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3 ways nurse leaders can change workplace culture


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By Jennifer Thew, RN

Is the old adage, "Happy nurses equal happy patients" true? 

Healthcare leaders at North Carolina–based Vidant Health have put this saying to the test. The organization committed resources to change the workplace culture for its nurses with the philosophy that engaged and motivated nurses provide better care to patients. Linda Hofler, PhD, RN, NEA?BC, FACHE, senior vice president and nurse executive at Vidant Medical Center describes the implementation as a "holistic approach to organizational excellence" that benefits the nurses and trickles down positively to the patients.

The goal of the approach, she explains, is "to improve team member experience and rebuild joy in the workplace. [It's not just] focused on patient experience but on team member, provider, and environmental experience as well."

The Institute for Healthcare Improvement treats on the idea that creating joy in the workplace is also an antidote to burnout, which is a major issue among clinicians. In 2017, the organization released its white paper, IHI Framework for Improving Joy in Work. 

Hofler became interested in a holistic approach to improving organizational outcomes when Vidant's chief experience officer Julie Kennedy Oehlert, RN, DNP, was doing doctoral research on the healthcare environment.

"[Her idea was] that if you just focus on the patient experience that you [don't] really get the engagement of your team members," Hofler says.

To test this theory, Oehlert and Hofler, along with their chief quality officer, assessed correlations among data related to employee engagement, complaints and grievances, patient experience, employee turnover data, and various nurse sensitive quality indicators.

"Sure enough, there are patterns and trends that would lead you to believe—at least our theory is—that if you can improve the team member experience, then the other things will get better too," Hofler says.
 
The Finer Points of Engagement
A recent meta-analysis from Penn Nursing’s Center for Health Outcomes and Policy Research (CHOPR) seems to support this idea. CHOPR researchers synthesized 16 years of studies to show the association between the nurse work environment (i.e., organizational elements that influence nursing care quality, such as nurse-physician collaboration, nurse manager support, and nurse involvement in decisions affecting clinical care) and four sets of outcomes: nurse job outcomes, nurse assessments of quality and safety, patient health outcomes, and patient satisfaction.
"Our quantitative synthesis of the results of many studies revealed that better work environments were associated with lower odds of negative outcomes ranging from patient and nurse job dissatisfaction to patient mortality," says the study's lead-investigator Eileen T. Lake, PhD, MSN, FAAN, the Jessie M. Scott Endowed Term Chair in Nursing and Health Policy, in a news release.

Vidant's focus on its team members' experience has been occurring for about two years, Hofler says.

"This is probably the most rewarding work I've done in a long time, but it's hard work because in the business of healthcare, people want to check a box and go on to the next thing," Hofler says. "And this is not about checking a box. It's about building networks and finding ways to create new and different ways of doing and being."

In a recent interview with HealthLeaders, Hofler shares three ways she and the leadership team at Vidant have reshaped the nurse work environment to achieve organizational excellence.

1. Nursing Salons
In the tradition of Ancient Greece and the French Enlightenment, Vidant has launched small gatherings known as salons. Historically, salons have been places where individuals increase their knowledge and share ideas and experiences through rich conversations.

During Vidant's salons, attendees—with the help of a facilitator—focus on a specific topic and engage in dialogue and learning. Hofler says the groups are limited to no more than 30 participants and meet for about an hour.

For example, the organization has a salon for leaders that focuses on the topic of empathy and is designed to be highly interactive, where participants engage in storytelling and sharing of experiences.

"During that hour, not only are you learning content, but you're learning from the experiences of the other people in the room, so it becomes very rich," Hofler says of the group. "It's kind of a recommitment to why you came into a healthcare profession. For nursing, that resonates with folks because it's so easy in the business to forget why you really wanted to do the work to begin with."
 
2. Games
Adding a little friendly competition among nurses when practicing problem-solving skills seems to be paying off at Vidant.

"We did a game with all of my leadership team and their direct reporting lines where they had an hour to devise a plan for how they were going to do something to focus on engagement [with] their teams," Hofler says. "They were going to get $100, so [the question was], 'How would they use that [money to engage with their employees]?"

One group created a circus theme to help connect with their employees. They designed a cart that looked like a circus tent and they dressed like circus performers and took circus-related snacks to the employees on the unit. They used that as an opportunity to start conversations "about what was the most important thing that leadership should be doing to support patient care at the front line," she says.

In the end, Hofler estimates she spent about $1,500 on that exercise.

"They all implemented their projects, took pictures, and came back, and we had a celebration at the end. We saw a change in our [employee] engagement scores. It was a small incremental change, but that's what you want … small changes over time that are sustainable," she says.

Additionally, the organization had a "Rounding Olympics."

"It was a system process and it was to determine what units could get the highest scores [regarding patient] answers to the question, 'Did a leader round on you during your hospital stay?' " she says. 

The winners received $1,000 to have a party or redecorate the breakroom.

"Again, not terribly expensive, and it got a ton of people engaged, and they were excited about it and it was fun," says Hofler.
 
3. Support Breaks
"[Part of Vidant's philosophy] is to create a culture where team members can be resilient, where they find joy in what they do, and where they're able to show up and be their best every day," says Hofler.

One example of this culture of support is a change that occurred in the emergency department, which sees about 120,000 patients a year, says Hofler.

On a particularly busy day, she asked to see the department's breakroom.

"They asked, 'Why do you want to see the breakroom?' I said, 'Well, [the ER] is like a war zone. People are just coming and there's no stopping. Where do you go get yourself centered again?' " Hofler recounts.

The answer was typical of most nurses: "We don't do that."

And, even if the nurses did take a break, the ED space was not conducive to grounding oneself during a frenzied shift.

Hofler was able to help carve out a space that is visually appealing, and is outfitted with refrigerators, a microwave, and a serenity room painted with calming colors and inspirational quotes.

"Now [nurses] will go in there and talk to each other," she says.

Hofler says getting the physicians and the nurses committed to taking breaks and having charge nurses ensure that staff members are taking the much-needed recovery time has helped the nurses' workplace experience.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.