Driving Organizational Change From the Bedside: The AACN Clinical Scene Investigator Academy

Creation and development of the AACN CSI Academy began by searching for best-in-class demonstration programs. Children’s Mercy Hospital in Kansas City, Missouri, had developed a CSI Academy with funding from a Partners Investing in Nursing grant.⁶  Seven area hospitals sent teams of staff nurses to learn leadership and QI skills to systematically improve a clinical outcome and achieve a financial impact. The teams implemented change projects, with all projects achieving positive patient and fiscal outcomes.⁷  The Kansas City CSI Academy was viewed as a good match for AACN because this Academy had an overall goal of providing leadership skills to staff nurses, which matched what AACN wanted to accomplish in their program. The Kansas City CSI program director and AACN staff adapted the original program and curriculum based on current evaluation feedback, and the newly adapted program was named the AACN CSI Academy.

AACN staff believed the most efficient way to deliver the program was to provide the Academy experience in specific regions of the country in a cohort manner. The objective was to seek applications from hospitals within the identified region with the help of a chief nursing officer (CNO) familiar with AACN. Seven hospitals were then chosen to participate in the regional cohort. Each hospital sent 2 to 4 staff nurses to participate in the 16-month program, creating a peer learning community among the 7 regional hospitals and 28 CSI nurses. The hospitals chosen were granted $10 000 from AACN to assist with backfilling shifts and to support the projects with supplies needed for implementation.

The 6 regions selected for cohorts were Indianapolis, Raleigh-Durham-Chapel Hill, Austin, Boston, Philadelphia, and New York City. The first cohort (Indianapolis) launched in June 2012, and the 5 remaining cohorts had staggered launches 2 to 4 months apart, with the last launch in September 2013.

The Academy was an interactive, experiential program for the staff nurse. Over the course of 16 months, the CSI teams from each hospital unit came together in an all-day workshop that met 7 to 8 times. The program’s curricular content included the concepts of leadership, such as influencing through communication and empowering teams. Specific QI tools such as Plan-Do-Study-Act, project planning with logic models, data collection, and analysis were an integral part of the Academy (see Table 1 for concepts, objectives, and learning activities). Logic models are a representation of a program showing logical relationships among available resources, the activities, and the anticipated outcomes.⁸  Faculty presented social entrepreneurship as a conceptual means to creatively think through solutions to unit-specific problems. They presented and discussed change concepts in terms of making change work in the staff nurses’ specific unit and how to make the change persist. The CSI teams worked together to select an issue to change with their unit-specific project plan, which included an evaluation of outcomes. Interactive content allowed for immediate application and collaboration across sometimes competing institutions.

AACN staff who provided Academy content delivery and mentoring all had at least masters degrees and were clinical leaders with backgrounds in learning facilitation. These staff were called the AACN CSI Academy faculty. The faculty for each cohort served as facilitators of learning and provided mentoring, one-on-one support, consultation with the CSI team’s clinical coach (see below), and served as consultants to the hospital CNO. Between each workshop, program faculty used email, telephone, and web-mediated interactive communication to review project plans, consult with teams, and respond to unanticipated challenges.

The faculty led qualitative evaluations in an open forum format at the end of each workshop. Participants identified what did and did not work for the learning experiences of that day and offered suggestions for the next workshop. Faculty identified immediate needs to target and followed up with phone meetings or consultations with the CSI groups as necessary. In addition, based on feedback from the CSI nurses, the faculty adjusted content and delivery methods as the Academy proceeded.

The Academy program used a hospital-selected internal coach to serve as a resource for the project teams. These coaches were someone other than the CSI participants’ nurse manager and were selected based on their ability and availability to mentor and help project teams navigate the hospital system to secure project resources. As invaluable resources to the CSI faculty and program staff, they attended program workshops when appropriate content related to project goals were presented.

The end of the program culminated in a city-wide innovation conference in which Academy faculty and participants presented the projects to the health care community. Nurse speakers offered inspirational messages about the power of staff nurse engagement and innovation. The conference spotlighted completed work, the growth of individual nurses, and the new skills that will be available to each institution and its community. The conference helped the nurses realize their full potential as leaders of innovation and change.

The faculty chose John Kotter’s 8-step change theory to frame the program’s curricular concepts of change, as that model has been used successfully to manage transformational change in health care.^9,10  Because managing people is crucial in order to change practice, Kotter’s model creates urgency, communication, vision, and empowerment as guides to successful change. When changing behavior, leaders must provide compelling reasons to change along with education. According to Kotter, an important strategy to successful change is communicating the vision and embedding the vision in all that is done. Therefore, logos, slogans, and visual cues are necessary to create reminders and excitement and to brand the initiative.

Each team picked project launch dates with educational and promotional materials that included these slogans and visual cues. Some teams engaged nurse peers in selecting the slogans, with the added benefit of generating initial buy-in. When enthusiasm from unit staff waned, the CSI teams developed creative “redosing” strategies to deliver the core message and mitigate flagging interest.

The approach to the Academy evaluation comprised a variety of conceptual evaluation areas: (1) continuing education (CE) evaluation data and overall satisfaction with the program; (2) assessment of the CSI nurses’ professional growth and development; (3) project outcomes including sustainability and scaling; and (4) regional and national impact of the projects, including dissemination activities. See Table 2 for the evaluation plan and methods. The evaluation was both formative (at the end of each workshop day) and summative (immediately on completion and 1 year after program completion). A mixed methods approach was used, employing both qualitative and quantitative assessment techniques.

At the end of each workshop, the CSI faculty asked for feedback in a qualitative, open-forum format. CE workshop quantitative session evaluations were completed online within 3 weeks of the workshop day. Participants also had an opportunity to write in comments. The faculty used these data to facilitate changes for the next workshop. See Figure 1 for the qualitative and quantitative CE evaluations.

CSI faculty developed semistructured phone interviews to obtain evaluative aspects of the program from the CNOs. The CSI program director facilitated these interviews, completed at the end of the program, to gather thoughts from the CNOs about the program and its impact on their hospital and staff. All 42 CNOs were interviewed (Figure 2).

The Academy staff set out to understand the possible effect of the program on the professional growth and development of the CSI staff nurses. In this case, the evaluation method was intentionally correlated to the original purpose of the program: to provide staff nurses with the knowledge and support necessary to become leaders who guide and partner with peers to create unit-based change. The aim was to evaluate the nurses’ satisfaction with the knowledge gained, as well as to evaluate their professional growth and development as leaders of change. At a summative evaluation, the CSI faculty conducted a qualitative, open-format feedback session on the last workshop day asking questions about their perspective of professional growth related to participating in the Academy. The 1-year postprogram evaluation also assessed professional growth. This 1-year postprogram evaluation used a combination of quantitative and qualitative techniques (Figure 3).

In addition to these assessments, a research study was implemented to assess professional growth of the CSI nurses with pre/post measures of empowerment, engagement, and social entrepreneurship. The CSI program staff surveyed nurse participants on the first workshop day (pre) and last workshop day (post) using 3 established instruments: (1) the Conditions of Work Effectiveness Questionnaire-II to measure empowerment; (2) the Oldenburg Burnout Inventory to measure engagement; and (3) the Social Entrepreneurship scale. The University of Missouri Kansas City institutional review board approved the study, and data collection occurred between June 2012 and August 2014.

Laschinger and colleagues¹¹  developed the Conditions of Work Effectiveness Questionnaire-II based on Kanter’s model of empowerment.¹²  The 19-item tool, answered using a 5-point Likert scale, measures opportunity, information, support, resources, formal power, and informal power. Cronbach α is 0.91.¹³  The 16-item Oldenburg Burnout Inventory measures exhaustion (Cronbach α, 0.74) and disengagement from work (Cronbach α, 0.79) on a 4-point Likert scale.^14,15  Low scores indicate high engagement. The Social Entrepreneurship scale consists of 3 subscales: innovation, proactiveness, and risk taking. With established validity and reliability, the scale measures the individual’s perceptions of the level of social entrepreneurship within his or her organization using a 10-item, 8-point scale.¹⁶ 

To further assess the effect of the CSI Academy on nurse participants, the coaches completed a summative quantitative and qualitative survey at the end of the 16-month program. The Academy staff wanted to understand the coaches’ perspective on the professional growth of the CSI nurses and gather their opinions on the Academy program.

Over the 6 cohorts, Academy staff gathered a list of all CSI projects, their focus, and clinical outcomes. As part of their project outcomes, the CSI nurses calculated, as best as possible, an estimated impact to the hospital’s financial bottom line. To maintain financial consistency, the AACN CSI program staff developed a standard list of costs per event, based on a literature review of the most common project outcomes. CSI Academy participants based their calculations on their individual hospital’s available data, with each project team collecting and analyzing its own institution data to determine patient outcomes and estimated financial impact. Because data availability and access varied among hospitals, some teams had to identify other sources in order to approximate unavailable records. The hospitals provided support from their own quality departments, data analysts, research personnel, and other professionals to assist the CSIs in data acquisition, data analytics, and patient and estimated fiscal outcome measures.

In addition to tracking project outcomes, Academy staff captured sustainability and scaling of the projects through subjective evaluation from the CSI nurses. Sustainability was defined as the project continuing past the 16 months of the Academy, as assessed at the 1-year postprogram evaluation. Scaling was defined as having the project continue after the 16 months by other units within the hospital or across hospital systems, with or without adaptation, again assessed at the 1-year postprogram evaluation.

CSI faculty created the 1-year postprogram evaluation to assess, albeit in a small way, the CSI nurses’ professional growth and development and project dissemination activities, and to gather CSI perspective on the projects’ scaling and sustainability (Figure 3). The Academy sent this survey a year after the Innovation Conference and used an online platform.

The fourth evaluation piece assessed the Academy’s impact on regional and national awareness and use of the CSI team project information. Individual project information, searchable by clinical outcome and region, is available for public access at the AACN CSI Academy Innovation Database (www.aacn.org/csi). Each project includes a project summary, tools, and the innovation conference slide presentation. Quantitative metrics were assessed by “hits” on the innovation database that were quantified and graphed over time. In addition, Academy staff gathered lists of other CSI programming that occurred at AACN’s National Teaching Institute, presentations at regional and national conferences, and publications completed by CSI nurses about their projects. The 1-year postprogram evaluation survey asked the CSIs if their projects were disseminated and in what venue (Figure 3). The survey also asked if the CSI nurses had been contacted for more information about their projects and requested the specific circumstances in which this occurred. The objective of assessing regional and national impact was to generate enough interest in the projects that other nurses would either adopt or adapt the completed projects for their own use.

Quantitative analysis was completed using descriptive statistics. Paired t tests were completed for the empowerment, engagement, and social entrepreneurship measures using SPSS, version 23. For the qualitative analysis of the CSIs’ program evaluation, the semistructured CNO interviews, and the qualitative questions from the coach surveys, qualitative descriptive analysis was completed, and themes emerged from the answers to the structured questions.^17,18 

The first 6 cohorts consisted of 164 nurses and 43 project teams from 42 hospitals. One hospital had 2 teams of 2 CSIs. The extensive evaluation plan provided a large amount of data affecting just-in-time adjustments to workshop programming. No feedback led to substantially changing the curricular model. Because of the large amount of data, summarized information is presented for some of the evaluation areas.

The CE learning outcomes and program satisfaction were measured and assessed with each workshop to ensure immediate follow-up for CSI project issues and to readjust workshop programming. The overall program evaluations were overwhelmingly positive, with few suggestions for improvement from one workshop to the next. These suggestions were treated as just-in-time feedback, changing programming as needed. Summaries of aggregated data from the session evaluations (both quantitative and qualitative), end-of-program qualitative evaluation, and CNO semistructured interview were as follows:

• More than 90% of nurses gave highly positive responses on session evaluations.

• A theme of the qualitative program evaluation was CSI nurses appreciated the collaborative nature of the program and hearing from nurses across the region.

• From the semistructured interviews, all CNOs said they would participate in the program again.

With the qualitative evaluation completed at the end of the program, more than 90% of the CSIs responded that they gained leadership skills, specifically influencing clinical processes. In addition, more than 90% of the coaches agreed the program helped nurses develop leadership skills and confidence. Table 3 presents qualitative themes from CSIs, coaches, and CNOs, showing global improvement in the nurses’ feelings of empowerment, improved collaboration, and marked assessment of building skills.

Table 4 presents the analysis of the measurements of empowerment, engagement, disengagement, and social entrepreneurship (and subsequent subscales) completed during the first (pretest) and last workshop (posttest) sessions. Findings revealed a statistically significant difference for structural empowerment (P = .016), with participants reporting a higher perception of empowerment after completing the program. Other scores were not statistically significant.

The 1-year postprogram evaluation was sent to all 164 CSIs, with 40 returning the survey (response rate of 24%). For the 6 cohorts, the response rates ranged from 7% to 32%.

Twenty-eight of the 40 respondents (70%) thought participation in the program had contributed to their professional growth in some form (Table 5). Nurses answering “other” forms of professional growth noted maintaining their clinical ladder level, presenting national conferences, becoming generally more involved in their work, or applying to a graduate school. The survey also asked about levels of collaboration and confidence and the ability to influence. Most reported that since completing the program, they noted higher levels of confidence in leading innovation and collaborating with other health care team members, and an improved ability to influence other team members (Figure 4).

To obtain additional context to interpret quantitative responses, nurses were asked for qualitative feedback about how participation in the AACN CSI Academy positively affected their collaboration, confidence, and ability to influence others. Synthesis of qualitative data revealed a heightened sense of empowerment. One nurse noted that participation in the program reinforced that “nursing is a team sport.” Another theme that emerged was that nurses earned respect and admiration from peers and managers as a result of their projects. Peers sought them out as expert resources. An additional theme was that public speaking, including presentations, in the hospital and at national conferences helped to increase their reported level of professional confidence.

Table 6 presents the types and frequency of projects that were undertaken by the CSI groups. Table 7 presents a sample of the clinical outcomes in each region, along with each cohort’s combined estimated annualized financial impact. The impact on patient outcomes could be attributed to other environmental factors and not solely to an AACN CSI Academy project, and the estimated fiscal impact of each project was based on generalized financial data noted in the literature. Each hospital owns the pre/post data about patient outcomes, process work, and estimated fiscal impact. Several CSIs have published their specific CSI project outcomes or their experiences and knowledge gained from the CSI Academy.^19–28 

The 1-year postprogram evaluation examined sustainability and scaling. Respondents rated 10% of the projects as “a great deal” sustained, with 48% reporting them as “a lot” sustained and 28% as “somewhat” sustained. Fewer individuals reported “not much” (13%) or “not at all” (3%) sustained.

Participating nurses cited continuous education and reeducation of new and seasoned peers as the most common ways for sustaining the projects. Some posted best-practice models and their unit’s current infection rate or celebrated favorable project outcomes. Others made presentations, facilitated peer buy-in of project goals, maintained project teams or created new ones, and extended projects across the entire hospital or health system.

Nurses also reported changes in project outcomes. From the end of project completion, 40% said the results fluctuated, with 28% reporting improved outcomes and the same number reporting no change. Only 2 reported worse outcomes after the project ended.

The AACN CSI Academy sought to expand the reach of the original Kansas City pilot project, so the projects developed through the program could become more widely available. In the 1-year postprogram evaluation, 80% of reporting nurses were contacted for project information, mostly by nurses and health care providers in other units, but also by audience members after presentations. Nurses reported being asked for consultation, which included helping with hospital- and system-wide project expansion. More than half (53%) said their projects were implemented in other areas, most often in other units, but also in other hospitals.

The AACN CSI Academy Innovation Database received 9197 unique visitors between November 2013 and January 2016, with 25 828 unique project material downloads. Promotional activities, such as email blasts, speaking engagements, media releases, and webinars, increased visits and downloads. Mobility, pressure ulcer prevention, and communication with patients and family were the 3 clinical issues most often downloaded.

Ongoing communication with program participants and hospital leaders pointed to the potential of replicating and disseminating successful projects to other clinical units and institutions, as units experiencing the same clinical problem sought out the nurses as change advisors. They were often asked to speak to unit councils and QI committees.

Program nurses have published their projects and shared best practices in hospital-based, local, and national podium and poster presentations, abstracts, and webinars.^19–28  Venues have included the AACN National Teaching Institute & Critical Care Exposition, the Society of Critical Care Medicine Congress, the Institute for Healthcare Improvement annual conference, and the American Organization of Nurse Executives annual conference. Local print and broadcast media also picked up success stories, and creative solutions have been uploaded to YouTube.^{19,21,25,27,29–31}  One CSI nurse participated in the Nurses in Washington Institute, which is a program that provides nurses with an opportunity to learn advocacy strategies to further professional nursing and health care concerns through the legislative and regulatory processes. The CSI nurse met with a staffer for her house representative and 2 senators. She spoke to them about her personal experience with the AACN CSI Academy and how her team was able to improve patient and fiscal outcomes. The CSI nurse emphasized the change in practice that occurred as a result of program participation and the importance of funding Title VIII Nursing Workforce Development Programs, National Institute of Nursing Research, Title VIII Nursing Workforce Reauthorization Act, and Veterans Health Care Staffing Improvement Act to allow other nurses to also bring about change.

The positive outcomes of the AACN CSI Academy’s leadership initiative indicate that, when given the tools, competencies, resources, and time, staff nurses can positively impact patient outcomes and a hospital’s financial health. Improved patient outcomes cannot be attributed solely to the program’s projects. However, the change actions and targeted approaches boost the program’s impact.

During the first workshop, participants often said they lacked the confidence to tackle an improvement project and create the environmental change necessary for success. Over 16 months, the nurses reported their own personal and professional growth. The pre-post paired t tests measured this transformation, reflecting the program’s effect on feelings of empowerment which, as described above, was considerable. In addition, CNOs reported professional growth as a positive aspect of participation in the AACN CSI Academy. The CNOs noted that nurse involvement favorably influenced confidence, collaboration skills, and the ability to influence other team members. In addition, they thought nurses who went through the CSI Academy learning experience were better equipped to handle challenges in the work setting.

The CSIs’ efforts to reduce hospital-acquired conditions, such as falls, pressure ulcers, catheter-associated urinary tract infections, and central catheter–associated bloodstream infections, are clinically important and support nurses’ ethical obligation to ensure quality care and improve health. The success supports reports from other initiatives that engaged staff nurses in improvement projects that resulted in positive patient, nurse, and organizational outcomes, including decreased nurse stress and increased communication and collaboration.^2,32 

The AACN CSI Academy incorporated innovative curricular content to support the sustainability of project results over time. In the 1-year postprogram evaluation, more than half of respondents reported project results were fully sustained a year after completion. An additional 28% said their project results were somewhat sustained.

Ensuring change persists is never easy. Assuring staff nurses help design and implement the change may contribute to sustainability.³³  Infrastructure changes are also vital. Attitudes and culture need to change, and these aspects take more time to take effect. Ongoing education related to the changed practice is an iterative mechanism that requires “redosing” to sustain motivation and knowledge. Formal and informal nurse leaders are influential in reinforcing change until processes, attitudes, and behaviors can become socialized into sustained new practice.^33,34 

Recognizing the connection between effective nursing care and prevention of hospital-acquired conditions supports the business case that nurses can improve hospital financial outcomes.³⁵  The estimated annual financial impact in excess of $28 million by 43 AACN CSI Academy project teams lends support to the financial impact of nurse-led improvement projects and spotlights the contribution staff nurses can make to a hospital’s bottom line.

Evidence derived from empowerment theories suggested that organizations can create structures that support individual nurses to feel empowered and have autonomy and control over their practice.^{11,12,36–38}  The AACN CSI Academy and participating hospitals provided these structures based on evidence that structural and psychological empowerment boosts job satisfaction and decreases job strain.³⁸ 

This type of staff empowerment to lead planning efforts that improve clinical outcomes has not become the industry standard, although it is required for successful implementation.³⁹  Top-performing hospitals believe excellent process and patient outcomes are driven by engaged employees with input from frontline staff.⁴⁰  These hospitals distinguish themselves by training clinical staff in QI and process improvement methods. They expect staff nurses to solve quality problems as part of their job. Hospital leaders consistently communicate and reinforce a culture of excellence by offering meaningful opportunities for frontline staff to improve the care they provide.

Hospitals seeking healthy patients and bottom lines would do well to harness this untapped potential. In turn, staff nurses seeking to improve quality of care should become what Omery⁴¹  calls bilingual—conversant in QI, professional practice, and business models. Continued improvement of nurses’ financial acumen is vital to leverage this untapped contribution.

Enabling nurses to lead change requires time and resources to equip them with the necessary knowledge, skills, and abilities. Participating hospitals provided opportunities and support for program participants to acquire these qualities. Together, the Academy and the hospitals addressed 2 recommendations from the National Academy of Medicine’s (formerly the Institute of Medicine) Future of Nursing report.⁴²  Recommendation 2 seeks to expand opportunities for nurses to lead and participate in collaborative improvement efforts. Recommendation 7 seeks to prepare and enable nurses to lead change to advance health.

This evaluation of the AACN CSI Academy has several limitations. Hospital CSI teams were responsible for their own project data collection, and sometimes data were unavailable to the teams. In such cases, the nurses’ ability to demonstrate their impact may have been limited. The program was completed after 16 months, and several of the participants were lost to follow-up. The 1-year postprogram evaluation had a low response rate of only 24%. A higher response rate would have strengthened the evaluation of the primary goal—nurse leadership growth and development—as well as the assessment of the sustainability and scaling of the projects.

Because of their proximity to the point of care, staff nurses are familiar with barriers to positive patient outcomes and are uniquely able to identify ways of overcoming them. In collaboration with participating hospitals, the AACN CSI Academy provided the resources, time, support, and skill acquisition for staff nurses that resulted in immediate leadership skills application through change projects aimed to bring about positive patient outcomes. The program challenged traditional views of so-called nonproductive time by showing that carefully managed time away from direct care responsibilities can lead to transformative innovation.

The authors thank the staff nurses, as well as the nursing and other leaders from each organization. Without their dedication, the program would not have been possible.