Survey prompts nursing retention and quality efforts
In 2006, Southampton (NY) Hospital's Department of Nursing conducted a needs assessment focusing on the quality of patient outcomes, staff recruitment and retention, and patient safety. Part of the assessment included distributing the Agency for Healthcare Research and Quality's (AHRQ) Hospital Safety Survey to staff.
"What we got back were some not-so-great results," says Patricia Darcey, MS, NE-BC, chief nursing officer and vice president of patient care services at Southampton Hospital. "So what we decided to do was to take the survey and make it the foundation for where we want to go.
"The survey gave us a lot of areas we could concentrate on," adds Darcey. "The goal was to bring leadership to the floor, to make leadership very visible."
Involving leadership in bedside care
Along with Eileen Newell, RN, director of quality nursing and education, Darcey and the nurse managers made rounds during both day and night shifts.
Darcey moved her office temporarily to one of the units and worked with the staff. Once a week, she and leaders from nursing education and nursing quality would come in and work a day, evening, and night shift (from 8 a.m. to 2 a.m. the next day).
"I was able to see the dialogue, communication, rounds, observed how staff gave report to each other; we observed whether staff came in on time, properly dressed, and generally whether they were prepared to meet the challenges of their shift," says Darcey.
Getting staff to understand the benefits of change was difficult. "We were not only focused on observing the staff but on changing their behavior," says Darcey. "It took a lot of action, a lot of participation, and a lot of patience."
The hospital repeated the AHRQ survey in 2009 and saw overall perception of safety increase by 40%, as well as a 24% rise in the perception of "open communication."
"The open communication question was very important to us. We wanted them to be able to bring safety issues forward without fear of being penalized," says Darcey. "The only way we were able to overcome that [fear] is meeting directly with the staff when an unsafe situation occurred and perform a root cause analysis in which no staff member was penalized."
Creating a just culture in which staff are unafraid to report mistakes proved to be a challenge. Darcey and Newell learned that trust needed to be earned to achieve such a culture, and part of earning that trust was empowering the staff to influence changes at the hospital.
"We told them: 'You're the staff. You need to tell us what policies, procedures, what tools you need to make this safer for the patient.' And they did. They came forward and they told us," says Darcey. "We were able to negotiate more toward the trust and away from the fear."
Involving leadership helped spur that new culture. "You change one thing, and then it has ripple effects. I think that's what happened here. What we changed was the separation of leadership from the staff," says Darcey. "We went up to the floor, we worked side by side with them. And doing that made such a tremendous impact that it wasn't just in one area."
Being involved doesn't just mean giving orders, either. Darcey says it's critical to remember to listen to staff feedback. It's also important to truly understand how the hospital is operating-even if the truth is difficult to accept. "You have to listen. You have to be willing to accept that things are not the way they should be. It was hard," she says.
Respecting staff and redirecting behavior
In 2006, when their efforts began, Darcey and Newell were fairly new to the organization and found staff resistant to change. But both say you can't shy away from working with staff to increase patient safety.
"It was difficult. They were not warm and fuzzy to us during that. But when you go to the bedside is when you see how bad it can really be," says Newell. "You can't rely on what other people say; you have to be there. When we had an uptick in falls, it didn't make sense to do research. We had to go and see what was going on."
"As the CNO, I'm removed from the bedside care. As the director, Eileen is removed from bedside care," says Darcey. "By the time you hear of issues, it's watered down. Seeing it firsthand made a tremendous difference, and I can bring a stronger case forward to the CEO."
To change the way a nurse performs a task takes understanding, patience, and respect. "You have to understand, whether the nurse has been doing the job for five years or 35 years, he or she takes pride in his or her practice," says Darcey. Resistance to change can stem from that pride, from having someone new step in and say there might be better ways of doing something.
"You have to tell them: 'We're not focusing on you, we're focusing on the patient.' You have to tell them: 'If you really want what is best for the patient, you have to try some of these different ways,' " says Darcey. Change has to be introduced slowly, but with a plan in mind so it doesn't drag on.
"You need a plan. As much as we got their input and worked with them side by side, we knew what our goal was. We had our plan," says Darcey.
Keeping respect for nurses' practice is important, even if you discover that the practice doesn't follow policy.
"People take policies and procedures sometimes and they think they know it," says Newell. "The norm then becomes the wrong way to do it if they are mistaken. When it becomes the norm, you really have to make them think about why it's wrong, rather than show them it's wrong."
Be prepared to be surprised by a few elements of nurses' practice, and realize your reaction means a great deal.
"If there is a widespread practice that surprises you because it goes against policy or might be unsafe, be careful how you react to it," says Newell. "Realize that the staff have accepted this practice or behavior, and that behavior might be exhibited by people they respect, such as preceptors or mentors."
Recruitment and retention
One challenge Southampton was having trouble with was recruitment and retention-not surprising, considering the hospital is in a seasonal area whose population triples during the summer. It is a small 125-bed hospital that usually functions at about 65-75 beds. The hospital has two main medical-surgical units and one telemetry. It also has an eight-bed ICU. "Not surprisingly, it's difficult finding the right mix of staff at the right time," says Darcey.
In 2006, Southampton implemented a program in which housing, 12-hour shifts on a full-time schedule, and bonuses were offered to nurses willing to work from Memorial Day to Labor Day (including at least two federal holidays). Since then, the same staff often comes back year after year.
In 2006, Southampton's vacancy rate was very high. It was hit hard by the nursing shortage because of its location-about 75 miles out from New York City, with the nearest hospital 35 miles away.
"We were dealing with a high cost of living that required incentive programs to get staff to come work at the hospital," says Darcey.
The other problem was simply getting to the hospital. With a two-lane highway that had some sort of construction daily, even a short commute could become an arduous journey. The hospital recognized the problem; it gave out gas cards and scheduled patients to come in outside of rush hour. Some members of leadership were among the outspoken community voices who pushed to get another lane added to the highway-and their efforts succeeded. The new lane alleviated much of the traffic and helped with recruitment efforts.
Also in 2006, Southampton initiated a six-month internship program for RNs. In 2010, the hospital received 250 applications for its six slots. People began hearing about the program through word of mouth. "We did not have to advertise it," says Darcey.
The housing arrangements, highway advocacy, and internship program were all part of a five-year plan to improve Southampton's staffing and retention. The plan also included partnering with the local community college for education and increasing the per diem pool of nurses.
"We hired a part-time nurse recruiter who got the per diem and increased our staffing, decreasing our vacancy rate from 15.2 in 2007 to 5.1 in 2009," says Darcey. "Now, any position that's open is really temporary due to budgetary constraints, not because we can't find staff.
"The new plan also helped us increase our hours per patient day, which increased from 4.8 to 6.2, and we probably average more like 6.6 on our med-surg floors," says Darcey. "That made a big difference in safety as well."
Hours per patient day is not the total number of staff needed on a unit; rather, it is a measurement of the average number of hours needed to care for each patient on the unit. The measure takes into account not only the number of patients, but the required level of care for each patient, the physical layout of the unit, any communication issues presented by the patients, the level of staff training and orientation, and a number of other factors.
Darcey and Newell embraced "real-time coaching," in which they fixed as they observed. "Real-time coaching is done on the spot. We did rounds with the staff. We didn't observe them and then sit down with them and go over it-we did it right then and there," says Darcey. "If we saw something that was going right, we took them aside and told them. If we saw something going wrong, we took them aside to talk about it right then. Real-time mentoring helped to instill critical thinking in how they would interact with patients."
Another of Southampton's education initiatives included the implementation of an annual skills day for the staff.
"It's a great interdisciplinary effort with all of the managers, along with nursing education, on identifying what areas we want to concentrate on for the year," says Darcey. The day focuses on policies and procedures, and generally has a theme-last year's was medication safety. One of the staff's favorite events was a simulated environment in which staff had to identify what was wrong or unsafe within three minutes.
"The idea was to show them you can identify these things within three minutes, that it can be done in daily activities-you don't need 20 minutes for each patient," notes Darcey. She and Newell always ask for feedback from the staff regarding what they liked and what they want to see for next year's skills day.
Over five years, Southampton Hospital worked toward a safer culture. Here are some lessons Patricia Darcey, MS, NE-BC, chief nursing officer and vice president of patient care services, and Eileen Newell, RN, director of quality nursing and education, can share:
- The Agency for Healthcare Research and Quality's Hospital Safety Survey not only provides valuable input and a benchmark for progress, but lets staff know you care what they think
- Quality and patient safety must be intentional and planned
- Negative outcomes are drivers for change
- Respect the staff and current practices, even if those practices need to be changed
- Involve staff in the improvement process, but keep your ultimate goals in mind
- Involve leadership at the bedside so everyone has a clear understanding of current care practices
- To improve, you have to accept that you will find mistakes in your hospital
- When redirecting behavior, ensure staff understand the focus is patient safety, not punitive action