Document Type

Report

Publication Date

Spring 2023

Date of Final Presentation

3-30-2023

Committee Chair

Cara Gallegos, PhD, RN

Committee Member

Katherine Doyon, PhD, M.Ed., RN, CHPN

Optional Additional Committee Member

Joseph L. Greene, DNP, RN

Coordinator/ Chair of DNP Program

Teresa Serratt, PhD, RN

Abstract/ Executive Summary

Problem Description

Low nurse job satisfaction and engagement have historically been associated with high attrition. While it is too soon to fully quantify the impact of Covid-19 on nurse satisfaction, engagement, and turnover, evidence is emerging that high chronic fatigue and persistent feelings of being overwhelmed are causing nurses to either leave the bedside or quit nursing altogether, exacerbating existing nurse staffing challenges caused by a decades long nursing shortage that, pre-pandemic, predicted a national deficit of over one-half million nurses by 2030. The financial impact of competing for experienced nurses, and recruiting, hiring, and training new nurses to replace those who have left, is high. Additionally, chronic short staffing and/or an overreliance of new graduates negatively impacts the quality and safety of patient care by either not having enough resources to perform necessary care or by diluting the experience level at the bedside.

Setting

This project occurs in a middle sized tertiary acute care hospital in California. Project participants are the managers and registered nurses from the Intensive Care Unit, Emergency Department, Nursing Float Pool, General Medical-Surgical unit, and Oncology unit.

Rationale

Kanter’s Theory of Structural Empowerment states that empowerment is promoted in work environments that provide employees with access to information, resources, support, and the opportunity to learn and develop. The literature reveals a theme of successful interventions that fall within these four constructs and contribute to nurse job satisfaction and engagement, which has been shown to reduce turnover and contribute to nurse retention.

Transformational leaders create an empowered work environment where employees can innovate, create, and problem solve. The behaviors associated with transformational leadership cultivate and enable structural empowerment to not only exist but thrive. Nurses who perceive their manager’s leadership style as transformational have lower intention to leave than nurses who view their manager’s style as transactional or passive avoidant.

These traits are associated with hospital Magnet Status, and thus are desirable attributes for organizations to achieve.

Specific Aims

This project aimed to improve nursing leadership by implementing an evidence-based education and coaching program. Managers received education, coaching, and mentoring on structural empowerment and transformational leadership concepts and behaviors.

Project Outcomes

This project has nine short term change outcomes. Five outcomes were developed based on select questions from the organization’s annual caregiver engagement survey that measure specific elements of structural empowerment and nurses’ intent to stay directly and by asking about burnout. Four additional outcomes were developed to assess overall leader engagement and uptake and utilization of knowledge obtained during the implementation phase of the project.

Implementation and Evaluation Plan

Managers and the registered nurses from participating units were emailed a pre-project survey. Following a three-week period for completion of the surveys, managers participated in an education session on transformational leadership and structural empowerment. Each manager subsequently participated in weekly 1:1 coaching and mentoring sessions with their DNP-student coach/mentor. The project culminated in post-project surveys to assess project outcomes.

Results

While there was improvement in four outcome measures, only one was met and one was partially met. Four of nine outcomes had decreased scores compared to pre-project survey scores and one outcome remained unchanged overall. The best improvements were in leader level of uptake and utilization of transformational leadership and structural empowerment, and appreciation demonstrated by the nurse leader. Communication, access to supplies and equipment, and the ISA scores for registered nurses decreased. Burn out was unchanged.

A contextual element that may have interacted with the results was the implementation of a new, all-in-one, timekeeping, payroll, procurement, human resources and talent acquisition platform that resulted in widespread pay discrepancies, procurement problems for minor but necessary supplies and equipment, and position requisition issues that delayed hiring, exacerbating staffing challenges.

Interpretation

The five managers who responded to the Level of Knowledge Use Surveys (LOKUS) had significant individual improvement in their individual knowledge uptake and utilization (KUU) for both transformational leadership (TL) and structural empowerment (SE). While the 50% threshold for SE KUU was not reached, each manager had individual improvement of two to four levels in TL and SE. While the contextual issues experienced at the hospital during the project implementation period had a significant impact on individual employees, small improvements in some ISA domains, only small increases in others, and lack of change in burnout suggests that TL with SE can prevent a bad situation from getting worse.

Conclusions

Although the stated outcomes were not met seven of nine times, multiple outcomes did improve despite significant organizational adversities. TL and SE may serve as stabilizing forces during the time of organizational strife. This model is dependent upon senior nurse leaders who value TL characteristics and the empowerment of staff. Embarking on a Magnet journey could serve to embed and codify this into the organization’s nursing leadership DNA. TL and SE should be nurtured so that the desired behaviors do not degrade during times of stress or high transactional demands from nursing leaders.

TL and SE are not exclusive to nursing. Including other health disciplines in this training has the potential to create a standard and aligned leadership approach. An engaged and empowered workforce is primed to collaborate across disciplines, embracing evidence-based practice to and improve patient care.

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