Identification of the Patient Population
Anoka-Metro Regional Treatment Center (AMRTC) provides inpatient psychiatric care to adult men and women that require hospital-level treatment and supervision. These individuals exhibit a variety of diagnoses that cannot be treated within a standard community hospital. According to Vollm et al. (2018), the prevalent patient populations in medium to high-security psychiatric wards such as AMRTC are violent offenders, which constitute 60% of the long-stay population. From that sample, about 20% are both sexual and violent offenders, 27% have committed a violent or a sexual assault within an institutional setting, and 26% have done at least 1 attack on staff members within the last 5 years (Vollm et al., 2018). The average duration of stay for the majority of patients is 100 days, and the clinic sees about 300-400 long-term patients per year.
The predominant diagnoses for medium to high-security hospitals include schizophrenia, personality disorder, and intellectual disability. Very few have not been convicted of any offense and do not have any index offenses prompting admission (Vollm et al., 2018). These finding roughly match the profile of patients and the array of treatments provided by AMRTC, which was used to harbor criminals pending trial to provide them the necessary supervision and psychiatric help. It also explains the reasons why the number of assaults on personnel at AMRTC is significantly higher when compared to community-based hospitals in the area.
Performance Scorecard Outcome Measures
The provided scorecard focuses on the population of AMRTC, which have been identified as largely violent patients diagnosed with schizophrenia, personality disorder, and various intellectual disability. The outcome measures that are the focus of the scorecard are illustrated in the table below:
|Performance|| ||Increased performance is associated with a higher number of patients serviced per year. Increased amounts of time dedicated to each patient and high nurse-per-patient ratios are associated with better short-term and long-term performance.|
|Quality|| ||Nursing mistakes are associated with poor quality of care. Patient perceptions are a subjective, but valuable metric of how well patient-centered care is provided. Quality performance tends to reduce the duration of patient stay.|
|Patient Safety|| ||Patient-nurse related violence incidents typically result in trauma and sedation of the patient. The lower the number of those – the better. Not all violence incidents end up in trauma, however, a low trauma vs. non-trauma rate indicates high patient safety. In addition, the inhabitants of the facility must feel safe, as perceived threats result in violence.|
|Employee Engagement|| ||Employees have different perception of their own engagement – what could be seen as a lack of engagement could be the best the employee has to offer. Positive and negative perceptions of practices have an influence on employee engagement.|
Processes that Drive Outcome Measures
To achieve positive outcome measures, there are specific necessary processes that AMRTC must focus on in its change program. Performance outcomes include the number of patients serviced per year, the amount of time dedicated to patients, and the nurse-per-patient ratio. The former can be achieved by increasing the number of nurses currently in employ at the facility. As it stands, AMRTC does not operate at its peak capacity, fielding only 110 beds out of 200, and only partially utilizing the support facilities (MDHS, 2020). Should the organization acquire more nurses and retain their numbers throughout the years, the number of patients serviced can be significantly increased, to up to two times the current capacity.
The amount of time dedicated to each patient is a fluid matter. Some patients require less time, while others – more. The issue of appropriate time management can be solved through training as well as the supply of additional cadres to fill in the spots (Shin et al., 2018). That way, nurses would not feel overworked and will be able to attend to each patient based on the need’s basis rather than under the pressure of limited resources and increased workloads.
Finally, the nurse-per-patient ratio can only be increased by hiring and retaining more nurses, rather than lowering the overall capacity of the facility like it had been done before. A high nurse-per-patient ratio corresponds with higher levels of patient satisfaction, reduced chances of nurse mistakes, quicker response to patient needs, and other beneficial outcomes (Shin et al., 2018). Therefore, it could be concluded that the necessary process behind all three outcome measures is to hire and retain more nurses.
Quality-related outcome measures include decreasing the number of nursing mistakes per year, patient perceptions of the quality of treatment, and the duration of patient stay. Nurse mistakes are affected by numerous factors, such as the quality of education, practical experience, the amount of work distributed on a nurse, the levels of burnout and care fatigue, as well as others. Burnout and care fatigue can be addressed by establishing proper schedules, reducing overtime, providing emotional support for nurses, and ensuring their safety (Hester et al., 2016). These factors are particularly important within the AMRTC setting. Thus, the necessary processes might include therapy and relaxation practices for nurses as well as additional security measures to protect them from violence.
Patient perceptions of the quality of treatment are a subject infrequently explored within high-security psychiatric facilities. They are notorious for depriving the patient of their agency under the assumption that they are incapable of judging the performance of doctors treating them (Wykes et al., 2018). This creates a situation where the quality of care can be measured solely by nurses themselves, which is prone to bias (Wykes et al., 2018). To address this issue, the necessary process would include interviewing each of the patients to learn about their perceptions of treatment.
Duration of patient stay is a potentially quantitative metric to measure the quality of treatment with. If the quality is improving, the required results are achieved faster, making it pointless to keep a patient inside longer than necessary. With the average duration of stay in AMRTC being around 100 days, it is possible to reduce the number by improving the quality of treatments (MDHS, 2020). The necessary process here would be to decrease the possibility of patient rehospitalization as a result of a nurse mistake or misdiagnosis.
Patient safety can be measured by analyzing the number of patient-nurse-related violence incidents, the amount and nature of trauma they caused to the patient, as well as the patient’s perceptions of safety. Many patients with a schizophrenic or personality disorder do not actively seek conflict, but rather react to the perception of being threatened by someone else (the nurse) (Pekurinen et al., 2017). To address this issue, the proper necessary processes should include frequent surveys of patients, especially after violent incidents, to learn what triggered them.
Reducing the number of patient-related incidents is one of the primary steps to ensure patient safety. During an incident, the primary means of pacifying the patient include physical restraints or sedative medications, both of which are potentially harmful to the patient in question (Goulet & Larue, 2016). Therefore, achieving an effective reduction of incidents is of primary importance in AMRTC, especially considering that the issue was the cause of many problems that plagued the organization since 2018 (MDHS, 2020). The necessary procedure would be for the nurses to learn the specific triggers to violence for each patient and seek to avoid them, to reduce the chances of violence.
Finally, in an event where violence is inevitable, reducing the chances of patient trauma is crucial to ensuring patient safety. As it stands, the measures implemented at AMRTC are insufficient, which results in successful violence attempts on nurses (MDHS, 2020). The proposed necessary process in the situation would be to limit contact between particularly violent patients and nurses, thus reducing the chances of triggering violence. Another option would be to implement non-invasive preventive treatment methods, such as dance and motion therapy (Biondo, 2017).
Employee engagement is an important metric that allows estimating the quality and zeal behind nurses in their everyday duties as well as burnout and retention rates (Dempsey & Assi, 2018). The three measures include estimating accurate personal perceptions of engagement and analyzing the positive and negative sides of hospital practices. The necessary process for measuring employee perceptions of engagement is a hospital-wide survey. Doing so would help learn how engaged the employees are, from their perspective.
Perceived positive sides of hospital practices are the strong sides of AMRTC or any other similar facility. These are the points that should be used to the program’s advantage and capitalization. Once more, surveying the nursing staff would be the appropriate process to learn those. Discussing the negative parts of the existing practices, however, would require changes to the already proposed surveying method, by including a section about what should be changed to improve the situation (Dempsey & Assi, 2018). In addition, the hospital could introduce round tables of discussion, where nurses could develop joint strategies against identified issues (Dempsey & Assi, 2018).
The additional indicator to be added to the existing scorecard would be staffing. As was indicated in the previous section, employee numbers, recruitment, and retention play a very important part in AMRTC’s current situation, affecting the hospital’s performance, quality, patient safety, while maintaining a relation to employee engagement. A nurse leader should monitor not only the available numbers of nurses on shifts (which is a necessary part of the scheduling and workload distribution process), but also the retention rates, engagement, and work satisfaction levels (Griffiths et al., 2018). Keeping those parameters high would allow the nurse leader to positively affect the number of patients served per year, nurse-per-patient ratio, as well as potentially reduce the number of nursing mistakes and improve the patient’s perceptions of quality (Griffiths et al., 2018).
Advantages of the Proposed Performance Scorecard
The primary advantage of the scorecard proposed above is that it is tailored to the needs of AMRTC. The choice of outcome measures about performance, quality, patient safety, and employee engagement were all related to the existing situation within the hospital, making the scorecard a highly-relevant document to be used in improving the situation. The custom fit may make the scorecard less applicable to other locations but makes it more useful to AMRTC when compared to generalized balanced scorecards, which tackle general problems found across the psychiatric care industry rather than those of a specific organization and patient population.
The second advantage lies in the number of potential measures to select from. It is understandable if the hospital is not capable of pursuing all of these at the same time. Nevertheless, the wide selection will allow AMRTC to develop a policy or a strategy to address those it currently has the capacity, resources, and knowledge to address. It makes the instrument flexible and offers nurses the possibility to determine their course of action rather than attempt to pursue a pre-ordained path that was conceived without the intricate knowledge of the situation inside the hospital.
Finally, the solutions and necessary processes discussed in the scope of the proposed scorecard are very ubiquitous and allow covering for different measures while focusing only on a single process. For example, improving nurse staffing rates has a positive effect on all other metrics across the board, meaning that the organization can yield higher results than by focusing on several non-related issues at the same time. The identification of the major directions in which to push allows for the development of comprehensive change strategies with a single strong vector, which is easy to explain and justify to the personnel.
Current Trends in Psychiatric Nurse Employee Engagement
Some of the current trends in psychiatric nurse employee engagement and medical worker engagement, in general, include the growing lack of engagement and the increased levels of intent to leave the profession among young and old nurses alike, though for different reasons. These trends are motivated largely by the increased workloads on nurses, 12-hour schedules with regular mandatory overtime, increased levels of violence towards nurses in psychiatric hospitals, and the exacerbation of the nurse employment crisis in the US and the world.
The 2020 PRC National Engagement report states that engagement levels have been drifting lower and lower with each passing generation since the Boomers. According to PRC (2020), the Boomer generation exhibits the highest levels of engagement (53.4% fully engaged, 36.1% engaged, and 10.5% not engaged), when performing their nurse duties. For Generation X nurses, 47% were fully engaged, 38.9% engaged, and 14% not engaged. Finally, for Millennials, who have recently entered the workforce, 36.8% of respondents identify themselves as fully engaged, 46.1% – as engaged, and 17.1% as not engaged (PRC, 2020). These self-reporting surveys, at the same time, are likely to not present the whole picture, as other studies dedicated to nursing burnout indicate that burnout rates in various hospitals vary between 25% to 75%, meaning that the engagement numbers are likely underestimated (Djukic et al., 2017).
Engagement is directly related to the number of hours a person is working. The existing practice of 12-hour shifts plus mandatory overtime is one of the biggest offenders when it comes to burnout and decreased employee engagement, since nurses constantly find themselves overworked and under stress, which, in turn, results in care fatigue (Djukic et al., 2017). When related to psychiatric nursing, the issue is exacerbated by constant exposure to potential patient violence.
To compensate for the generally negative trend of assigning 12-hour shifts and often prolonging them for employees, some organizations have sought to implement compensatory psychological mechanisms for nurses. These include meditation and relaxation times, massages, and behavioral therapy sessions for nurses (Pospos et al., 2018). The systemic solution of implementing proper schedules, abolishing 12-hour shifts in favor of 8-hour shifts, and removing mandatory overtime, while generally agreed upon by the nursing community to be the proper first step towards mitigating significant drop-out rates among first and second-year nurses, is seldom implemented out of fear for short-term drops in quality and capacity for care during the organization period (Djukic et al., 2017).
The Relationship Between Employee Engagement and Healthcare Quality
PRC (2020) sustains that high employee engagement is paramount to the excellence and high quality of healthcare efforts. The document defines workforce engagement as “the extent of workforce commitment, both emotional and intellectual, to accomplishing the work, mission, and vision of the organization” (PRC, 2020, p. 6). A fully-engaged nurse, thus, would give her all and go above and beyond the call of duty to serve the patient and provide the best healthcare outcome possible. A non-engaged nurse, on the other hand, would only provide a bare minimum as required by the instructions, and nothing beyond that. Such an attitude results in lowered patient outcomes and a greater capacity for mistakes because the border between the bare minimum and insufficient care is hard to estimate (PRC, 2020).
While there is a small percentage of nurses that are not engaged by default and do not belong in the profession, the majority of individuals that end up adopting the practice do so as a result of care fatigue (Sagherian et al., 2017). It is a condition that appears in nurses as a result of burnout and being overworked, while not receiving adequate financial and psycho-emotional compensation for constantly providing physical, medical, and emotional support to patients (Sagherian et al., 2017). Therefore, burnout and nurse engagement exist in a direct correlation to one another. The higher the burnout rates among the populace – the lower is the emotional engagement of nurses. The quality of treatment drops as a result. Based on the evidence provided above, it could be concluded that employee engagement, healthcare quality, and various other parameters, such as scheduling, workloads, perceived and existing rewards all coexist in a mutually-influencing connection with one another.
Tools for Measuring Employee Engagement
There is a lack of data on what kind of tools does AMRTC uses to gauge the engagement, burnout, and content levels of its employees. That could be the explanation for why the hospital was faced with strikes and large-scale union action throughout 2018-2019 (MDHS, 2020). Either their tools do not provide adequate results to examine and address the complex issues, or the hospital leadership is incapable of performing changes so desperately needed, considering the importance of AMRTC to Minnesota and the counties the hospital services. As it was already established that employee engagement hinges on several important factors, such as work/life balance, burnout, and the overall psychological status of the nurse, it is important to utilize several means to create a complete picture of the situation.
The employee satisfaction tool to be utilized in AMRTC could be the Swedish Satisfaction with Nursing Care and Work Assessment Scale (SNCW), developed by Brodaty, Draper, and Low, and frequently used in studies both inside and outside of Sweden (Holmberg et al., 2016). It has a reliability rating of.857, can be self-administered by mail or online, and provides a series of items to measure nurse engagement based on the 5-point Likert scale. Work-life satisfaction can be measured using the Work-Life Satisfaction and Engagement Survey, which consists of 29 items and can be passed online (Raso, 2018). The reliability rating is very high, around.93, making it an excellent tool for the job. Finally, burnout can be measured using the Maslach Burnout Inventory, which also sports a high-reliability rating (.93-.94 for nurses), and consists of 22 items (Knox et al., 2018). This tool is often used in burnout-related research.
Improving Employee Engagement Plan
The proposed plan will address two important measures listed in the scorecard, namely improving nurse safety by splitting patients into colored groups based on their propensity to violence and facilitating 8-hour schedules instead of the existing 12-hour shifts. The changes are expected to reduce burnout and provide nurses with a measure of safety, thus reducing their burnout rates and improving engagement as a result.
The safety plan involves splitting the patients into three groups based on their diagnosis and propensity to violence. Green would work for the non-violent patients, yellow – for individuals that might engage in violence if scared or provoked, and red for willfully violent patients. Treating each would come with specific clearances and security protocols. For yellow and red groups, direct contact with nurses will be limited, for their safety. In addition, newly-recruited or young nurses will not be permitted to work with individuals from these groups, which should prevent their lack of experience from escalating the situation. This change is largely organizational and can be completed within a month. Evaluation of the success or failure of this intervention can be done utilizing the survey tools discussed in the previous section, to see the changes in nurse engagement. That could be done within 3 months after the change. Finally, the effectiveness of the initiative on actually reducing violence could be estimated within a year by comparing the number of patient-nurse incidents to the last year’s parameters.
Introducing 8-hour shifts instead of the existing 12-hour schedules is a much more significant undertaking. It would put the hospital under the pressure of maintaining existing functionality, hiring additional staff to make up 3 shifts instead of 2, and dealing with potential protests from the existing nurse core, some of which might prefer 12-hours to 8. The change process, thus, must begin with explaining the goals of the intervention to the nursing staff. The transition must be gradual, with core personnel retaining 12-hour shifts until the transformation is complete. The entire process, including finding new personnel and switching operational models would take a year. Once the system is fully accepted and new standards have become solid, another year would have to pass before surveys could be distributed. It is expected that nurse engagement would increase as a result of better work-life balance, reduced workloads, and no mandatory overtime, which could be measured using the aforementioned survey tools.
Best Leadership Practices
Leadership practices for a nurse professional in charge of the healthcare organization or a subdivision of thereof should focus on increasing nursing engagement and improving their responsiveness to changes. As such, the two proposed models include servant leadership (SL) and transformational leadership (TL) styles. SL is a type of leadership that is defined by the role of the leader to empower others to improve and do great things (McCay, 2018). It is conducive to nurse engagement, as the very concept suggests taking an active part in improving the skills and attitudes of those around to achieve a common goal (McCay, 2018). Since modern nursing is patient-centered, such an attitude would resonate in others and benefit patients in two ways – first, the direct improvement of nursing skills would mean they would receive a better quality of care; second, the increase in employee engagement would also mean nurses shall become more attentive to patient requests.
Transformational leadership (TL) is a concept that is both similar and different from servant leadership. While SL puts other nurses and employees first and makes the leader play the role of a stepping stone for others to improve, TL uses the figure of an inspiring leader to advocate for change and inspire others to do the same (McCay, 2018). TL is very useful for organizations going through changes, which AMRTS is currently in a dire need of. The main traits of TL are personification, communication, and personal excellence (McCay, 2018). When looking at a nurse leader, others must identify the change with them, understand what the change is about, and strive to adhere to the same standard of excellence. Doing so improves morale and increases nurse engagement.
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