Much has been written about the importance of implementing care based on evidence-based practices, but the importance of using evidence-based practices for managing the delivery of care has not received the same attention. The special comments by Dr. Jennings emphasize this point. She discusses the limited funding provided for nursing administration research and proposes building stronger ties between nursing administration research and the better-funded health services research to strengthen the contribution each makes to evidence-based management practices in healthcare.
The recently released report by the Institute of Medicine (IOM) Keeping Patients Safe: Transforming the Work Environment of Nurses1 places increased emphasis on the importance of incorporating evidence-based practices into management decision making.
The IOM report states that leadership needs to "assure the effective use of practices that (1) balance the tension between production efficiency and reliability (safety), (2) create and sustain trust throughout the organization, (3) actively manage the process of change, (4) involve workers in decision-making pertaining to work design and work flow, and (5) use knowledge management practices to establish the organization as a 'learning organization.'"1(p. 8) To do this, Recommendation 4-4 of the Institute of Medicine report states that "professional associations, philanthropic organizations, and other organizational leaders within health care industry should sponsor collaboratives that incorporate multiple academic and other research-based organizations to support health care organizations in the identification and adoption of evidence-based management practices."1(p. 155)
The American Organization of Nurse Executives (AONE), the professional association for nurse executives and nurse leaders, is committed to identifying and adopting evidence-based management practices. AONE believes that nursing leadership plays an extremely important role in creating the work environments that attract and keep nurses and that current management practices are not uniformly successful. New strategies and practices are needed, but AONE believes that changes in managing patient care and the work environment must be implemented based on best practices and research. As identified in its strategic plan, AONE promotes the evidence-based practice of nursing leadership and encourages the dissemination of new research that adds to the knowledge available to leaders in nursing and that assists in decision making. 2 To further assist in this endeavor, AONE has identified education and research priorities that direct the association in developing its education programming and research initiatives. 3
AONE uses the priorities for developing its educational programming and resources and for directing the use of its time and resources in building evidence-based management practices. AONE awards research grants, conducts its own research, and supports partnerships with other organizations in conducting research consistent with the identified priorities. At its annual meeting, AONE recognizes an outstanding nurse researcher who has made significant contributions to building knowledge consistent with the research priorities.
The first education and research priority for 2004 is to be stewards of leadership. AONE strives to be a national leader in strengthening nursing's leadership across the continuum of care in all types and sizes of healthcare settings. In this role, AONE wants to promote evidence-based leadership, mentor aspiring nurse leaders, and engage in effective succession planning. Strong evidence exists that the effectiveness of the manager is directly related to the retention of staff. But, it is not only those in formal leadership positions who are responsible for creating positive, healthy work environments. All nurses must be committed to elevating the work environment and improving relationships with all members of the healthcare team. Understanding the key leadership skills and how to mentor those skills in nurses in leadership positions is important.
The article by Duffield et al focuses on a different way to evaluate the value of skills acquired by nurses. Instead of studying nurses still in hospital nursing, Dr. Duffield and her associates identified the range of positions outside of hospital-based practice to which registered nurses moved and how those nurses evaluated the skills gained from nursing.
Many of the nurses in this study moved into management positions in other fields and reported that the skills acquired in nursing were very helpful in making the transition to these diverse management positions. Some of the skills reported as important for these positions were teamwork, accountability, negotiation, and organization. Instead of simply viewing this movement of nurses from hospital-based practice as a negative for the profession, more should be learned about the leadership and management skills and what gaps in those skills exist.
Additional study should focus on the management and leadership skills needed by all nurses, not just those in formal leadership positions, and ensuring that all nurses are competent in performing the priority skills. A solid understanding of critical management and leadership skills serves as the basis for developing strategies for building expert leadership and management skills, and attention should be directed at how to better mentor nurses for leadership roles and succession planning.
The second education and research priority for AONE is the implementation and evaluation of future patient care delivery models. The goal is to design and develop patient care delivery models that leverage new technologies, improve provider and patient safety, honor a diverse work force, and support quality care and satisfying work for nurses. Several research articles have been published recently on the appropriate levels and mix of registered nurse staff, but they have still focused on staffing as it exists today. The article by Seago et al is an example of this. Dr. Seago's study examined the differences in nurse staffing for medical-surgical patients and hospital ownership in California as the basis for evaluating the impact of California's newly mandated staffing ratios.
The patient care delivery models and staffing of the future will be very different as integration of technology and availability of people will change how things are done today. Current studies will serve as a basis for evaluating future models of care and comparing effectiveness of the new models to current models of care. Much work still needs to be done to determine the critical elements of care that must be performed by the nurse, what can be delegated, and what constitutes appropriate oversight of delegated tasks. Nurses must understand variation in care delivery processes and demonstrate the ability to institute change.4(p. 128)
The article by Capuano et al focuses on the effectiveness of a strategy for eliminating unnecessary work. Abundant evidence exists documenting the inordinate amount of time nurses spend in functions other than providing patient care; these tasks contribute to low job satisfaction and a frustrating work environment.4(p. 126) Capuano et al involved nurses in identifying and redistributing work and providing more direct patient care time for nurses. This type of redesign that involves the nurses providing care is an extremely important strategy for addressing the unnecessary and duplicative work embedded in the work environment. Critical thinking is extremely important when making decisions that ultimately affect the structure of patient care delivery and the outcomes of care, however.
The third education and research priority for AONE is creating positive and healthy work environments in nursing and healthcare. Innovation requires strong, capable leaders, especially in the challenging environment of constrained financial resources, increasingly acutely ill and frailer patients, and mushrooming technology. Nurse leaders are also accountable for guiding the development of the work force and promoting professional growth and continuous learning.
The article by Holtom and O'Neill on job embeddedness is an interesting analysis of what attracts and keeps nurses committed to an organization and goes beyond the factors related to retention that are usually studied. Most retention studies examine job satisfaction and organizational commitment. Job embeddedness captures the linkages employees have made, not only in the organization, but also in the community. The concept of job embeddedness gives nurse managers additional evidence about factors that bind nurses to an organization and expands the options on which managers must focus, both on and off the job. Building stronger relationships between hospitals and nurses is critical to improving quality and assuring the safety of patients in their care. 4(p131)
It is hoped that the IOM's report will bring new attention to the importance of investing additional resources in research that builds knowledge in management and leadership practices. It will not be possible to solve the nursing shortage and ensure the safest patient care environments unless expert nurse leaders play a key role in decision making about the models of care delivery and about key work environment initiatives. AONE is committed to participating fully in advancing this agenda and has incorporated a strong research agenda in its strategic plan, as articulated in its education and research priorities; however, AONE is also engaged in several key partnerships to collaboratively push its research agenda. A strong commitment to building evidence-based management research and incorporating those practices in the work environment will have a positive impact on the work force and the work environment.
REFERENCES