igh-reliability organizations ensure that patients receive safe, consistent and high-quality care (Agency for Healthcare Research and Quality, 2008). Health care institutions are challenged to achieve this goal despite operating amid highly complex environments that rely on multidisciplinary teams to provide the best care for all patients. A critical element of successful organizations is the ability to develop and sustain high levels of sta� engagement in shaping the work environment and unit governance. � is article discusses how one health care system utilizes the clinical nurse specialist (CNS) to help successfully engage sta� nurses.

SuccessfulOne Health Care System’s Story

Nurse Engagement

Karen Harmon, RNC-OB, MSN, CNSRachelle Sey, RNC-NIC, MSN, CNSJacqueline Hiner, RN, MSN/EdSue Faron, RNC-OB, MN, CNSAnne McAdam, RN, MSN

H

About the OrganizationSharp Healthcare is the largest integrated health care system in San Diego County, providing a multitude of services throughout the full continuum of care. It’s the largest health care employ-er in the county, with more than 14,000 employees providing services through a large health care plan, a� liated physician group practices, four acute care hospitals and three specialty hospitals, one of which is dedicated to the care of women and newborns. More than 16,000 infants are born each year in this hospital system.

In 2007, Sharp received the Malcolm Baldrige National Quality Award, the highest Presidential honor for quality and organizational performance excellence. In addition, two hospi-tals within the Sharp system have been awarded Magnet® desig-nation by the American Nurses Credentialing Center. Because of the complexity of this system and the high volume of patients that are served each day, the organization must strive to achieve and maintain high-quality care. As technology changes and hospitalized patients require higher levels of care, the presence of a CNS is invaluable to support nurses on the units, identify learning needs of the sta� , monitor quality of patient care and introduce innovative approaches to evidence-based patient care. Sharp’s Women’s Service Line educational team, composed of 11 hospital-based CNSs and educators, has recognized the importance of techniques that aid organizations in achieving high reliability and have focused recent e� orts on improving sta� engagement, teamwork and patient satisfaction.

What is Engagement?Engagement is a process that speci� cally targets sta� involvement

and active participation to shape the elements and outcomes of a project or initiative. Speci� cally in nursing, this process can be best utilized in such areas as program development, change projects and procedural/policy changes, as well as within com-mittees or councils. In a time when there is potential for high sta� turnover, increased patient acuities, shorter hospital stays, extreme economic pressures and an unpredictable nursing job market, the incorporation of nurse engagement has demonstrat-ed improvements in many areas a� ecting nursing. � is manu-script describes how nurse engagement a� ects this profession.

Successful engagement of nurses requires early sta� involve-ment and commitment to a process (Gawlinski, 2008; Kalisch, Curley, & Stefanov, 2007). Early involvement not only demon-strates respect for those a� ected by the change, but also enables the group and a project to evolve together from start to � nish. Inviting sta� to participate halfway through a project carries the risk of decreased buy-in and feelings of questionable value. In addition, progress toward the goal can be hindered as the new participants to the project raise valuable ideas or insights that may not have been considered in the early stages. Not en-gaging nurses in a project that may a� ect them will decrease their likelihood of buy-in and support. � is may doom the project to failure because the nurses don’t fully understand the impetus and rationale behind a project or initiative (Draper, Felland, Liebhaber, & Melichar, 2008).

Involvement of sta� nurses facilitates recognition of both the nurses’ clinical expertise as well as their ability to in� uence and guide clinical practice. Additionally, involvement helps increase sta� creativity and involvement through active participation (Gawlinski, 2008). Creating a culture of engagement invites sta� members to participate in their work in ways that are meaning-ful to them as individuals (Robinson-Walker, 2002). � e added bene� t is support and respect for achieving their own personal goals and a� rming individual values, which could in turn result in greater satisfaction with their work environment.

Successful sta� engagement also requires hospital nursing leadership support. Building a culture that values sta� mem-bers’ engagement in all aspects of the initiatives that a� ect their clinical care and/or a� ects their work environment requires support and enthusiasm from the organizations’ leaders at all levels (Luther et al., 2002). Laschinger and Leiter (2006) con-cluded in their study that nursing leadership is a driving force that strongly in� uences the degree of work engagement. Sup-portive hospital leadership in the form of � nancial or addition-al sta� resources as described by Draper et al. (2008) is one of many key strategies for successful sta� engagement in quality improvement activities.

Role of the CNS in Engagement� e CNS is a licensed advanced practice nurse with graduate education (master’s or doctorate degree) and expert clinical skills in a focused specialty area. � e CNS integrates theory,

44 © 2010, AWHONN http://nwh.awhonn.org

Karen Harmon, RNC-OB, MSN, CNS, is a perinatal clinical nurse spe-cialist; Rachelle Sey, RNC-NIC, MSN, CNS, is a neonatal clinical nurse specialist; Jacqueline Hiner, RN, MSN/Ed, is a senior nursing specialist in the Women’s Center; Sue Faron, RNC-OB, MN, CNS, is a perinatal clinical nurse specialist; Anne McAdam, RN, MSN, is a senior nursing specialist in the postanesthesia care unit; all authors except Jacqueline Hiner are at Sharp Mary Birch Hospital for Women and Newborns in San Diego, CA; Ms. Hiner is at Sharp Grossmont Hospital in La Mesa, CA. Address correspondence to: karen.harmon@sharp.com.

DOI: 10.1111/j.1751-486X.2010.01506.x

• A critical element of suc-cessful organizations is the ability to develop and sustain high levels of staff engagement.

• Staff engagement can be fostered in many ways, including relationship-centered care and mentoring.

• A culture that fosters staff engagement can in-crease nurse retention and patient satisfaction.

Bottom Line

February March 2010 Nursing for Women’s Health 45

clinical skills and evidence-based knowledge into patient care (National Association of Clinical Nurse Specialists, 2005). � e clinical expertise of the CNS is utilized to provide rationale for quality initiatives at the bedside on individual nursing units, as well as in individual hospitals and throughout a health care sys-tem, thereby positively a� ecting the quality of nursing care and patient outcomes (Lewandowski & Adamle, 2009). A key role of the CNS is the identi� cation of sta� learning needs utilizing a variety of methods, such as formal needs assessment, qual-ity assurance reports related to adverse events, documentation review and conversations with sta� .

Increasing demands from regulatory agencies, higher patient acuity and time constraints are some of the challenges a CNS faces when trying to engage and inspire perinatal nursing sta� (Millhaem & Timm, 2007). Because of these challenges, the CNS must be able to utilize formal and informal nursing leaders with-in the clinical sta� to engage nurses in projects and initiatives and disseminate education in a creative and stimulating format. To this end, Sharp has developed a formal nursing role—the ad-vanced clinician (AC). ACs are highly skilled clinical nurses who, under the guidance and support of the CNS, promote the profes-sion of nursing through evidence-based practice to improve the clinical skills of all sta� . � ey function as expert clinicians, unit mentors, preceptors and participants in sta� development.

� e ACs work closely with the CNS and educator of their departments when clinical practice decisions or change proc-esses are needed. � ey assist in identifying educational needs and implementing educational programs to meet those needs. As part of their role, all ACs are expected to participate in projects that support the operation of their clinical units and the organization. Examples of AC projects include assisting in

annual competency validation, providing simulation drills and participating as the voice of frontline sta� in multiple system-wide committees and unit council meetings. � is advanced bedside role encourages engagement of experienced sta� nurses and cultivates their creativity, innovation, professional growth and development.

By virtue of their position on the hospitals’ leadership teams, the CNSs have the ability to directly a� ect patient care by o� ering ongoing input regarding decisions related to cur-rent practice and evidence-based improvements. Role-mode-ling high levels of clinical competence and critical thinking are vital aspects associated with the CNS position. At Sharp, the CNS group is able to create an environment that fosters im-proved clinical performance by providing various educational opportunities in an atmosphere of consistent clinical guidance and support. For example, the CNSs and educators engage sta� by providing ongoing fetal monitoring strip review of complex cases or cases with adverse outcomes. � is enables the sta� to develop to their full potential by utilizing mistakes as opportu-nities for learning and developing critical thinking skills.

Staff Engagement Through Relationship-Centered CareNursing is a unique profession in which compassion, knowl-edge, skill and critical thinking are harmoniously combined. Nurses have the opportunity and privilege to provide holis-tic care by creating intimate connections with their patients. Finfgeld-Connett (2007) terms this relationship-centered care “artful nursing.” Artful nurses strive to fully understand their patient’s needs and provide care based on those needs in an ever-changing situation (Garrett, 2005; Gramling, 2006).

Relationship-centered care is a critical element of a suc-cessful hospital experience for the perinatal patient. � is is

evident in patient satisfaction surveys in which patients frequently name nurses and describe how the nurses

A critical element of successful organizations is the ability to develop and sustain high levels of staff engagement in

shaping the work environ-ment and unit governance

46 Nursing for Women’s Health Volume 14 Issue 1

made a di� erence in their experience. � e following submitted by a patient who experienced a high-risk pregnancy:

“Maria was the nurse who admitted me and was there my � rst few days in the hospital. � ose � rst few days were awful; the hardest days of our lives. She was there to sit and hug me while I cried, pray with me and just be my friend. About three weeks or so into my stay she gave me a bracelet that I still have. Someone had given it to her when she was going through a really hard time and she said she wanted to pass it on to me. � e bracelet says ‘Ex-pect Miracles.’”

Another patient wrote, “I had the best nurse ever. She was friendly with a great attitude, caring and respectful.” � ese comments demonstrate the importance of the relationship each nurse has with her patient. Indeed, those of us who have been stopped in the supermarket by the mother who calls us by name and shows o� her child you helped deliver 4 years ago, as if your relationship then resulted in a long-term friendship, understand the impact of artful nursing.

Working in the perinatal setting allows nurses the privilege of witnessing and participating in miraculous and life-altering events on a daily basis. Being present at the birth of a child is both an honor and a great responsibility. Patients who are admit-ted to the hospital to deliver a child may expect more of a life-long memory from their hospital experience than a surgical or medical patient. � is expectation both empowers and compels the nurse to engage personally with every patient, every day.

Although nurses commonly become desensitized to situa-tions that are seen on a regular basis, the focus on providing a memorable experience rather than a successful hospitalization allows the nurses to reengage with each new patient. Sharp has adopted clinical standards that emphasize the personal aspect of nursing care. � is empowers nurses and hospital sta� to tend to the emotional and personal needs of the patient by purpose-fully taking steps to begin building a relationship before ad-ministering clinical care.

Another avenue of engaging with our patients is accom-plished through daily bedside patient rounding by the leader-ship/CNS team. � is allows the opportunity to connect with each patient on a personal level and receive comments regard-ing their care. Rounding allows the patients to participate in an interdisciplinary approach to care as well to express any posi-tive feedback or concerns. With the information received during rounds, the leadership team can then present the nurses with immediate reward and recognition for positive behaviors, which may encourage further professional engagement. When areas for improvement are discovered, relevant and timely coaching is provided, which in turn supports patient satisfaction initiatives.

In a setting with the potential for increased patient acuity and decreased length of hospital stay, a nurse may experience signi� cant stress, which intensi� es the importance of relation-

ship-centered care. � e bond created between the nurse and the patient may allow for increased satisfaction for both par-ties. Artful nursing empowers sta� to create strong and last-ing bonds with their patients and provides a more positive and enjoyable work experience, as well as the potential for in-creased employee satisfaction. Nurses who are more person-ally engaged in their patients’ care tend to be more invested in the outcome and the overall experience for the patient. � is personalized care may create a more meaningful and valuable hospital experience and result in increased patient satisfaction (Finfgeld-Connett, 2007).

Engagement Through MentoringWithin the Sharp Healthcare system there is a highly successful, administratively supported mentoring program that focuses on the individual emotional needs of our nurses. Entering the nursing profession or a new nursing specialty can be an intimi-dating and stressful experience. During the orientation period, the mentoring program establishes professional partnerships between the newly hired nurses and the experienced, dedicated and motivated nurses on the same unit. � e partnerships are created based not only on clinical needs, but also on personality traits and preferences.

� e mentoring relationships encourage new nurses to be-come familiar with the culture of the facility and department, create relationships with colleagues and gain clinical competence and con� dence during the � rst year in their position. Many nurs-es involved in the mentoring program, in the roles of both men-tor and mentee, have reported increased professional satisfaction and increased support from colleagues. And there has been a no-table decrease in the nurse turnover rate since the implementa-tion of the mentoring program (Faron & Poeltler, 2007).

A new development within the mentoring program has been the addition of physician mentors. Several physicians from varying specialties have volunteered to act as mentors to the newer nurses. � ey have made themselves available for providing education, answering questions and being a liaison between the nurse and physician communities. � is develop-ment has encouraged professional engagement on the part of both the nurses and the physicians.

Benefi ts to Patients � e results of patient-centered care include engaged sta� , im-proved patient satisfaction and the establishment of long-term relationships between sta� , patients and their families (McAl-lister & Dionne, 2006; Wolf et al., 2008). As has already been noted, a patient’s experience in the hospital has the potential to have a profound emotional impact on patients and their fami-lies. � is is enhanced by long-term hospitalizations. � e emo-tional impact may last well a� er discharge. Patient satisfaction surveys reveal that patients, particularly parents of babies in the neonatal intensive care unit (NICU), seek consistent informa-

February March 2010 Nursing for Women’s Health 47

to improve teamwork both within units and interde-partmentally to provide the best quality of care to pa-tients. For example, sta� members have been trained through team training following examples from the

aviation industry to improve communication, improve proc-esses, reduce error and prevent adverse events (McFerran, Nunes, Pucci, & Zuniga, 2005).

Teamwork is further enriched through collaboration among the various units, particularly within the NICU and perinatal special care unit. Mothers of infants with potential admission to the NICU following delivery receive various consults from social workers, neonatologists and nurses in preparation for what to expect with an admission to the NICU. � e parents also receive a tour of the NICU before delivery if possible. � is strategy not only improves the communication and teamwork among caregivers, but also includes the family as part of the interdisciplinary team. When the multidisciplinary team is en-gaged and teamwork is visibly enacted, the patient bene� ts as re� ected in improved patient satisfaction (Triolo et al., 2002).

CNS EngagementNurses in leadership positions o� en overlook their own needs in support of the system endeavors. As previously noted, Sharp’s Women’s Service Line CNS/educator team has recognized the need to continually and actively seek opportunities to better support and sustain the engagement of the entire nursing sta� . Additionally, this CNS/educator team acknowledged that it is equally important to foster professional satisfaction and en-gagement in their own role, which led to the development of a writing group (and, subsequently, this manuscript).

Writing for publication for many is a daunting task, but when pursued as a group it has allowed for safe opportunities to explore and demystify the publication process. Assembling as a writing group has provided a forum for a supportive envi-ronment, which encourages individual as well as collaborative projects. � is CNS/educator group hopes to lead by example in identifying their own individual needs for development and

tion, communication, caring, education, participation and sup-port from the multidisciplinary team (McAllister & Dionne).

Patient-centered care is implemented in many ways, includ-ing the use of primary care nursing in the NICU, which provides the opportunity for improved sta� teamwork and engagement. A team of one or more nurses care for the same patient from admission to discharge. � is model is also used with the other health care providers, including social workers and physicians, and provides a sense of consistency for parents. By consist-ently caring for the same patient, nurses begin to notice subtle changes in patient conditions, which are acted on earlier than if a nurse is not as familiar with the patient. � e nurse also gains increased credibility with the other members of the health care team due to the innate knowledge of the patient. Furthermore, the nurse begins to build a strong relationship with the family that o� en lasts beyond discharge. � e success of this model is demonstrated through positive comments on the NICU patient satisfaction surveys. One NICU parent described the experi-ence as follows: “Although we wished not to have the baby here and have him home instead, the communication and way we and the baby were treated was extraordinary. Your NICU really helped ease the stress, because we knew for a fact that our baby was in extremely good hands.”

In addition to patient-centered care, teamwork also im-proves quality of care, increases job satisfaction, enhances patient safety and provides greater patient satisfaction, thus leading to increased sta� engagement (Kalisch, Curley, & Ste-fanov, 2007; Triolo, Hansen, Kazzaz, Chung, & Dobbs, 2002). Kalisch et al. conducted a study looking at an intervention to increase teamwork and sta� engagement on a nursing unit; their results showed that improved teamwork and sta� engage-ment was in� uential in improving patient outcomes and pa-tient satisfaction. Sharp Healthcare provides several resources

Creating a culture of engagement invites staff members to participate in their work in ways that are meaningful to them as individuals

48 Nursing for Women’s Health Volume 14 Issue 1

No. 3. Washington, DC: Center for Studying Health Care Change. Retrieved from http://hschange.org/CONTENT/972/

Faron, S., & Poeltler, D. (2007). Growing our own: Inspiring growth and increasing retention through mentoring. Nursing for Women’s Health, 11(2), 139–143.

Finfgeld-Connett, D. (2007). Concept synthesis of the art of nursing. Journal of Advanced Nursing, 62(3), 381–388.

Garrett, F. (2005). End note: � e rocker. Nursing Education Perspec-tives, 26(2), 134.

Gawlinski, A. (2008). � e power of clinical research: Engage clini-cians, improve patients’ lives, and forge a professional legacy. American Journal of Critical Care, 17(4), 315–326.

Gramling, K.L. (2006). Sarah’s story of nursing artistry: � ey do it with joy. Journal of Holistic Nursing, 24, 140–142.

Kalisch, B., Curley, M., & Stefanov, S. (2007). An Intervention to en-hance nursing sta� teamwork and engagement. Journal of Nursing Administration, 37(2), 77–84.

Laschinger, H.K., & Leiter, M.P. (2006). � e impact of nursing work environments on patient safety outcomes: � e mediating role of burnout/engagement. Journal of Nursing Administration, 36(5), 259–267.

Lewandowski, W., & Adamle, K. (2009). Substantive areas of clinical nurse specialist practice: A comprehensive review of the literature. Clinical Nurse Specialist, 23(2), 73–90.

Luther, K.M., Maguire, L., Mazabob, J., Sexton, B., Helmreich, R.L., & � omas, E. (2002). Engaging nurses in patient safety. Critical Care Nursing Clinics of North America, 14, 341–346.

McAllister, M., & Dionne, K. (2006). Partnering with parents: Estab-lishing e� ective long-term relationships with parents in the NICU. Neonatal Network, 25(5), 329–337.

McFerran, S., Nunes, J., Pucci, D., & Zuniga, A. (2005). Perinatal patient safety project: A multicenter approach to improve per-formance reliability at Kaiser Permanente. Journal of Perinatal and Neonatal Nursing, 19(1), 37–45.

Millhaem, T.B., & Timm, K. (2007). Identifying the educational needs of nursing sta� : � e role of the clinical nurse specialist in perinatal nursing. Journal for Nurses in Sta� Development, 23(6), 277–282.

National Association of Clinical Nurse Specialists. (2005). White paper on certi� cation of clinical nurse specialists. Retrieved from http://www.nacns.org/LinkClick.aspx?� leticket=%2FtvaTXjUbGY%3D&tabid=116

Robinson-Walker, C. (2002). � e role of coaching in creating cultures of engagement. Seminars for Nurse Managers, 10(3), 150–156.

Triolo, P. K., Hansen, P., Kazzaz, Y., Chung, H., & Dobbs, S. (2002). Improving patient satisfaction through multidisciplinary per-formance improvement teams. Journal of Nursing Administration, 32(9), 448–454.

Wolf, D., Lehman, L., Quinlin, R., Rosenzqeig, M., Friede, S., Zul-lo, T., et al. (2008). Can nurses impact patient outcomes using a patient-centered care model? Journal of Nursing Administration, 38(12), 532–540.

satisfaction and being proactive in creating the opportunity for nurses in all levels to grow professionally.

ConclusionA� er many years of working with women and infants, it may be very easy for nurses to become complacent about their roles and duties and the e� ect they have on their patients. Actively engaging sta� through involvement in development of clinical practice and education, while ensuring they understand the processes and tools to actively engage with their patients and colleagues, has made a positive di� erence in the quality of care that is delivered at Sharp Healthcare. It also has increased the levels of both sta� and patient satisfaction demonstrated by sat-isfaction surveys.

� is group of CNSs and educators has found di� erent meth-ods of inspiring and engaging nursing sta� in their professional growth and development. Participating in this writing group has allowed this team to re� ect on and celebrate many success-ful collaborative professional endeavors. In addition, it has in-spired celebration and sharing, which has enhanced the focus on the positive aspects of the role and providing opportunities for continued CNS/educator engagement. � e teamwork and cohesiveness of this group helps this organization come closer to its vision of being the “Best place to work, the best place to practice medicine and the best place to receive care.” NWH

ReferencesAgency for Healthcare Research and Quality. (2008). Becoming a

high reliability organization: Operational advice for hospital lead-ers. Retrieved from http://www.ahrq.gov/QUAL/hroadvice/

Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). � e role of nurses in hospital quality improvement, Research Brief

This advanced bedside role encourages engagement of

experienced staff nurses and cultivates their creativity,

innovation, professional growth and development

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