Fostering a culture of nursing excellence during the COVID-19 crisis.

Medical center uses Pathway to Excellence® framework to sustain a positive practice environment.

No caption available.

The unprecedented COVID-19 pandemic has changed the healthcare landscape and challenged the existing healthcare system, including the response to the needs of patients and healthcare workers. When the COVID-19 pandemic began early in 2020, nurses were on the front lines of healthcare, providing clinical care, creating protocols, augmenting manpower, and identifying innovative alternatives to insufficient medical resources during difficult circumstances.1 Nurses faced stressful situations, including the complexity of caring for patients with COVID-19, new ways of working, and having to accommodate new protocols.

These problems were further aggravated by issues such as a lack of available personal protective equipment (PPE), limited manpower, an insufficient number of available hospital beds, fear of the unknown, poor working conditions, and most especially, physical and mental exhaustion.2-7 This article describes how a tertiary academic medical center in the Philippines implemented the Pathway to Excellence® framework and effectively sustained a positive practice environment during the COVID-19 crisis.

Nurse retention problems

Even before the spread of the deadly virus, the Philippine government had problems retaining healthcare workers and struggled to understand the reasons why nurses were leaving their jobs or the profession.8 Although other parts of the world have considered the Philippines to be a source for nurses, the constant trend of turnover within the country has threatened the adequacy of personnel and the quality of patient care.9 This dilemma was magnified when the pandemic hit the healthcare system. With approximately 18,500 nurses moving abroad each year, there's an estimated shortage of 23,000 nurses in the Philippines.10

Recent studies have shown that Filipino frontline nurses experience mild to moderate levels of fear of COVID-19, which is linked to increased psychological distress, lower job satisfaction, decreased health perceptions, and increased turnover.9 More specifically, nurses working in isolation units reported increased levels of psychological stress, fear, and anxiety that affected their quality of work.11

To retain and strengthen the current workforce, the International Council of Nurses recommends that organizations explore how to improve working conditions and the work environment, protect the safety and well-being of nurses, provide adequate support in light of the traumas they face, and make a sustainable investment in training to build a resilient and safe workforce.12 Recognizing the complementary relationship between the practice environment and nurse retention, researchers report that a healthy nurse practice environment (NPE) has a significant effect on nurses' psychological health.13 Likewise, previous studies have demonstrated the importance of favorable working conditions and a positive practice environment to the clinical outcomes of patients in addition to the welfare of staff.14,15

Committed to the goal of establishing a healthy workplace for its clinical nurses, St. Luke's Medical Center (SLMC) in Quezon City (QC), Philippines, started adopting the American Nurses Credentialing Center Pathway to Excellence® framework in 2017, and the organization achieved Pathway designation in April 2020. As a Pathway-designated organization, SLMC QC makes proactive efforts to provide and sustain a positive practice environment, even amidst the pandemic, as guided by the six Pathway to Excellence Standards: shared decision-making, leadership, safety, quality, well-being, and professional development.16

During these trying times, nurse leaders are pushed to use critical decision-making to adapt to novel situations and issues. The pandemic crisis taught nurse leaders to create environments that lift morale and engage nurses and other healthcare staff in activities that make them feel supported.17 As emphasized in a recent study, supporting employees in the workplace, particularly during crisis situations, can enhance frontline experiences and increase confidence in employers.18 The benefits of a positive practice environment on overall staff safety and well-being shouldn't be underestimated because this can translate to various levels of the organization and to the patients.19

This study aimed to describe nurse satisfaction levels and selected clinical nursing outcomes, such as inpatient injurious fall, catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP), before and after the implementation of bundled institutional programs in response to the COVID-19 pandemic based on the Pathway to Excellence framework. This can provide a benchmark for other healthcare organizations within the region for ensuring staff well-being while meeting patients' clinical needs, especially during the pandemic. Additionally, the study provides recommendations to guide nurse leaders in their essential role when implementing their own responsive programs for nurses according to the Pathway framework.

Methods

This study used descriptive design and was conducted in a 550-bed capacity Pathway to Excellence-designated tertiary academic medical center in Metro Manila, Philippines. Using the Pathway framework, bundled initiatives presented in Figure 1 were implemented and strengthened from March to May 2020 in 62 patient-care units. The figure illustrates proactive efforts to sustain a positive practice environment during the pandemic. Interventions included the application of shared decision-making to promote convergence between nurses and healthcare teams and help standardize the hospital's management of COVID-19. Leadership support was exemplified through special hazard pay and early release of salaries. To further safeguard the holistic well-being of nurses, several initiatives were implemented, including the provision of free meals, scrub suits, vitamins, overnight accommodations, and transportation to and from the hospital, especially when strict community lockdown measures were in place. The organization also conducted virtual training activities on competencies to promote nurses' continued professional development and ensure their proficiency in providing patient care.

Figure

Figure 1

Measures of nurse satisfaction—such as through the Press Ganey National Database of Nursing Quality Indicators® (NDNQI®) RN Survey, which includes nursing practice environment, job enjoyment, and nurse-to-nurse interaction—and clinical nursing outcomes were gathered and compared as indicators of performance. Clinical nurses working as regular, full-time employees with a minimum of 3 months' tenure during the time of survey, and who spent at least 50% of their time in direct patient care, answered the satisfaction surveys conducted in June 2019 and June 2020.

Selected clinical nursing outcomes were compared using the actual inpatient clinical data analyzed for quality and patient safety before (March 2019 to March 2020) and after (June 2020 to June 2021) the intervention period (April to May 2020), and measured against external benchmarks, such as the International Nosocomial Infection Control Consortium (INICC) and the CDC's National Healthcare Safety Network (NHSN) values for CAUTI and VAP rates.

The survey strictly adhered to the Press Ganey NDNQI RN Survey and research ethics. Participation in the survey was strictly voluntary. Steps were taken to ensure that nurses were not coerced or influenced to participate. These measures included noninvolvement of unit managers in survey follow-up, the electronic nature of the survey, and confidentiality of individual results such that a third-party vendor provided only the aggregate results to the organization.

Results

As shown in Table 1, there was a 100% response rate among eligible nurse respondents in both survey periods. The resulting satisfaction level derived from this survey reflects the perception of all eligible respondents during the given period.

Table 1:

Profile of the survey respondents

Profile	2019 (n = 754)		2020 (n = 853)
	Frequency	Percentage	Frequency	Percentage
Age group (years)
≤30	560	74.32	550	64.49
31-40	145	19.29	240	28.13
>40	48	6.38	63	7.38
Sex (%)
Male	156	20.63	182	21.33
Female	598	79.37	671	78.67
Years in practice
≤1	159	21.10	178	20.89
>1-2	120	15.97	82	9.60
>2-5	254	33.63	312	36.59
>5-10	148	19.59	189	22.11
>10	73	9.72	92	10.81
Years on the unit
≤1	270	35.84	328	38.47
>1-2	131	17.31	133	15.59
>2-5	222	29.40	247	28.95
>5-10	85	11.28	87	10.22
>10	47	6.18	58	6.77
Highest education level
Bachelor's degree	732	97.08	806	94.49
Master's degree	22	2.95	47	5.51

Almost 80% of respondents in both periods were female, and most were 30 years old or younger, in practice 5 years or less, and had a bachelor's degree in nursing. The mean age of respondents in both surveys was about the same (2020 M = 29.56, SD = 6.48 versus 2019 M = 29.12, SD = 6.56). This illustrates that most nurses staying in the institution are part of the younger workforce group, but a considerable number of staff belonging to the older workforce demographic also remained at the institution. The profile of respondents in the 2020 survey didn't vary significantly when compared with the 2019 survey respondents. This apparent similarity can also be seen in the profile based on years in their unit—most of them stayed in their original unit. The respondents who answered the 2019 survey were almost the same as those who answered the 2020 survey.

In Table 2, improvement in the mean scores of NPE (M = 3.55, SD = 0.28), nurse-to-nurse interaction (M = 5.48, SD = 0.45), and job enjoyment (M = 4.73, SD = 0.63) were observed in the 2020 RN satisfaction survey with a percent increase of 14%, 8.95%, and 13.70%, respectively.

Table 2:

Nurse satisfaction survey results

	2019		2020
Nurse satisfaction measures	Mean	SD	Mean	SD
Mean practice environment scale score	3.14	0.27	3.55	0.28
Subscales:
Nursing participation in hospital affairs	3.15	0.3	3.55	0.31
Nursing foundations for quality of care	3.26	0.23	3.62	0.24
Nurse manager ability, leadership, and support of nurses	3.15	0.36	3.52	0.38
Collegial nurse-physician relationships	3.33	0.29	3.62	0.29
Staffing and resource adequacy	2.82	0.43	3.45	0.44
Job enjoyment	4.16	0.6	4.73	0.63
Nurse-to-nurse interaction	5.03	0.44	5.48	0.45

Figure 2 shows the injurious fall rate before and after reinforcement of the Pathway framework. The mean injurious fall rate after the intervention was 0.09 per 1,000 patient days. Although slightly higher when compared with the preintervention rate (0.06), the rate was still below the hospital benchmark (0.30). The highest fall rate (0.40) was observed in September 2020. Thereafter, no injurious fall incident was observed for 4 consecutive months before the occurrence of two injurious cases in March 2021. Nevertheless, all postintervention months have outperformed the hospital benchmark, except for September 2020.

Figure 2:

Injurious fall rate per 1,000 patient days

The mean postintervention CAUTI rate was 0.42 per 1,000 device days, which was below the INICC and NHSN benchmarks. The postintervention rate was slightly lower when compared with the preintervention rate (0.68). As shown in Figure 3, after the intervention, the highest CAUTI rate (1.47) was noted in September 2020 and there were 5 months without any cases of infection. When compared against the external benchmarks during this period, all months outperformed the benchmarks.

Figure 3:

CAUTI rate per 1,000 device days

As shown in Figure 4, the mean postintervention VAP rate was 0.34 per 1,000 device days, slightly higher than the preintervention rate (0.10). After the intervention, no case of infection was recorded, except in October 2020 (one case) and May 2021 (two cases). The hospital outperformed the INICC and NHSN benchmarks throughout the postintervention period.

Figure 4:

VAP rate per 1,000 device days

Discussion

The age and sex distributions of nurses in this study are similar when compared with the nursing workforce distribution in the Philippines as reported in a recent study that indicated most nurses are female and younger than age 30.20 On the other hand, it appears that the mean age of respondents is younger than the median age group (52 years) found in the 2020 National Nursing Workforce Survey conducted by the National Council of State Boards of Nursing among employed RNs in the US, where 3% of respondents were Filipino.21

The annual survey was conducted in June 2020 to measure nurses' satisfaction after 3 months of implementing the interventions. Although there was a slight increase in the subscale ratings, the increase may not be attributed solely to the implemented bundles. Rather, the short time frame between the implemented interventions and the follow-up survey may have posed a cognitive bias. Nevertheless, most nurses agreed that they work in an environment that's favorable to professional practice.

The data revealed that key clinical outcomes didn't seem to vary after implementation of the organization's bundled initiatives. Because inferences can't be fully established in the descriptive design, it can be assumed that despite the challenges in staffing and changes in the health protocols, quality of care was still provided and maintained (if not significantly improved) as evidenced by outperforming the benchmarks during most months following the intervention.

From the onset of the pandemic, efforts were made to provide nurses with a positive practice environment through initiatives that prioritized their safety and welfare, making flexible adjustments when necessary. Implemented programs included monetary compensation, continuous update of health protocols, and well-being activities that target the needs of nurses and other healthcare team members. Through webinars and virtual meetings with managers and staff, hospital leaders maintained their accessibility and visibility to ensure their continued support and advocacy for nurses.

Developing a positive practice environment helped boost levels of nurse satisfaction. The more nurses perceive that they're working in a positive practice environment, the more they feel a significant increase in their job satisfaction.22 The Pathway Standards guided the organization through its elements of performance, which require direct involvement of nurses when working toward the creation of a positive practice environment. Enhancing nurse participation in hospital affairs and providing adequate staffing and resources on shared governance activities helped maintain a healthy practice environment amid the pandemic. In terms of efficient use of resources, shared governance strategies were found to be cost-effective yet promising for improvement of nurse satisfaction and retention.23

Similar to difficulties identified by other healthcare facilities, the organization faced challenges, including the review of nurses' roles in emerging practice settings (such as COVID-19 units for patients in need of critical care and progressive care), unexpected patient admission surges, management of protective and critical resources, the ability to meet professional and ethical obligations, and workforce management to accommodate fluctuations in personnel availability due to sickness, unexpected leaves, and time in quarantine.18,24 When addressing these challenges, use of the Pathway Framework encouraged the organization's leadership to create more innovative programs that are responsive to the well-being and needs of the nursing staff, while ensuring that patients' needs are well met. For example, the organization fully protected all healthcare providers with the necessary PPE. Ensuring optimal par stocks per unit (the minimum amount of a items that should be available in stock) and responsible use of PPE became part of the solution. Trained PPE spotters were deployed to monitor PPE adherence and proper use, especially in hot zones (designated COVID-19 units). Free pocket-sized hand sanitizers, cleansing wipes, vitamin supplements, meals (including breakfast, lunch, dinner, and night snacks), and laundry and overnight accommodation services were provided to keep the staff healthy, energized, safe, and recharged for the succeeding duty days. To lessen the distress of employees going to and from the hospital during local community lockdowns, the healthcare organization provided free transportation services, which included buses and vans with different routes and pickup and drop-off points both in Metro Manila and in nearby provinces and towns. The free shuttle service had and continues to have numerous scheduled trips to cover employees' shifting schedules.

When the World Health Organization, the CDC, and the Philippine's Department of Health released COVID-19-related interim guidelines, leaders identified gaps in the staff's readiness for modified roles based on revised policies, guidelines, and protocols and explored alternative and flexible training modalities to accommodate these additional training needs. Virtual competency enhancement training sessions have been instrumental in disseminating useful information, such as recent updates in the management and care of patients with COVID-19 and infection control measures. The use of technology was beneficial in broadening the reach of learning and training sessions to more nurses and even allied health partners.

This was supplemented by conducting unit-based orientations, using printed materials such as posters to serve as visual reminders, and documenting information related to the medical center's COVID-19 response and protocols. Internal processes and workflows were modified to help protect the clinical nurses, while maintaining the quality of patient care. Researchers have found the presence of social support, adequacy of healthcare worker protection, and appropriate preparations and training help mitigate distress, build resilience, and reduce healthcare workers' perceived risk of acquiring the deadly virus.24 Contingencies were also made to assist the nursing units by upgrading staffing, scheduling, and floating strategies, as well as sending nurse managers from nonpatient-facing departments and offices to provide additional support.

To build a more resilient workforce, additional programs were created to address staff well-being. Building resilience among nurses is as important as effective crisis management during this pandemic because it provides the ability to resist disruption by anticipating and preparing for the event.25,26 The organization is cognizant that, in essence, the “other PPE” is the invisible structure that's created by improving safety and protecting clinicians.27 Developing support mechanisms was beneficial in establishing an open, two-way communication strategy, which serves as a conduit for continuous listening, effective interaction, and partnership between staff and management. The hospital and nurse leaders led with transparency to drive a culture of trust, reinforce the message about the importance of personal care, and build a culture of psychological safety. Recognizing the impact of emotional and mental distress experienced by healthcare workers, the organization launched an initiative called Caring for Others with Positivity and Encouragement (COPE) to help employees feel that they weren't alone in the battle. Any healthcare staff member (medical or nonmedical) experiencing emotional exhaustion was encouraged to seek assistance and speak with assigned volunteers. All employees were also given access to COPE prayer hotlines and self-care resources. Further, the hospital administration demonstrated its appreciation to the healthcare staff by providing free grocery items for staff members and their families.

Overall, the commitment and focus on nurses' well-being resulted in stronger staff engagement, increased well-being and morale, and helped reduce staff burnout, all of which contributed to the quality and safety of patient care.26 Consistent and systematic application of the Pathway to Excellence framework has influenced the enculturation of nursing excellence, resilience, and convergence, which has resulted in a better patient experience, increased nurse satisfaction, and sustained quality of nursing care even during the pandemic. To achieve the organization's vision and goals, it's paramount to engage the hospital's greatest asset—its nurses.

Implications for nurse leaders

Implementing resilience-building measures is critical for supporting nurses' mental health and increasing their job satisfaction.28 Nurse leaders play a critical role in bridging the gap between top management and clinical nurses. Guided by the Pathway standards, nurse leaders and managers must advocate for their clinical nurses, anticipating and voicing their needs so they can continuously provide extraordinary patient care.

A key strategy is to directly involve clinical nurses in decision-making. This can be accomplished by engaging in meaningful conversations with clinical nurses, learning firsthand what they need and how leaders can best help them during this pandemic, and using that information as basis in decision-making. Likewise, short surveys are an effective way to gather their insights, opinions, and suggestions, such as assessing their perceptions of PPE use and their clinical experiences.

With safety as a priority, nurse leaders need to use accurate data to make informed decisions such as in day-to-day planning, staffing, and scheduling. Understanding the real situation based on data helps ensure the safety of patients and nurses. In addition, closed-loop communication between nursing staff and leaders must be maintained for timely escalation of pressing concerns. Within nursing units, safety huddles at the start of the shift provide an opportunity to cascade information regarding the latest updates and an avenue to lessen anxiety and motivate staff. Because nurse leaders serve as a link between clinical nurses and administration, effective communication is an important part of unit management. Aside from their daily updates, managers serve as bearers of collective strength and inspiration to minimize fear of the COVID-19 virus while on duty.

While the extensive spread of the virus has induced anxiety in the public and exhausted healthcare providers, fear can be alleviated by minimizing ambiguity and enhancing understanding. Nurse leaders must also be aware of their coworkers' concerns, prioritize their safety, and protect their well-being. Lastly, managerial creativity through unit-based initiatives is critical for raising morale at the unit level while remaining aligned with the corporate goals. Nurse leaders must keep up with the latest programs offered by the institution to guarantee that clinical nurses will have access to those programs when needed.

Limitations

One limitation is the descriptive nature of the design. The primary clinical nursing outcomes measured in this evaluation study were limited to injurious fall, CAUTI, and VAP rates. These patient outcomes may be associated indirectly with the nursing practice environment through unidentified mediating variables, such as processes of care. Healthcare provider factors, which include the nurses' level of competencies, as well as the profile of the patients during the study period, weren't collected and measured but may have influenced the outcomes. In addition, data collection was limited to one hospital only. Lastly, nurse satisfaction data were collected in a different time frame than the selected clinical nursing outcomes.

Recommendations

Further research is recommended to determine statistically significant differences in outcomes as an effect of implementing interventions and strategies aligned with the Pathway framework to sustain a culture of excellence during the pandemic. Comparing organizational outcomes with those of non-Pathway-designated organizations could also be done as collective case studies. Future research studies could explore mediating or moderating variables to understand the reasons for reduction or maintenance of selected nursing outcomes such as injurious fall, CAUTI, and VAP. To expand knowledge, researchers could investigate other nursing outcomes such as patient safety events from medication errors. Further, data on nurse satisfaction and clinical nursing outcomes should be collected concurrently or in a similar time frame to facilitate stronger comparison and analysis of results.

Sustained quality and satisfaction

Maintaining a positive practice environment seemed to provide comparable benefits in nurses' satisfaction and clinical nursing outcomes. This study could add knowledge and value to how changing the practice environment results in higher levels of nurse satisfaction and sustained quality of nursing care.

Other hospitals can use the results of this study as a benchmark for the benefits of using the Pathway framework to create a synergized effort to address pandemic-related challenges faced by the healthcare system. It also offers lessons for non-Pathway-designated hospitals regarding management changes they can put into practice to maintain quality patient care, ensure staff safety, and promote nurse retention amid this healthcare crisis.