BY: MARJORIE BEYERS, RN, PhD, and MARY ANNE WILSON, MHA, MBA
Dr. Beyers is a patient care consultant and Ms. Wilson is vice president,
nonacute care services, Bon Secours Health System, Inc., Marriottsville, MD.
A Bon Secours Group Develops a Vision for Nursing in the Future
Imagine a health care system with enough qualified nurses to meet
patient needs in all of its settings and a national reputation for excellence
in nursing services. That is the vision of Bon Secours Health System, Inc. (BSHSI),
Marriottsville, MD. "We realized that in creating the vision for nursing, we
were committing ourselves to making that vision a reality," says Sr. Patricia
A. Eck, CBS, chairperson of BSHSI's board of directors. Sr. Eck and her colleagues
knew that the growing nursing shortage in an already turbulent health care environment
presented a formidable challenge.
The effort to create Bon Secours' vision of the future—a competent nursing
staff to provide high-quality patient care—began two years ago. At that time,
the debate was about whether the nation had a nursing shortage or merely a maldistribution
of nurses. BSHSI's leaders, recognizing that the nursing workforce—dwindling
or not—would continue to be affected by rapid changes in health care delivery,
decided to tackle the problem directly. Taking steps to ensure excellence in
nursing services would, they knew, require the commitment of system resources.
BSHSI's nursing shortage, mirroring the national experience, began insidiously.
It was marked by increasing difficulty in recruiting nurses in critical care,
surgical services, and other specialty areas. These difficulties increased over
the next two years.1 Although the nursing shortage's effects vary
throughout the system, recruitment and retention of qualified nurses has become
a focused system initiative.
Stephanie McCutcheon, the system's chief operating officer and the executive
leader of the nursing initiative, says that BSHSI is using a two-pronged approach
in creating for itself a vision of future nursing. First, the system leaders
understand that a health care delivery organization that is strong in every
setting will naturally attract qualified staff. To that end, BSHSI continues
to work toward continued improvement of health care delivery through effective
governance and management. Second, burgeoning issues in nursing indicate that
nursing leaders have a specific role to play in shaping the future of patient
care delivery in BSHSI.
For the second prong, the system formed what it calls its Nursing Collaborative,
a systemwide group of nursing leaders that has been charged with studying the
issues, identifying priorities, and making recommendations for action.
The Organization
The first prong of the BSHSI response to nursing relates to the organization
itself. Sr. Eck notes that discussions of the nursing shortage tend to overlook
the power a sound organization exerts in the recruitment and retention processes.
As providers, employers, advocates, and citizens, BSHSI leaders have found that
people, whether community members or employees, are attracted to a sound, well-managed
organization. BSHSI, a fully integrated health system that provides health care
services in nine states, has an enviable track record of organizational stability.
BSHSI's mission is the unifying force for both the system as a whole and for
each local system, Sr. Eck says. BSHSI's mission statement promises "to bring
compassion to health care and to be good help to those in need, especially the
poor and the dying. As a system of caregivers, we commit ourselves to help bring
people and communities to health and wholeness as part of the healing ministry
of Jesus Christ and the Catholic Church."
Embedded in the BSHSI mission is sensitivity to health care services that
communities expect and need. The mission unifies multiple health care organizations
in nine states. Naturally, differences exist among the states and communities
served and among the types of services offered (acute care hospitals, ambulatory
care, home care and hospice, and long-term care). Because health care is local,
each BSHSI entity has its own culture. Even so, BSHSI's mission is reflected
in each organization in the system, providing guidance for decisions about how
resources are used.
Today, ensuring sufficient resources for care delivery is an ongoing challenge.
McCutcheon points out that, despite the turbulence in health care in recent
years, BSHSI has remained stable because of its mission-driven strategic thinking
and planning. In fact, BSHSI experienced a banner year in fiscal 2001. Efforts
to improve specific systemwide clinical and financial performance continue through
the implementation of both cultural change and process improvements in local
systems. The result in 2001 was that budgeted operating income was exceeded.
The hard work and dedication of clinical and nonclinical colleagues continue
to help the system move closer to its vision. All this has increased public
trust in the organizations that constitute the system. BSHSI also has systemwide
programs that work continually to improve clinical quality; a recent program
focused on care management initiatives. In the same way, BSHSI supports its
local systems in their efforts to recruit and retain competent staff.
A health care system depends on competent staff to provide the services that
local communities require. "The nature of the services that communities want
and need determine the selection of qualified staff in every type of position
in the health care system," McCutcheon says. BSHSI concentrates on supporting
excellence in performance by all staff.
Why a Nursing Collaborative?
Systemwide successes in achieving better-than-budgeted operational and financial
performance provide experience that can be applied to recruitment and retention
of a qualified workforce. The platform for BSHSI's nursing collaborative work
is the system's mission and its strategic and operational plans, Sr. Eck says.
The decision to form the Nursing Collaborative was not made easily. Christopher
Carney, BSHSI's system's president and chief executive officer, notes that the
system has deliberately maintained a small corporate staff focused on providing
system services guided by the strategic and financial plans. National workforce
shortages are not limited to nurses. Shortages also exist among pharmacists,
therapists, and others.2 BSHSI decided to focus on nursing because
of several factors: the role of nurses in the system, the nature of nursing
issues and local responses to them, and the complexity of the issues surrounding
nursing.
The work of nurses is vital to health care. As Sr. Eck puts it:
Nurses are on the front line. Every day, the work of Bon Secours nurses
directly affects the health and welfare of the communities we serve. From
the BSHSI perspective, nursing staff members, constituting the largest cohort
of caregivers, are also community members. Nurses are in a position to interact
with communities intimately through family, friends, and neighbors. These
nurses have to deal daily with fallout from the national public media, which
has reveled in stories about nursing's discontent, issues of patient safety,
and effects of shortages on emergency and other services. Being involved in
a systemwide effort to achieve the future vision of nursing is important to
these nurses. Thus our Nursing Collaborative was designed not so much to single
out nursing as to carve out a significant component of health services for
concentrated attention. The collaborative was designed to provide connections
between executive management and nursing, to help the system better understand
and thus deal with factors influencing the nursing shortage.
Issues that concern nursing at the national and international levels can potentially
threaten the stability of the nursing workforce.3 Having sufficient
numbers of qualified nurses to provide health care throughout an integrated
system is necessary to its mission. Bon Secours nurses are not immune to the
broader issues in nursing. As McCutcheon says of the Nursing Collaborative:
This is the logical group to examine these issues, to determine priorities
for BSHSI. Even though the issues are national, solutions have to work locally
to be effective. The thinking was that the BSHSI Nursing Collaborative could
make sense of the complex issues, to inform the system about useful strategies.
In view of the increasing severity of the nursing shortage, it is clear that
even well-managed organizations may not have the power to overcome the nursing
shortage in today's environment. A strong nursing component within the organization
can provide the connections between the global nursing scene and the system.
Nursing issues are sometimes so complex that they can overwhelm the best of
thinkers. BSHSI's leaders considered a systemwide Nursing Collaborative an effective
way to focus attention on nursing and the ways nursing issues might affect BSHSI
both as a system and locally.
"It is a forum for sharing resources and establishing networking and interaction
throughout the system," McCutcheon says. "This approach is appropriate because
of the global nature of nursing issues, the universality of nursing practice,
and widespread public awareness of nursing concerns, as well as the predictions
of worsening shortages." The Nursing Collaborative has established a panel of
experts to help the system deal with future challenges. "Experts believe that
the technological revolution in health care interventions will soon reach critical
proportions," she notes. "Medical technology has already proved to be a driving
force in changing the way patient care is delivered. New technologies are introduced
at an amazing rate and may well be the next challenge to nursing leadership,
because they have a direct impact on how nursing services are organized and
managed to provide patient care."
Forming the Nursing Collaborative
The Nursing Collaborative was formed in 2000. Its members represent executive
nursing leadership from acute care hospitals, home care and long-term care,
ambulatory care, and nursing education facilities in each geographic region
served by BSHSI. The collaborative was designed to complement existing functions
in the system and fit its systemwide culture of collaboration, McCutcheon says.
At the system level, the corporate support staff provides services and resources
for local systems. The operations group, made up of system-level leadership
and senior management of the local systems, carries out strategic and financial
planning. "The Nursing Collaborative was created to function as a forum in which
the system's nursing leaders can conduct systemwide strategic thinking and planning
for the nursing workforce," McCutcheon says. In establishing the collaborative,
BSHSI's leaders intended not to reinstitute a "silo" effect but, rather, to
employ nursing talent to sort out what might be done at the system level to
strengthen nursing in the local systems. The Nursing Collaborative was intended
to:
- Identify systemwide nursing issues in nursing
- Provide an opportunity for nursing leaders to have formalized input in
system initiatives
- Develop a means of sharing "best practices"
Because the collaborative was positioned to make recommendations for systemwide
strategy, the three objectives fit the corporate culture. BSHSI's executive
leaders articulate the system's goals and performance objectives through a strategic
plan that will guide systemwide efforts to achieve the system's mission.
The Collaborative's Work
The Nursing Collaborative began by agreeing to study the issues, weighing them
according to priority, and then develop an action plan. The three top issues,
the group decided, were recruitment and retention, nursing practice models,
and leadership. The collaborative formed task forces to work on each of these
issues. Each task force was charged with studying its issue in depth, analyzing
the findings thereof, and making recommendations to the collaborative as a whole
concerning possible action.
Diann Johnston, a vice president for patient care services in the system's
Northeast Division, says the Nursing Collaborative's members discovered from
their discussions that many issues previously thought to be local were in fact
systemwide. The collaborative focused on creating a vision for nursing that
would be both systemwide and applicable to all local systems. According to Sr.
Anne Lutz, CBS, the senior vice president of sponsorship, Northeast Division,
and the coleader of the Nursing Collaborative, one of the unique strengths of
nursing in Bon Secours is its Catholic identity. The collaborative held a special
session to explore the meaning of Catholic identity for nursing. The group,
strongly affirming BSHSI's values and beliefs about caring and compassion, decided
that the system's vision statement concerning a future nursing model should
say: "Bon Secours will be identified as a national leader in achieving a high
level of patient care quality and a reputation of nursing excellence in the
community. Nurses will be proactive in strengthening the image of nursing. Bon
Secours nurses will influence their work environment to provide quality patient
care." This vision would, the collaborative decided, serve as its action plan.
The vision helped the collaborative's task forces analyze their findings concerning
the issues assigned to them. Sr. Lutz, describing the process used by the collaborative,
says, "The task was to synthesize the issues to inform the system and to decide
which issues to deal with in future action strategies." With Marjorie Beyers,
RN, PhD, a consultant, the collaborative's members reviewed the literature and
determined future steps. They affirmed that the current nursing shortage is
different from others. The collaborative considered the literature concerning
the shortage, noting that some experts see it as the result of a tangled health
care system. The restructurings and reorganizations of the past two decades,
demands for more services at lower cost, the effects of the 1997 Balanced Budget
Act, and public discontent with aborted health care reforms—all these factors
have all taken their toll. Other experts point to the changing culture of health
care, changing utilization of health care services, and evolving lifestyles
as significant causes of the shortage. Even more sobering are the demographic
projections indicating worsening shortages in the years to come. By 2023 the
nation is expected to have 20 percent fewer nurses than it needs.4
Further complicating the shortage is the fact that nurses now have numerous
options for employment in nontraditional settings.
Since 1960, about two-thirds of practicing nurses have been employed by hospitals.5
This number is now declining as nurses pursue other types of positions with
insurance companies, health-related businesses, and other new programs. Johnston
notes that reports of nurses' waning satisfaction with hospital employment indicate
that the issue is worldwide. The professional literature calls for new patient
care delivery models that will better meet patient care demands, new and more
effective productivity measurement and management, and new staffing and scheduling
tools. Today's media are full of stories about job stress and concerns about
quality, staffing, and safety. The hospital environment, workplace issues, and
staffing are targets for reform. Long-term care facilities are also affected
by the nursing shortage. National initiatives responding to the nursing shortage
have concentrated on improving the image of nursing, increasing nursing school
enrollment through scholarships and grants, revising nursing school curricula,
and devising improved recruitment and retention strategies. Some groups are
also working on ways to meet the need for new patient care models and to improve
the workplace.6
The Nursing Collaborative studied the literature concerning the shortage and
the various solutions proposed for it. BSHSI will support national efforts to
increase funding for nursing education, scholarships, and further study of nursing
issues, McCutcheon says. "But the more difficult questions are: "What have we
learned from our review of the literature and what is relevant to nursing at
BSHSI?"
The collaborative decided to use its energy to shape the future. Guided by
its vision of the future, the group began to develop strategies to move from
the present toward this vision. Its members decided to assess the current capacity
for development. Carol Greenberg, vice president of patient services for Bon
Secours Cottage Health Services, Clinton Township, MI, notes that capacity for
change is key. From previous experience, nursing leaders had learned that many
interventions, although sound in design, were beyond the capacity of the organization.
To avoid this pitfall, the collaborative decided in 2001 to conduct an assessment
of the current status through a survey. Each task force developed survey questions
whose answers would supply the data required to make informed decisions about
strategies intended to achieve the future vision.
The survey questions were to be answered by all BSHSI hospitals and long-term
care entities. The survey was meant to:
- Obtain data on the current status for strategic improvement analysis and
planning
- Establish baselines for monitoring progress
- Develop a data collection tool for the systematic reporting and sharing
of internal benchmarks
Completing the survey was a learning experience in itself. The process revealed,
for example, that BSHSI needed systemwide definitions of key areas, improved
and more complete data collection, and systematic data collection. The assessment
process was a measure of BSHSI's commitment to meeting the challenges of the
nursing shortage, McCutcheon says. The involvement of the system's finance,
human resources, and nursing departments was needed to complete the assessment.
The survey data were compiled in an inventory that recorded the responses
by each local system to each question, thereby providing a systemwide picture
of nursing. They were published in BSHSI's 2001 Nursing Assessment Report, which
contained four sections:
- A nursing staff profile
- Recruitment and retention practices
- Nursing/patient care models
- Staffing practices
As expected, the nursing staff profile and staffing sections showed differences
between hospitals and long-term care facilities. Long-term care facilities,
for example, have a larger proportion of nurses' aides and licensed practical
nurses than hospitals do. The collaborative was surprised by the extent of variation
in recruitment and retention practices and in nursing practice and by the finding
that care delivery models were related not to type of service but rather to
geographic location. Johnston and Greenberg say that this finding will be important
in the drafting of new system approaches to nursing care. Another important
finding was that few settings have an overarching nursing-care practice model,
although most do use patient care delivery models such as primary, team, or
total patient care. A single model prevails in some settings, but the assessment
revealed a definite trend toward adapting traditional models of primary, team,
total patient care, and others to fit the needs of specific patient populations.
In many settings, combinations of the care delivery models are used. These combinations
can be considered a first step toward development of new approaches, Johnston
says.
The survey data proved to be useful even before they were analyzed. For one
thing, the survey itself offered a profile of the current nursing staff. Working
with it, the collaborative will develop the profile of a "desired" nursing staff,
based on patient population needs, to provide direction for recruitment and
retention strategies.
Even as it was working on its analysis of the current situation, its vision
of the future, and its assessment of the survey, the collaborative had begun
efforts to formalize nursing input in systemwide activities. Realizing that
BSHSI's human resources and nursing departments have a mutual interest (and,
sometimes, overlapping efforts) in the recruitment and retention of nurses,
a joint task force made up of Nursing Collaborative and human resources leaders
met to share insights and strategies. To facilitate that dialogue, David Jones,
the system's vice president of human resources, conducted a series of phone
conversations with the human resources and nursing leaders of the local systems
to discuss working relationships, priorities, and collaboration. A summary of
these calls is being used to advance the dialogue between human resources and
nursing departments.
The Nursing Collaborative has also exchanged information with BSHSI's information
systems department, fostering an understanding of the ways the two departments
can work together. As BSHSI continues to enhance its communications technology,
Nursing Collaborative members have begun to join the panels of experts that
the system has appointed to shape new information systems. By the same token,
joint meetings between the Nursing Collaborative and physicians have been held
to share progress and ideas for patient care quality improvements.
The Nursing Collaborative has also explored possible collaboration with external
partners. Johnston, chair of the leadership task force, led that group in discussions
of partners who, by providing services and expertise, could complement the collaborative's
work. As a result, BSHSI has joined the Advisory Board's Nursing Executive Center,
thereby enabling the system's nursing leaders to participate in the center's
activities and to network with colleagues from other settings. The collaborative
is also exploring relationships with national groups noted for excellence in
nursing services, such as the Magnet Nursing Services Program, intending thereby
to determine the cost-benefit ratio of participating in this voluntary recognition
program.
The Work in Progress
To fill the gap between current and future nursing services management, the
Nursing Collaborative has designed a nursing practice model. The new model is
a hybrid of the traditional nursing practice model and a business planning model.
Nursing practice models are typically conceptual frameworks, whereas business
models typically describe the way an enterprise works.7 The latter
model is more amenable to cost and value analysis, Greenberg says.
The collaborative's members intended the new model to be one that could be
adapted in any setting. They wanted a model with which they could establish
interfaces between and among care settings and within the system, establish
a common language for deliberations and discussions about nursing within BSHSI,
and guide collaborative strategies for achieving the future vision. The new
model is patient-focused. It puts an emphasis on clinical excellence, accountability,
clinical competence in the nurses needed to provide the care, and the organization
and leadership needed to continue the journey toward excellence.
The model not only provides guidance for nursing practice development in accordance
with the system's mission and goals. It also interfaces with the human resources
department; the Bon Secours Institute, which provides education and development
support; and the system's finance and information systems departments, thereby
facilitating planning and accountability. Collaboration with clinical colleagues,
physicians, pharmacists, and others is integral to the model.
As a result of the collaborative's work, BSHSI's nursing leaders today have
a clearer view of the resources that will be needed for current and future development.
However, the collaborative's work is not prescriptive; it provides guidance
and direction, which can be applied in daily operations in each setting. Johnston
and Greenberg say that networking with colleagues, support for renewed commitment
to the future, and energy to deal with the chaos of daily operations are just
some of the benefits from the collaborative's efforts. Also important, they
add, is a shared vision and attitude, which have a profound impact on the nursing
staff. Acknowledgement of the importance of nursing in each local system and
the system as a whole goes a long way to let nurses know they are respected
and trusted.
Johnston says that the Nursing Collaborative:
has been an invaluable resource for nurse executives throughout BSHSI. Through
the collaborative, nurse executives and their managers can readily network
with colleagues through e-mail, conference calls, video conferences, and in
face-to-face meetings. We use the collaborative to share policies, protocols,
and best-demonstrated practices. It also affords smaller local systems the
ability to consult with clinical experts who may only be employed in a larger
local system. Nursing across the system has been strengthened because of this
effort.
The Nursing Collaborative is a wise investment for both the present and the
future, McCutcheon says. "Thoughtful deliberation about the future enables everyone
to plan for the ongoing changes that will be needed to continue the BSHSI legacy
for quality nursing care," she says. "It adds value to the system."
NOTES
- United States General Accounting Office, Emerging Nursing Shortages,
Washington, DC, 2001.
- InBox, "Staffing Shortages, Charting Workforce Woes," Hospitals and
Health Networks, vol. 76, no. 3, March 2002, p. 24.
- Linda H. Ainen, et. al., "Nurses' Reports on Hospital Care in Five Countries,"
Health Affairs, May-June 2001, pp. 43-53.
- U.S. Department of Health and Human Services, National Sample Survey
of Registered Nurses, Bureau of Health Professions, Health Resources and
Services Administration, Rockville, MD, 2000.
- Heather K. Spence Laschinger, Judith Shanian, and Donna Thomson, "Impact
of Magnet Hospital Characteristics on Nurses' Perceptions of Trust, Burnout,
Quality of Care, and Work Satisfaction," Nursing Economics, September-October
2001, pp. 209-219.
- Brenda Nevidjon and Jeannette Ives Erickson, "The Nursing Shortage: Solutions
for the Short and Long Term," Online Journal of Issues in Nursing,
vol. 6, no. 1, January 31, 2001.
- Joan Magretta, "Why Business Models Matter," Harvard Business Review,
vol. 80, no. 5, May 2002, pp. 86-92.
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.