the project, thus strengthening the forces working for change. She also addressed the concerns of those who were lukewarm or resistant to it to neutralise the forces against change. This is a recommended practice because in doing so, she was able to ascertain the general sentiments of the staff and monitor for buy-in and resistance. Buy-in indicates acceptance of and movement towards cementing new norms in staffing and clinical development.
Evaluation of Concepts
Workplace culture pertains to the underlying values, norms, and beliefs of an organisation (Soh, Soh & Davidson 2013: 100). It is manifested in the vision, mission, philosophy, and objectives. It is also embodied in the structure of the organisation and the types of systems and policies in place. Workplace culture is established by senior leaders who have the power and authority to make the organisation what it is and influenced by the larger health care system with its regulations and guidelines. It sets the boundaries for what is acceptable and unacceptable behavior among lower level managers and employees.
As an example, leaders of an organisation with a culture of safety in place will encourage and support quality improvement by creating a position for the leadership and management of such efforts, allotting a budget for related activities, and ensuring managers have the knowledge, skills, and attitudes necessary to help steer the organisation towards this end. It reflects a willingness to exercise clinical governance to ensure that practices are aligned with the organisations goals. In addition, an organisation that values excellent care and its human resources will make a strategic investment in providing opportunities for professional development that will enable employees to provide the desired quality of services. For this reason, mistakes are regarded as learning opportunities rather than an opportunity for blame. The root-cause analysis highlights the system influences to suboptimal performance (Jayaram 2009: 372) and was adopted in the assessment of the problem. The information led to system level changes as these are beyond the control of individual nurses.
The quality of teamwork also reflects on the wider organisation. A culture that values cooperation and collaboration creates such expectations among the staff resulting in an effective project committee. With well-delineated roles and responsibilities of each member that ensures accountability and clear goals, there are additional elements that make teamwork successful. It includes group cohesion, respectful and open communication, conflict resolution, constructive attitudes, supportiveness, and valuing one another (Nelsey & Brownie 2012: 199). Horizontal leadership enabling consensus building and role bending that allows everyone to take on the leadership role when necessary also contribute to an effective team (Clark 2009: 224). In summary, a team characterised by delineated roles, good working relationships, non-autocratic and flexible leadership, and accountability will be able to manage a project and the change it represents more efficiently. Team-building activities can help develop internal relationships especially when members are working with each other on change for the first time.
Based on Lewin’s theory, change typically undergoes the phases of unfreezing, moving, and refreezing (Bozak 2003: 83). Change typically involves the adoption of new ways of doing and thinking and the values that support them. As such, the role of change management is to ensure that the new becomes the norm. In the theory, unfreezing refers to creating a sense of urgency for change by creating awareness of its need (Bozak 2003: 83). In calling meetings involving stakeholders, the problem is presented with supporting data and the cross-work nurses’ experiences. Recognition of the problem led to the identification of the solution and its implementation resulting in the transition or movement from old to new. Refreezing pertains to reinforcing the change through policies, guidelines, and rewards and other systems that serve to cement the change (Bozak 2003: 84). For instance, encouraging supportive nurses to reinforce desirable behaviors, the role modelling of mentors, creating a curriculum to institutionalise the training, and monitoring learning progress are ways to achieve refreezing. Reinforcement ceases only when the new norm is firmly established and there is a high likelihood of compliance that controls become unnecessary.
Given the discussion of the concepts above, the relationship between workplace culture, teamwork, and quality improvement can be inferred. Workplace culture serves as the larger setting of teamwork and quality improvement. The operating room is a microcosm of the larger organisation with the project team reflecting many aspects of the organisation’s dominant leadership style and systems of communication, collaboration, sense of accountability, and valuing. Although individual leadership styles come into play, these would likely still conform to the norm as deviation will be sure to be met with control in the same manner that deviant behavior in the larger society is disapproved of and discouraged.
Workplace culture also strongly influences the quality improvement process because a genuine commitment will entail the inclusion of this function in the organisational structure with a respective budget allocation matching the need and level of prioritization given to ensure related activities are carried out. A culture of safety will also need to be adopted because it is most consistent with QI in that there is a proactive attitude toward health care issues. In this scenario, the organisation is truly serious in its effort to improve care recognising the influence that entrenched systems, processes, and even culture have on clinical practices. The openness to change that quality improvement will bring about is evidence that the organisation is willing to grow. It also signifies a commitment to patients. Hence, successful QI will depend on a compatible organisational culture and team leadership.
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