Exemplar Unit Initiative Framework: Engaging Faculty and Staff to Improve Patient and Student Outcomes

In an effort to fully explicate the academic service partnership between the University of Michigan School of Nursing and University of Michigan Health System, three pilot units were chosen to participate in the exemplar unit initiative (EUI). Work done previously in the partnership had made advances in student experiences but had not achieved improved patient outcomes. Objectives of the EUI included:  (1) provide structure for improved communication and integration between clinical leadership and clinical faculty; (2) create an environment for a robust, mutually beneficial partnership aimed at improving patient care quality; and (3) ensure alignment with unit-specific goals and effective resource use to reach goals. Common goals included providing evidenced-based care and improving patient outcomes (e.g. falls, satisfaction with pain).  These goals were attained through the implementation of specific EUI central and unit-level structure and process components.

EUI Intervention      

An EUI leadership team—Associate Dean for Clinical Practice, Director of Research and Innovation, and lead faculty—created the EUI intervention.  The microsystem intervention was based on the Donabedian’s Quality Outcomes Model, which incorporates structure, process, and outcome into a linear model for understanding care quality (Table 1).¹

The structural component activities included consistent meetings for both unit and larger EUI teams. Teams met locally on the unit and then all local teams met with the central leadership team.  This ensured opportunities for all members of the initiative to discuss (1) progress towards attaining goals; (2) changes needed in processes to achieve goals; (3) current state of the intervention and (4) problem-solve as needed.  

Additionally, the embedded faculty was expected to become an active member of the unit-based shared governance committee, providing leadership in an area aligned with their clinical expertise.  Other ways that faculty became more embedded and a part of the unit team included meeting with nursing unit leadership, rounding on staff/students, providing expert consultation, problem-solving with staff on student issues, and generally being more visible on the unit.

Process component activities provided guidance towards unit-specific area of focus and implementation strategies.  Specifically, each microsystem/unit team identified a quality indicator goal and a professional practice model goal.  Upon mutually identifying the goals, the team created an action plan (e.g. objective, key action steps, accountable person(s), and due dates). Another process component included rounding on the units by the EUI leadership team to understand the dynamics of the EUI and progress towards unit-specific goal attainment. 

 Outcomes of the EUI were evaluated on an ongoing basis, including determination if the EUI intervention was actualized and identification of improvements in the microsystem unit quality and model of care goal.  It was expected that patient care would be improved; student learning would be maximized as students were engaged in work around improving a specific quality indicator, and staff/students would be active members of the team.

The EUI components were developed to provide guidance to the units, realizing each unit would individualize the intervention to align with the uniqueness of their respective microsystem. The initiative occurred over a 12-month timeframe, with specific touch points throughout the intervention to ensure progress towards reaching the EUI goals.

EUI Evaluation

A primary aspect of the evaluation was determining the actualization of each of the EUI components.  Each EUI components was reviewed to determine if the structure and processes were met/not met.

Central Structure & Process Components.  All of the central structure and process component activities were successfully implemented.  All members of the EUI—including the EUI leadership team, nurse mangers, directors, and faculty—met monthly during the intervention.  Additional members of the unit leadership team (e.g. CNS, unit-based committee lead) were asked to join the meeting very early on in the intervention, as it became clear they were needed to ensure intervention success. All members were highly engaged in the discussions, providing opportunities for reflection and learning from others. Quality indicators chosen by the units included patient satisfaction with instructions for home, patient satisfaction with pain, and falls; professional practice model goals included self-care efficacy and patient story—both critical elements in the health system’s nursing model of care.

Rounding by EUI leadership began approximately four months after implementation of the EUI. Observations from the rounds included significant engagement of students, staff, and unit leadership in attaining the quality and model of care goal.  Staff members articulated goals of the intervention, describing ways in which students were assisting with attaining those goals.  Staff mentors reported students being more prepared and helpful to their practice. Faculty on the unit were identified as ‘one of them’, a valued member of the team. Additional process components, identified in a monthly meeting, included an individual meeting with each microsystem team and central leaders to gain clarity around quality metrics.

Unit-based Structure and Process Components. Each of the unit based structure and process components were implemented, although the manner in which they were implemented varied across units.  For example, the embedded faculty was asked to communicate with the staff nurse mentors the general learning expectations for each level of learner on the unit.  One faculty member held ‘open houses’ for staff, providing an opportunity for the staff nurses to hear about learning expectations, as well as provide an avenue to give initiative feedback.  Another faculty created and disseminated YouTube videos in collaboration with her students, outlining the student goals for the week throughout the semester. 

Another unit-based component was to ensure embedded faculty were actively engaged in the unit-based committee (UBC).  All of the embedded faculty were members of the UBC and were involved in staff meetings.  In one unit, the embedded faculty provided educational training to staff around skin/wound assessment and treatment. The additional components were achieved by all three pilot units.  The faculty and unit leadership met both formally and informally throughout the intervention to review progress towards the goals, communicate initiatives at the school of nursing and health system, and evaluate current status of the EUI.

Outcomes. Unit teams embraced each of the model components, operationalizing each structure and process in alignment with the unit environment.  Unit leadership, faculty, staff, and students all described benefits of the EUI.  As noted above, staff regarded the faculty as ‘part of the team’, feeling very confident in reporting any concerns they have related to student education. Students described improvements in their confidence levels around patient interviewing—a component of most unit action plans—as well as feeling engaged and ‘valued’ for the work they did towards improving quality. 

A second factor in determining the success of the EUI was to identify attainment of the two goals (e.g. quality goal, model of care goal) set forth by the respective units.  In all three units, patient and/or student outcomes improved during the intervention. Specific findings will be discussed in the remaining presentations within this symposium.

Conclusion

Evaluation of the EUI provided evidence that we were successfully able to embed faculty into a clinical unit, further strengthening the academic partnership.  Many of the activities described by the unit teams portrayed that of a successful academic partnership, including frequent communication/open dialogue; appropriate allocation of shared resources; shared vision/goals/mission; trust, respect, and commitment.²  Unit leadership, faculty, nurse mentors, and students all clearly identified the positive impact of the EUI on education and practice.  Embedded faculty were completely integrated into the unit team, being seen as a valued team members, which led to trust, collaboration, ability to problem-solve, and open dialogue related to feedback on the initiative. Additionally, students were actively engaged in an initiative aimed at improving patient care.  Staff members saw students as ‘value-added’ as they saw the impact their work had on improving clinical practice and outcomes.

This model is mutually beneficial—impacting patient outcomes while developing staff and students in a collaborative team environment. This model will impact practice in the future by fostering nurses who not only have been trained around world-class clinical standards, but also how theory and research are applied in clinical practice.  Using this approach, the next generation of nurses will become strong leaders who can facilitate the advancement of nursing science.

Table 1:  EUI Structure and Process Components

Central / System Processes

EUI lead and unit teams meet monthly to discuss unit activities, improvements in care, and actualization of EUI components.

A quality area of focus and one Patient Care Model goal is mutually identified.

An action plan is developed based on the unit goals.

EUI lead team rounds to understand dynamics of the CEI, and progress toward improving the QI area.

Additional process components implemented based on unit needs.

Unit-based Structures

EUI lead and unit teams meet to determine unit priorities.

The embedded faculty is an engaged member of the unit-based committee.

The embedded faculty communicates with the nurse mentors the student learning expectations.

Students review their daily learning goals with their mentor and faculty.

The nurse manager seeks opportunities to embed faculty on the unit.

The nurse manager communicates to faculty major unit initiatives/priorities.

The unit team problem-solves as issues arise related to students, mentors, action plan.

The nurse manager shares QI data with faculty as appropriate.