APA REFERNCE SUBMISSION

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Barbara B. Brewer, PhD, RN, MALS, MBA, FAAN, is Professor, The University of Arizona, College of Nursing, Tucson, AZ.

Megan C. Quinn, PhD(c), RN, is Clinical Nurse, Neonatal Intensive Care Unit, Banner Health, Phoenix, AZ.

Claire Bethel, MSN, RN-BC, is Doctoral Student, The University of Arizona, College of Nursing, Tucson, AZ.

What Makes a Medical-Surgical Unit Excellent?

Barbara B. Brewer Megan C. Quinn

Claire Bethel

T he Academy of Medical- Surgical Nurses (AMSN) de - veloped the Premier Recog -

nition In the Specialty of Med-surg (PRISM) Award® to recognize med- ical-surgical nursing units on which exemplary professional practice and care are delivered. The first PRISM Award was made in 2013. As of July 2019, 41 medical-surgical units had received PRISM designation (AMSN, 2019a). The award is based on a written application addressing unit characteristics in six areas: leader- ship, recruitment and retention, evi- dence-based practice, patient out- comes, healthy practice environ- ment, and lifelong learning. The purpose of this article is to report findings from a qualitative study using content analysis and descrip- tive statistics to describe PRISM units based on responses to award applications. The study was com- missioned by the AMSN Board of Directors to identify key characteris- tics of medical-surgical units exem- plifying healthy practice environ- ments and excellence in nursing practice.

Research Questions The research questions were as

follows: Are there differences in demographic characteristics of units that did and did not achieve PRISM status? What are the key characteris- tics of each of the PRISM Award cri- teria (effective leadership, recruit- ment and retention of competent nurses, evidence-based practice, pos- itive patient outcomes, healthy practice environment, lifelong learn ing)?

Review of the Literature Literature published 2013-2019

was searched using Google Scholar and CINAHL databases. Search terms were healthy work environments for nurses, healthy practice environ- ment for nurses, or nurse practice envi- ronment. Seminal literature related to Magnet® hospital recognition also was included.

The beneficial effect of healthy practice environments on nurse and patient outcomes has been recog- nized for several decades (McClure & American Academy of Nursing Task Force on Nursing Practice in Hospitals, 1983; McClure et al., 2002). Subsequent to early research initiated by the American Academy of Nursing, many researchers have studied the effects of healthy work environments in critical care units (Ulrich et al., 2019), medical-surgi- cal and specialty units (Kramer et al., 2017; Kramer et al., 2014; Kramer et al., 2013; Stimpfel et al., 2015), and behavioral health units (Frechette et al., 2018). In a systematic review, Wei and colleagues (2018) identified five major themes related to healthy practice environments. In all cases, healthy work environments were related positively to better patient and nurse outcomes, better interper- sonal relationships among care- givers, and the presence of nurse Instructions for

CNE Contact Hours MSN J2008

Continuing nursing education (CNE) contact hours can be earned for

completing the evaluation associated with this article. Instructions are available

at amsn.org/journalCNE

Deadline for submission: June 30, 2022

1.4 contact hours

This study analyzed PRISM unit applications to identify key charac- teristics of units that did and did not achieve recognition. Results may provide unit leaders with a roadmap for achieving excellence in medical-surgical patient care.

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leaders committed to changing cul- ture to enable healthy practice struc- tures and processes.

Leaders of hospitals and other healthcare organizations have sought evaluation and recognition of excel- lence of their practice environ- ments. Three of the best known are Magnet recognition, an organiza- tional credentialing program of the American Nurses Credentialing Center (2019); Beacon Award, a crit- ical or progressive care unit recogni- tion (American Association of Critical Care Nurses, 2019), and PRISM Award, AMSN’s medical-sur- gical and specialty unit recognition award. In particular, PRISM Award applicants must show evidence of leadership effectiveness, recruitment and retention of competent staff, healthy practice environments, evi- dence-based practices, lifelong learning, and positive patient out- comes (AMSN, 2019b).

Sample Selection The available sample consisted of

applications submitted to AMSN February 2014-April 2018. Suc cessful and unsuccessful applications were included, resulting in 75 applications from 50 unique units. Units submit- ting multiple applications were con- sidered successful if their resubmis- sion application was successful, and only this application was considered for analysis. Units were considered unsuccessful if they never received the award after an original applica- tion or resubmission. The sample consisted of 10 PRISM-awarded and 3 non-awarded units from throughout the United States. They consisted of the following specialties: medical- surgical (n=3), medical-surgical with cardiac focus (n=3), surgical (n=3), and other specialties (n=1). The non- awarded units included one medical- surgical unit and two surgical units.

Ethics Human subjects review by The

University of Arizona Institutional Review Board deemed the study non-human subjects research. Com - pleted applications were uploaded to a secure cloud site by AMSN staff for researcher access.

Design and Method A qualitative descriptive ap -

proach was used to guide the study. Narrative data from identified PRISM Award applications were uploaded into Atlas.ti for analysis. Krippendorff’s (2013) method for content analysis was used to evalu- ate these data. Inductive and deduc- tive codes were applied to describe key phrases and concepts. Successful PRISM Award applications were ana- lyzed first, and were selected pur- posefully from the sample to ensure applications across the time period were analyzed. Awarded applica- tions were reviewed until no new codes or concepts relating to the leadership characteristics were re - vealed. Unsuccessful applications then were analyzed following the same method of applying codes and concluding when no new codes or concepts were revealed. These were selected purposefully from the sam- ple pool in the same manner as the awarded applications, but units that initially were not awarded and sub- sequently were awarded on applica- tion resubmission were not included in the group of unsuccessful applica- tions. Each application question was reviewed in group discussion by the team to determine common codes and synthesize similar codes into themes.

Demographic information was analyzed using SPSS (v.26). Demo - graphic results included characteris- tics, such as bed size, skill mix, and average daily census. The same demographic characteristics were reported for successful and unsuc- cessful units. Differences based on PRISM designation were determined using parametric statistics.

Aim

Analyze PRISM award applications for key characteristics of medical-sur- gical units awarded PRISM designation. Characteristics assessed in award applicants included six domains: leadership, recruitment and retention, evidence-based practice, quality patient outcomes, work environment, and lifelong learning.

Method

The sample consisted of 75 applications from 50 unique units represent- ing 27 applications of awarded and 23 applications of non-awarded units. Content analysis was used to analyze applications for themes within each of the application categories.

Results

Six themes (support and empowerment, a welcoming environment, a foundation for professional practice, providing quality for patients and families, a positive place to work, commitment to professionalism) emerged consistent with the question prompts representing six domains from the PRISM application. Saturation was reached with 13 applications.

Limitations and Implications

Themes were influenced highly by application question prompts. Few differences were identified among awarded and non-awarded applica- tions. The major difference was in depth of description and examples illustrating clinical nurses in leadership roles in awarded units.

Conclusion

A content analysis study of applications for PRISM recognition resulted in identification of six themes representing excellence in medical-surgical nursing.

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Trustworthiness Relevant details of unit character-

istics were gathered and reported to describe the sample and establish transferability. Two authors re - viewed applications at the begin- ning of analysis to determine simi- larity in coding and identification of key concepts. Coding decisions were agreed upon between these authors, enhancing dependability of results. Applications were selected for analy- sis from earlier and more recent dates in the sample period to ensure similarity of results across time. Raw and coded data, along with code networks used to establish relation- ships between codes and determine themes, are available for review. Exemplar quotations from the appli- cations were chosen and included to establish a connection between data and the authors’ interpretations.

Findings and Discussion No differences were identified in

demographics of awarded and non- awarded units with one exception. Awarded units (M 41.6, SD=8.8) had significantly fewer, t(11)=3.109, p=0.01, registered nurses than non- awarded units (M=62.7, SD=15.4) (see Table 1 for unit demographics).

Saturation was achieved with 10 PRISM-awarded applications and three non-awarded applications for comparison. Six themes were found across all application categories. The following sections represent the six themes, including examples of strategies used by the units to achieve excellence.

Support and Empowerment Leaders in PRISM units supported

nursing practice and empowered clinical nurses to play an active role in the unit. Shared governance was a primary way for clinical nurses to participate in shared decision-mak- ing. Unit-based councils comprised of clinical nurses and some represen- tative leaders were common, with stated goals of discussing ongoing unit challenges, practice changes, quality improvement initiatives, and staff recognition. Some units reported shared governance com- mittees with specific foci, such as quality and safety, education, reten- tion, and recognition; these allowed staff to influence changes in desired areas. Eliciting staff input through on - line surveys and employee forums was another way leaders ensured staff had influence over unit deci- sions. Encouraging staff to partici- pate in unit goal setting also was

empowering and achieved primarily through unit council membership.

Leaders and institutions further supported staff by recognizing their achievements and excellence. Unit- based recognition was achieved on a small scale through bulletin boards, daily huddles, and staff meetings during which small notes of thanks from patients, families, and col- leagues could be shared. Some units selected an employee of the month to recognize an individual. Insti - tutional recognition often occurred for larger accomplishments, such as cer- tification, “good catches” and other safety awards, institution-wide Nurses Week awards, and regional or national awards (e.g., Daisy, Petal awards).

A culture of trust and respect was upheld by following principles of just culture, encouraging peer review, and addressing errors with a non- punitive approach. Leader modeling and coaching of respectful behavior was described as a key strategy to see positive collegial behavior reflected in their staff. Building relationships between staff through mentoring programs and team-building activi- ties was a foundation for trust and respect in professional relationships. Some units reported communica- tion training to facilitate these rela-

What Makes a Medical-Surgical Unit Excellent?

TABLE 1. Demographics for Awarded and Non-Awarded Units

Awarded (N =10) Non-Awarded (N =3)

Mean (SD) Mean (SD)

Number of Beds 32.4 (6.2) 31.0 (8.5)

Average Census 28.0 (8.0) 26.0 (10.8)

RN-to-Patient Ratio 5.2 (0.7) 4.3 (0.6)

Number of Staff 65.6 (20.7) 59.5 (16.4)

Registered Nurses 41.6 (8.8) 62.7 (15.4)*

Licensed Practical Nurses 0.6 (1.1) 0.0 (0.0)

Unlicensed Personnel 16.2 (15.3) 6.6 (11.4)

Certified 13.3 (4.7) 11.3 (9.5)

Length of Service on Unit 7.3 (2.1) 6.3 (1.1)

Turnover Rate Last Fiscal Year: Facility 8.1 (3.5) 11.5 (3.5)

Turnover Rate Last Fiscal Year: Unit 9.2 (7.2) 12.2 (5.7)

Note: *p£0.01

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tionships further and teach staff how to manage interpersonal chal- lenges respectfully.

A Welcoming Environment Creating a welcoming environ-

ment was an essential theme for recruitment and retention of new staff. Applicants described their staff’s role in attracting new employ- ees largely through interaction with student nurses. Creating a welcoming environment for students was accom- plished by mentoring and encourag- ing students, and enthusiastically inviting them to participate in unit processes and activities (e.g., rounds, huddles, care activities). Some insti- tutions offered student nurse precep- torship work programs as educational opportunities for student nurses, and allowed nurse leaders to teach and evaluate students for their abili- ties to learn and fit within the unit. Dedicated preceptors facilitated devel- opment of mentoring relationships between staff members and stu- dents, and provided continuity dur- ing the education and evaluation process. General student rotations and more formal preceptorships (described as “extended interviews”) facilitated staff referral of students for hiring consideration. Staff also were involved in recruitment of new employees who were not students through direct referrals and internal transfers, especially through ad - vancement of employees previously working on the unit as unlicensed staff.

During orientation, staff were made to feel welcome and support- ed through several different pro- grams. Some units had an advanced residency program through which newly hired staff, particularly new graduate nurses, received extra edu- cation, support, and time to com- plete their orientation. One applica- tion noted, “The [residency] pro- gram integrates peer-to-peer interac- tions with all generations, instruc- tor-led sessions, interactive activities to build relationships and team spir- it, and simulation to enhance knowledge, critical thinking, and skills.” Mentorship programs also were described as valuable support struc- tures for novice nurses. The mentor

was to enhance socialization of the novice nurse, and to provide a resource person who was not responsible for orientation and who could remain in a supportive role throughout the novice’s early pro- fessional development. Preceptor pro- grams were universal among appli- cants, but they described varying levels of consideration for preceptor selection, matching, education, and evaluation. In some units, precep- tors were selected by a clinical nurse specialist or unit-based council. In other units, nurses simply needed to express interest and demonstrate teaching and communication skills.

As an aspect of cultivating a posi- tive working environment, strate- gies for addressing cultural diversity were described. Meals with a specific cultural focus were one of the most common ways of celebrating cultur- al diversity; some of these meals included an educational element by displaying facts about the culture of interest. Some applicants described diversity education offered by their institutions, such as, “Cultural diversity events offered throughout the system which include quarterly in-services and an annual Cultural Diversity Symposium.” Three units included specific examples of diver- sity education beyond that provided in annual competency training for most institutions.

A Foundation for Professional Practice

Professional development programs, which provide opportunities for or incentivize staff’s professional devel- opment, were common across units. These programs often were de - scribed as clinical ladders on which nurses could advance through levels of expertise, often requiring evi- dence of continued education, lead- ership, and contribution to the unit or profession through service in shared governance, quality im - provement, and support of novice colleagues. Providing staff with sup- port for obtaining their professional certification through review courses and materials, peer mentoring, and study sessions also was described. Institutions provided financial incentives for certification by fund-

ing or reimbursing examination costs and offering bonuses for certi- fied nurses.

Evidence-based practice (EBP) resources available to complete and disseminate evidence included ac - cess to experts, library resources, and financial support. Most common was access to research through insti- tutional databases and availability of medical libraries. Journal clubs provided a discussion forum and access to current research. Many applicants described availability of expert consultation by medical librar- ians, statisticians, health informati- cists, and doctorally prepared nurse researchers. These experts assisted staff with research activities, such as literature searches, mentored data analysis, and synthesis of evidence. Some experts provided research edu- cation at the institutional level geared toward developing clinical staff research skills. Dissemination of EBP was completed on a local level by hosting institutional research conferences, and featuring research completed by staff and displayed for colleagues. To disseminate findings more widely, some institutions pro- vided financial support for conference presentations by funding conference registrations for staff; in some cases, travel/lodging and paid time for conference attendance also were offered. Incorporating EBP into unit policy was accomplished by consult- ing professional standards and having a policy committee to review EBP at unit and hospital levels. Reviewing professional standards allowed poli- cy changes to be made without requiring independent EBP projects for practices considered standard of care.

Providing Quality for Patients and Families

Information regarding patient outcomes was presented in exem- plar format. Because applicants were able to choose from a variety of clin- ical outcomes, direct comparisons between strategies and efficacy of interventions was difficult. Staff edu- cation and re-education was the most common intervention found in all exemplars. Several applicants de - scribed outcomes declining after a

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previous practice change requiring re-education for staff to emphasize previously implemented interven- tions. Other applicants described the need to educate staff about new interventions recommended by quality groups and interprofessional task forces. Monitoring of compliance and outcomes often was reported to help determine intervention effica- cy and further staff needs for educa- tion or coaching. Regularly updated bulletin boards provided real-time feedback on how interventions were helping to improve patient care.

Exemplars demonstrating caring, specifically to empower a patient or to care for a patient at end of life, were described. A common finding was prioritizing patient and family emotional and personal needs. Ex - amples included reducing surgical procedures and other medical inter- ventions, and being flexible with typical unit schedules and processes to fulfill a personal need vital to the patient or family’s emotional well- being or quality of life. Facilitating family presence at the bedside also was described commonly in these exem- plars. Staff accomplished this by providing meals and sleeping accommodations at the patient’s bedside, and using Comfort Carts and similar resources.

A Positive Place to Work A positive place to work encom-

passed leaders’ efforts to create a positive, healthy work environment for clinical nurses and other staff. Many applicants described using a peer review process and nonpunitive approach for assessing errors. Staff socialization occurred through casual gatherings outside work, and cele- brations of unit accomplishments and important life events (e.g., wed- dings, upcoming births, gradua- tions). Team-building activities im - proved collegiality, often through community service or outreach activities.

In addition to collegiality among nursing staff, interprofessional col- laboration was accomplished prima- rily through interprofessional rounds. The structure, schedule, and disci- plines involved in these rounds dif- fered among units. However, rounds

were held to coordinate patient care and discharge plans, and always included nursing representation. Collaboration in quality improvement was described, especially when the quality initiative was uniquely rele- vant for a non-nursing discipline; for example, physical therapists were involved in projects to reduce patient falls, and respiratory thera- pists led teams to decrease pneumo- nia. In-room white boards enabled additional interprofessional com- munication, creating opportunities for everyone entering the patient’s room to visualize the plan of care easily and identify the patient’s goals.

Workplace safety also contri - buted to a positive workplace. Staff physical well-being was protected through institutional investment in lift devices and equipment to pre- vent movement and ergonomic injury, as well as other commonly used equipment such as safety nee- dles. Workplace violence prevention was addressed through education on risk reduction and de-escalation of conflict; in some units, panic but- tons and other physical security enhancements were used. Emotional and mental well-being was protected by offering employee assistance pro- grams and counseling. Education included training on incivility and bullying, with a few units also offer- ing anonymous hotlines or comput- er systems for reporting incidents of harassment and incivility. Wellness initiatives, such as pet therapy, mas- sage therapy, and respite rooms, were available in some units.

All units reported multi-faceted cri- teria for determining staffing and assignments to prevent burnout and unsafe patient assignments. Staffing grids informed by computer-based acuity tools were used to determine base levels of staff required for each shift. Nurse leaders had authority to be flexible with the staffing plan based on competence and skill level of staff, skill mix of available staff, continuity of care, and patient and family requests or personal needs. Clinical nurses were able to advo- cate for rearrangement of assign- ments or extra support staff to accommodate increased patient

needs. Patient care support took a variety of forms: nursing aide staff, feedback to leaders throughout the shift to ensure appropriate work- load, and charge nurses serving as resources without patient assign- ments.

Commitment to Professionalism

Leaders facilitated continuing edu- cation through flexible staffing when individuals wanted to attend educational sessions that conflicted with their schedules. They support- ed and participated in nursing grand rounds and published educational opportunities to encourage staff attendance. Educational initiative was supported by encouraging pro- fessional development; programs designed to incentivize staff devel- opment and clinical excellence required additional formal and informal education. Formal educa- tion was facilitated through flexible scheduling for staff in degree pro- grams, with some institutions offer- ing tuition reimbursement or schol- arships to reduce financial burden on staff advancing their education, and incentivizing retention for staff with higher education.

Professional activities in which staff participated were not always essential to their bedside role, but they contributed to the profession of nursing or their own professional development. All applicants de - scribed staff as belonging to profes- sional organizations such as AMSN, with some being more involved as board members or speakers at local chapter meetings. All applicants described staff involvement in vol- unteer work as well, including com- munity food, clothing, or toy drives and donations. Health-related com- munity outreach also was described:

The clinical nurses of our unit volunteer and are involved in community outreach pro- grams sponsored by our facili- ty. This program titled ‘Healthy Sundays’ provides health pro- motion, flu vaccines, glucose testing, and blood pressure screening to local parishes and community centers.

What Makes a Medical-Surgical Unit Excellent?

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Applicants described flexible staff - ing and multiple methods of notify- ing staff of education opportunities as aspects of facilitating education attendance. Education notice boards, unit-specific bulletin boards, and newsletters were common ways to communicate continuing education opportunities. Another essential facilitator of lifelong learning was financial support for education. An allowance of a set number of paid education hours and funding for conference attendance were com- mon examples. Applicants also described the inclusion of funding for educational activities in the annual budget.

Communication about EBP was accomplished through staff meetings or gatherings, such as shared gover- nance meetings, daily huddles, and journal clubs. Staff education also was used, especially to communi- cate EBP relating directly to changes in practice or policy. Institutional conferences offered opportunities to communicate EBP through formal presentation of findings, though this strategy was used less frequently than others.

Few differences were found among awarded and non-awarded PRISM unit applications. The major qualitative difference involved the depth of description in examples of how the unit was meeting specific criteria. In addition, non-awarded applications demonstrated less evi- dence of clinical nurse empower- ment and autonomy. Interestingly, awarded units had significantly fewer registered nurses (p£0.01). Otherwise, no significant quantita- tive demographics differences were found among the units.

Limitations Although no literature describes

excellence in medical-surgical units specifically, findings from this study are consistent with the literature describing professional nursing practices in Magnet and aspiring Magnet hospitals (Kramer et al., 2017; Kramer et al., 2011). As in this study, building a work environment in which adequately staffed clinical nurses are empowered to use the lat-

est evidence to provide patient care within a strong interprofessional team results in quality patient out- comes and successful staff retention and recruitment. A notable limita- tion to the study was related to the nature of the data; they were com- pleted applications and offered researchers no opportunity to ask clarifying questions. As a result, opportunity existed for misinterpre- tation of the meaning of the data by the researchers. Response details and examples veered little from prompts and examples given in the application questions. Question prompts may have limited the wealth of possible examples that could have been provided by indi- viduals completing the applications.

Nursing Implications Medical-surgical units contain

highly complex patients who require care that is attentive to rapid changes in condition. Possible out- comes may be unpredictable due to interactions among multiple co- morbidities, medications, and other treatments. Nurse leaders who rec- ognize the importance of building structures and processes through which staff are empowered, able to advocate for their patients, and have access to resources (e.g., adequate number of competent staff) will position their units to demonstrate excellent patient care. Unit leaders will decide if they apply for recogni- tion of excellence. However, appli- cation criteria provide a roadmap for implementing structures and pro - cesses to improve the work environ- ment for staff and the care environ- ment for patients and their families.

While the PRISM application may not be successful, leaders will learn where gaps may exist and will be able to focus attention on areas in need of strengthening. Future research focused on patient out- comes across time and across units may demonstrate differences among units with more advanced or mature structures. Examples of measurable outcomes include patient falls, hos- pital-acquired pressure injury, and patient satisfaction with nursing care.

Conclusion This study is the first to describe

characteristics of medical-surgical units that have achieved distinc- tions of excellence based on PRISM criteria. Content analysis to describe themes emerging from responses to PRISM application questions result- ed in six themes. The themes in - cluded support and empowerment, a welcoming environment, a foun- dation for professional practice, pro- viding quality for patient and family outcomes, a positive place to work, and commitment to professional- ism. Differences between units that achieved the award and those that did not centered around the rich- ness of details of examples and evi- dence of the empowerment of clini- cal nurses.

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