Helping Nurses Become Innovators

May 7, 2013, 12:00 PM

In 2003, the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation launched Transforming Care at the Bedside (TCAB), a nationwide, nurse-focused effort to improve health care delivery. TCAB recognized that nurses often hold the key to making hospital care more effective, patient-centered and efficient. David Harrington, RN, BSN, CMSRN, has been a nurse at Providence St. Vincent Medical Center since 2006 and a TCAB leader there for two years. Erin Hochstein, RN, BSN, PCCN has been a staff nurse at Providence since 2010 and a TCAB leader for two years. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.


As nurses, we are with our patients and their families during some of the most pivotal moments in their lives, which is a true honor. Yet, with the ever-increasing demands of health care, the responsibilities of nurses have become greater, pulling us away from the bedside. To curb this trend we were given the opportunity, at Providence St. Vincent Medical Center, to adopt Transforming Care at the Bedside (TCAB), a program that gives bedside staff the chance to streamline care and improve patient outcomes.


By allowing us direct input on our workflow, we have the opportunity to develop rapid tests of change that we implement over the course of one shift.  This adjustment in practice empowers frontline nurses to be catalysts of change for patient care, permitting us creative liberty in finding solutions to practice and system issues we face on a daily basis.

The Providence St. Vincent TCAB team began its journey in 2010 by visiting Prairie Lakes Hospital in Watertown, South Dakota, one of the original TCAB pilot sites, as part of an innovation grant provided by Providence Health & Services. Nurse representatives from three medical-surgical units along with hospital leaders were introduced to TCAB in action. As newly appointed TCAB leaders, we returned from the trip feeling motivated, inspired, and ready for change.

However, with our new sense of empowerment, we soon realized how little we actually knew about the TCAB method and how massive an undertaking it would be; we had witnessed only the fruits of TCAB, but not the process. This was apparent in our early group development as both the nursing staff and hospital leadership grappled with how to honor TCAB’s bottom-up approach to change. With time, we were able to reach a consensus on how to effectively support the development of TCAB.

“TCAB gave us the courage to imagine what our jobs would be like without wasted time and unnecessary workarounds.”

We received some much-needed support from the Oregon Association of Hospitals and Healthcare Systems when we joined their TCAB collaborative in September 2011. We also added two other units to the St. Vincent TCAB team at this time. During leader meetings, we learned about the driving forces of TCAB and tools we could use to achieve our goals. Our next step was to put the theories to the test and, as expected, we made mistakes along the way. However, with each stumble we were able to glean some practical knowledge for our next attempt.

A common error most units made at first was starting out projects on too large a scale and finding that they were not sustainable, requiring more involved rework than would be necessary on a smaller test of change. Over time, staff on the participating units became more aware of TCAB’s purpose and began incorporating it into their practice. This shift in unit culture is quite apparent as one walks the halls of these units, sometimes catching multiple staff members using the phrase “TCAB it” when discussing issues that need improvement.

TCAB gave us the courage to imagine what our jobs would be like without wasted time and unnecessary workarounds and then provided us with the tools to work toward making our visions a reality. TCAB also offered us the freedom to reach our goals however we saw fit. Many units focused on the same areas of improvement, yet each reached it in a different way. This eclectic quality of TCAB, which allows it to be used to cater to one’s specific needs, promoted its acceptance and success across multiple units. This was most evident when each unit was working to reorganize nursing supplies to meet their needs, as well as when working to improve staff satisfaction. Other successful TCAB projects included a team-focused admission process during night shift to increase patients’ rest, and a patient experience booklet to help patients and guests understand the hospital environment.

In the TCAB world, collaboration is key. We learned to “steal shamelessly” from one another to encourage the spread of good ideas. We saw this with the spread of publicly displaying staff pictures with the patient assignment, so that other staff members, patients, and visitors could easily identify the care team. This limited unnecessary searching and phone calls.

Together, we are all motivated for change to improve quality, enhance satisfaction, and provide the best possible care for our patients.  It is more important than ever to share our successes and our struggles.

The role of the bedside nurse holds many responsibilities; we act as a caregiver, patient advocate, teacher, counselor and, now, at Providence St. Vincent Medical Center, we act as an innovator. We are proud to be part of TCAB, a groundbreaking new process, which has given us the means to make necessary changes to improve the care we offer and ultimately spend more time with our patients.

Learn more about Transforming Care at the Bedside here and here.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.