American Society of Registered Nurses
American Society of Registered Nurses

Empowering Nurses To Innovate At The Bedside, Then Spread Their Innovations

Professional associations play an important role in stimulating and diffusing clinical innovation in health care by influencing quality, safety, and patient outcomes. Nurses—the largest group of health professionals in the U.S. at 3.2 million—are ideally positioned to identify, create, and sustain innovative improvements in patient care.

By Caryl Goodyear-Bruch, Marian Altman & Karen Cox

Professional associations play an important role in stimulating and diffusing clinical innovation in health care by influencing quality, safety, and patient outcomes. Nurses—the largest group of health professionals in the U.S. at 3.2 million—are ideally positioned to identify, create, and sustain innovative improvements in patient care. By partnering with professional associations, health care organizations gain an ally in leveraging the power of the staff nurse.

The 2010 Institute of Medicine (IOM) Future of Nursing report confirmed the vital role nurses must play as change leaders in this time of transformation in healthcare. The closest clinicians to patients at the bedside, nurses are uniquely positioned to understand patient needs and initiate innovative solutions. The evidence linking patient safety, nurse satisfaction, and staff retention with improved patient outcomes, the financial bottom line and quality work environments in hospitals is irrefutable.

However, nurses often do not feel empowered to use their expert knowledge to devise innovative solutions that improve patient outcomes. Key to harnessing the power of this formidable group is delivering educational content that improves leadership and influence skills, instilling confidence in nurses to lead change.

Introducing and diffusing nurse-led innovation is crucial for improving patient outcomes in this historic period of turbulence and change in healthcare. The financial challenges of value-based care and reimbursement models, combined with the uncertainty around the Affordable Care Act, generate the perfect opportunity for developing creative solutions that address hospital-acquired conditions and other pressing patient issues.

For the American Association of Critical-Care Nurses (AACN), the untapped power of staff nurses, the IOM Future of Nursing report, and the challenges of our current healthcare environment sparked the bold step of developing the AACN Clinical Scene Investigator (CSI) Academy.

Nurse Leadership Academy

The AACN CSI Academy is a 16-month, hospital-based nurse leadership and innovation training program designed to educate and empower bedside nurses to effect positive change. Through the program, nurses become leaders and change agents whose initiatives measurably improve patient and fiscal outcomes.

At its core, AACN CSI Academy leverages the staff nurse’s expertise to enhance patient care, building on that expertise with additional leadership skills gained through team education, coaching and mentoring. The program aims to provide staff nurses with the knowledge and support to guide and partner with peers and interdisciplinary team members in creating unit-based change that is scalable for maximum impact.

AACN CSI Academy curriculum is delivered in an experiential learning environment, including on-site workshops, webinars, and regular faculty-peer consultations in person, by phone, and via email.

Unit-based teams of two to four nurses work together throughout the program. The nurses immediately apply their learning by working with CSI Academy faculty and a mentor to identify priority patient-care challenges in their unit that fall within the nursing sphere of influence. Teams then develop, implement, and evaluate solutions that achieve quantifiable clinical and financial improvements.

Program faculty engage bedside nurses in quality improvement initiatives and evidence translation. Unlike other quality-focused programs, AACN CSI Academy goes beyond offering sound tools and step-by-step processes, emphasizing the theory, and practice of implementing change.

Specific topics addressed include change management, creativity and innovation, project development, improvement science, and sustainability—plus diffusion planning to help mitigate the barriers to practice. To that end, AACN CSI Academy specifically focuses on the “how to” of creating change, applying John Kotter’s eight-step change model for transforming ideas into an impactful project.

Program goals often include decreasing hospital-acquired conditions (HACs) and/or increasing patient/family satisfaction and staff communication and satisfaction.

AACN CSI Academy in Action

Among the earliest CSI Academy participants was a team of intensive care unit (ICU) nurses from Duke Raleigh Hospital in Raleigh, North Carolina. For its “Walk This Way” project, the Duke Raleigh team envisioned implementing a new standard protocol of increased mobility for their ICU patients—especially patients receiving mechanical ventilation.

The outcomes targeted for improvement were ventilator days, length of stay, and hospital-acquired conditions.

The Duke Raleigh CSI nurses’ strategy involved developing and communicating a vision of change, generating buy-in from various healthcare providers, implementing new mobility and charting protocols, celebrating small wins, and rewarding staff and patient involvement.

New educational flyers communicated the purpose and goals of early mobility to patients and their families. Families, specifically, were invited to partner with clinicians in helping their loved ones ambulate—an effort recorded by a local TV news crew.

To encourage patients and add some fun, CSI nurses introduced an Olympic theme where patients carried a torch while they walked. White boards in each patient’s room tracked their distance walked and mobility goals achieved. Unit staff participated in reaching patient mobility goals, noting their own progress with mobilizing patients on a chart in the break room—a fun way for nurses to compete.

The team measured improvements with staff surveys, audits of protocol adherence, and targeted patient outcomes.

Barriers to instituting the team’s mobility program included involving professional disciplines beyond nursing—such as physical therapy and respiratory therapy—and hesitance from some staff who balked at the take extra time and work to ambulate ventilated patients.

The CSI team overcame these challenges by engaging all staff in the project vision: providing education, humanizing the work by connecting the “what” and the “why” through patient stories, and generating buy-in with incentives, such as parties, contests and gift cards.

The team’s efforts paid off. Not only did the nurses and staff improve patient mobility, their unit decreased patient length of stay and mechanical ventilation days. Further, occurrence of HACs then fell to zero. Financially, the CSI nurses estimated a six-month savings of $620,981. Their project was not solely responsible for these numbers, but reflects the contribution of nurse-led initiatives to overall quality of care.

AACN CSI Academy Program Outcomes

Using innovative approaches like Duke Raleigh’s to tackle problems unique to their unit, 67 teams of nurse from nine United States regions have significantly improved patient outcomes—all while realizing a collective fiscal impact of approximately $34 million. Some of the clinical outcomes achieved by teams focused on associated issues include, on average:

  • More than 50 percent reduction in HACs, such as central line-associated blood stream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia
  • More than 50 percent decrease in patient falls
  • Nearly 50 percent decrease in pressure injuries
  • Up to 40 percent reduction in CAM-ICU positive scores for delirium
  • A one-day decrease in ventilator days
  • A one-day reduction in overall hospital length of stay
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    The CSI teams’ change initiatives often resulted in positive clinical outcomes beyond original objectives. For example, efforts by 11 CSI teams to increase patient mobility often also reduced HACs and improved patient/family satisfaction. Similarly, 10 CSI teams focused on communication-related issues—such as bedside report and patient handoffs—not only decreasing errors in these areas, but decreasing length of stay and improving patient and staff satisfaction as well.

    To encourage widespread diffusion of innovation and empower all nurses to lead change that benefits both patients and organizations, AACN offers online access to CSI Academy Innovation Projects—including project plans, interventions, data collection tools, outcomes, and references.

    Evidence shows positive sustainability of CSI project results over time. In a one-year post-program survey of participants, more than half of respondents reported that project results remained “fully sustained.” Another 28 percent said project outcomes were “somewhat sustained.”

    Over 50 percent of respondents saw their own projects later implemented in other units and hospitals. CSI nurses report being asked to help with expansion of their projects. For example, Boston CSI nurses continue to apply and expand program methodologies through the formation of a city-wide, five-hospital collaborative focused on decreasing delirium and its costly side effects. Early achievements include securing IRB approval and data-sharing agreements across participating hospitals.

    A recent article in shares more details on survey results and sustainability, with myriad stories suggesting significant diffusion of CSI projects to other units and institutions.

    Academy participants report experiencing significant personal and professional growth. Many alumni CSI nurses have taken new leadership-focused jobs, pursued advanced education, become certified in their specialty, and/or progressed along their clinical ladder (e.g. recognized for growth within their current role). They have shared their work in peer-reviewed journals and educational webinars, and given podium and poster presentations at local and national conferences.

    Another noteworthy outcome for CSI Academy hospitals is documented improvements in unit morale and the nurses’ work environment. Participating hospitals reported the program favorably influenced nurses’ confidence in decision making, communication and collaboration skills, and ability to lead—all aspects of a healthy work environment.

    AACN CSI Academy aligns with AACN’s Healthy Work Environment standards, contributing to higher workplace engagement of staff. According to recent Press Ganey research, the most successful hospitals optimize workforce engagement to improve patient outcomes and experiences.

    How We Got Here: AACN CSI Academy Development And Spread

    As mentioned earlier, turbulent times for healthcare, the potential of nurses as leaders and a commitment to acting on the IOM Future of Nursing report led AACN to explore options for empowering bedside nurses.

    AACN learned of a grant-funded nurse leadership program called “CSI Academy” at Children’s Mercy Hospital in Kansas City, Missouri. This original CSI Academy pilot program was unique in its focus on improving the leadership skills of nurses working directly with patients at the bedside.

    The program closely aligned with AACN’s vision of a bedside nurse leadership program. Guided by a dedicated steering committee, the Children’s Mercy Hospital program director and AACN staff adapted the original pilot to create the AACN Clinical Scene Investigator Academy.

    The AACN CSI Steering Committee realized the program’s success depended on relationships with individual hospitals. Bringing the group’s vision to fruition required engaging a local chief nursing officer (CNO) to bring the Academy to their region. Successful cultivation of these CNO champions determined the location of the first CSI Academy participants.

    Beginning in 2012, AACN launched CSI Academy cohorts in nine United States regions from New York to San Diego, each staggered several months apart. On average, seven hospitals participated per region, with each hospital selecting two to four nurses participate. To date, nearly 250 nurses have completed the program.

    With each successive cohort, AACN has fine-tuned the original curriculum and structure based on participant and faculty feedback. For instance, after working with several cohorts, distance-learning technology was introduced to deliver some content virtually rather relying solely on in-person sessions. Templates, tools, and documentation for use by participants also evolved.

    AACN’s investment in the CSI Academy has been substantial, and reflects the organization’s clear commitment to creating change that impacts both patient outcomes and nurses’ growth.

    Conclusion

    Based on participation, outcomes, and evaluation data from the first nine cohorts, the possibilities for the future of the CSI program appear limitless. Enthusiasm for scaling and spreading the program at a national level is strong.

    By quantifying the connection between effective nursing care, HAC prevention, improved communication and reimbursement policies, nurse-led QI projects demonstrate the sizeable contribution of bedside nurses to a hospital’s bottom line. Confident, empowered nurses have demonstrated ability to lead change on their unit and diffuse this change to other units and hospitals— affecting patient outcomes and improving the fiscal health of their organizations.

    Both for-profit and non-profit entities must provide the strategic, human resources, and financial support necessary for driving the innovation in health care. Professional associations—with their mission-driven wisdom and influence—are ideally positioned to provide the thought leadership and resources that propel the healthcare communities they serve into the best possible future.