Acute-care registered nurses (RNs) play a key role in preventing many adverse patient events, including falls, pressure ulcers, and hospital-acquired infections. When considering strategies to improve patient outcomes, RNs typically think first of evidence-based prevention bundles for these adverse events. But even with these bundles, achieving sustained improvement in patient outcomes is challenging. Organizations that have achieved sustained improvement began by creating a work environment that promotes a commitment to excellence in nursing care.

Many work-environment models have been used to promote safety, including a culture of safety and the requirements for the American Nurses Credentialing Center’s Magnet Recognition Program®. These models share certain features that can be applied in acute care, including a shared vision, authentic leadership, a commitment to life-long learning, and intentionality in daily practice. Achieving a good work environment creates a spiral of improvement in RN job satisfaction and retention, a more experienced and skilled nursing workforce, and safer patient care. (See Spiral of improvement by clicking the PDF icon above.)

Start from the data

All improvement activities, including improvement of the nursing work environment, start by examining data on the current performance level. What do RNs think about the work environment? What aspects do they think should be improved? Job-satisfaction and job-context surveys can provide a wealth of information, especially when reports are accompanied by comparison data from peer organizations. Talking directly with RNs to understand their ideas for change also is crucial to improvement.

For acute care, the best data come from nursing care units, where patients with specific needs interact with a team of nurses and their interprofessional partners. The National Database of Nursing Quality Indicators® (NDNQI®), a program of the American Nurses Association (ANA), produces unit-based performance reports on both the quality of the nursing work environment and the quality of nursing care for units in participating hospitals.

What the case studies show

ANA has published a series of monographs with case studies of units that have achieved sustained improvement in the nursing work environment and quality of patient care. By examining these case studies, we’ve identified several characteristics of units that have improved their work environments. First, all of these units emphasize the importance of identifying specific aspects of the environment needing improvement. Successful units use the NDNQI RN Survey to identify targets for improving the nursing work environment.

Second, once a target area is identified, successful units develop a concrete plan with a focused intent toward improving that specific aspect of the work environment. These plans commonly include administrative support and unit leadership. Unit leadership that takes day-to-day responsibility for guiding change is essential. A capable, respected nurse manager is fundamentally important to team building and achieving sustained improvement in the work environment.

Third, staff RNs must be invested and embedded in the process. Common elements on successful units are shared governance, unit-based councils, and change champions. Although strong leadership is important, leaders must work with staff RNs to identify targets and develop plans for improving the work environment. Many successful units have used open forums with staff RNs to discuss the underlying causes of low satisfaction on the identified target. This procedure of drilling down to the core of the problem allows teams of leadership and staff to develop specific plans for improvement together.

Finally, successful units invest in the continuing professional development of their RNs, whether through continuing education, conference support, or support for advanced degrees and national specialty certification. Successful units monitor the work environment year after year through the NDNQI RN Survey. They also may conduct mid-year reviews using internally developed surveys or periodic team meetings to discuss progress or make changes to the plan for improving the target. They celebrate their successes along the journey, and many successful units have been recognized by their hospitals for their efforts.

Improving patient safety

We used case studies to gain insight into successful organizational change leading to improved patient outcomes. RN success in providing safe, effective care and reducing adverse events depends on four factors:

• quality of the nursing work environment
• availability of unit-level data and comparison data on nursing quality indicators
• preventive capacity of evidence-based practice
• staff RNs’ readiness for change.

Within a supportive, professional work environment, unit RNs who review their NDNQI performance reports may decide one or more patient outcomes need to be improved. They also may use the reports to review staffing levels and nursing-process measures related to specific outcomes.

Example: Patient-fall rate

For example, if unit RNs find their unit’s patient-fall rate is among the highest 25% of peer units, the first step of that unit’s quality council is to examine the research-, clinical-, and evidence-based literature to identify factors related to patient falls. They’ll find higher levels of RN staffing are linked to lower fall rates. The next step is to compare their unit’s staffing levels to peer units’ levels to determine if low staffing may be contributing to the problem.

Then the quality council will examine data on fall-prevention processes in their NDNQI report. When they drill down through their prevention process data, they’ll find the pattern shown in Prevention process pattern, which points to opportunities where the fall-prevention process could be improved.

Results of this data review may lead to a further series of questions. For instance, should the unit change its policies on which patients need to undergo risk assessment? Is there a better type of risk assessment to use? Are better evidence-based prevention measures available?

Achieving change in patient-safety practices requires many of the same resources and structures as those needed to change the nursing work environment—a specific goal and plan, supportive leadership, a unit-based champion to model and encourage changes in practice, shared decision making with input from staff RNs, and support for continued education on patient-safety practices. Changing usual practices is as difficult as changing habitual practices. Successful change requires education, champions, reminders, focus, and persistence.

Celebrating success

As units undertaking changes in the work environment or patient-safety practices monitor their progress over time, they should celebrate improvements on the journey toward their goal. Sustained improvement can’t be achieved with a single episode or single activity, or within a brief period. Most successful case-study units worked on achieving their goals for several years. To maintain staff engagement and intentionality of practice, celebrations are wonderful tools for creating momentum to drive change.

Selected references

Duncan J, Montalvo I, Dunton N. NDNQI Case Studies in Nursing Quality Improvement. Silver Spring, MD: American Nurses Association; 2011.

Dunton N, Gajewski B, Klaus S, Pierson B. The relationship of nursing workforce characteristics to patient outcomes. OJIN. 2007;12(3). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingWorkforceCharacteristics.html. Accessed November 29, 2012.

Lake E, Shang J, Klaus S, Dunton N. Organizing nursing resources to reduce the risks of patient falls. Res Nurs Health. 2010;33(5):413-25.

The authors work at the School of Nursing at the University of Kansas Medical Center. Nancy Dunton is a research professor and director of NDNQI. Diane K. Boyle is an associate professor and deputy director of NDNQI. Emily Cramer is a senior research associate.