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JONA Volume 45, Number 4, pp 179-182 Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

Meaningfully Incorporating Staff Input to Enhance Frontline Engagement

Sarah Strumwasser, AB Katherine Virkstis, ND

Nurses play a critical role in care transformation. To achieve trans- formation, frontline staff must be engaged in their work, committed to their organization’s mission, and capable of delivering high- quality care. Data from the Advi- sory Board Survey Solutions show that nurses are both the least engaged and most disengaged among all frontline staff. To iden- tify the most promising opportu- nities for driving engagement, researchers from The Advisory Board Company analyzed engage- ment survey responses from more than 343,000 employees at 575 healthcare organizations. This ar- ticle describes 3 strategies for addressing 1 of the greatest oppor- tunities identified from the data: ensuring that nurses feel that their ideas and suggestions are valued by the organization.

A growing body of evidence links workforce engagement to better performance on indicators used to measure ‘‘value,’’ including patient satisfaction, productivity, and turnover.1-4 Although there are various tools and methodologies available for measuring frontline engagement, the core attributes of an engaged employee are widely accepted across the healthcare in- dustry. Engaged employees are in- dividuals who are inspired to do their best work, feel personally motivated to help the larger orga- nization succeed, and are willing to exceed the expected level of ef- fort.5(p12) To better understand current trends in nurse engagement and opportunities to positively in- flect those trends, Advisory Board Survey Solutions (ABSS) developed the Employee Engagement Survey (EES).6

Research Background and Methodology A suite of validated surveys focused on enhancing workforce culture is offered by ABSS, including em- ployee engagement, physician alignment, and patient safety. Re- searchers developed the EES in 2006 through both qualitative and

quantitative research, including an extensive review of the academic literature on engagement, assess- ment of currently available surveys, interviews with industry experts, and validation of the survey through an alpha group of partic- ipants. Respondents answer ques- tions on a 6-point Likert scale ranging from strongly disagree to strongly agree (http://www.advisory .com/talent-development/employee- engagement-initiative). Today, the database is composed of more than 343,000 employees from 575 health- care organizations, which includes 87,355 RN responses across 18 dif- ferent unit types.6

The survey instrument includes 3 sets of questions: a 4-question en- gagement index, 42 driver ques- tions, and an optional 9-question MagnetA bundle. On the basis of responses to the 4-question en- gagement index, each nurse is categorized into 1 of 4 categories: engaged, content, ambivalent, and disengaged (Table 1). Researchers of ABSS conducted a multivariate regression analysis to determine which of the 42 engagement drivers have the most significant impact on nurse engagement. To further nar- row the list of opportunities, re- searchers applied 3 additional

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Author Affiliations: Senior Director, Ad- visoryBoardSurveySolutions(MsStrumwasser), and Practice Manager, Nursing Executive Cen- ter (DrVirkstis),TheAdvisoryBoardCompany, Washington, DC.

The authors declare no conflicts of interest. Correspondence: Ms Strumwasser, The

Advisory Board Company, 2445 M St NW, Washington,DC20037([email protected]).

DOI: 10.1097/NNA.0000000000000179

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

filters. First, they removed drivers with limited room for improve- ment (defined as national perfor- mance averaging above the 60th percentile). Second, they eliminated any drivers requiring only ‘‘baseline performance.’’ Baseline drivers re- flect more basic employee needs and typically do not demand high-level performance to achieve widespread engagement (eg, ‘‘My organization pays me fairly for my job’’). Third, researchers removed any drivers requiring outsized investment, or those where significant effort may be needed to achieve minimal per- formance improvements.

To further understand the pri- mary drivers of nurse engagement, Advisory Board experts next conducted a series of qualitative analyses. Researchers facilitated approximately 50 focus groups across more than 20 organizations nationwide to understand the root cause of each driver of nurse en- gagement. Focus group partici- pants included frontline staff, managers, directors, and vice pres- idents from a variety of depart- ments. On the basis of the findings from these focus groups, researchers from the Nursing Executive Center (NEC) conducted more than 100 telephone interviews with hospital- based nurse executives, directors,

and managers to identify strategies for driving nurse engagement.

Top 5 Opportunities for Improving Nurse Engagement Findings from the 2014 EES data- base reveal that less than one-third of nurses are considered engaged. Furthermore, nurses have the low- est level of engagement when com- pared with other clinical roles within the health system, including patient care associates, licensed practical nurses, and physicians.6 The re- sults of the multivariate regression identified 19 drivers as having an outsized impact on nurse engage- ment (Table 2).6 After applying the 3 additional filters and find- ings from focus groups and tele- phone interviews, researchers further narrowed this list down to the following 5 best opportuni- ties for improving nurse engage- ment: clarify the linkage between executive actions and organiza- tional mission, reduce stress and burnout, demonstrate that the or- ganization values nurse input, en- sure that recognition is professionally meaningful, and broaden access to nontraditional professional devel- opment opportunities. The full findings of this study were pub- lished by the NEC in fall 2014 in

The National Prescription for Nurse Engagement.5

Why Nurses Do Not Feel Their Ideas Are Valued

Among the top 5 opportunities for improving nurse engagement, per- haps the most frustrating and con- founding among organizations is nurse input. Considering all nurse leaders do to gather frontline feed- back, how is it that fewer than half of nurses agree or strongly agree with the statement ‘‘My ideas and suggestions are valued by my organization?’’6

Participants from the focus groups facilitated by ABSS re- searchers confirmed that the typi- cal hospital has a number of mechanisms for nurses to submit ideas and suggestions, including shared governance, unit-based taskforces, and senior leader rounding. Only a small minority of participants cited a lack of fo- rums for staff input as the primary challenge. Instead, 2 main reasons emerged for frontline nurses’ per- ception that their feedback is not valued. First, leaders fail to ‘‘close the loop,’’ or provide a response to staff once ideas have been submit- ted. Second, staff observe little or no change after submission of ideas for improvement. In short,

Table 1. Engagement Category Definitions

Category Definition

Engaged Go above and beyond to see the organization succeed, tying personal success directly to that of organization Highly loyal and emotionally committed to the organization

Content Solid contributors, satisfied with their jobs and the organization Lacking emotional commitment to organization

Ambivalent Would leave if presented with a better offer See job as paycheck more than anything else

Disengaged Least satisfied with their job and organization Tend to be most vocal, actively detracting from quality of workplace for peers

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

whereas leaders excel at capturing staff feedback, they fail to either act on the suggestions or explain why they cannot. This challenge is further complicated by the high volume of feedback received. Of- ten, nurses are uncertain aboutwhere the organization most needs their help and provide feedback on many topics beyond core organizational objectives.

Promoting Quality Input Over Quantity

Three primary strategies were identified by NEC researchers for capturing and incorporating staff input in a meaningful manner: request input on specific chal- lenges, provide exemplars to gen- erate actionable ideas, and close the loop every time. The overarch- ing goal of these strategies is to value the quality of ideas over the quantity, focusing staff efforts on areas that will result in the greatest overall impact to the organization.

Request Input on Specific Challenges

When nurse leaders ask staff for input, they often ask for open-ended feedback, resulting in an influx of well-intentioned suggestions that are unrelated to the organization’s strategic objectives. To avoid this, top-performing healthcare sys- tems define concrete, specific chal- lenges for which they desire input. By defining a narrow set of topics, leaders purposefully direct staff feedback to key areas where input is most needed, such as reducing patient falls, improving medica- tion reconciliation compliance, and enhancing teamwork during discharge planning. When submit- ting a suggestion, nurses must indicate the specific challenge that their idea addresses and comment on a series of pointed questions regarding the indicated challenge, including proposed solutions, background evidence or informa- tion supporting the proposed so- lutions, and desired outcomes.

Such specificity encourages staff to think critically about their idea before submission, helping them to recognize and withhold incom- plete ideas.

Provide Exemplars to Generate Actionable Ideas

In addition to creating a highly structured submission process, high-performing organizations provide guidance to staff for po- tential solutions based on existing best practices. For example, the chief nursing officer at 1 organi- zation on the East Coast asked her shared governance councils to work on 4 strategic priorities: hourly rounding, bedside hand- offs, nurse-to-nurse communica- tion, and nurse empathy. To support these efforts, each council was given 2 NEC toolkits, Build- ing Peer Accountability7 and The Patient Experience Toolkit.8 The councils were encouraged to cus- tomize existing practices from each toolkit to address the unique

Table 2. Top 19 Drivers of Nurse Engagement Based on Results of Multivariate Regression

"

I believe in my organization’s mission. .128 My organization provides excellent care to patients. .111 My ideas and suggestions are valued by my organization. .101 The actions of executives in my organization reflect our mission and values. .084 My organization helps me deal with stress and burnout. .077 I am interested in promotion opportunities in my unit/department. .073 My current job is a good match for my skills. .071 My organization pays me fairly for my job. .059 My manager stands up for the interests of my unit/department. .046 Training and development opportunities offered by my organization have helped me to improve. .045 I understand how my daily work contributes to the organization’s mission. .045 My most recent performance review helped me to improve. .044 My organization recognizes employees for excellent work. .044 My organization supports employee safety. .036 I have job security. .034 Executives at my organization respect the contributions of my unit/department. .033 My organization provides excellent customer service to patients. .033 I have a manageable workload. .031 Over the past year, I have never been asked to do something that compromises my values. .025

R2 = 0.644. N = 87,355 RN responses.

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

challenges of their unit. Providing exemplars in such a manner has the added benefit of easing the burden on staff to come up with new and innovative ideas.

‘‘Close the Loop’’ Every Time

Even organizations with well- constructed processes for captur- ing employee feedback cannot (and should not) implement every idea. But leaders must respond to every employee suggestion. The more organizations promote the quality of ideas over the quantity of ideas, the easier this process becomes. One hospital in the Northeast uses a highly transpar- ent, interactive process for closing the feedback loop centered around each unit’s daily huddle board. The boards facilitate ongoing dia- logue among staff regarding the status of all suggested ideas, in- cluding those not used. During a daily huddle, each idea is assessed based on its impact and level of complexity, then placed into 1 of 4 categories: implement (high-impact, low-complexity ideas ready for im- plementation), challenge (high- impact, high-complexity ideas requiring additional consider-

ation), possible (low-impact, low- complexity ideas requiring additional consideration), and kibosh (low- impact, high-complexity ideas that will not be pursued). The dis- cussion is limited to 5 minutes in length and focuses solely on triaging ideas appropriately. The purpose of the huddle is not to solve the problem, but rather to ensure staff are regularly updated on the status of ideas submitted for consideration.

Conclusions Absent buy-in from frontline nurses, an organization’s ability to operationalize their care transfor- mation efforts will be a struggle at best. Meaningfully incorporating staff input into process improve- ment initiatives is 1 critical element to building an engaged workforce. Highly engaged nurses feel valued for their ideas and suggestions, increasing their sense of buy-in to organizational priorities. Center re- searchers found organizations that successfully incorporate staff input into unit or organizational initia- tives have implemented 3 primary strategies: requesting input on spe- cific challenges, providing exem-

plars to generate actionable ideas, and closing the loop every time.

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.