Te University of San Francisco USF Scholarship: a digital repository @ Gleeson Library | Geschke Center Doctor of Nursing Practice (DNP) Projects Teses, Dissertations, Capstones and Projects Winter 12-18-2015 Impetus to Transform: Essential Nursing Leadership Development through Simulation Mary J. Mete University of San Francisco, Running head: IMPETUS TO TRANSFORM 1 Impetus to Transform: Essential Nursing Leadership Development through Simulation Mary JoAnn Mette DNPc, MPH, RN, NEA-BC University of San Francisco DNP Comprehensive Project IMPETUS TO TRANSFORM 2 Acknowledgments This Doctor of Nursing evidence-based change in practice project is dedicated to all the individuals who have supported me during the last two years. It is a journey that has taken me to new levels of professional engagement. I would not have been able to do this without the support and encouragement I have received. There are specific individuals I must thank who spent countless hours assisting me. These include: Dr. K. T. Waxman and the faculty of the University of San Francisco. A special thank you must be paid to my advisory committee, Dr. Mary E. Foley and Dr. Judith Lambton, for their time and professional consideration of this project. This project would not be a reality without the support and assistance from Anita Zuniga, MSN, RN; Jim D’Alfonso, MSN, RN; Patricia McFarland, MSN, FAAN, RN; Sheila Gilson, MS, RN; Cathy Parker, BSN, RN; and Nora Tam, Senior Project Specialist. Without their collective skills and support, this challenging task would have been insurmountable. A significant contributor over the last two years is Joyce Zdyrka, MBA, RN, who has dedicated many hours editing and supporting this experience. She has my eternal gratitude. To my family, specifically my sister, Margaret, whose very special support and assistance enabled me to reach my dream of completing a doctorate degree. To my brothers and sisters-in- law and nieces and nephews, Michelle, Matt, Ethan, Michael, Nick, Joe, and Stacey, thank you for believing in me. I must also acknowledge my peers for their support and friendship. Their presence brought joy to the journey. A final thank you must be extended to Colleen McKeown, MN, RN, who showed me the art of leadership. IMPETUS TO TRANSFORM 3 Table of Contents Section I. Title and Abstract Title ................................................................................................... 1 Acknowledgments ............................................................................. 2 Abstract ............................................................................................. 6 Section II. Introduction Background ....................................................................................... 7 Local Problem ................................................................................... 9 Intended Improvement ...................................................................... 10 Review of the Evidence .................................................................... 12 Conceptual and Theoretical Framework ........................................... 21 Section III. Methods Ethical Issues .................................................................................... 25 Setting ............................................................................................... 26 Planning the Intervention .................................................................. 27 Cost Benefit Analysis/ Return on Investment ................................... 28 Implementation of the Project ........................................................... 29 Planning the Study of the Intervention ............................................. 30 Evaluation ......................................................................................... 32 Analysis ............................................................................................. 33 Section IV. Results Program Evaluation and Outcomes .................................................. 35 IMPETUS TO TRANSFORM 4 Table of Contents (cont.) Section V. Discussion Summary ........................................................................................... 39 Relation to Other Evidence ............................................................... 40 Barriers to Implementation ............................................................... 42 Interpretation ..................................................................................... 42 Conclusion ........................................................................................ 43 Section VI. Other Information Funding ............................................................................................. 44 Section VII. References ............................................................................. 45 Section VIII. Appendices Appendix A. Transformational Leadership Survey .......................... 54 Appendix B. Evidence-Based Rating Scale ...................................... 58 Appendix C. Evidence-Based Table ................................................. 59 Appendix D. Taxonomy of Significant Learning ............................. 64 Appendix E. Transformational Leadership Model Diagram ............ 66 Appendix F. Sample Scenario / Statement of Determination ........... 67 Appendix G. SWOT Analysis ........................................................... 73 Appendix H. IRB Waiver / Statement of Determination ................... 74 Appendix I. Initial Manager Survey Demographics ......................... 75 Appendix J. Messaging Plan ............................................................ 78 Appendix K. Cost Benefit Analysis / Return on Investment ........... 79 ® Appendix L. Survey Monkey .......................................................... 83 IMPETUS TO TRANSFORM 5 Table of Contents (cont.) Appendix M. PDCA Cycle Diagrams ............................................... 84 Appendix N. Gantt Chart .................................................................. 86 Appendix O. Work Group Demographics ........................................ 88 Appendix P. Role Playing Survey Comments .................................. 91 Appendix Q. Transformation Leadership Self-Assessment Responses 92 Appendix R. Survey Responses ........................................................ 94 Appendix S. Post Simulation Education Experience Survey ............ 96 IMPETUS TO TRANSFORM 6 Abstract A nurse manager’s ability to effect positive change and inspire others to higher levels of achievement is related to his or her leadership style in the practice setting, as well as the culture present in the organization as a whole. The aim of this Doctor of Nursing evidence-based change in practice project was to create an educational modality that supported training nurse leaders through innovation and creative problem solving in today’s acute healthcare setting. A survey was administered to 48 frontline managers in a Northern California healthcare system to access the gaps and voids in their ability to integrate transformational leadership as a model for performance. Survey results guided a process for manager development in the domains of execution competencies of accountability, change leadership, impact and influence/team building, and organizational awareness. The learning modality selected for this leadership development was the use of simulation scenarios that incorporated the four identified elements from the survey results to augment didactic transformational knowledge. Simulation has been positively associated with the development of transformational leadership skills. An evidence- based business case demonstrates the outcomes, including the return on investment for the retention of nurse managers in a role that has seen a high turnover in this Northern California healthcare system. The manager, adept in transformational leadership skills, can drive the alignment of staff at the unit level to establish a culture that offers patient quality care in a safe environment. Keywords: execution competencies, nursing leadership, nurse manager, simulation, transformational leadership. IMPETUS TO TRANSFORM 7 Section II. Introduction Background Twenty-first century healthcare challenges facing the nation are dramatically shifting the access and delivery processes for care. The most recent major shift to our traditional healthcare system came with the passage of the Patient Protection and Affordable Care Act (ACA, 2010). This requirement is driving providers to find new ways to deliver services regardless of setting, diversity of populations, cost restraints, and consumer demand for safety and consistency in service delivery. Key individuals essential for a successful change in healthcare are nursing leaders responsible for the care of patient populations in the acute care hospital setting. These contemporary nurse leaders must be visionary in identifying where change is needed to respond to the shifting foundations in the organization. Traditional management and leadership solutions in healthcare systems have limited the innovation needed to create and adapt to a new model that could better answer the present healthcare challenges (Hemp 2008). Malloch and Porter-O’Grady (2006) suggested that the future will increasingly call for fluid, flexible, and adaptable work environments. Flexibility is critical to the successful adaptation of these changes, as leaders must directly initiate or respond to mandates by organizational strategy (Marquis & Houston, 2009). Without understanding these emerging realities in the healthcare setting, outcomes will be unrealized or ineffective in attempting change. Hemp (2008) noted that such profound changes are not easy and bring feelings of loss and stress. However, it is critical to develop management practices that create safe environments, promote organizational effectiveness, and demonstrate service and quality. IMPETUS TO TRANSFORM 8 Effective nurse leadership is acknowledged as an essential factor for achieving optimal patient outcomes and workplace enhancement. Over the last two decades, research and literature on nursing leadership have been dominated by the conceptual theory of transformational leadership. This theoretical framework has provided insight into various leader characteristics, with findings offered as persuasive evidence of the model’s effectiveness (Hutchinson, & Jackson, 2013). In contrast to the opportunity that the conceptual theory of transformational leadership offers, its implementation of achieving optimal patient outcomes and effective workplaces is not always realized. Nurse leaders struggle to be transformational in today’s complex and fast-paced healthcare environment (Sammer & James, 2011). Researchers have also identified that many organizations are not investing resources in the development of current and future leaders (Sherman, Bishop, Eggenberger, & Karden, 2007). Sherman and Pross (2010) identified that nursing leadership’s greatest challenge is guiding team members to get past their daily problems and move toward a goal of developing consistently high performing work teams. Every healthcare system in the United States today is facing changes in all aspects of healthcare delivery. No department will be exempt from finding and eliminating inefficient practices. Healthcare leaders must understand the critical importance of performing with a style of leadership that will ensure their staff feel empowered and supported, as they implement some of the greatest changes in healthcare since the introduction of Medicare (Delmatoff & Lazarus, 2014). Nursing leaders must promote behaviors which focus on staff and patient care and support the complex issues of human relations. The 2001 Institute of Medicine (IOM) report identified nursing as a discipline that has significant impact in the past, present, and future of healthcare. In 2015, the IOM has not wavered in the call for nursing leadership to play a leading role in transforming healthcare delivery. IMPETUS TO TRANSFORM 9 Local Problem It has been increasingly unacceptable for hospitals to perform poorly on both publicly reported clinical care processes and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures (Hunstock, 2013). Consequently, it has become a key strategic priority for many large healthcare systems to address these outcome measures, learning from both successes and failures. A large Northern California healthcare system, which is comprised of 17 acute care hospital facilities, is currently facing a significant turnover in the ranks of nurse managers throughout the system. Assumptions behind this shortage are the complexity of the job, performance expectations, and the volume of work required. Within this organizational structure, the nurse manager must drive operational performance for nursing care, finance, quality indicators, patient satisfaction, length of in-patient stay, and employee engagement. This key group is faced with accountability for achieving these organizational metrics on a daily basis. Nurse manager support consists of assistant managers assigned to oversee each 24-bed unit on all three shifts. Assistants have 8-hour accountability, oversee 25 to 30 employees per shift, and report directly to their manager. Partly as a result of this nurse manager shortage and turnover, the hospitals in this system have not been able to achieve successful performance in the area of service, quality, and cost on a consistent basis for each entity. Given the significance in the scope and size of patient care service’s budget, compared to the hospital as whole, it is critical to meet nurse manager metrics in order to address the volatility of the economics of reimbursement today. In the last 16 months, the healthcare system began to address this critical need for leadership by providing the group of nursing managers with monthly, 8-hour didactic training courses to develop skill sets for the implementation of a