Gail A. Wolf

The Impact of Staffing on Patient Outcomes Across Specialty Units

Objective Determine the relationships between nursing staffing and specific nurse-sensitive outcomes (central line blood-associated infection, pressure ulcer, fall, medication error, and restraint application duration rates) across specialty units (cardiac and noncardiac intensive care, cardiac and noncardiac intermediate care, and medical–surgical). Background A number of hospital-level studies have demonstrated that lower staffing levels are associated with higher adverse patient outcomes. However, insufficient insight into unit-level staffing relationships is available. Further unit-level inquiry is necessary to fully explicate the relationships between staffing and outcomes and to provide assistance to nurse administrators as they seek to develop blueprints for staffing plans that are linked to quality outcomes. Methods Secondary analysis of prospective, observational data from 95 patient care units (cardiac intensive care, n = 15; noncardiac intensive care, n = 7; cardiac intermediate care, n = 18; noncardiac intermediate care, n = 12, and medical–surgical, n = 43) across 10 acute care hospitals. Results No statistically significant relationships were found between central line infection and pressure ulcer rates and staffing across specialty units. Significant inverse relationships were present between staffing and falls in cardiac intensive care, medication errors in both cardiac and noncardiac intensive care units, and restraint rates in the medical–surgical units. Conclusions Results from this study suggest that the impact of staffing on outcomes is highly variable across specialty units; however, when present, the relationships are inversely related with lower staffing levels, resulting in higher rates of all outcomes.

Driving improvement in patient care: lessons from Toyota.

Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)—a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance. The authors discuss the rationale for applying TPS to healthcare and implementation of the system through the development of “learning unit” model lines and initial outcomes, such as dramatic reductions in the number of missing medications and thousands of hours and dollars saved as a result of TPS-driven changes. Tracking data further suggest that TPS, with sufficient staff preparation and involvement, has the potential for continuous, lasting, and accelerated improvement in patient care.

Transformational leadership in nursing service. A test of theory.

What are the leadership dimensions that result in low turnover or work satisfaction? Intellectual stimulation, charisma, and individual consideration constitute aspects of transformational leadership that are suggested to enhance retention and staff satisfaction. In this study, the authors tested transformational leadership theory in one nursing department with an executive, 11 midlevel administrators, and 77 staff registered nurses. Findings support the predictions. Composed of teachable components, transformational factors are similar to leadership qualities described in magnet hospitals, offering positive implications for nursing administration and professional nursing practice.

Magnet recognition program: the next generation.

Twenty-five years ago, the foundation of the Magnet Recognition Program was established. Magnet designation has served as the hallmark of excellence for nursing practice, and research has demonstrated a profound impact on nursing practice and patient care. The purpose of this article was to forecast the direction of the Magnet Recognition Program. The authors discussed the results of a multivariate structural analysis of the forces of magnet and the subsequent future model for Magnet.

Nurse manager leadership development: leveraging the evidence and system-level support.

The complexities of healthcare demand new leadership approaches to achieve organizational goals while developing and sustaining healthy work environments. The nurse manager is the defining role, crucial to achievement of workplace outcomes. Preparing nurses for this dynamic, complex role is often dependent on didactic education or on-the-job training that falls short of true leadership development. The authors describe an innovative approach to the development of successful nursing leaders across an integrated healthcare system.

Blueprint for design: creating models that direct change.

The need for healthcare system change is overwhelming: broken systems, an inadequate workforce, patient safety failures, and lack of access to healthcare are but a few of the significant problems confronting healthcare today. Most people agree that things need to change, but they are not sure on what to change or how to change them. A well-developed model can serve as the currency for that change. By considering the evidence of what has worked well in the past and marrying that with what the future will require, we can create a strong sustainable model for professional practice. The authors explore that evidence and discuss the structure, process, and outcomes that should be considered in designing care delivery models for the future.

Transformational leadership skills of successful nurse managers.

The principles of transformational leadership (TL) are nationally recognized as standards for the contemporary practice of nurse executives. Transformational leadership is often cited as an effective approach in which leaders set the tone for positive change by building trust within their teams. The theory of TL, originally developed by Bass and Avolio, is best described as ‘‘leader behaviors that transform and inspire followers to perform beyond expectations while transcending self-interest for the good of the organization.’’ Using TL as an organizational strategy improves patient care outcomesVreducing adverse events while improving patient satisfaction. In addition, TL is an effective method for managing a diverse nursing workforce. In a systematic review of 53 studies on leadership styles, Cummings et al reported that TL was proven to enhance nurse satisfaction, recruitment, and retention and to promote healthy work environments. It is especially critical for the frontline nurse managers (NMs) who are responsible for the dayto-day operations of nursing units to be transformational in their leadership. An effective and successful frontline NM is invaluable in the retention of a professional staff because nurses who are dissatisfied with their NMs are twice as likely to consider leaving their current position. Strengthening the leadership competence of NMs is especially needed today, in light of economic uncertainties, increasing challenges in providing excellent patient care, and the cost of nursing turnover.

A Transformational Model for the Practice of Professional Nursing: Part 2, Implementation of the Model

Our healthcare system is undergoing major transformation. Most nurse executives are convinced that change is necessary and inevitable, but they are less certain how to position their departments for future success. The Transformational Model for the Practice of Professional Nursing was developed as a “road map” for that purpose. Part 1 (JONA. April 199 i) discussed the professional practice paradigm shifts that are needed for future success. The model components were presented and applications identified. Part 2 discusses the implementation of this model in a practice setting.

A curriculum designed to decrease barriers related to scholarly writing by staff nurses.

Demonstrating professional development outcomes, such as scholarly publication, is critical as nurse leaders guide organizations seeking recognition as centers of excellence. However, personal and situational barriers often prevent staff nurses from achieving scholarly publication. This project tested a workshop and mentoring approach to decrease publication barriers with staff nurses in 2 community hospitals. Self-efficacy principles guided the curriculum that resulted in a statistically significant improvement in staff nurse perception of successful scholarly publication endeavors.

Developing a Multi-institutional Nursing Report Card

As regulatory and public interest groups demand information on the quality of patient care outcomes produced by their hospitals and care providers, nurse administrators are establishing processes for the effective and efficient definition, retrieval, and reporting of patient outcomes thought to be nursing-sensitive. The authors describe the administrative infrastructure and the data management processes used by one large integrated healthcare system to establish a nursing report card and maintain it for several years.