NUR410 Leadership in Nursing: Exploring Styles & Characteristics PDF

FOUNDATIONS OF LEADERSHIP IN NURSING: EXPLORING STYLES AND CHARACTERISTICS OF LEADERS WEEK 1 LEARNING OBJECTIVES Define leadership and associated competencies. Discuss the importance of nursing leadership. Identify task focused and relational styles of leadership. Describe the characteristics of clinical leadership. Define followership and follower responsibilities. CNO ENTRY TO PRACTICE COMPETENCIES 6. Leader: Registered nurses are leaders who influence and inspire others to achieve optimal health outcomes for all. 6.3 Participates in innovative client-centred care models. 6.4 Participates in creating and maintaining a healthy, respectful, and psychologically safe workplace. 6.5 Recognizes the impact of organizational culture and acts to enhance the quality of a professional and safe practice environment. 6.6 Demonstrates self-awareness through reflective practice and solicitation of feedback WHAT IS LEADERSHIP? A process whereby an individual influences a group of individuals to achieve a common goal. (Northouse, 2018, p.43) Process, considered by some to be a skill, behaviour or a role Doesn’t require formal authority of a management position Can be demonstrated by all nurses NURSING LEADERSHIP Nurse leaders influence and inspire others with the goal of achieving optimal outcomes at all levels of the health system. o Establish vision and direction o Lead the “design and delivery of excellent care” (Duncan & Wignall, p.173) o Influence care delivery, clinical operations, change, quality, research, policy, ethical practice, system transformation etc. Requires strong professional identity grounded in nursing knowledge, embedded in relational & ethical practice. BENEFITS OF NURSING LEADERSHIP Leadership behaviours are associated with o Improved patient outcomes o Quality nursing care o Healthy work environments o Nurse job satisfaction, organizational commitment and intent to remain employed. o Enhanced team collaboration o Increased innovation APPROACHES TO LEADERSHIP Task Focused o Transactional o Autocratic o Laissez-Faire Relational o Democratic o Authentic o Resonant o Servant o Transformational TRANSACTIONAL LEADERSHIP Focused on exchange between leader and follower. Provides rewards for meeting or exceeding expectations. May offer negative feedback, corrective action or punishment if standards are not met. Uses bureaucratic leadership: o Maintains formal roles o Follows organizational structures o Clarifies work tasks AUTOCRATIC LEADERSHIP Highly directive. Decisions are made for the followers/staff. Followers are not able to participate in decision making. LAISSEZ-FAIRE LEADERSHIP The leader takes a back step. Non-hierarchical. Encourages autonomy. Relies heavily on trust. Important decisions are left to the staff with little or no direction. DEMOCRATIC LEADERSHIP Encourages active participation in decision-making. Emphasis on collaboration, shared responsibility and open communication. May result in more collaborative and inclusive work environments. AUTHENTIC LEADERSHIP Leaders remain true to their values and beliefs. Respect and listen to others, build on strengths. Self-aware of own values, ethics & emotions. Role-model. RESONANT LEADERSHIP High levels of emotional intelligence. Builds strong, trusting relationships. Coaches, develops and mentors others. Creates climate of optimism. SERVANT LEADERSHIP Places the follower at the forefront. Leader is a steward. Less reliance on hierarchy. Focus on collaboration, trust, empathy & ethical use of power. TRANSFORMATIONAL LEADERSHIP Challenges the status quo. Creates and communicates vision. Empowers staff. Inspires and motivates followers to go above and beyond. Attends to the needs of followers. Emphasizes relationships and a positive working environment. A CRITIQUE OF TRANSFORMATIONAL LEADERSHIP Focused upon heroic and distant leaders – assumption that a strong leader will automatically lead to organizational success. Idealizing a leader – organizations follow the leader too easily and do not challenge leadership decisions. Less attention to leader personal integrity – less attention to the ethical work of leaders (e.g. to promote social justice). Fails to address “dark” or immoral leader behaviors – a leader could be manipulative, narcissistic, or promote self-interests. Privileges certain stereotyped gendered assumptions – a feminist perspective of leadership is often missing. COMPETENCIES OF EFFECTIVE LEADERS LEADS IN A CARING ENVIRONMENT FRAMEWORK L – ead Self E – ngage Others A – chieve Results D – evelop Coalitions S – ystems Transformation LEADS IN A CARING ENVIRONMENT – CANADIAN COLLEGE OF HEALTH LEADERS Domain Definition Lead self Leaders are self-aware, manage and develop themselves and demonstrate character. Engage others Leaders foster the development of others, contribute to the creation of healthy organizations, they communicate effectively and build teams. Achieve results Leaders set direction, strategically align decisions with the organization’s vision, values and evidence, take action to implement decisions and assess and evaluate. Develop coalitions Leaders build partnerships and networks to create results, demonstrate a commitment to patients/clients, mobilize knowledge and navigate socio-political environments. Systems Leaders demonstrate critical thinking, encourage and support innovation, transformation orient themselves to the future and champion and orchestrate change. (Canadian College of Health Leaders, 2024; Dickson & Tholl, 2020) EMOTIONAL INTELLIGENCE (EI) “Abilities, skills and personality traits and/or competencies that enable you to recognize your own feelings and emotions and those of others AND to manage those emotions in your decisions, relationships AND adaptation to daily work and life.” Research suggests that emotional intelligence is twice as important as technical skills and cognitive abilities in developing leadership competence. 4 COMPETENCIES OF EMOTIONAL INTELLIGENCE (EI) Competency Description Self-awareness Knowing oneself including strengths & weaknesses. Recognizing the impact of your emotions on others. Self-management Managing your emotions. Social awareness Recognizing others’ emotions. Relationship management Managing relationships including influencing others and resolving conflict. STRENGTHENING EI Reflective practice Paying attention to your emotions Active listening Getting feedback from others FOLLOWERSHIP “Followership is a relational role in which followers have the ability to influence leaders and contribute to the improvement and attainment of group and organizational objectives. It is primarily a hierarchically upward influence.” (Crossman & Crossman, 2011, p. 484) There are no leaders without followers. Followers may promote team-effectiveness through relationships, providing feedback and sharing responsibilities. FOLLOWER RESPONSIBILITIES Develop high degree of literacy about organization. Take ownership of work. Be active rather than passive. Become self-aware of personal and professional values. Engage in self-management. Contribute to team while being aware and raising relevant concerns. Express opinions. Be open to change. CLINICAL LEADERSHIP “Clinical leaders are clinical experts in their field and are followed because they match their actions with their values and beliefs about quality patient care.” (Stanley et al., 2022, p. 21) CHARACTERISTICS OF CLINICAL LEADERSHIP Characteristic Definition Clinical Clinically credible and directly involved in the delivery of nursing care. Expertise Recognized as having clinical competence and expertise in a clinical area. Effective Central attribute. Able to communicate at the right level, highly developed Communication listening skills. Collaboration Has strong interpersonal skills, teamwork abilities, and group process. Cultivates a collegial orientation with front-line staff and are willing to work with them to provide optimal patient care. Role Modeling Other nurses view clinical leaders as aspirational and seek to emulate their professionalism, practice expertise, and work behaviors. Coordination of Plans and organizes care holistically while prioritizing needs and sharing Care information to promote the delivery of effective care. Advocacy & Acts on behalf of patients and in some cases, staff. Escalates issues as required. Empowerment Education Serves as a source of knowledge for staff and patients. Provides information that is accessible. Accountability Sets expectations for patients and holds them accountable in achieving goals. Accountable for their own actions. Authenticity Acts with integrity and honesty. Empathy Understands the perspectives of others, being caring and compassionate, helpful and respectful. Vision & Driving Develops a strategic sense of how frontline practice might be improved and Change articulates this vision to others to promote change. Facilitators & Barriers to Clinical Leadership Facilitators Barriers Positive relationships with management Lack of support from manager Positive relationships with interdisciplinary Ineffective teamwork, poor team inter/intradisciplinary relationships Positive relationships with intradisciplinary Increased workload team Burnout Positive culture Poor communication Enabling structures Lack of confidence Lack of training and development opportunities SUMMARY Leadership is a process of influencing others to achieve common goals, essential for effective nursing practice. Effective nursing leadership is associated with improved patient outcomes, quality care, healthy work environments, and increased job satisfaction. Leadership styles may be categorized as task-focused (Transactional, Autocratic, Laissez-Faire) or relational (Democratic, Authentic, Resonant, Servant, Transformational). Clinical leaders are clinical experts in their field who lead by aligning actions with values and beliefs about quality patient care. From Bedside to Boardroom: Leadership is Part of Everything Nurses Do Week 2 Learning Objectives Compare and contrast leadership and management. Explain the functions of a nurse manager. Discuss management and leadership roles in nursing. Describe seven types of power. Examine the differences between psychological and structural empowerment. Define shared governance in nursing. Identify different organizational structures and cultures. Describe quality practice environments. Compare and contrast models of care. Leadership vs. Management Leadership Management The process of influencing others The accomplishment of tasks or goals Creative thinking Has formal authority to direct the work of a Establishes a vision, sets direction, given set of employees communicates values Engages in analysis and problem solving Motivates, inspires and empowers others Takes responsibility for the quality and cost of Produces change work Produces results Management Functions Management involves systematic planning, organizing, leading, coordinating and controlling of staff, resources and services to ensure the delivery of timely, safe and effective patient care. Planning Choosing appropriate goals and objectives Determining which strategies to use, which actions to take Deciding which resources are needed to achieve goals Organizing Establishing structure to achieve the plan. Determining roles, tasks and oversight. Leading Articulating a vision Energizing employees Inspiring and motivating people using: o Vision o Influence/persuasion o Delegation o Effective communication & conflict management skills Staffing Recruiting, hiring and retaining employees for positions within teams and departments. Controlling Evaluating how well: o Goals were achieved o Performance was improved o Actions were taken Establishing standards to measure, compare and make decisions Leading and managing as point-of-care nurses Planning – Plan for clinical goals for the day (e.g. prepping patient for surgery). Leading - Assign, delegate, or direct work to other clinical staff. Organizing – Work with colleagues to establish plans. Controlling – Change work process based on unexpected clinical events. Why does a nurse/nurse manager need to be both a leader and manager? Nurses as Managers Nurses as Leaders Point-of-care nurses need to accomplish clinical All forms of nursing practice involve influencing tasks and maintain quality within finite others, being persuasive, creative thinking, and resources. establishing a vision for practice. Similarly, nurse managers need to accomplish organizational tasks (e.g. run the unit) and maintain quality within finite resources (e.g. budget and staffing). How might nurse/unit manager positively influence the work life of nurses? Exhibit a good combination of being both a manager and leader. Exhibit transformational/relational leadership. Exhibit and support clinical leadership in front-line nurses. Promote a safe, open, and democratic unit culture. Types of Management in Nursing Nurse Managers Nurse Executives Nurse Managers Titles include: o Unit manager o Nurse manager o Nursing unit supervisor o Clinical manager o Nursing unit administrator (NUA) In 2022, 5,540 of Ontario RNs held a management position (CIHI, 2023). Responsibilities of Nurse Managers Have a range of complex responsibilities, primarily related to a unit or set of specific clinical services. Promote high quality care with respect for patient/family rights and preferences. Participate in nursing policy formulation and decision making. Participate in recruitment, selection, and retention of personnel (nurses and others). Assume oversight for staff performance. Provide feedback and evaluation for staff. Promote staff and patient safety. Develop, implement, and monitor unit budget. Performance Appraisal Individual evaluations of work performance. Often performed annually, although may occur more frequently. Feedback provided to employees aimed at: o Improving performance o Improving accountability o Promoting growth and development o Acknowledging work well done Unit-Based Performance Measures for Nurse Managers (Inpatient Surgical Unit Example) A. Clinical Quality o Patient Falls. o Medication Errors. o Restraint Use. o Infection control reporting of wound and catheter associated infections. o Injuries to employees resulting in back injuries. o Chart audits to meet compliance standards. o Competency records of nursing staff. B. Access o Tracking of time to accept patients from the Emergency Department. C. Service o Patient satisfaction surveys o Number of complaints against staff D. Cost o Nursing staff productivity o Maintaining or exceeding budgets o Number of overtime hours. Nurse Executives Titles include: Director of Nursing Chief Nursing Officer Chief Nursing Executive Vice President CEO Establish a vision and direction for the nursing practice at an organizational level. Ensure that all nursing care is consistent with the objectives of the organization. Select, supervise and develop other executives and managers. Manage important and/or high-cost operation issues at an organizational level. Multihospital systems may have a single Chief Nursing Executive. Represent nursing interests in top-level meetings. Sometimes lead other departments in addition to nursing. Point of Care Leadership Leadership role for staff involved in the direct delivery of care. Titles include: Charge nurse Head nurse Shift supervisor Team leader Client care coordinator Coordinate the activity for staff nurses and supervise other healthcare team members. May or may not have managerial authority over the nursing staff they are leading (i.e., cannot terminate or formally reprimand followers). Other Formal Leadership Roles Title Role Nurse Preceptor Supports the growth and development of students and new staff. Nurse Educator Develops, implements and evaluates staff education. Nurse Champion Promotes the implementation of either unit or organizational change. Federal Chief Nursing Officer (CNO) Canada’s first CNO was appointed in 1968. The position was eliminated in 2012 and reinstated in 2022. Dr. Leigh Chapman o Provides strategic advice to Health Canada o Represents the Federal Government domestically and internationally o Plays a convening role by engaging and collaborating with the nursing community. Representation in Nursing Leadership Under-representation of racialized and nonbinary nursing leaders. Black, Indigenous and nurses of colour represent less than 20% of leadership roles (Nelson et al., 2023). Barriers include systemic racism and discrimination, lack of mentorship and networking opportunities and biased hiring processes. Strategies to promote representation include mentoring, fostering a culture of inclusion and collaboration, education and training. Power “The ability to mobilize resources (human and material) to get things done” (Kanter, 1997, p. 136) Can be seen as positive or negative. May involve influence and authority. Types of Power in Leadership Type of Power Definition Legitimate Based on formal position providing the right to exert influence and expect compliance. Referent Informal power where others recognize a person has special qualities and is admired. Expert When a person is respected for their expertise, including knowledge and skills. Persuasive When a person uses persuasion to influence others. Coercive Based on punishment when someone does not do what is desired. Reward The ability to reward others when they perform well. Informational Power that arises when a person can access and share information. Psychological Empowerment Individual level construct. Cognitive, subjective, and motivational process where individuals perceive themselves as having the ability to influence their work environment and outcomes. Meaning: Degree to which individuals find their work meaningful and aligned with their values. Competence: Belief in one's capability to perform work activities with skill. Self-Determination: Sense of having control over one's work and the autonomy to make decisions. Impact: Perception that one's actions can influence organizational outcomes. Psychological empowerment leads to positive work behaviours and influences: o Burnout o Job satisfaction o Retention Structural Empowerment Organizational level construct. Focused on the structures, policies and practices within an organization that provide power, authority and control to staff. o Access to opportunity o Access to information o Access to support o Access to resources Structural empowerment influences psychological empowerment. Structural empowerment influences: o Stress levels and burnout o Job satisfaction o Retention o Overall performance Span of Control The number of individuals supervised by a manager. Span of control impacts manager’s ability to supervise. As span of control increases, organizations may experience increased adverse outcomes (patients and staff) and decreased job satisfaction. Organizational Structure Design of organization Characterized by: o Complexity: division of labour, specialization of labour, number of hierarchical levels and geographic dispersion. o Formalization: Degree to which an organization is guided by rules and policies that define a member’s function. o Centralization: location where decisions are made. Centralized organizations make decisions at the top. More common in larger organizations. Decisions are made at or closer to the level of patient care in decentralized organizations. Flat organizations: few layers of manager between staff and senior administrators. Tall organizations: Many layers of managers – aka hierarchical structure. Organizational Structure – Example Flat Structure Matrix Structure Shared Governance Shared decision making among different roles in an organization. Sometimes referred to as professional practice model. Allows nurses within organization to be involved in decision making related to their professional practice. Might include a council structure – where different unit level committees influence care policies and procedures, and address practice issues. Shared Governance Councils Type of Duties and Responsibilities Council Quality Quality management initiatives Council May play a role in the hiring of new staff by reviewing applicants’ skills and qualifications. Education Assess and oversee the learning needs of staff and develop new educational Council programs to meet these needs. Research Incorporate research-based findings into the clinical standards of the unit. Council Management The unit manager is usually a standing member. Council Ensure that the standards of the other councils are upheld Ensure adequate resources to deliver good care. Coordinating Facilitate and integrate the activities of other councils. Council Mission, Vision and Values Mission: Describes the organization’s purpose or focus. Vision: Describes the long-term goals and aspirations of where the organization wants to be in the future. Values: Guiding principles and beliefs that shape behaviour and decision making within the organization. Organizational Culture Based on shared experiences of members Socially constructed Helps to make sense of workplace & experiences Invisible, intangible Every organization has a unique culture Impacts employee productivity, commitment and morale Organizational Cultures Safety Culture o Leadership commitment to safety o Open communication founded on trust o Organizational learning o Non-punitive approach to adverse event reporting and analysis o Teamwork o Shared belief in the importance of safety Just Culture o “an atmosphere of trust in which healthcare workers are supported and treated fairly when something goes wrong with patient care” (Health Quality Council of Alberta, 2025). ▪ Open communication ▪ Repairing harm ▪ Learning vs. blaming Quality Practice Environments “A quality practice environment supports the delivery of safe, compassionate, competent and ethical care while maximizing the health of clients and nurses” (CNA & CNFU, 2015) Communication and collaboration Responsibility and accountability Safe and realistic workloads Leadership Support for information and knowledge management Professional development Organizational culture Healthy Work Environments Healthy work environments in nursing are workplaces that promote the physical, mental, and emotional well-being of nurses. These environments are characterized by mutual respect, effective communication, and a commitment to safety and quality care. Healthy Work Environments Quality/effective leadership Relational exchange Communication and collaboration Effective teamwork Professional autonomy Environmental elements Contextual factors Sample Strategies Regular staff meetings and opportunities to provide input and feedback. Create brave spaces and address bullying. Implement policies that support the mental health of providers (e.g., Code Lavender). Implement policies that promote a healthy balance between work and personal life (e.g., self-scheduling). Staff wellness programs. Mentorship programs. Acknowledge and celebrate staff success. Models of Care Collaborative Practice / Team-Based Care o Diverse inter/intraprofessional teams supporting patients, typically led by a nurse team leader. o Seen by some as the ideal model. o May be used in times of nursing shortages. o Benefits: ▪ Improved patient satisfaction. ▪ Improved patient outcomes. o Drawbacks: ▪ Potential for fragmented care if leadership skills are lacking. Functional o Work is divided up by task, includes both regulated and unregulated care providers. o For example, one nurse does vital signs for all patients. o Benefits: ▪ Staff become more efficient at completing their tasks. o Drawbacks: ▪ Care may become fragmented – psychological and emotional needs may not be met & changes in patient status may not be noticed. ▪ Can become complicated to implement and challenging for patients and families to know who to consult. ▪ May result in staff dissatisfaction. Individual o Oldest care delivery model. o Single nurse takes full responsibility for a patient or group of patients during a shift. o Benefits: ▪ Consistency for patients, may result in improved satisfaction. ▪ Easier to detect changes in patient status. o Drawbacks: ▪ Costly for organizations ▪ Challenging to implement during nursing shortages. Primary o A single nurse is assigned accountability for managing all aspects of a patient’s care plan. o Other nurses follow the primary nurse’s plan of care. o Benefits: ▪ Improved relationship with patients and families, which results in increased satisfaction. o Drawbacks: ▪ Not all nurses will have sufficient experience to function in this role. ▪ Potential for communication gaps. ▪ Challenging when shortage of nursing staff exists. Magnet Hospitals Originally developed to improve recruitment and retention. Demonstrate higher levels of nurse job satisfaction and reduced nurse burnout. Improved patient outcomes including lower rates of falls and reduced mortality. “Must demonstrate evidence of organizational reform of nurses’ work environments that would facilitate the achievement of desired patient outcomes” (Wagner, 2018) Magnet Recognition Component Description Transformational Leadership team creates a vision for the future, and the systems and leadership environment necessary to achieve it. Structural Structures and processes developed by leadership create an innovative empowerment environment where strong professional practice flourishes and where the outcomes important for the organization are achieved. Exemplary professional “A comprehensive understanding of the role of nursing; the application of practice that role with patients, families, communities, and the interdisciplinary team; and the application of new knowledge and evidence. “ New knowledge, “Magnet organizations have an ethical and professional responsibility to innovations and contribute to patient care, the organization, and the profession in terms of improvements new knowledge, innovations, and improvements…new models of care, application of existing evidence, new evidence, and visible contributions to the science of nursing” Empirical outcomes Improved clinical outcomes related to nursing; workforce outcomes; patient and outcomes; and organizational outcomes. More on Magnet Hospitals 617 Magnet hospitals worldwide 601 Magnet hospitals in US 1 Magnet hospital in Canada Summary Leadership: Influences others, establishes vision, motivates, inspires, and produces change. Management: Directs work, responsible for quality and cost, produces results. 5 management functions – planning, organizing, leading, staffing, controlling. Psychological empowerment is focused on the level of the individual, structural empowerment is related to organizational structures, policies and practices that provide access to opportunities, information, support and resources. Organizational structures may be described as tall (many layers of management, hierarchy) or flat (few layers of management) with decision making centralized or decentralized. Shared governance is a participatory decision-making model that empowers staff. Organizational culture is described as shared values, beliefs and behaviours within an organization. Models of care include collaborative/team-based care, functional, individual and primary. Quality practice environments support the delivery of compassionate, ethical and competent patient care while maximizing health of clients and nurses. Healthy work environments are focused on promoting the physical, mental and emotional wellbeing of nurses. Magnet hospitals are characterized by transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovations and improvement as well as empirical outcomes. Quality First: The Essentials of Improvement Week 3 Recap Leadership: Influences others, establishes vision, motivates, inspires, and produces change. Management: Directs work, responsible for quality and cost, produces results. 5 management functions – planning, organizing, leading, staffing, controlling. Organizational structures may be described as tall (many layers of management, hierarchy) or flat (few layers of management) with decision making centralized or decentralized. Shared governance is a participatory decision-making model that empowers staff. Organizational culture is described as shared values, beliefs and behaviours within an organization. Nursing Retention Toolkit Learning Objectives Describe quality improvement and how it can shape quality of care Compare and contrast quality and quality improvement Discuss the importance of teams in quality improvement Explain the Model for Improvement Apply tools used in quality improvement Entry to Practice Competencies Competency 6.2: Integrates continuous quality improvement principles and activities into nursing practice Competency 6.5: Recognizes the impact of organizational culture and acts to enhance the quality of a professional and safe practice environment What is Quality in Healthcare? Domain Definition Equitable Every patient receives high quality care that is fair and appropriate to them, no matter where they live, what they have or who they are. Effective Care is based on the best available evidence and produces the desired outcome. Patient Centered Patient autonomy in decision making is promoted, care reflects patient’s preferences and goals. Efficient Waste is eliminated and efforts are made towards streamlining and coordinating care. Timely Patients receive the care they require within an acceptable wait time. Safe People are not harmed by the system. Policies, processes and procedures are in place to ensure everyone’s safety. What is Quality Improvement? “A systematic, formal approach to analyzing performance and efforts to improve performance”(Ontario Health, 2024, p.3) The goal is to continuously look for ways to improve the quality of an organization’s outputs (e.g., products or services) and outcomes. Quality vs. Quality Improvement Quality o Safe o Timely o Equitable o Effective o Efficient o Patient Centered Quality Improvement o The goal is to continuously look for ways to improve the quality of an organization’s outputs (e.g., products or services) and outcomes. Quality Improvement Steps 1. Planning for Change 2. Implementing Change 3. Sustaining Change Approaches to Quality Improvement LEAN 6 SIGMA MODEL FOR IMPROVEMENT Model For Improvement Plan: identify tasks, task owners, objectives, outcomes and implementation plan (what, when, where, who) Do: put plan into action and record data Study: evaluate data to see if plan is working Act: adopt, adapt or abandon intervention Steps for Applying the Model for Improvement: Fundamental Principles 1. Know what you want to improve 2. Have a feedback mechanism in place to tell you if improvement is happening 3. Develop an effective change that will result in improvement 4. Test a change before you attempt to implement it 5. Know when and how to implement a change and make it permanent Forming a Team Teams are necessary for quality improvement work Need diversity in the team members: o Different health professionals o Different areas & levels of expertise o Different perspectives on the problem Engage people who will benefit from the problem being solved QI Team Composition Team lead Executive sponsor Point of care staff & those who are familiar with the process (clinical or non-clinical) Patients/clients and families Benefits of Team Decision Making [recitation stuff] Drawbacks of Team Decision Making [recitation stuff] Team Size Big enough so that there are enough people to do the work Small enough to allow for: o Effective communication o Decision making o Scheduling CIHC Competency Framework Identifying Problems & Opportunities for Improvement Patient perspectives – patient complaints/feedback, or what would better look like to our patients? Staff perspectives - what would better look like to our colleagues? Practice data – how does our performance compare to others? OR to the ideal? Research evidence and guidelines – is there new evidence that suggests we should change how we deliver care? New guidelines we should implement? Clarifying the Problem A problem is a gap between the current and future state Defined with problem statement o What is the problem? o Who is affected? When? o How long has the problem existed? o What is known about the problem (frequency, causes etc.) o What research and evidence exists? o What is the impact? Links to Weeks 1 & 2 Content Consider the contextual factors that may be influencing or contributing to the problem: o Organizational structure o Organizational culture o Leadership o Policies o Resources (e.g., staffing, equipment etc.) Why is Understanding Problems Necessary? Having a clear understanding the problem will allow you to identify goals, potential solutions and desired outcomes. Poor understanding of the problem can lead to inappropriate and/or ineffective solutions. Example - Problem High # of falls leading to injury on night shift in an in-patient medicine unit. Tools for Exploring the Problem 5 Whys o Repeated cycles of asking “why” this is occurring, until arrive at root cause. Fishbone diagram o Identify the contributing factors (cause and effect diagram). Process map o Map of the current process, helps to identify gaps. Fishbone Diagram Process Mapping o Process mapping (aka flowchart) is most frequently used to document and gain insight into a process. Can be used to: o Identify unnecessary steps/handoffs/time spent in existing programs/processes – current state. o Create a shared understanding. o Map out the ideal process for a new program – future state. Pareto Chart 80/20 principle Used to prioritize factors that contribute to problems. Vital few vs. trivia Model For Improvement Setting an Aim Aim statements need to be SMART: Specific - actionable & targeted Measurable – from current to future state Achievable – based on team member perspectives Relevant/Realistic – patient-centered, impact potential Time-bound/Timely – specific timeline for change Links to Weeks 1 & 2 Content Aligning the project aim with organizational priorities will help in generating support for your project. Consider the mission, vision and values of the organization. Model For Improvement Change Concept General approach/notion that informs the development of change ideas. Change Concepts & Change Ideas Change Concept Change Ideas Eliminate waste - Eliminate equipment that is not useful, eliminate multiple EHR entries Improve workflow - Minimize handoffs, find and remove bottle necks, change the order of steps in a process Change the work environment - Give people access to information, conduct training, share risks Listen to customers - Talk to or survey patients about their experiences Error proof - Add in forcing functions, automate, reminders & alerts, visual cues Driver Diagram Diagram of the relationship between the project aim and secondary drivers that influence the primary drivers. o Primary/key drivers: what is needed to accomplish aim o Secondary drivers: influences on primary aim o Change ideas Completed with the QI team. Driver Diagram Examples Factors Impacting Improvement Organizational culture Lack of cohesive mission and vision Inadequate infrastructure Competing priorities Dysfunctional external relations Links to Weeks 1 & 2 Persuasion and influence are highly important in QI work o Need to convince others that change is needed o Need to keep people engaged throughout the project o Need to manage competing priorities Organizational culture, mission, vision and values may influence success. Benefits of Being Involved in QI Opportunities to develop leadership skills. Opportunities to improve patient care and contribute to better patient outcomes. Opportunities to collaborate and build relationships. Engaging in QI is associated with higher job satisfaction, wellbeing and reduced unscheduled time off. Driving Results: Testing and Measurement in Quality Improvement Week 4 Follow Up – 5 Whys Used to explore the causes of a problem with your team. o State the problem. o Ask why is this happening (~5 times). o The final why is a cause you can address. Recap QI projects require teams comprised of diverse professions, expertise and perspectives, including patients and families. Include those who are impacted by the problem. Ideal team size is ~6-10 to allow for effective communication, decision making and scheduling. Having a fulsome understanding of the problem is an important first step in QI work. Not understanding the problem may lead to ineffective solutions and wasted resources. The Model for Improvement includes 3 key questions: what are we trying to accomplish (aim), how will we know that a change is an improvement (measures) and what changes can we make that will result in improvement (change ideas). Learning Objectives Differentiate between quantitative and qualitative data Select measures that support the plan for evaluation Explain run chart rules and how they can indicate changes in data Apply the PDSA cycle Discuss the importance of sustainability in quality improvement Entry to Practice Competencies Competency 6.2: Integrates continuous quality improvement principles and activities into nursing practice Competency 6.5: Recognizes the impact of organizational culture and acts to enhance the quality of a professional and safe practice environment Case Example - Problem High # of falls leading to injury on night shift in an in-patient medicine unit. Case Example – Aim & Drivers Aim: To reduce the incidence of patient falls on night shift in the in-patient medicine unit by 30% by December 1st, 2025, measured using unit incident reports. Primary drivers: o Identify patients at risk o Develop and implement plans to address falls risks o Raise staff awareness about falls risks and interventions Model For Improvement If you can’t measure it, you can’t improve it! QI vs Research Quality Improvement Research Purpose Learn and improve processes, practices, costs Test hypotheses, contribute to or generate new or productivity. knowledge. Study Iterative design, randomization not usually Systematic and rigorous designs, may involve Designs involved. randomization. Sample Involves all or most of the population involved in Inclusion and exclusion criteria, may involve process/practice; may also include convenience sample size calculations. samples. Measures Usually simple, easy to administer, confounding Valid and reliable instruments, confounding variables acknowledged but not measured. variables are measured and/or controlled. Timelines Short, rapid cycles, often weeks to months. Depends on size and scope, generally longer than QI. Project and PDSA Measures Project Level Measures o Collected and monitored throughout the project. o Collected again on project completion to determine the overall impact. o Support decisions around sustainability. PDSA Level Measures o Collected to determine whether a change is working. o Also known as temporary measures. Data Quantitative Data o Can be measured numerically. o Quantity, amount etc. (e.g., number of nosocomial infections) o Can be visualized over time using run charts. o Sometimes analyzed using descriptive and inferential statistics. Qualitative Data o Information that can be observed and recorded that is not numerical. o Perspectives, opinions, feelings, meaning (e.g., patient experience of waiting). o Often analyzed using qualitative methods such as thematic or content analysis. Family of Measures Structure o Healthcare setting o Physical environment o Human resources Process o Delivery of care o Activities of healthcare system Outcome o Impact of care o Disease outcomes Balancing o Consequences of improvement efforts Structure Measures Describe the setting and environment, including resources. Not always measured in QI. Examples Nurse to patient ratio Use of electronic medical record Model of care Process Measures Offer more precise reflections of what is happening as process measures reflect what needs to happen to accomplish project aim. Likely to see changes in process measures before outcome measures. Examples % of patients with intentional rounding completed on schedule % of patients whose hemoglobin A1c level was measured twice in the past year Outcome Measures Related to project aim. Demonstrate the impact vs. activity. Take longer to show improvement. Examples Adverse drug events per 1,000 doses Average hemoglobin A1c level for patients with diabetes Balancing Measures Highlights consequences in other parts of the system – intended or unintended. Examples: Readmission rates (if trying to reduce length of stay) Workload or staff satisfaction (if introducing new process) Measurement Tips Keep it simple. Start with the project aim and determine how it can be measured (outcome). Driver diagrams can provide insight into processes that can be measured. Brainstorm potential consequences to develop balancing measures. Ensure that you have an operational definition including a specific and detailed description of what is captured. o Counts – how many o Averages/means require the calculation o % or rates – help to standardize data, require numerator (key measure) and denominator (volume) Be clear about the data source, how data will be collected, when, how often and who will collect it. Leverage existing data. Case Example - Measures Structure: Average nurse patient ratio on nights in last month. Process: % of newly admitted patients with documented falls risk assessment in last month. [Number of newly admitted patients with risk assessment complete / Total number of newly admitted patients] Outcome: Rate of falls on nights in last month. [(Number of falls / Occupied bed days) x 1,000] Balancing: # of restraints used on patients at risk for falls in last month. HOW MIGHT WE MEASURE IMPROVEMENT? Variation Random: Natural variation inherent in any process o Random Variation / Common Cause ▪ Variation that is inherent in processes and systems. ▪ Will continue unless there are changes. E.g., weight, blood pressure Non-Random: Atypical variation o Non-Random Variation / Special Cause ▪ Variation that is not typical. ▪ Caused by changes to a process or system. ▪ Not always intended - may reflect unstable processes. ▪ May be intended when change introduced. Run Chart X axis – usually time Y axis – measure of interest Central line – median 10 or more points Annotations Median Midpoint in the data set. Same number of points above and below. If even number of points, add the two middle numbers and divide by 2. Median is not influenced by outliers in the data. Run Chart Rules Rule 1: Shift 6 or more consecutive points, either all above or all below the median. Do not count the points that fall on the median. Rule 2: Trend 5 or more consecutive points all going up or down; 5 or more sequential data points in a row all increasing or decreasing. If the value of two or more consecutive points is the same, ignore one of the points and continue counting. Can cross the median. Rule 3: Too Many or Too Few Runs Count the number of data points. Count the number of runs - # of times the data line crosses the median + 1. A run is a series of points on one side of the median line. Too few or too many based on probability tables. Consult the data table. Rule 4: Astronomical Point A point that is obviously different from the rest of the points; Clear outlier from the remaining points. Relies on opinion of team. Benefits of Run Charts Can help monitor how things are going over time. Can help to evaluate the project as it is happening. Can provide insight into what interventions have the most impact. Easy to use and share with team members. Control Chart / Shewart Chart X axis – usually time Y axis – measure of interest Central line – mean Upper Control Limit (UCL) +3SD Lower Control Limit (LCL) – 3SD 20 or more points Annotations Baseline Data Need to establish a baseline – ensure that you collect data before beginning any type of improvement. Need approximately 10-15 data points for run chart. Need approximately 20-25 data points for control chart. Model For Improvement 1. Plan: identify tasks, task owners, objectives, outcomes and implementation plan (what, when, where, who) 2. Do: put plan into action and record data 3. Study: evaluate data to see if plan is working 4. Act: adopt, adapt or abandon intervention Case Example – PDSA Cycle Sequential PDSA Cycles Best used when… o Adapting an existing approach. o Testing individual program/project components. o Scaling change ideas. Concurrent PDSA Cycles Best used when… o Testing multiple change ideas. o Scaling multiple change ideas. Common Errors with PDSA Cycles Plan lacking detail. Failure to make predictions. Insufficient data collection plan. Lack of team member engagement. Failure to learn from findings. Steps for Applying the Model for Improvement: Fundamental Principles 1. Know what you want to improve. 2. Have a feedback mechanism in place to tell you if improvement is happening. 3. Develop an effective change that will result in improvement. 4. Test a change before you attempt to implement it. 5. Know when and how to implement a change and make it permanent. Sustainability Ensuring gains are maintained beyond the life of the project. Sustaining the ideas, beliefs, principles, or values underlying an initiative, or “when new ways of working and improved outcomes become the norm”. Nurses are a driving force in sustainability. Benefits & Drawbacks of QI Benefits o Pragmatic approach o Provides flexibility o Promotes learning o Data driven o Builds evidence for change o Can provide opportunities to engage stakeholders Drawbacks o Not a silver bullet o Often implemented with poor fidelity o Can be led by individuals with limited expertise, power and/or resources o Focus on local improvement o Lack of rigor in evaluation Summary The primary measures used in QI are process, outcome and balancing measures. Process measures reflect what needs to happen to accomplish the aim, outcome measures are directly linked to the project aim and balancing measures reflect other impacts on the system. Measurement in QI is focused on learning and improvement. It is best to keep measures simple and use available data where possible. Run charts can be used to detect unexpected (non-random) variation. Control charts are more sophisticated and can be used to detect special cause variation. PDSA cycles can be used to test and adapt change ideas. They can be used sequentially as well as concurrently. Once we are confident about a change, it is important to consider how the change will be sustained in practice. If we don’t sustain the change, we will waste valuable time and resources.

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