Review the Resources and reflect on the definition and goal of EBP. Choose a professional healthcare organization?s website (e.g., a reimbursing body, an accr

Guest Editorial

Nurse Educators: Leading Health Care to the Quadruple Aim Sweet Spot

Eighteen years ago, an alarming report on preventable deaths from medical errors was released by

the Institute of Medicine (IOM, 2000). That report featured the estimate that approximately 100,000 people in the United States die each year because of preventable medical errors. A subse- quent IOM report (2003) called for all health professionals to be better pre- pared to keep patients safe, focusing on five core competencies for health professions education: patient-centered care, interprofessional collaboration, evidence-based practice, quality im- provement, and informatics.

Visionary leaders in nursing educa- tion were ahead of the curve, responding to the call for safer and more effective care via the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007). In 2008, the Institute for Healthcare Improvement announced a major initiative—the Triple Aim—which focuses on “simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (Berwick, Nolan, & Whittington, 2008, p. 759). Subsequently, Bodenheimer and Sinsky (2014) proposed a fourth—a quadruple—aim to improve the work life of health care providers, both clinicians and staff.

What progress has been made during the past 19 years since the IOM report, with 10 years of QSEN education, and 9 years after the Triple Aim was launched? Improvements in some health outcomes have been reported. For instance, the United States has seen a 15% reduction in infant mortality rates compared with 2005

(Kochanek, Murphy, Xu, & Tejada-Vera, 2014). Numbers of hospital-acquired con- ditions, such as central line-associated bloodstream infections (CLABSIs), pres- sure ulcers, and falls with injuries have significantly decreased from 2010 to 2013, according to a recent report from the American Hospital Association (2015). However, in terms of better care and lower costs, we are not yet there. James (2013) has estimated annual hospital patient deaths due to preventable harm to be over 400,000 per year. Reports from consumers of health care continue to include stories of poor care experiences, including lack of compassion and frustrations in navigat- ing the complexities of the care system. Further, the aim of lower costs per capita has yet to become reality. Although an estimated 20 million people were newly insured through the Patient Protection and Affordable Care Act (ACA, 2010), political challenges to the ACA remain, including rising costs, high out-of-pocket expenses, and access to affordable insur- ance.

In the world of leadership, there is a term referred to as the sweet spot, where economic health and the common good coexist and are the keys to achieving vi- able and sustainable solutions (Savitz & Weber, 2008). Is it possible to reach the sweet spot of the Quadruple Aim? Acad- emy Health and the Robert Wood John- son Foundation are partnering to pursue this formidable aim, proposing that care delivery systems collaborate across mul- tiple sectors to provide an affordable ap- proach to improving population health (Hacker, 2017).

Are we as a profession just going to sit back and wait for that to happen? I be-

lieve that nurse educators are well posi- tioned to lead the way to this lofty sweet spot goal. Nursing schools and nurse educators already work across multiple sectors to prepare nurses at all levels, from prelicensure to doctoral education. Nurse educators are already in all settings across the care continuum as practitioners themselves and as mentors to nursing stu- dents applying theory in practice. Many, if not most, prelicensure through DNP nursing students have been well prepared with the QSEN competencies. Those at the graduate level are leading evidence- based systems improvement initiatives as a part of their practice immersion and culminating projects.

I have seen the power of what nurses can do to bring the multiple sectors to- gether in the interest of patient safety, quality, population health, and affordable care. Faculty and students have taken a Quadruple Aim approach. Working in communities and across the globe, they have engaged with community and global leaders and local health advocates, such as Promotores (lay Hispanic health advocates), to partner for better health outcomes. Faculty and students have con- ducted community needs assessments to identify health priorities. They have pro- vided health education and health screen- ing. They have applied the processes and tools of the science of improvement to community-based projects to facilitate collaboration across sectors to improve health outcomes. They have been part of teams who have provided resources that communities often cannot afford alone. They have gathered and analyzed the metrics to measure results. The response from local leaders and health advocates

707Journal of Nursing Education • Vol. 56, No. 12, 2017

GUEST EDITORIAL

is consistently positive, acknowledging their contributions. And both students and faculty have benefitted from these practice experiences.

My greatest concern is that those who lead national associations in both education and practice have not found a way to rise above their respective self- interests with a genuine commitment to work in partnership towards the Qua- druple Aim sweet spot. Some have not yet learned what visionary 20th century organizational leadership pioneer Mary Follett Parker taught about the distinc- tion between power with versus power over (Briskin, Erickson, Ott, & Callahan, 2009). Power over depends on relation- ships of polarity, suspicion, and differ- entials in power. Power with relies on relationships of respect, stakeholder en- gagement, and multisector approaches, resulting in co-created power.

Faculty and students typically work in collaboration with their patients and families, as well as their clinical partners across sectors, to improve health care and health outcomes. That is what QSEN has taught us. Through care coordina- tion models, we typically collaborate in a power with stance to reach both optimal learning and optimal health outcomes, contribute to cost-effectiveness, and con- tribute to quality of life. Coordination of care, including patients as partners in care, is one evidence-based strategy for reaching the Triple Aim. Care coordina- tion is a philosophy and attitude as much as it is a process. We need to teach our politicians and public officials about the care coordination model and how it ad-

dresses gaps in care in order to achieve optimal health outcomes. I have seen this facilitative education around care coordi- nation take place when students and fac- ulty are present at the policy table as im- portant health care issues are addressed, specifically relating to homelessness and care for children and families who are at high risk for foster care. Conversations have moved beyond debate to generative dialogue because nurses (faculty, stu- dents, nurse leaders, and nurses as board members) have been at the table.

Faculty, students, and their precep- tors could teach many organizational and political leaders by modeling how lever- aging a power with approach is a viable pathway to the Quadruple Aim’s sweet spot. Power with is what makes clinical nurses, nurse educators, and nurse lead- ers so effective and so special. With a rising emphasis on population health, we have many more opportunities to com- municate with political leaders and other policy makers. We must believe in our- selves as leaders of the Quadruple Aim and act accordingly if we are ever going to reach the sweet spot.

Power with and power ahead. What a concept!

References American Hospital Association. (2015). Zeroing

in on the Triple Aim. Retrieved from http:// www.aha.org/content/15/brief-3aim.pdf

Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27, 759-769. doi:10.1377/ hlthaff.27.3.759

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires care of the provider. Annals of Family

Medicine, 12, 573-576. doi:10.1370.afm.1713 Briskin, A., Erickson, S., Ott, J., Callanan, T.

(2009). The power of collective wisdom and the trap of collective folly. San Francisco, CA: Berrett-Koehler.

Cronenwett, L., Sherwood, G., Barnsteiner, J. Disch, J. Johnson, J., Mitchell, P., . . . War- ren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122-131. doi:10.1016/j.outlook.2007.02.006

Hacker, K. (2017, March 27). Bridging the di- vide: The sweet spot in health care and pub- lic health. [Web log post]. Retrieved from http://www.academyhealth.org/blog/2017- 03/bridging-divide-sweet-spot-health-care- and-public-health

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press. https:// doi.org/10.17226/9728

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press. https:// doi.org/10.17226/10681

James, J.T. (2013). A new, evidence-based esti- mate of patient harms associated with hospi- tal care. Journal of Patient Safety, 9, 122-128. doi:10.1097/PTS.0b013e3182948a69

Kochanek, K.D., Murphy, S.L., Xu, J., & Tejanda-Vera, B. (2014). Deaths: Final data for 2014. National Vital Statistics Reports, 65(4). Retrieved from https://www.cdc.gov/ nchs/data/nvsr/nvsr65/nvsr65_04.pdf

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).

Savitz, A.W. & Weber, K. (2008). The sustainabil- ity sweet spot: Where profit meets the common good. In J.V. Gallos (Ed.), Business leadership: A Jossey-Bass reader (2nd ed., pp. 230-243). San Francisco, CA: John Wiley & Sons.

Jan Boller, PhD, RN Adjunct Associate Professor

College of Nursing Creighton University

The author has disclosed no potential conflicts of interest, financial or otherwise.

doi:10.3928/01484834-20171120-01

708 Copyright © SLACK Incorporated

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.

Original Article

Predictors of Evidence-Based Practice Implementation, Job Satisfaction, and Group Cohesion Among Regional Fellowship Program Participants Son Chae Kim, RN, PhD • Jaynelle F. Stichler, DNS, RN, NEA-BC, FACHE, FAAN • Laurie Ecoff, RN, PhD, NEA-BC • Caroline E. Brown, DEd, CNS • Ana-Maria Gallo, PhD, CNS, RNC-OB • Judy E. Davidson, DNP, RN, FCCM

Keywords

evidence-based practice,

fellowship, EBP beliefs,

EBP implementation, job satisfaction,

group cohesion, group attractiveness

ABSTRACT Background: A regional, collaborative evidence-based practice (EBP) fellowship program utiliz- ing institution-matched mentors was offered to a targeted group of nurses from multiple local hospitals to implement unit-based EBP projects. The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model postulates that strong EBP beliefs result in high EBP implementation, which in turn causes high job satisfaction and group cohesion among nurses.

Aims: This study examined the relationships among EBP beliefs, EBP implementation, job satis- faction, group cohesion, and group attractiveness among the fellowship program participants.

Methods: A total of 175 participants from three annual cohorts between 2012 and 2014 com- pleted the questionnaires at the beginning of each annual session. The questionnaires included the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness scales.

Results: There were positive correlations between EBP beliefs and EBP implementation (r = 0.47; p <.001), as well as EBP implementation and job satisfaction (r = 0.17; p = .029). However, no statistically significant correlations were found between EBP implementation and group cohesion, or group attractiveness. Hierarchical multiple regression models showed that EBP beliefs was a significant predictor of both EBP implementation (β = 0.33; p <.001) and job satisfaction (β = 0.25; p = .011). However, EBP implementation was not a significant predictor of job satisfaction, group cohesion, or group attractiveness.

Linking Evidence to Action: In multivariate analyses where demographic variables were taken into account, although EBP beliefs predicted job satisfaction, no significant relationship was found between EBP implementation and job satisfaction or group cohesion. Further studies are needed to confirm these unexpected study findings.

BACKGROUND The adoption and implementation of evidence-based practice (EBP) in nursing and other healthcare disciplines are recog- nized as essential in ensuring optimal patient outcomes and quality of care (Aarons, Ehrhart, & Farahnak, 2014). Although EBP is considered to be the gold standard in nursing practice, the actual implementation of EBP has been inconsistent due to barriers related to nursing workload, lack of organizational support, lack of EBP knowledge and skills, and poor attitudes toward EBP (Brown et al., 2010; Ramos-Morcillo, Fernandez- Salazar, Ruzafa-Martinez, & Del-Pino-Casado, 2015; Squires, Estabrooks, Gustavsson, & Wallin, 2011). Although many hos- pitals have used professional development courses individually

to encourage nurses’ implementation of EBP through im- proved nurses’ knowledge and attitudes about EBP, successful outcomes have been elusive (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014; Pryse, McDaniel, & Schafer, 2014; Underhill, Roper, Siefert, Boucher, & Berry, 2015).

A regional, collaborative EBP fellowship program, the EBP Institute, was founded in 2006 by nurse leaders from multi- ple hospitals and academia in San Diego County, California, to promote implementation of EBP by hospital nurses. The fel- lowship program utilized institution-matched mentors to assist in executing unit-based EBP projects, and included didactic as well as interactive learning experiences in six daylong educa- tional sessions over a 9-month period. A formal graduation day

340 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article completed the learning experience, with the fellows present- ing their EBP projects in poster and podium presentations. A previous report on this program showed improvements in the participants’ knowledge, attitudes, and practice associated with EBP, as well as a reduction in barriers to EBP implementation (Kim et al., 2013).

LITERATURE REVIEW The literature is replete with evidence and opinions that ef- forts to educate nurses regarding EBP have improved nurses’ knowledge and attitudes. However, these efforts have not nec- essarily resulted in actual improvements in EBP implementa- tion, nor have they changed clinical practices (Aarons et al., 2014; Melnyk et al., 2014; Pryse et al., 2014). Although barri- ers to EBP implementation have been well-documented, some authors have also cited the importance of organizational cul- ture and leadership in reducing barriers and fostering EBP implementation.

Organizational Culture and Leadership for EBP An organizational culture that emphasizes making clinical de- cisions based on evidence is critical for improving and sus- taining safe and high-quality patient care (Melnyk, Fineout- Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010). Al- though leaders influence the organizational culture, they also play an important role in supporting implementation of EBP and other innovative practices. Supportive leaders obtain fund- ing, provide resources, allow the time necessary for nurses to engage in EBP implementation, and reward those nurses who participate in evidence-based change projects in perfor- mance evaluations (Aarons et al., 2014; Ehrhart, Aarons, & Farahnak, 2015). Ehrhart, Aarons, and Farahnak (2015) have reported that clinical nurses with the greatest clinical exper- tise and EBP knowledge were most helpful in advancing EBP skills and positive EBP attitudes among their coworkers. This finding supports the importance of mentorship in improving nurses’ knowledge, attitudes, and practice of EBP (Abdullah et al., 2014; Green et al., 2014; Magers, 2014).

Furthermore, organizations that engage in the Magnet Recognition Program have been recognized for nurse engage- ment in EBP and implementation of clinical practice changes. The Magnet journey transforms organizational cultures, and ensures leadership support and resources necessary to facili- tate nurses’ engagement in EBP (American Nurses Credential- ing Center, 2014; Black, Balneaves, Garossino, Puyat, & Qian, 2015; Wilson et al., 2015).

Educational Processes to Enhance EBP in Healthcare Settings A number of studies have described the structures, processes, and outcomes of programs

The post Review the Resources and reflect on the definition and goal of EBP. Choose a professional healthcare organization?s website (e.g., a reimbursing body, an accr first appeared on Nursing Worker.