The problem. Nursing executives at Inova Health System in Northern Virginia wanted to improve the hospital working environment for nurses and give them more time with patients. But how would the nurses, who were already overwhelmed with daily tasks, find the time to put more healing and caring back into their schedules? How could the nursing leadership team help streamline work processes and make more time for caring? Inova Health System is a nonprofit system with five hospitals, two long-term care facilities, emergency care centers and ambulatory services.
The proposal. Karen N. Drenkard, Ph.D., R. N., was chief nurse executive and senior vice president of the Inova Health System, responsible for the system's nearly 5,000 nurses. She wanted to find ways to streamline work processes and give nurses more time to create a healing environment-and to study the results of these changes. Through a grant from the Human Health Resources and Services Administration (HRSA) and a fellowship in the Robert Wood Johnson Foundation Executive Nurse Fellows programs she had the opportunity to do this.
The project. In 2003, Drenkard received a $685,000, four-year grant from HRSA to work to improve nurse satisfaction and retention at Inova by decreasing work intensity, streamlining cumbersome processes in the workplace and creating what she termed a "human caring environment." Called "Making Time for Caring," the grant reflected the work of Jean Watson, Ph.D., R.N., the founder of the Watson Caring Science Institute that promotes restoring time for direct patient care back into the nursing profession.
Just as Drenkard began the HRSA grant, the Robert Wood Johnson Foundation (RWJF) selected her to join the Executive Nurse Fellows program. "Making Time for Caring" soon became a collaborative research project for Drenkard with funding from both HRSA and RWJF. Using four medical units (the intervention group) and four surgical units (the comparison group) in four Inova hospitals, Drenkard began a two-phase study that looked at how to decrease work intensity for nurses and give them more time at the bedside.
In Phase 1, Drenkard studied how to improve and streamline nursing processes in four core areas: medication administration; patient admissions, discharges and transfers; communication; and documentation of equipment and supplies. Participating nurses helped develop and then implemented the new processes. Drenkard collected data on the time each process took before and after the new processes were implemented.
In Phase 2, Drenkard studied key factors of a human caring work environment that help improve nurse satisfaction and reduce turnover rates, which, in turn, impact the quality of patient care and improve patient satisfaction. Participating nurses were trained to implement "caring activities," such as incorporating intentionality and centering techniques to be "in the moment" with patients instead of focusing on tasks, and using relaxation and meditation techniques, along with music therapy, to decrease stress and improve concentration for nurses and patients. Drenkard used various surveys of nurses and patients and health system data to measure outcomes.
Results. According to Drenkard, Phase 1 of the study resulted in some "optimistically positive" changes that gave nurses 20 extra minutes to provide patient bedside care every day. For instance, a new system gave nurses recorded patient histories and shift reports, saving nurses' time reading and processing reports. A new scanning system saved time ordering medications from the pharmacy.
Phase 2 of the study emphasized the importance of the quality of a nurse's bedside time. "Every day, the nurses had to spend five minutes in a patient's room without relying on equipment," said Drenkard. "They had to be the agents of caring."
When nurses had more time for patient caring, they reported reduced workload intensity and improved co-worker relationships, and patients reported an increase in caring behaviors, according to Drenkard's surveys. Health system data showed that the pilot units had lower nurse turnover and vacancy rates than the comparison units during the study period. Nurses also reported that their relationships with patients were the number one source of job satisfaction.
In summary, Drenkard wrote that, "streamlining work processes can gain time back at the bedside, giving nurses the opportunity to establish a more meaningful, caring connection with their patients. This enhanced ability to provide nursing care in a healing and caring environment has led to greater work fulfillment, a sense of belonging, commitment to the unit and improved morale."
Drenkard perspective. As part of her Executive Nurse Fellows program, Drenkard wrote about the results of her study in "Making Time for Caring," which she disseminated by mail to more than 2,000 hospitals around the country. She also wrote an article about the study that was published in Critical Care Nursing Clinics of North America. ("Integrating Human Caring Science Into a Professional Nursing Practice Model," 20(4): 403–414, 2008. Abstract available online.)
The executive coaching and mentoring Drenkard received as an Executive Nurse Fellow helped her not only prepare her report but present it to others locally and nationally. For instance, in 2006 Drenkard presented her research to the American Organization of Nurse Executives and to the World Congress Leadership Summit for Senior Healthcare and Nurse Executives. "RWJF provided a coach to work with me on how you present and what you present. You get real feedback," she said.
Drenkard owes her choice of nursing as a career to the mentorship of her grandmother, her experience with an appendectomy and Earth Day.
When she was 11 years old, Drenkard had her appendix removed, an emergency procedure that at the time required up to 10 days of hospitalization. Drenkard was hospitalized on Monday and pleaded with her nurse that she had to be out of the hospital by Friday because she was in charge of her school's Earth Day celebration and dance. "The nurse said, 'You work with me, and I will work with your doctor to get you home,'" remembered Drenkard. "And I got to go to the Earth Day celebration and dance.
"I started thinking this is about helping patients do the best they can do and maximizing their potential. Also, my grandmother was a nurse, and I loved everything about it. I guess you can say that I was an early convert who saw the power of nursing advocacy firsthand as a young person. Mine was not a tragic story, but it was a choice I made after being empowered with an experience that reflected good nursing care."
Drenkard got her bachelor's degree in nursing from Russell Sage College (Troy, N.Y.), and an M.S.N. degree in nursing administration from Marymount University (Arlington, Va.). She held various nursing positions at George Washington University Hospital before she began working at Inova Health System as patient care director and nursing coordinator at Inova's Fairfax Hospital in 1987. She served in multiple administrative, nursing and quality-management positions before being promoted to chief nurse executive and senior vice president of the health system in 1999.
During her fellowship, Drenkard worked on her Ph.D. in nursing at George Mason University, a degree she received in 2006. Two years later, Drenkard left Inova to join the American Nurses Credentialing Center as director of the national nursing credentialing organization's Magnet Recognition Program®, which recognizes health care organizations that provide nursing excellence. Drenkard was promoted to senior director of the center's credentialing operations in 2010 and to executive director in 2011.
Looking back, Drenkard has no doubt that the Executive Nurse Fellows program prepared her for her new career. "Everything RWJF did, they really put you in a space where you can dream actually bigger than you would have if you hadn't been there," said Drenkard. "They try and really encourage people to strive to make a difference at a national level, and they want to create a network of people who can use each other in a positive way to make that happen. And they validate that by saying, 'You have all the skills you need to do that. Don't shy away from it.'"
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 select cadre of registered nurses who are in senior executive positions for 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 nurses 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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