A change in organizational culture was needed for RCHC to be successful and fiscally sustainable. Transformation began with creating a leadership team of DNP and PhD prepared nurses from both schools. The new leadership team faced multiple barriers because staff held an allegiance to their former models of health care delivery from their respective sites. In order to create a new culture that reflected nursing values the AACN standards for establishing and sustaining health work environments were adapted to a primary care model and used as the “toolbox” for initiating transformation .1 Using the AACN standards as a toolbox prevented the leadership from focusing solely on the tasks needed to succeed, but instead, allowed the nursing leaders to develop a style of leadership that empowered staff members, was relationship based, and visionary.2
The leadership was aware that merging two staffs meant merging cultures that might often be in conflict. The first goals for the new entity were to create a mission, vision, and core values for the new entity and establish a strategic plan that was acceptable to all. The leadership team used the AACN standards of skilled communication, true collaboration, and effective decision-making to achieve these goals. Clinical, administrative, support staff, and advisory board members (who were patients and community members) collaborated with the leadership team to create a mission statement, a vision of successful nurse-led health center, and foundational core values.
To help staff transfer their allegiance to this new model and coalesce as a team, staff meetings included discussion about how to integrate core values into the work day by identifying behaviors and actions that reflected the core values. Emphasis was given to the core values of respect (demonstrating in words and actions that each individual is valuable) and camaraderie (creating a safe and supportive environment in all we say and do). Recognition of helpful staff behaviors that contribute to a collegial working environment are important to building effective teams.3 A new tradition was created: at the end of staff meetings, members “shouted out” someone who displayed a behavior that reflected a core value during the previous week. Shouted out staff members were given a round of applause. Shout outs reinforced positive behaviors and promoted team cohesiveness.
Bullying and aggression can be responses to fear of change and is a barrier to creating a healthy work environment and have negative effects on productivity, retention, performance and staff well-being.1,2,3,4 It was important to address issues of incivility in a manner that was preventative rather than corrective. The nursing leaders presented a united front and role modeled the core values of respect and camaraderie in their interactions by providing direct patient care when needed to reduce staff workload, cleaning rooms between patient, answering phones, running interference with patient complaints, and acting as a buffer to allow staff to do their jobs without the need to address extraneous problems. The nurse leaders also held everyone accountable to the core values.
Utilizing the ACNN standard of effective decision making to develop a strategic plan to meet the requirements for FQHC status empowered and invested the staff in the working towards the success accomplishment of its aims. Board members, clinical, support, and administrative staff were asked for input during the SWOT analysis process; drafts of the strategic plan were circulated among all staff members for comment. Again, strategic planning provided an opportunity for team building; staff was assigned to different teams to complete the tasks needed to transform RCHC into an FQHC. Steps
towards accomplishing aims of the strategic plan, no matter how small, were opportunities for celebration and bonding between staff members.
The AACN standard for appropriate staffing suggests an evaluation to identify any mismatches in patient needs and nurse competencies. The nursing leadership identified a need to reassign responsibilities in order to improve the patient experience and reduce waiting time. Under the former models of care, the Nurse Practitioners (NPs) and Registered Nurses (RNs) took responsibility for all activities, except clerical, associated with a patient visit; Community Health Workers (CHWs) or Medical Assistants (MAs) handled clerical tasks. A new team member was introduced, the front desk receptionist, who assumed responsibility for clerical aspects of the visit. Tasks and associated documentation were shifted from the NPs and RNs to the MAs and CHWs. The MAs took responsibility for tasks associated with rooming the patient while CHWs took responsibility for assisting patients with outside appointments and specialty visits. The RN assumed responsibility for medical care coordination including facilitating transitions in care and chronic disease self-management education. The NPs were now able to focus on clinical management of the patient. These staffing changes resulted in better documentation in the chart, which has been shown to increase in clinic revenue and patient panels.5
Another innovation that was implemented along with staffing changes was the use of pre-visit planning prior to clinic hours, which allowed the clinical team to plan for each patient’s anticipated needs and resulted in a smoother workday for the team. Appropriate staffing assignments and pre-planning increased patient satisfaction, reduced waiting time, closed the loop on referrals to specialists, and improved clinical outcomes. Task shifting allowed all staff to work at the top of their license, increased job satisfaction, promoted teamwork, and facilitated the creation of an organizational culture unique to RCHC.
According to the AACN standards, authentic leadership needs a commitment to the development of others in a structured format1. The leadership realized it was important create
opportunities for future nurse leaders to emerge. This creation of a Quality Improvement Committee (QI) was the platform used to foster leadership among the nursing staff. Nurses self-selected to lead quality improvement task forces and led teams that included physicians, MAs, CHWs, social workers, pharmacists, and often a community member. These self-selected leaders were deemed Nurse Champions (NCs). Faculty from Rutgers School of Nursing were recruited to mentor the NCs as they led their team in creating and implementing strategies to improve the clinical care. In turn, Nurse Champions mentored DNP students as well as students from the schools of pharmacy, medicine, and the health professions. NCs led meetings that included case presentations, discussions of clinical guidelines, and in-services on new protocols. As expert clinicians, the nursing leaders of RCHC were resources for NCs as they prepared for these meetings.
After several months, it was clear that although the two staffs were beginning to work as one team, the stress from merging and transitioning to an FQHC was beginning to effect staff morale and endanger the successful transformation. Workplace stress can lead to cynicism, diminished productivity, and burnout that can result in negative patient outcomes. 5,6 The leadership decided to incorporate self-care sessions that included yoga, meditation, and aroma therapy into staff meetings. Although these sessions were voluntary, 90% of the staff took part. Each participant was given a vial of calming aromatherapy to keep and use whenever he or she felt stressed. Nursing leaders monitored the staff for signs of increasing stress and reminded them to take a minute to slow down, breathe, and “go to their happy place.”
Although the merging of two teams, creation of an FQHC, and cultural transformation was not easy, RCHC derived many benefits. Nurses, other staff members, and students from various healthcare disciplines, assumed leadership and ownership of initiatives that improved patient care. This resulted in clinical plans to address obesity, diabetes, and hypertension that included chronic disease self-management programs for patients. Other initiatives included a health literacy programs, asthma
prevention, walking and Tai Chi programs for older adults, and team visits to homebound patients living in public housing. The CHWs and nursing staff took the initiative to establish relationships with public and charter schools, local urban service organizations to provide needed care to the undocumented, Hispanic-Latino community, recent parolees, the homeless, veterans, and the LGBT community.
Nursing leadership is a crucial component of a healthy and happy workplace.7 In accordance with the evidence, the nurse leaders learned that involved and committed nursing leadership results in effective transformation with positive effects on job satisfaction and staff engagement. 2,3,6 A successful team transformation process requires involving the entire workforce while supporting future nursing leaders as they self-identify and assume leadership in the organization.