NUR 506W5

W5.pdf

Original Article

The Effect of Transforming Care at the Bedside Initiative on Healthcare Teams’ Work Environments Mélanie Lavoie-Tremblay, N, PhD, FRSQ • Patricia O’Conner, N, MScN, CHE, FCCHL • Anastasia Harripaul, N • Alain Biron, N, PhD • Judith Ritchie, N, PhD • Genevieve L. Lavigne, PhD • Sophie Baillargeon, N, MSc • Justin Ringer, MBA • Brenda MacGibbon, PhD • Sharon Taylor-Ducharme, N, BsN, MA • Jacynthe Sourdif, N

Keywords

work environment, working conditions,

care delivery system, program evaluation,

quantitative methodology, health policy,

social support, support networks,

social environment

ABSTRACT Background: Different initiatives have been implemented in healthcare organizations to improve efficiency, such as transforming care at the bedside (TCAB). However, there are important gaps in understanding the effect of TCAB on healthcare teams’ work environments.

Aim: The specific aim of the study is to describe findings regarding the TCAB initiative effects on healthcare teams’ work environments.

Methods: A pretest and posttest study design was used for this study. The TCAB initiative was implemented in fall 2010 in a university health center in Montreal, Canada. The sample consisted of healthcare workers from four different care units.

Results: Statistically significant improvement was observed with the communicating specific in- formation subscale from the measure of processes of care variable, and a significant difference was found between the support from colleagues variable, which was higher at baseline than postprogram. The differences for psychological demand, decisional latitude, and effort–reward were not significant.

Conclusions: TCAB is an intervention that allows healthcare teams to implement change to improve patients’ and families’ outcomes. Ongoing energy should focus on how to improve communication among all members of the team and ensure their support.

BACKGROUND AND SIGNIFICANCE Inefficient work processes and outmoded physical environ- ments significantly impede the delivery of safe, effective, and efficient care. Nurses spend too much time “hunting and gath- ering” and performing other nonvalue added activities. Ulti- mately, when valuable resources are not used effectively, pa- tients suffer. According to Runy (2008) and others (Hendrich & Chow, 2008; Hendrich, Chow, Skierczynski, & Lu, 2008; In- stitute of Medicine, 2004), the best way to address this issue is to ask nurses about barriers to efficiency in their work environ- ments, create work environments that foster communication and teamwork, provide the technological and information in- frastructure needed, and minimize wasteful work.

Many organizations are struggling to find answers while controlling costs. Transforming care at the bedside (TCAB), a program developed by the Institute for Healthcare Improve- ment (IHI) and the Robert Wood Johnson Foundation, is specifically designed to address these challenges. Initially, the TCAB framework included four themes for change, namely

safe and reliable care, vitality and teamwork, patient-centered care, and value-added processes (IHI, 2012). In Phase III, trans- formational leadership was added as a fifth theme (IHI, 2012). TCAB facilitates positive results for a variety of reasons. It aims to create a work culture that promotes performance improve- ment and value-added activities (Bolton & Aronow, 2009). Sev- eral articles have been published on TCAB and its impact on patient outcomes (Ackerman, 2011; Chaboyer, Johnson, Hardy, Gehrke, & Panuwatwanich, 2010; Gould, 2007; Lorenz, Green- house, Miller, Wisiniewski, & Frank, 2008; Scott-Smith & Greenhouse, 2007). However, there are significant gaps in our understanding of TCAB’s impact on healthcare teams. Most reports focus on single-item measurement or indicators, re- sulting in incomplete information. Engaging healthcare em- ployees is a critical component in implementing or sustaining quality improvement programs (Parkerton et al., 2009), and it is important to understand employees’ experiences through TCAB and the way in which TCAB affects their perception of their work environments.

Original Article PURPOSE AND AIMS The purpose of this article is to describe the results of a study that examined the effects of TCAB on healthcare teams, specifi- cally the effect of TCAB on healthcare teams’ perception of their work environments. Because the TCAB program is designed to improve efficiency, it is crucial that this improved efficiency be demonstrated empirically when introduced in new healthcare organizations. Furthermore, no changes can result in signifi- cant improvements if they impact healthcare providers nega- tively; thus, this study attempted to determine specifically how the TCAB program impacted healthcare teams’ psychosocial work environments.

LITERATURE REVIEW The IHI and the Robert Wood Johnson Foundation partnered to improve health care on medical and surgical units (IHI, 2012). In 2003, three innovative hospitals in the United States were chosen to serve as prototypes to test ideas to determine the feasibility of a process for transforming care (IHI, 2012). The results showed promise, so a pilot phase involving 13 hos- pitals was launched in 2004 to improve outcomes under the five TCAB themes (IHI, 2012). In 2007, 10 of the hospitals proceeded to Phase III of TCAB, in which they continued de- veloping and refining concepts (IHI, 2012). More than 200 hospitals in the United States have joined TCAB since then, and in 2010 the McGill University Health Centre partnered with the IHI, extending the program into Canada (O’Connor, Ritchie, Drouin, & Covell, 2012).

TCAB fosters continuous quality improvement with an overarching approach to empower and inspire frontline staff, multiprofessional teams, and managers to make changes that transform bedside care (Melichar, 2011). The TCAB method consists of nine steps, as can be seen in the process used at the Seton Family of Hospitals: (a) storytelling to describe an expe- rience that had a strong impact on the unit; (b) deep diving or snorkeling to brainstorm ideas for change; (c) prioritizing in- novations to test; (d) building hypotheses using plan-do-study- act (PDSA) cycles; (e) carrying out small tests of change; (f) evaluating outcomes; (g) determining if an innovation should be abandoned, adapted, or adopted; (h) performing rapid-cycle testing to modify the innovation; and (i) disseminating the results (Rutherford, Moen, & Taylor, 2009). By redesigning patient-centered care, work processes become more effective, resulting in improved clinical outcomes and cost savings (Has- smiller & Chiverton, 2007).

Overall, studies have demonstrated improvements in safe and reliable care outcomes, such as decreased patient falls and the less frequent calling of “code blue” (Chaboyer et al., 2010; Gould, 2007; Martin et al., 2007; O’Neil, Holecek, & DeLima, 2011; Valente, 2011). Similarly, studies have highlighted im- provements in patient-centered care outcome measures, in- cluding patient satisfaction, readmission rates, and the amount of time nurses spend on direct patient care (Chapman, 2009;

Donahue, Rader, & Triolo, 2008; Lorenz et al., 2008; Martin et al., 2007; Valente, 2011).

Although we know from some studies that TCAB has a positive effect on healthcare team vitality (Needleman et al., 2009; Upenieks et al., 2008), we do not know the effects on the work environment, based on theoretical frameworks and validated tools. In their study, Upenieks et al. (2008) evaluated the number and type of innovations tested on the medical– surgical units participating in TCAB and examined the rela- tionship between the innovations tested and changes in nurse vitality on the units. In the 16 units studied, 426 innovations were tested. These data suggest that vitality increased as nurses became more involved in testing and implementing changes in care on their units, such as whiteboards in patient rooms and computerized bedside documentation. The measure of change in vitality was created from data collected through semistruc- tured interviews of managers. There was no direct measure of healthcare team vitality.

Needleman et al. (2009) reported on the overall effect of TCAB on 10 hospitals and found that the units tested 533 changes and adopted and disseminated a significant number of them. The investigators reported highly positive staff responses to a question from the Healthcare Team Vitality Instrument (HTVI) about feeling part of an effective work team that contin- uously strives for excellence, but did not report on other HTVI questions. Other studies used informal discussions with in- dividuals who had TCAB experience (Chapman, 2009; Lewis, 2009; Lorenz et al., 2008; Stefancyk, 2008, 2009) or used sur- veys without describing psychometric data (Chapman, 2009; Gould, 2007; Nelson & Massey, 2010; Parkerton et al., 2009; Popkin, Callahan, Scanlon, & White, 2007). Other authors re- ported on the impact of TCAB on healthcare employees using indicators such as the decrease in nurse turnover rates (Chap- man, 2009; Hassmiller & Chiverton, 2007; Martin et al., 2007; O’Neil et al., 2011; Popkin et al., 2007). There are significant gaps in our understanding of the effect of TCAB on the work environments of healthcare teams.

THEORETICAL FRAMEWORK Kristensen’s model (1999) for society, stress, and health has been used by several researchers to assess the workplaces of nurses and healthcare providers. This model is based on well-substantiated research evidence and provides a useful framework for this study. The model is built on two inter- nationally recognized models of psychosocial risks at work (Bourbonnais, 2007; Bourbonnais, Malenfant, Vézina, Jauvin, & Brisson, 2005; Trudel et al., 2009; Vézina, Bourbonnais, Brisson, & Trudel, 2006; Vézina, Cousineau, Mergler, Vinet, & Laurendeau, 1992), namely, Karasek’s job demand–control model (Karasek & Theorell, 1990) and Siegrist’s effort–reward imbalance model (Siegrist, 1996). Karasek’s job stress model suggests that individuals who are exposed to high psychologi- cal demand and low decision latitude are at risk for developing physical and mental health problems (Karasek & Theorell,

Bedside Initiative Healthcare Teams’ Work Environments

1990). Siegrist’s model, however, suggests that individuals who are exposed to a combination of significant effort and low rewards on the job are at risk for developing physical and mental health problems (Siegrist, 1996). Some studies have shown a more specific relationship between Karasek and Siegrist’s models and psychological distress among nurses and their intent to leave their employment and profession (Lavoie- Tremblay et al., 2008a; Lavoie-Tremblay, O’Brien-Pallas, Gélinas, Desforges, & Marchionni, 2008b). According to Kristensen’s model, the optimal work environment for social and psychological well-being includes demands that fit the re- sources of the worker, a high level of basic predictability, good social support, a high level of influence at work, and a balance between effort and rewards. Some investigators add a health care-specific dimension to this model, namely, the healthcare provider’s experience with patients (Lavoie-Tremblay, Viens, & Mayrand Leclerc, 2002). In summary, the dimensions are psychological demands, decision latitude, social support (Karasek model), effort–reward imbalance (Siegrist model), and healthcare provider’s experience with patients.

METHODS Design A pretest and posttest study design was used for this study in order to detect significant differences attributable to the TCAB program. The TCAB program was implemented be- tween September 2010 and June 2012 in four different care units in a multihospital academic health science center in Mon- treal, Canada.

Participants The sample consisted of healthcare workers from four differ- ent care units of an academic health center in the province of Quebec, Canada, namely, an internal medicine unit, a neuro- surgical unit, a gynecology–oncology unit, and a multiservice general surgical unit. These units were selected to implement TCAB based on these criteria: (a) not involved in a major trans- formation or project; (b) stable nursing leadership team; and (c) engagement of physician and nurse manager leaders from the unit. The health center is a major university healthcare center composed of six hospitals, 14,000 employees, and over 600 researchers. In order to reach a statistical power of .80 with a probability level of .05, we aimed at having a final sample of between 100 and 150 healthcare workers. Out of 272 poten- tial respondents from the four care units, 175 completed and returned a questionnaire at Time 0 (T0; October–November 2010), for a 64% response rate. Of the 175 respondents, 103 completed and returned their questionnaire 18 months later, at Time 1 (T1; April–May 2012), for a 59% response rate. Time 1 was done 18 months after the completion of the last training module of the TCAB program. More details on the sample’s characteristics (job category, shift, gender, education, age, and tenure) are shown in Table 1.

Table 1. Sociodemographics of the Sample

Gender 80.8% Female

19.2% Male

Age (years) Mean= 40.54 SD= 11.06

Education 36.7% Technical/college

11.2% Certificate

34.7% Bachelor’s degree

11.2% Master’s degree

6.1% Other

Current position 72.0% Nurse

14.0% Patient care attendant

14.0% Other

Years in the position Mean= 8.90 SD= 7.94

Shift 77.6% Full-time

18.4% Part-time

1% Occasional part-time

3.1% Other

Years of experience Mean= 13.92 SD= 9.93

Instruments Decision latitude. Decision latitude was measured with nine questions from the widely used and validated Job Content Questionnaire (JCQ; Karasek, 1985). This variable was com- posed of two subscales: use of qualifications (six items, e.g., “My job requires that I learn new things”) and control over task (three items, e.g., “On my job, I have very little freedom to decide how I do my work”). Items were answered on a 4- point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Potential scores for the decision latitude variable ranged from 24 to 96. A high decision latitude score indicated a high level of latitude (high use of qualification and high control over task) whereas a low score indicated a low level of latitude. At T0 the scale’s internal consistencies were α = .64, and at T1 they were α = .59. Respondents with scores less than or equal to 72 (the median score observed in a reference group of work- ers from the Quebec population) were considered the exposed group, with low decision latitude (Institut de la Statistique du Québec, 2000).

Original Article Psychological demands. Psychological demands were also measured by nine questions from the JCQ (Karasek, 1985). Sample items are “My job requires working very fast” and “My tasks are often interrupted before they can be completed, requiring attention at a later time.” Items were answered on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). Potential scores for the psychological demands variable ranged from 4 to 36. A high score indicated a high level of psychological demand at work. At T0 the scale’s inter- nal consistencies were α = .66, and at T1 they were α = .56. Respondents who had a score greater than or equal to 24 (the median observed among workers in Quebec) formed the group with a high level of psychological demands in the workplace (Institut de la Statistique du Québec, 2000).

Social support. Social support at work includes support from both colleagues and superiors. The three components of social support are socioemotional support or esteem, instrumental support, and hostility or conflict (Karasek, 1985). A 4-point Lik- ert scale ranging from 1 (strongly disagree) to 4 (strongly agree) was used to measure social support. Social support from col- leagues was measured using five statements (e.g., “People I work with take a personal interest in me”) and social support from superiors was measured using six statements (e.g., “My immediate superior is concerned about the welfare of those under him”), all from the JCQ (Karasek, 1985). These scales have been used in several studies with nurses (Bourbonnais, Comeau, & Vézina, 1999; Bourbonnais & Mondor, 2001), and they present good psychometric qualities. Potential scores for the social support variable ranged from 11 to 44, with median scores of 33.0 and 34.00 at T0 and T1, respectively. At T0 the scale’s internal consistencies were α = .82, and at T1 they were α = .82. A high score on this variable indicate a high per- ception of social support in the workplace. The groups with low social support from colleagues and superiors consisted of participants with a social support score that was less than the median score.

Effort–reward imbalance. Reward has three dimensions: money, esteem, and career opportunities. It was measured us- ing 11 questions from Niedhammer and Siegrist’s instrument (Niedhammer & Siegrist, 1998). Sample items are “Consider- ing all my efforts, I receive the respect and prestige I deserve at work” and “I receive the respect I deserve from my superi- ors.” Potential scores for the reward variable ranged from 11 to 44. At T0 the scale’s internal consistencies were α = .78, and at T1 they were α = .84. Effort was measured using six questions that referred to demanding aspects of the work en- vironment (three questions measuring quantitative load, one measuring qualitative load, one measuring the increase in to- tal load over time, and one measuring physical load; Siegrist et al., 2004). Sample items are “I am often pressured to work overtime” and “I have many interruptions and disturbances in my job.” The potential range of the effort variable was 6–24. At T0 the scale’s internal consistencies were α = .63, and at T1 they were α = .61. In this study, imbalance between effort

and rewards was measured for each participant using the ratio e/(r × c), where e is the total score on the effort scale, r is the total score on the reward scale, and c represents a correction factor for different numbers of items in the nominator and denominator. A correction factor of 6/11 was used. As a result, a value close to zero indicates a favorable condition (relatively low effort and relatively high reward); whereas values above 1.0 indicate that a high amount of effort was expended without receiving or expecting commensurate rewards (Siegrist et al., 2004).

Healthcare providers’ experience with patients. To assess healthcare providers’ experience and behaviors when working with patients and their families, participants completed the Measure of Processes of Care for Service Providers (MPOC- SP; Woodside, Rosenbaum, King, & King, 2001). This measure was originally developed as a self-assessment questionnaire for pediatric caregivers working with children with chronic health or development problems. It was adapted from the established Measure of Processes of Care (MPOC), which is a 56-item in- strument for parents to quantify the extent to which they expe- rienced family-centered services (King, Rosenbaum, & King, 1996). The MPOC-SP is composed of 27 items divided into four subscales: showing interpersonal sensitivity (e.g., “In the past year, to what extent did you take the time to establish rapport with patients and their families?” 10 items, T1: α = .95, T2: α = .95); providing general information (e.g., “In the past year, to what extent did you [or your organization] pro- mote family-to-family ‘connections’ for social, informational or shared experiences?” 5 items, T1: α = .92, T2: α = .94); communicating specific information (e.g., “In the past year, to what extent did you tell patients and their families about the results from tests or assessments?” 3 items, T1: α = .88, T2: α = .90); and treating people respectfully (e.g., “In the past year, to what extent did you accept patients and their fami- lies in a nonjudgmental way?” 9 items, T1: α = .94, T2: α

= .93). The terms children and parents were replaced with pa- tients and families in the present research in order to expand its applicability to all types of patients. Questions were answered using a Likert-type scale ranging from 1 (not at all) to 7 (to a very great extent), with 0 indicating nonapplicability. Higher scores indicate behaviors that are more family centered. The reliability and the structural and discriminant validity of the MPOC-SP have been supported elsewhere (Woodside et al., 2001).

Procedure A member of the research team visited the four surveyed units to meet the healthcare teams, explain the research project, and provide questionnaires. Unit managers were asked to distribute the questionnaires to staff members who missed the presen- tations. The survey package also contained a short sociode- mographic section and an internal return envelope. Respon- dents were asked to return the survey directly to the research group.

Bedside Initiative Healthcare Teams’ Work Environments

Intervention The TCAB program was implemented in the four units be- tween September 2010 and June 2012, with financial support from the organization and a Canadian Health Services Re- search Foundation patient engagement grant that supported the involvement of patient representatives on the unit redesign teams. The following were the key interventions of the TCAB program at the organization: (a) patient representatives from the organization’s patient committees were recruited to join the teams of the four units in the codesign work; (b) frontline staff volunteered to be TCAB champions for their units and, together with two or three patient representatives, were trained in rapid-cycle improvement processes (PDSA) to identify the work processes they wanted to improve, set specific goals, make predictions, plan and take measurements, conduct simple tests of change, evaluate the results of each test of change, and then adopt, adapt, or abandon each change; and (c) TCAB organiz- ing committee experts provided the unit teams with facilitator support. Coaching focused on building new skills in front- line staff, such as setting agendas and managing meetings, engaging stakeholders, building consensus among peers, set- ting priorities, managing conflict, developing communication strategies, and measuring and getting feedback on the results of tests of change.

In year 1 (2010–2011), the unit teams and patient represen- tatives participated in biweekly learning webinars presented by IHI faculty. In year 1, the lack of protected release time slowed the pace of work as staff members found it difficult to do TCAB work in addition to their regular patient load. There was no pro- tected release time during which staff members were replaced to do TCAB work.

In year 2 (2011–2012), several changes were made in the program. Protected release time (1 or 2 days per week) was provided during which two registered nurses, one patient at- tendant, and one unit coordinator were released and replaced. Three formal 10- to 12-week learning modules were introduced with specific deliverables (performance improvement targets): Module 1—Improving the Physical Environment with 5S (sort, set, shine, standardize, sustain), Module 2—Patient and Fam- ily Experience of Care, and Module 3—Improving Admission and Discharge Processes Using Process Mapping Techniques (currently ongoing). Each module began with a full-day work- shop in which staff members presented their results and ex- perts presented content for the following module. A total of 11 full-day workshops were held (five in year 1 and six in year 2). Over 2,000 staff members attended the workshops, and senior managers were also present.

Throughout the 2-year period, staff members received feed- back regularly (during workshops) on how well they were doing with regard to results of the Hospital Consumer Assessment of Healthcare Provider and Systems (Agency for Healthcare Research and Quality, 2012) and results of semistructured in- terviews of discharged patients about their experience of care on the four units. Patient representatives were engaged in ev- ery step of the program (e.g., grant applications), served on

the TCAB Advisory Committee and the Measurement Work Group, gave presentations at TCAB workshops on their experi- ences with unit teams, and participated in data collection and analysis and in the reporting of results locally and nationally. At the end of each module, interprofessional frontline staff and patient representatives presented their results to the other teams, to senior management, and to funders. Table 2 shows the changes made in the units over the past 2 years.

Data Analysis First, to detect differences between those who did not com- plete the second questionnaire 18 months after the first one and those who completed both questionnaires, one-way anal- yses of variance were performed on the study variables at T1. Then, to compare T0 and T1 scores, paired sample t-tests were conducted on each variable. All analyses were conducted with SPSS 20.0 (SPSS, Inc., Chicago, IL, USA).

Ethical Issues The study was approved by the ethics review boards of the participating healthcare organizations. Participants consented in writing to participate.

RESULTS Results of the scores at baseline (T0) and 18 months later (T1) are summarized in Table 3. One significant difference was found in the psychological demand variable at T1 between the respondents who completed both measurement points and those who only completed the questionnaire at baseline (F(1,191) = 5.188, p = .024). Specifically, the healthcare profes- sionals who completed both measurement points (M = 26.12, SD = 3.06) reported a significantly higher level of psychologi- cal demand than those who completed the questionnaire at T0 only (M = 25.11, SD = 3.14).

There was a significant difference between the two mea- surement points of the support from colleagues variable (t(90) = 2.159, p = .034). The scores at T0 (M = 18.16, SD = 2.46) were significantly higher than the scores at T1 (M = 17.65, SD = 2.45), indicating a decrease in perceived social support from colleagues. The difference between the two measurement points was also significant in the “total support” variable (t(85) = 3.268, p = .002). Once again, the scores at baseline (M = 33.98, SD = 4.09) were significantly higher than the scores 18 months later (M = 32.78, SD = 4.27), once again indicating a decrease in perceived social support overall. The differences for effort, reward, psychological demand, control over task, use of qualifications, and decisional latitude were not signifi- cant.

Finally, one significant difference was found with regard to the MPOC-SP. The scores for the communicating specific information subscale at T1 (M = 3.97, SD = 1.37) were signifi- cantly higher than the scores at baseline (M = 4.27, SD = 1.38, t(78) = –2.20, p = .031).

Original Article Table 2. Examples of Interventions Introduced on Units

Outcomes of Module 1—Improving the physical environment with 5S (sort, set, shine, standardize, sustain)

� Relocating equipment significantly reduced the time spent hunting and gathering on all units. Examples of redesigned areas include nursing stations, medication rooms, family visiting rooms, treatment rooms, supply rooms, staff lounges, and patient dining areas. In each case, before and after pictures (and time measures) were taken, and the results have been dramatic

� Medical equipment was found and returned to Biomedical Engineering as a result of “clean-ups.” On average, $3,000 worth of equipment was returned per unit

� Staff members have acquired skills to measure the effects of improvement efforts and apply plan-do-study-act to simple work problems. During this module, patient representatives on one unit were somewhat less active, whereas representatives on other units took the lead in other improvements and staff members performed the 5S tests of change. In three units, the staff and patient representatives developed improvements together, e.g., remodeling a family visiting room and creating a new quiet space (for difficult conversations or preoperative work)

Outcomes of Module 2—Patient and family experience of care results

� In Module 2 the staff and patient representatives continued to work on sustaining Module 1 changes to ensure that improvements were not lost

� Therapeutic questions: In a back-to-basics move, staff members were trained to ask a few basic questions on each shift to find out the patient’s priority for the day

� Whiteboards were installed at every bedside as a two-way communication tool between staff and patients or families

� Every 1–2 hours, bedside intentional rounds (also called comfort rounds) were introduced. These rounds focus on managing pain, preventing pressure ulcers (by turning the patient), helping the patient to the bathroom (preventing falls), and ensuring that all items are within reach. Staff members are continuing work on these implementations

� On a couple of units, a patient information board and suggestion box was set up. Surveys before and after indicate increased satisfaction

� A biweekly environmental scan was performed to promote patient safety

� A patient information pamphlet was produced on the basis of recommendations from patients and staff members

� Staff huddles were held to improve communication before comfort rounds

� Prizes were awarded for the best room, to encourage staff to participate in environmental rounds

� A clock was installed in each patient room

� Improvements were made in several of the unit-based family visiting rooms (e.g., family room television and computers) so that patients could manage their banking and other important activities while in hospital

� A plasma screen displaying patient information and health promotion videos was installed

� Staff members and patient representatives worked together to develop improvements (e.g., remodeling a family visiting room and creating a new quiet space for difficult conversations and preoperative work)

Outcomes of Module 3—Admission and discharge processes

� Process mapping allowed staff members to identify and address barriers to efficient and effective care and interprofessional communication

� Handovers between different levels of care improved

� Creating a communication binder improved the communication between nurses and physicians

� A room turnover magnet project improved the communication between team members and housekeeping at the time of discharge and room preparation

� The following were standardized:

� patient teaching information

� nursing admission documentation (streamlined content)

� training and orientation of residents and medical students by nursing team

� The following checklists were used:

� admission checklist for internal medicine residents

� discharge checklists for patients (developed by patients) and nurses

� checklists to standardize room equipment and preparation upon admission

Bedside Initiative Healthcare Teams’ Work Environments

Table 3. Paired Sample t Tests

T0 T1

Mean (SD) Mean (SD) t-Value, p-value

Effort–reward imbalance questionnaire

Effort 18.15 (2.27) 18.22 (2.42) t(90)= −.315, p= .754 Reward 30.85 (4.52) 30.90 (5.30) t(93)= −.126, p= .900 Effort–reward ratio 1.12 (.24) 1.14 (.32) t(81)= −.889, p= .377 Support from colleagues 18.16 (2.46) 17.65 (2.45) t(90)= 2.159, p= .034 Support from superiors 15.44 (2.65) 15.14 (2.55) t(95)= 1.212, p= .228

Job content questionnaire

Total support 33.98 (4.09) 32.78 (4.27) t(85)= 3.268, p= .002 Psychological demand 26.26 (3.07) 25.98 (2.90) t(92)= .807, p= .422 Control over task 31.85 (4.64) 30.85 (5.01) t(100)= .366, p= .715 Use of qualifications 36.06 (4.55) 35.83 (4.54) t(102)= .705, p= .482 Decisional latitude 67.31 (7.59) 66.71 (7.78) t(98)= .880, p= .381

Measures of processes of care

Showing interpersonal sensitivity 4.90 (.99) 4.96 (.94) t(87)= −.53, p= .595 Providing general information 4.08 (1.22) 4.02 (1.43) t(76)= .36, p= .721 Communicating specific information 3.97 (1.37) 4.27 (1.38) t(78)= −2.20, p= .031 Treating people respectfully 5.42 (.89) 5.34 (.97) t(87)= .81, p= .423

DISCUSSION In this study, the scores for many of the dimensions examined were highly stable. The nursing staff’s perception of psychoso- cial demands did not improve or worsen. As Donahue et al. (2008) mentioned, staff members may view TCAB as addi- tional work rather than as a vehicle to package the work they are already doing. We consider it positive that most of the staff members were engaged in numerous changes but did not report an increased workload. In year 1, staff members were not provided with protected release time, but in year 2 several frontline staff members were replaced while they met for a full day each week to perform tests of change, measure results, and attend workshops. Parkerton et al. (2009) and Kliger, Lacey, Olney, Cox, and O’Neil (2010) also identified the allocation of time away from patient care responsibilities and coaching support as key factors affecting TCAB participation.

In our study there was no improvement or deterioration in decisional latitude or reward. Most TCAB studies that exam- ine these dimensions find that there is an improvement, given the bottom-up approach used to select innovations to address the issues identified by the staff (Burston, Chaboyer, Wallis, & Stanfield, 2011). According to Parkerton et al. (2009) and

Pearson et al. (2009), this bottom-up approach transfers some authority to the frontline staff and increases their autonomy, which is essential for a successful implementation. However, frontline staff in this study must simultaneously deal with im- posed organizational changes and other competing priorities, which can limit their decisional latitude and reward. In addi- tion, they must collaborate and negotiate with partners from other services or departments to implement some changes. They are involved in more decisions related to their work but have to negotiate with more partners. Future research should investigate this issue further and determine if the positive im- pacts of a TCAB program can only be observed after a longer period or if specific elements of the present program were not favorable to an increase in perceived reward and decision latitude compared with previous programs.

Social support from colleagues decreased since the start of the interventions. This outcome may be partially the result of challenges identified by a number of investigators, such as difficulty obtaining staff buy-in (especially in the context of competing priorities in an organization), staff engagement, managing change processes, and maintaining momentum af- ter a strong start (Martin et al, 2007; Parkerton et al., 2009).

Original Article In the workshops, TCAB teams in this study shared strategies between units to improve communication with staff members who were not participating in the entire thought process, to foster their support to maintain the changes introduced. There must not be a disconnect between the TCAB team and the other members of the unit. The decrease in scores over time may be a reflection of the difficulties involved in managing change processes. The frontline staff leading TCAB improve- ments had to develop new leadership skills to assess and en- gage stakeholders, manage conflict, and deal with resistance to change, especially from senior staff. These challenges likely affected their perception of the degree of social support from colleagues.

As for staff perceptions of providing patient and family- centered care, the results show significantly higher scores on the “communicating specific information” subscale of the MPOC after TCAB was implemented. Many of the innova- tions tested and adopted by the staff of the four units targeted improvements in communication processes with patients and families, as shown in Table 2. A few studies described inno- vations resulting from TCAB that have improved healthcare providers’ communication with patients and families. In an ef- fort to increase communication, two surgical units in Cedars- Sinai Medical Center implemented a video rounding system to facilitate communication among physicians, nurses, and pa- tients when physicians are unable to be physically present at the bedside (Hain, Ng, Aronow, Swanson, & Bolton, 2009). This innovation was tested on a sample of 10 patients, who agreed that video rounding should be used when a physician cannot be present at the bedside and should be implemented as routine care (Hain et al., 2009). Other studies described in- novations such as intentional or hourly rounding (Chapman, 2009; O’Neil et al., 2011; Valente, 2011) and bedside report (Chaboyer et al., 2010; Chapman, 2009; Hassmiller & Chiver- ton, 2007; O’Neil et al., 2011), which has reduced call bell use and increased patient participation in care and satisfaction with care.

In sum, the theoretical framework used in this study helps to explain how the TCAB program impacts healthcare teams’ psychosocial work environments. Based on the study results, the decision makers and educators are more aware of the need to better prepare managers and frontline staff for supporting these types of changes. It is important to find different methods of communicating the changes, progress, and issues among collaborators (e.g., newsletters, e-mails to staff, using TCAB communication board).

STUDY LIMITATIONS This study with a pre–post design did not include a control group, which could have helped determine that the observed differences between baseline and postprogram were caused by the TCAB program and not from one or multiple confounding factors. In addition, this study included only four units. This small sample size and the overall return rate over 18 months

limits the generalization of the results. Future research will need to be conducted with a larger number of units within a healthcare center in order to replicate and expend this study results. Some measures from the JCQ (Karasek, 1985) were found to have low levels of internal consistency. However, the JCQ has been extensively validated. Finally, to evaluate the program’s long-term impact, a longitudinal design with more than one follow-up is needed.

IMPLICATIONS FOR NURSING Decision makers, educators, and TCAB teams must find ways to communicate the reasons for change to team members who are not involved in the entire thought process and to foster their support within the team. TCAB is a program that supports frontline staff and managers in developing the skills needed to lead changes aimed at improving patient, staff, and organizational outcomes. Team building requires considerable attention to interpersonal and communication skills. It is important to involve as many staff as possible in the tests of change, have weekly meetings to inform oth- ers of progress, and regularly present results through e-mails, newsletters, and updates on the TCAB bulletin board. Chang- ing the TCAB team or champions with different modules increased the number of staff gaining the skills needed to lead quality improvement. Ensuring that staff members had protected release time and ongoing coaching support for in- troducing and managing change, and creating regular fo- rums in which they could share their challenges and suc- cesses were important elements in this TCAB implementa- tion. Middle and senior leader presence was very important to teams for feedback and encouragement. Staff members perceived that TCAB resulted in improved patient and fam- ily experiences of care, particularly with regard to communi- cating the specific information needed by patients and fami- lies.

There are huge “untapped” talents in frontline staff to co- lead quality improvement. Our study involved frontline staff to optimize effective practices with the participation of patient representatives into the redesign process. There is consider- able support for greater involvement by patients in health care. Future research should investigate how to engage patients and frontline staff in a process of redesigning care to optimize qual- ity of care.

CONCLUSIONS In sum, this study showed some improvements from the TCAB program such as on communicating specific information as well as showing very little adverse effect on psychosocial work environment perceptions. Thus, TCAB is an intervention that allows healthcare teams to implement change to improve pa- tients’ and families’ outcomes without deteriorating the work environment. Ongoing energy should focus on how to improve communication among all members of the team and ensure their support. WVN

Bedside Initiative Healthcare Teams’ Work Environments

Author information

Mélanie Lavoie-Tremblay, Associate Professor, Ingram School of Nursing, McGill University, Nurse Scientist, McGill Uni- versity Health Centre (MUHC), Montreal, QC, Canada; Patricia O’Conner, Director of Nursing & Chief Nursing Of- ficer, MUHC, Assistant Professor, Ingram School of Nurs- ing, McGill University, Montreal, QC, Canada; Anastasia Har- ripaul, Master’s student, McGill University, Ingram School of Nursing, Montreal, QC, Canada; Alain Biron, Assis- tant to the Director, Quality, Patient Safety, and Perfor- mance, MUHC, Montreal, QC, Canada; Judith Ritchie, As- sociate Director for Nursing Research, MUHC, Montreal, QC, Canada; Genevieve L. Lavigne, Post-Doctoral Student, In- gram School of Nursing, McGill University, Montreal, QC, Canada; Sophie Baillargeon, Assistant to the Director of Nurs- ing, MUHC, Montreal, QC, Canada; Justin Ringer, Asso- ciate Director for Nursing Information and Administrative services, MUHC, Montreal, QC, Canada; Brenda MacGib- bon, Adjunct Professor, Universite du Quebec a Montreal, Departmement de mathematiques, Montreal, QC, Canada; Sharon Taylor-Ducharme, Clinical Practice Consultant, Tran- sition Support Office, MUHC, Montreal, QC, Canada; Jacynthe Sourdif, Research Assistant, MUHC, Montreal, QC, Canada.

The authors would like to thank the Canadian Institute of Health Research CIHR and Fonds de la Recherche en santé au Québec FRSQ for providing financial support for this study on healthcare teams. Address correspondence to Dr. Mélanie Lavoie-Tremblay, In- gram School of Nursing McGill University, 3506 Univer- sity Street, Montreal, QC, H3A 2A7, Canada; melanie.lavoie- [email protected]

References Ackerman, C. L. (2011). “Not on my watch”: Treating and prevent-

ing pressure ulcers. MEDSURG Nursing, 20(2), 86–93.

Agency for Healthcare Research and Quality (AHRQ). (2012). Con- sumer Assessment of Healthcare Provider and Systems Hospital Survey: survey instructions. Rockville, MD: AHRQ.

Bolton, L. B., & Aronow, H. U. (2009). The business case for TCAB. American Journal of Nursing, 109(11 Suppl.), 77–88.

Bourbonnais, R. (2007). Are job stress models capturing important dimensions of the psychosocial work environment? Occupational and Environmental Medicine, 64(10), 640–641.

Bourbonnais, R., Comeau, M., & Vézina, M. (1999). Job strain and evolution of mental health among nurses. Journal of Occupational Health Psychology, 4(2), 95–107.

Bourbonnais, R., Malenfant, R., Vézina, M., Jauvin, N., & Brisson, I. (2005). Work characteristics and health of correctional officers. Revue d’épidémiologie et de sante publique, 53(2), 127–142.

Bourbonnais, R., & Mondor, M. (2001). Job strain and sickness absence among nurses in the province of Quebec. American Journal of Industrial Medicine, 39(2), 194–202.

Burston, S., Chaboyer, W., Wallis, M., & Stanfield, J. (2011). A discussion of approaches to transforming care: Contemporary strategies to improve patient safety. Journal of Advanced Nursing, 67(11), 2488–2495.

Chaboyer, W., Johnson, J., Hardy, L., Gehrke, T., & Panuwat- wanich, K. (2010). Transforming care strategies and nursing sensitive patient outcomes. Journal of Advanced Nursing, 66(5), 1111–1119.

Chapman, K. B. (2009). Improving communication among nurses, patients, and physicians: A series of changes leads to cultural transformation at a TCAB hospital. American Journal of Nursing, 109(11), 21–25.

Donahue, L., Rader, S., & Triolo, P. K. (2008). Nurturing inno- vation in the critical care environment: Transforming care at the bedside. Critical Care Nursing Clinics of North America, 20(4), 465–469.

Gould, J. (2007). Promoting patient safety: The rapid medical re- sponse team. Permanente Journal, 11(3), 26–34.

Hain, P. B., Ng, C. S., Aronow, H. U., Swanson, J. W., & Bolton, L. B. (2009). Improving communication with bedside video round- ing: TCAB and technology enhance nurse-physician collabora- tion and patient care. American Journal of Nursing, 109(11 Suppl.), 18–20.

Hassmiller, S., & Chiverton, P. (2007). TCAB: Getting nurses in- volved in improving care. Dean’s Notes, 29(2), 1–4.

Hendrich, A., & Chow, M. (2008). Maximizing the impact of nursing care quality: A closer look at the hospital work environ- ment and the nurse’s impact on patient-care quality. Healthcare Leadership White Paper Series (4 of 5). Retrieved from http:// www.healthdesign.org/sites/default/files/HCLeadership%204_ %20Maximizing%20Impact%20of%20Nursing.pdf

Hendrich, A., Chow, M., Skierczynski, B., & Lu, J. (2008). A 36- hospital time and motion study: How do medical-surgical nurses spend their time? Permanente Journal, 12(3), 25–34.

Institut de la Statistique du Québec. (2000). Enquête sociale et de santé, 1998. Quebec, Canada: Gouvernement du Québec.

Institute for Healthcare Improvement. (2012). Transform- ing care at the bedside. Retrieved from http://www.ihi.org/ offerings/Initiatives/PastStrategicInitiatives/TCAB/Pages/ default.aspx

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press.

Karasek, R. A. (1985). Job content questionnaire and user’s guide. Lowell, MA: University of Massachusetts Lowell, Department of Work Environment.

Karasek, R., & Theorell, T. (1990). Healthy work: Stress, productivity and the reconstructions of working life. New York: Basic Books.

King, S., Rosenbaum, P., & King, G. (1996). Parents’ perceptions of care-giving: Development and validation of a measure of pro- cesses. Developmental Medicine and Child Neurology, 38, 757–772.

Kliger, J., Lacey, S. R., Olney, A., Cox, K. S., & O’Neil, E. (2010). Nurse-driven programs to improve patient outcomes: Trans- forming care at the bedside, integrated nurse leadership pro- gram, and the clinical scene investigator academy. Journal of Nursing Administration, 40(3), 109–114.

Kristensen, T. S. (1999). Challenges for research and prevention in relation to work and cardiovascular diseases. Scandinavian Journal of Work, Environment and Health, 25(6), 550–557.

Original Article Lavoie-Tremblay, M., O’Brien-Pallas, L., Gélinas, C., Desforges,

N., & Marchionni, C. (2008b). Addressing the turnover issue among new nurses from a generational viewpoint. Journal of Nursing Management, 16(6), 724–733.

Lavoie-Tremblay, M., Viens, C., & Mayrand Leclerc, M. (2002). L’environnement de travail: Un élément déterminant du bien-être et de la qualité de vie au travail infirmières. Quebec, Canada: Presses Inter Universitaires.

Lavoie-Tremblay, M., Wright, D., Desforges, N., Gélinas, C., Mar- chionni, C., & Drevniok, U. (2008a). Creating a healthy work- place for new-generation nurses. Journal of Nursing Scholarship, 40(3), 290–297.

Lewis, L. (2009). Perspective of the patient and family: The TCAB approach is visible to and appreciated by patients. American Jour- nal of Nursing, 109(11 Suppl.), 53.

Lorenz, H. L., Greenhouse, P. K., Miller, R., Wisiniewski, M. K., & Frank, S. L. (2008). Transforming care at the bedside: An ambulatory model for improving the patient experience. Journal of Nursing Administration, 38(4), 194–199.

Martin, S. C., Greenhouse, P. K., Merryman, T., Shovel, J., Liberi, C. A., & Konzier, J. (2007). Transforming care at the bedside: Implementation and spread model for single hospital and multi- hospital systems. Journal of Nursing Administration, 37(10), 444– 451.

Melichar, L. (2011). Transforming care at the bedside for nurse faculty: Can continuous quality improvement transform nurs- ing education? Journal of Nursing Education, 50(11), 603– 604.

Needleman, J., Parkerton, P. H., Pearson, M. L., Soban, L. M., Upenieks, V. V., & Yee, T. (2009). Overall effect of TCAB on initial participating hospitals: Evaluation at 13 pilot facilities. American Journal of Nursing, 109(11 Suppl.), 59–69.

Nelson, B., & Massey, R. (2010). Implementing an electronic change of shift report using transforming care at the bedside processes and methods. Journal of Nursing Administration, 40(4), 162–168.

Niedhammer, I., & Siegrist, J. (1998) Facteurs psychosociaux au travail et maladies cardio-vasculaires: L’apport du modèle du Déséquilibre Efforts/Récompenses. [Psychosocial factors at work and cardiovascular diseases: Contribution of the Effort- Reward Imbalance model.] Revue d’épidémiologie et de santé publique, 46(5), 398–410.

O’Connor, P., Ritchie, J., Drouin, S., & Covell, C. L. (2012). Re- designing the workplace for the 21st century healthcare. Health- care Quarterly, 12(6), 30–35.

O’Neil, J. A., Holecek, N., & DeLima, M. (2011). Taking care of business with TCAB. Nurse Management, 42(12), 19–22.

Parkerton, P. H., Needleman, J., Pearson, M. L., Upenieks[O12], W., Soban, L. M., & Yee, T. (2009). Lessons from nursing leaders on implementing TCAB. American Journal of Nursing, 109(11 Suppl.), 71–76.

Pearson, M. L., Needleman, J., Parkerton, P. H., Upenieks, W., Soban, L. M., & Yee, T. (2009). Participation of unit nurses:

Front-line implementation on TCAB pilot units. American Jour- nal of Nursing, 109(11 Suppl.), 66–70.

Popkin, B., Callahan, B., Scanlon, K., & White, M. (2007). Trans- forming care at the bedside: A doorway to empowerment. Nurse Leader, 5(4), 50–53.

Runy, L. A. (2008). The nurse and patient safety. Hospitals & Health Networks, 82(11), 43–50.

Rutherford, P., Moen, R., & Taylor, J. (2009). TCAB: The “how” and the “what”: Developing an initiative to involve nurses in transformative change. American Journal of Nursing, 109(11 Suppl.), 5–17.

Scott-Smith, J. L., & Greenhouse, P. K. (2007). Transforming care at the bedside: Patient-controlled liberalized diet. Journal of In- terprofessional Care, 21(2), 179–188.

Siegrist, J. (1996). Adverse health effects of high-effort/low-reward conditions. Journal of Occupational Health Psychology, 1(1), 27–41.

Siegrist, J., Starke, D., Chandola, T., Godin, I., Marmot, M., Nied- hammer, I., & Peter, R. (2004). The measurement of effort- reward imbalance at work: European comparisons. Social Science & Medicine, 58(8), 1483–1499.

Stefancyk, A. L. (2008). Nurses participate in presenting patients in morning rounds: The first test of change was more complex than was anticipated. American Journal of Nursing, 108(11), 70–72.

Stefancyk, A. L. (2009). One hour off unit meal breaks. American Journal of Nursing, 109(1), 64–66.

Trudel, L., Vonarx, N., Simard, C., Freeman, A., Vézina, M., Bris- son, C., . . . Dugas, N. (2009). The adverse effects of psychosocial constraints at work: A participatory study to orient prevention to mitigate psychological distress. Work (Reading, Mass.), 34(3), 345–357.

Upenieks, V. V., Needleman, J., Soban, L., Pearson, M. L., Park- erton, P., & Yee, T. (2008). The relationship between the vol- ume and type of transforming care at the bedside innovations and changes in nurse vitality. Journal of Nursing Administration, 38(9), 386–394.

Valente, S. (2011). Rapid cycle change projects improve quality of care. Journal of Nursing Care Quality, 26(1), 54–60.

Vézina, M., Bourbonnais, R., Brisson, C., & Trudel, L. (2006). Définir les risques. Note de recherche: Sur la prévention des problèmes de santé mentale. Acte de la recherche en sciences so- ciales, 163(3), 34–38.

Vézina, M., Cousineau, M., Mergler, D., Vinet, A., & Laurendeau, M. (1992). Pour donner un sens au travail. Bilan et orientations du Québec en santé mentale au travail. Boucherville, Quebec, Canada: Gaëtan Morin Éditeur.

Woodside, J. M., Rosenbaum, P. L., King, S. M., & King, G. A. (2001). Family-centered service: Developing and validating a self-assessment tool for pediatric service providers. Children’s Health Care, 30(3), 237–252.

doi 10.1111/wvn.12015 WVN 2014;11:16–25

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