The problem: Seton Northwest Hospital, a 124-bed acute care hospital in Austin, Texas, was one of three pilot hospitals for Transforming Care at the Bedside (TCAB), an initiative launched in 2003 by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement. Joyce A. Batcheller, D.N.P., R.N., N.E.A.-B.C., F.A.A.N., senior vice president and chief nursing officer for the Seton Family of Hospitals, led the TCAB project at Seton Northwest. After the pilot resulted in better workplace efficiencies, less stress for nurses, improved nurse retention and more nursing time at the bedside, Batcheller, by then a new RWJF Executive Nurse Fellow, faced a challenging problem: How to expand TCAB to the other Seton hospitals?
Batcheller's background: Batcheller's interest in nursing began when she was five years old and hospitalized with severe injuries after being hit by a truck. She still recalls that family members were only allowed to visit her "for a few minutes here and there. The approach to patient care was very different then." An especially attentive nurse (also named Joyce) took time to explain important procedures to the young patient and enlisted a hospital volunteer to play cards with her. Batcheller never forgot the nurse's kindness. "I wanted to grow up and be like her and make a difference in someone's life," she remembers.
After receiving her Bachelor of Science in Nursing degree from the University of Texas Health Sciences Center at San Antonio School of Nursing in 1980, Batcheller held an increasingly responsible series of hospital nursing positions in Washington, D.C., and Virginia and, in 1994, joined the Seton Family of Hospitals in Austin as senior vice president and chief nursing officer. During her tenure, the Seton network grew from four hospitals to include (as of 2011) 24 facilities—five major medical centers, two community hospitals, two rural hospitals, a mental health hospital and other facilities and clinics that, together, provide a full range of health care services in central Texas.
The initial challenge: testing a new program. In 2003, RWJF hoped to include an Ascension Health hospital as one of three pilot hospitals in Transforming Care at the Bedside, its new program to empower front-line nurses and other staff to develop, test and implement changes to dramatically improve care on hospital medical/surgical units. Ascension chose Seton largely due to its Magnet Nursing status, another initiative overseen by Batcheller. The fundamental tenet of TCAB was that improvements in the nurse work environment would ultimately enhance the quality of patient care.
Batcheller selected Seton Northwest Hospital, with its 64-bed medical/surgical unit for the TCAB demonstration. Nurses and staff on the TCAB team met weekly to identify operational problems and develop solutions to them. Team members had authorization to take action to improve situations they already knew firsthand.
Two-year results were impressive: nursing time at the bedside increased dramatically, vacancy and turnover rates for nurses plummeted from double to single digits and nurses who once considered leaving the profession reported a renewed sense of purpose and dedication to nursing.
Batcheller now had a new challenge: How to expand the TCAB program throughout the medical/surgical units of all Seton hospitals? "The goal," she remembers, "was to get it everywhere."
The new challenge: expanding the program. RWJF selected Batcheller for the Robert Wood Johnson Foundation Executive Nurse Fellows national program in 2005. The timing could not have been better for Batcheller. She was determined to "focus my fellows project on how to spread the innovations and changes we put into practice in the Seton Northwest med/surg unit. You would think that would be easy. But it was one of the hardest things I've ever been involved in."
The results at Seton Northwest had earned the enthusiastic attention of other TCAB grantees eager to copy Seton's practices in their own facilities. Yet, ironically, Batcheller met resistance from staff at the other Seton hospitals, which caught her by surprise. "Some of the resistance was [the perception] that Seton Northwest was special and they were not," she recalls.
Batcheller worked with nursing staff and leadership to showcase improvements made by the Seton Northwest TCAB team to their work environment, such as a redesigned supply room, a staffing board that reflected individual nurses' stress levels related to work assignments, strengthening nursing teamwork and communications and making patient rounds with physicians and all health care team members. "A lot of this is not rocket science," says Batcheller, "but small changes that are easy to implement."
Batcheller hired outside consultants to provide leadership training for medical-surgical nurses and to help existing nurse management understand change. "The leadership element is the toughest nut to crack," she says. "Getting them to understand that if you are the leader you have to be the champion." She also helped nursing staff to accept the possibility of failure when "doing transformational work."
Impact on culture. Batcheller's efforts have fostered a Seton culture in which nurses play a critical role in creating positive work environments that lead to better patient outcomes. Four Seton hospitals have achieved Magnet Recognition, the national award given by the American Nurses Credentialing Center that recognizes quality patient care, nursing excellence and nursing practice innovation. Five have attained the American Nurses Credentialing Center Pathway to Excellence status, acknowledging the value placed on the hospitals' nurses.
Batcheller's experiences support key recommendations about the importance of improving the nursing work environment made by the Future of Nursing: Leading Change, Advancing Health, the landmark 2010 report by the Institute of Medicine (IOM), and RWJF's Initiative on the Future of Nursing at the IOM. The report's recommendations emphasize the need for nurses to lead efforts to redesign and improve health care practice. Says Batcheller, "I have always believed in the role of nursing leadership to empower staff to design methods of caring for patients efficiently, achieving the best outcomes for patients. Given the opportunity, nurses can do this at the bedside. They can do the same at the national level to lead change and advance health."
Batcheller's perspective. The RWJF Executive Nurse Fellows Program "has been the most amazing opportunity," says Batcheller. "Having the number of colleagues and the network of people to tap into—all with amazing expertise—jump-starts just about anything you want to do."
One message from the program made a lasting impression on her. "A lot of the program focuses on learning about yourself and how to leverage your strengths," she recalls. "No one had ever said that to me. That was just freeing."
RWJF perspective. The Robert Wood Johnson Executive Nurse Fellows Program was created in 1997 to capitalize on the profession's strengths and build the leadership capacity of nursing. The leadership development program is designed to prepare a cadre of registered nurses in senior leadership positions to assume influential roles in shaping the U.S. health care system of the future.
"Nurses are in a unique position to serve in leadership roles and contribute to transforming our health care system," says Susan Hassmiller, Ph.D., R.N., and RWJF senior adviser for nursing. "The Executive Nurse Fellows program is part of the Foundation's building human capital strategy to attract, develop and retain diverse and high-quality leaders and a workforce to improve health and health care."
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