nterdisciplinary Perspectives in Healthcare

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P I / O U T C O M E S M A N A G E M E N T

T he Affordable Care Act of 2010 has deemed patient experience one of the five domains of excel- lent care within an accountable care organization (ACO). An ACO is one that seeks to improve qual- ity, while decreasing cost. In addition, the health

care marketplace has become increasingly competitive, as patients now have easy access to Hospital Consumer Assessment of Healthcare Providers and Systems scores to guide them when choosing their providers. Hospi- tals nationwide are seeking ways to optimize the patient experience at their institutions. We hypothesized that improving nursing satisfaction would, in turn, improve patient experience.

METHODS To explore this hypothesis, multiple process changes were implemented simultaneously to create an ad- vanced practitioner-directed floor (APDF) on a 28-bed trauma, medical-surgical unit within in our Level II trauma center. Our center evaluates almost 3,000 pre- dominately blunt trauma patients annually. Our trauma

clinical team is composed of 7 full-time trauma sur- geons and 12 advanced practitioners (6 certified reg- istered nurse practitioners and 6 physician assistants). This floor serves as the primary medical-surgical admis- sion floor for trauma patients at our institution. First, advanced practitioners (APs) were used to provide 24- hr primary coverage for the floor. Next, clinical decision daily rounds were implemented at a standard time to create consistency, and these rounds were coordinated by the trauma AP and trauma attending physician. The patient’s bedside registered nurse (RN) and/or the unit’s nursing facilitator were assigned an active participation role on rounds, including discussion and development of the patient’s daily plan of care. The nurse facilitator is a role designed to provide patient-centric care and pro- mote quality, by serving as a clinical resource to foster collaboration, manage staffing resources, assess patient acuity, facilitate patient flow, communicate with nurs- ing house supervisors, and communicate with provider teams to optimize workflow. These daily rounds pro- vide a structured forum for communication. Additional changes included that postrounds the APs remained present on the APDF to facilitate face-to-face commu- nication and education between members of the mul- tidisciplinary team (nursing, case management, social work, physical and occupational therapy, nutrition, and respiratory, etc.).

ABSTRACT Patient experience is a vital component of quality health

care. In our institution we sought to improve both nursing

satisfaction and collaboration, in conjunction with

improving patient experience, predicting the two are directly

proportional. We hypothesized that a more satisfied nursing

team would result in an overall improvement in patient

experience. To explore this hypothesis, we implemented

multiple process changes to create an advanced

practitioner-directed floor (APDF) on our 28-bed trauma,

medical-surgical unit. These changes included advanced

practitioner (AP) 24-hr coverage, implementation of trauma

patient information packets, consistent daily rounds with

the nurse facilitator and/or bedside registered nurse

(RN), and increased floor presence of the AP, to facilitate

improved communication between the multidisciplinary

team. Nursing satisfaction surveys, postdischarge patient

telephone debriefings, and patient Press Ganey scores were

analyzed to assess nursing satisfaction, as well as patient

satisfaction pre- and postimplemented changes. Our findings

demonstrated that, following APDF implementation, RNs

felt more respected, stated that the trauma team was more

collaborative, and, in addition, overall patient and nursing

satisfaction improved. On the basis of our data collection and

perspective from nursing staff and nursing management, we

support the institution of an APDF to target improvements

in nursing satisfaction, by focusing on collaboration and

professional practice.

Key Words Advanced practice nursing , Nursing satisfaction , Patient

experience

Author Affiliation: Reading Health System, West Reading, Pennsylvania.

The authors declare no conflicts of interest.

Correspondence: Pamela Jones, MSN, CRNP, Reading Health System, West Reading, 6th Ave Spruce St, PA 19611 ( [email protected] ).

Improving Patient Experience Through Nursing Satisfaction

Amanda McNicholas , MSN, CRNP ■ Abby McCall , PA-C ■ Alanna Werner , BSN, RN, CMSRN ■ Ronda Wounderly , MSN, RN, CMSRN ■ Erin Marinchak , MSN, RN, ACNS-BC, CPHQ ■ Pamela Jones , MSN, CRNP

DOI: 10.1097/JTN.0000000000000328

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In addition, trauma information packets were devel- oped and provided to all trauma patients and their fami- lies for review. These packets included a description of the services provided by the trauma team, multidiscipli- nary staff, and collaborative specialty services. Photo- graphs and names of individual staff members, discus- sion regarding the flow of the average hospital stay, and recommendations of local accommodations and eateries were also included. Of note, no changes were made to the physician coverage and rounding model in the pre and postperiods.

The institutional review board has designated this pro- ject as a quality improvement initiative and not human subject research.

NURSE SATISFACTION DATA To determine whether initiation of the APDF impacted nursing satisfaction, a five-question Likert scale survey was completed by the nurses on the participating unit (Appendix A). The RN survey was completed 1 month prior to APDF implementation and 3–6 months after. All staff RNs (25 in total) were eligible to complete the sur- vey, and a total of 40 surveys were completed: 18 pre- APDF and 22 post-APDF. A 72% RN response rate was obtained for the preimplementation survey on the partici- pating unit. When the RNs were asked whether their con- cerns were heard and they were respected by the trauma team, 33% of RNs responded positively (agree or strongly agree). A postsurvey was conducted 3 months follow- ing implementation of the APDF, and percentages of RNs who agreed or strongly agreed their concerns were heard and respected increased to 95% ( Figure 1 ). When asked whether care of the trauma patient is multidisciplinary and collaborative, 50% of the nurses agreed or strongly agreed on the presurvey, and that percentage almost dou- bled to 95% on the postsurvey ( Figure 2 ).

Nurses were able to provide open-ended comments on both the pre- and postsurveys. Comments received on the presurvey included “It would be nice if the nurses are treated as significant part of the treatment team and not as insignificant nuisances,” and “We are often approached or spoken to as if we are below them [trauma team]-no

matter what we are calling in regards to. We are here for the patients and their families and while I understand some of the reasons we call the residents is less than exciting and could wait for a few hours, to the patient and family this may not be the case.” In contrast, survey comments received post-APDF implementation reflected positive changes. RNs stated, “I think there have been many improvements over the past several months. I really like rounds.” “There is much more face to face communi- cation and the RN’s get an idea of the plan for the day,” “Keep up the good work!,” and “I think that having one service [APDF] caring for all of our patients on the floor has made it much easier to access practitioners in a timely matter. It also helps to streamline communication, facili- tate more timely discharges, and I think the teamwork has improved.”

POSTDISCHARGE PHONE CALL DATA Another process change that was implemented during this period was the institution of postdischarge, debrief- ing telephone calls. These calls were made by the trauma AP team to all patients discharged directly to home, and patients discharged to a rehab or other medical facility were not included and did not receive a debriefing call. A total of 84 patients were debriefed via an AP telephone call pre-APDF, and a total of 103 post-APDF. Patients were asked scripted, open-ended questions about their hos- pital experience such as “How was your stay?” and “Is there anything we could have done differently to make your stay better?” For data collection purposes, overall patient feedback was classified to be “positive,” “nega- tive,” or “mixed” on the basis of their comments to the AP team member making the phone call. Of the 84 pa- tients surveyed prior to the implementation of APDF, 80% were categorized as “positive” with the care they received from the trauma team. However, comments from patients painted a slightly different picture. “Untimely discharge and lack of discharge communication to family” and (in reference to the trauma team) “would be in by the morning and then during the day things they said were

Figure 1. Registered nurses’ concerns heard and respected by trauma team.

Figure 2. Trauma team is collaborative/multidisciplinary.

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going to happen didn’t and it made [me] upset.” Postim- plementation of APDF, there was an increase in positive feedback, as 103 patients were surveyed, with 86.5% of patients reporting that they were “satisfied overall” with their trauma team care ( Figure 3 ). In addition, an increase in unprompted, positive comments was noted including “very pleased with the staff and the doctors,” and “I felt like part of the family.”

PRESS GANEY OUTCOMES Throughout the process of transitioning to an APDF, nursing staff and the trauma team closely monitored patient satisfaction data gathered from the Press Ganey database. Utilizing Q4 calendar year (CY) 2013 as a base- line, scores were followed through Q1 CY 2016. The following scores were reviewed: nurse and physician “overall” categories (including courtesy and kept patient informed) and discharge “overall” category (extent to which the patient felt ready for discharge and instruc- tions for self-care at home). Data were run quarterly ac- cording to date of received survey for patients discharged from the floor under the trauma service. Overall, nursing scores rose from a mean score of 84 in Q4 2013 (third percentile) to a mean score of 91.2 in Q1 2016 (68th per- centile) ( Figure 4 ). In addition, overall physician scores rose from a mean score of 81.5 (second percentile) to 84 (ninth percentile), and discharge scores rose from 73.6 (first percentile) to 89.1 (97th percentile) ( Figure 5 ). Per- centile ranks were based on the “large PG database” as a benchmark (741 other institutions in the Press Ganey database) ( Figure 6 ).

NURSE SATISFACTION Previous studies have described that patient satisfaction is directly correlated with nurse work environment, nurse satisfaction, and patient outcomes ( Boev, 2012 ). Nurs- es are integral resources, and supporting their role and their work environment is imperative to ensuring quality patient care and satisfaction (Andrews & Dziegielewski, 2005). The implementation of the APDF and its initiatives in February 2014 had an immediate positive impact on the nursing staff, as evidenced by improved nurse satisfaction in the nursing unit’s National Database of Nursing Quality Improvement RN Satisfaction survey results. Surveys were completed by clinical RNs in September 2012, Septem- ber 2014, and September 2015. The results revealed an increase in the mean Practice Environment Scale score of the 25th percentile in 2012 to the 75th percentile in 2014 and 2015. In addition, the survey demonstrated improve- ment in quality of care. In 2012, the nursing unit scored lower than the 10th percentile in quality of care; however, by 2014 the score increased to the 75th percentile, and that was maintained in 2015. The surveys also revealed an increase in positive work relationships between physicians and nurses from the 25th percentile in 2012, to the 75th percentile in 2014, and over the 90th percentile in 2015.

FINANCIAL IMPLICATIONS This APDF is also aligned with the national goal of provid- ing quality, accessible, and cost-effective health care to all. Although there is an associated cost of adding AP clini- cians to an institution’s infrastructure, there is also a well- documented benefit in both quality and length of stay with the utilization of APs in trauma care ( Morris et al., 2011 ; Collins et al., 2013). In addition, greater nursing satisfaction

Figure 4. Patient satisfaction data: nurses overall.

Figure 5. Patient satisfaction data: discharge overall.

Figure 6. Patient satisfaction data: physician overall.

Figure 3. Patient phone survey: overall satisfaction with care from trauma team.

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has been linked to higher retention rates (Li & Jones, 2013). This is translates into a cost benefit over time, as nurs- ing turnover has been reported to cost in the range from $22,000 to over $64,000 per nurse, and this cost includes both the direct and indirect costs, such as advertising and recruiting costs, or orientation and training costs ( Jones & Gates, 2007 ).

CONCLUSION Patient experience is recognized as a vital component of quality health care, and hospitals nationwide are seeking ways to optimize patient experience at their institution. Health care teams are constantly striving to examine current processes and make improvements that are aligned with the goal of providing cost-effective, accessible health care. Pre- vious research has suggested that patient satisfaction is di- rectly related to nursing work environment and satisfaction, effective team communication, and the presence of patient- centered care (O’Daniel & Rosenstein, 2008; Rogers et al., 2017; Shen, Chiu, Lee, Hu, & Chang, 2011). On the basis of our experience with the implantation of an APDF and pro- grams targeted at improving the trauma patient experience, we support the hypothesis that improvements focusing on nursing satisfaction will improve patient experience.

REFERENCES Andrews , D. , & Dziegielewski , S. ( 2005 ). The nurse manager: Job

satisfaction, the nursing shortage and retention . Journal of Nursing Management , 13 ( 1 ), 286 – 295 .

Boev , C. ( 2012 ). The relationship between nurses’ perception of work environment and patient satisfaction in adult critical care . Journal of Nursing Scholarship , 44 ( 4 ), 368 – 375 .

Collins , N. , Miller , R. , Kapu , A. , Martin , R. , Morton , M. , Forrester , M. , … Wilkinson , L. ( 2013 ). Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved patient satisfaction . The Journal of Trauma and Acute Care Surgery , 76 ( 2 ), 353 – 357 .

Jones , C. , & Gates , M. ( 2007 ). The costs and benefits of nurse turnover: A business case for nurse retention . The Online Journal of Issues in Nursing , 12 ( 3 ).

Li , Y. , & Jones , C. ( 2013 ). A literature review of nursing turnover costs . Journal of Nursing Management , 21 ( 1 ), 405 – 418 .

Morris , D. , Reilly , P. , Rohrbach , J. , Telford , G. , Kim , P. , & Sims , C. ( 2011 ). The influence of unit based nurse practitioners on hospital outcomes and readmission rates for patients with trauma . The Journal of Trauma and Acute Care Surgery , 73 ( 20 ), 474 – 478 .

O’Daniel , M. , & Rosenstein , A. H . ( 2008 ). Professional communica tion and team collaboration . In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses . Rockville, MD : Agency for Healthcare Research and Quality . Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2637/

Rogers , R. , Horst , M. , To , T. , Rogers , A. , Edavettal , M. , Wu , D. , … Brosey , L. ( 2012 ). Factors associated with patient satisfaction scores for physician care in trauma patients . The Journal of Trauma and Acute Care Surgery , 75 ( 1 ), 110 – 115 .

Shen , H. C. , Chiu , H. T. , Lee , P. H. , Hu , Y. C. , & Chang , W. Y. ( 2011 ). Hospital environment, nurse-physician relationships and quality of care: Questionnaire survey . Journal of Advanced Practice Nursing , 67 ( 2 ), 349 – 358 .

Waters , V. L. ( 2010 , September-October). Caring is the expectation . The Oklahoma Nurse , 55 , 5 – 7 . Retrieved from http:// web.b.ebscohost.com/nrc/pdf?vid = 9&sid = b05e223b-f448- 4cde-9517-d1250dad5fa9%40sessionmgr113&hid = 127

http://web.b.ebscohost.com/nrc/pdf?vid=9&sid=b05e223b-f448-4cde-9517-d1250dad5fa9%40sessionmgr113&hid=127

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APPENDIX A Circle the appropriate response

What shift do you primarily work? Days, evenings, nights

Based upon the following options, please select the response that most closely represents your opinion.

1 = strongly disagree, 2 = disagree, 3 = neither disagree or agree, 4 = agree, 5 = strongly agree

Do you feel your concerns regarding your patients are heard and respected by trauma services?

1 2 3 4 5

Do you feel you that trauma services discharge process is timely?

1 2 3 4 5

Do you feel the care of the trauma patient is collaborative and multidisciplinary?

1 2 3 4 5

Do you feel you that trauma services are easily accessible and prompt in their response?

1 2 3 4 5

Do you feel you know the treatment course and plan for the day for the trauma patient?

1 2 3 4 5

Do you feel there are adequate educational opportunities regarding topics related to care of the injured patient?

1 2 3 4 5

What barriers do you feel exist to prevent you from participating on daily rounds (if applicable)?

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