Leaders in healthcare have advocated and implemented the use of best evidence to improve patient care for more than a decade. For the most part, however, leaders who have staunchly advocated best evidence application in patient care have been less aggressive in applying the same logic to management decisions and organizational improvement.1 As reflected in the literature, evidence-based decision making and patient care standards are the norm for clinical nursing.2 Through the development of the American Organization of Nurse Executives (AONE) Nurse Executive Competencies, the work of the AONE Institute for Patient Care Research and Education, and ongoing strategic planning, AONE has taken the strongest possible position on the importance of using best evidence in leadership and management practices. Leadership's use of best evidence in making organizational decisions has potential to impact patient care to a greater extent than does a single clinician using best practices at the bedside.
This issue of The Journal of Nursing Administration presents several studies that illustrate this potential impact: resource factors associated with adverse events; identification of non-value-added staff utilization patterns; influence linkages among professional environment, conflict management, and unit effectiveness; elements of communication associated with nurse satisfaction; and 3 major factors associated with improving patient outcomes and nurse retention. This evidence, supported by the work of AONE, provides an excellent basis for each of us to evaluate organizational decisions and practices relative to these issues.
In this editorial, I am going to provide a brief overview of the 5 research articles highlighting the potential use for making evidence-based management decisions and describe AONE resources useful in developing systematic approach to evidence-based organizational improvement. The potential use of the information in the 5 research articles in this issue for making evidence-based management decisions, as well as the AONE resources useful in developing systematic approaches to evidence-based organizational improvement, follows.
Costs Associated With Adverse Events
The article by Pappas describes a method used to review patient-level data as well as a hospital's financial and clinical data to determine the incremental costs associated with adverse events and whether the expense associated with improved staffing would be offset by avoiding the adverse events. The findings support the value of nurse resource investment in preventing urinary tract infections, pressure ulcers, and pneumonia in specific medical and surgical populations. This methodology is one of the first to provide a means of generating evidence for making resource investment decisions for a specific patient population on a cost-per-patient basis. This study provides a model for making evidence-based decisions consistent with the AONE business skills competency that states that nurse executives must understand what organizations should measure to "balance" quality and financial outcome performance.3
Inpatient Unit Activity
Storfjell et al report an observational study of inpatient unit activity by a team of researchers over a 3-year period. Their findings from observations of 14 inpatient medical-surgical nursing units in 3 Midwestern urban and suburban hospitals indicate that nurses spent an inordinate amount of time on activities that were not associated with direct patient care activities. Their findings indicate that one-third of the nurse's time was spent in "non-value-added" activities. These authors make several suggestions which could impact future patient care delivery, nurse satisfaction, care efficiency, and the expense associated with patient care delivery. Evidence from this study has significant implications for staff utilization decisions. The AONE's 2008-2010 Strategic Plan promotes the adoption of the Nursing Organization Alliance's Principles and Elements of a Healthful Practice/Work Environment.4 One element of the Nursing Organization Alliance's Principles and Elements of a Healthful Practice/Work Environment is "the presence of adequate numbers of qualified nurses."5 The provision of adequate numbers of qualified nurses must be interpreted within the context of how these nurses are used to provide essential direct care services.
Unit Effectiveness
Siu et al describe study findings that link greater unit effectiveness to the quality of conflict management supported through professional practice environments and nurses' self-reported ability to engage in effective conflict management. Siu et al framed the study using Deutsch's theory of constructive conflict management and performed a secondary analysis of cross-sectional data collected from 678 nurses working in community hospitals from a 2006 Ontario study. From this theoretical perspective, conflict resolution patterns have the potential to influence relationships, decision making, and outcomes. The evidence from this study's findings reflects the import of constructive conflict resolution on the effective operation of a clinical service unit. The findings showed that nurses are more likely to manage conflict constructively within the context of a healthy, professional environment. These study results are consistent with AONE's strategic focus on healthful practice environments4,5 and provide evidence to support resource commitment to creating and sustaining such environments.
Communication Patterns
Another element of a healthful practice environment is a "culture where communication is clear, respectful, open and trusting."5 Manojlovich and Antonakos surveyed 866 nurses who worked in 25 intensive care units located in 8 hospitals in Michigan to determine if specific elements of communication affect nurses' satisfaction with communication patterns in their work setting. Manojlovich and Antonakos found that nurses reported greater satisfaction with communication when the communication is characterized by understanding, openness, and accuracy. Nurses reported satisfaction with their communications with attending physicians but not with first year residents. The authors concluded that satisfying physician-nurse communication patterns are developed over time because little communication education is provided for medical students or residents. Although their study findings indicated that openness, understanding, and accuracy were important elements in communication satisfaction for nurses, timeliness of communication was not identified as a communication satisfier. This evidence may have educational implications because communication timeliness is considered a major safety factor and has been identified as a priority by the Joint Commission.
Effect of Practice Environments on Outcomes
Aiken et al analyzed data from 168 Pennsylvania hospitals to determine the effects of practice environments on nurse and patient outcomes. As part of the study, they accounted for the impact of nurse staffing levels and nurse education levels. The study results indicated that each of the 3 variables (environment, staffing level, and education level) measurably impacts outcomes. The study analyses provide evidence that nurse leaders have at least 3 major options for improving nurse retention and patient outcomes: improving registered nurse staffing, employing a more educated nursing workforce, and improving the care environment. Their findings show that each of the described options for improving outcomes contributes independently to better patient outcomes, and maximizing all 3 options increases the probability of achieving the best outcomes. This study provides evidence for nurse executives to leverage resource allocations for strategic development of an optimal nurse workforce and practice environment.
Summary
The knowledge generated through the research presented in this issue provides evidence that is supportive of the various aspects of the AONE Nurse Executive Competencies; specific goal areas of the AONE 2008-2010 Strategic Plan, including the goal areas of design of future patient care delivery systems, healthful practice environments, and leadership; and the AONE Institute for Patient Care Research and Education 2007-2009 Strategic Plan. These AONE strategic documents provide the framework necessary for nurse leaders to establish evidence-based management as a norm in our organizations. The complex and important roles of nurse executives require the incorporation of the best available evidence into our practice. In the future, the most effective nurse executives will be those who generate new knowledge or those who base their decisions on the best available evidence.1 AONE's strong commitment to advancing evidence-based leadership and management is demonstrated by its delineation of the AONE Nurse Executive Competencies, supporting the generation of new knowledge through the AONE Institute for Patient Care Research and Education and its ongoing strategic planning.
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