WHERE IN THE WORLD IS EVIDENCE-BASED PRACTICE?

Guest Editorial

Nurse Educators: Leading Health Care to the Quadruple Aim Sweet Spot

Eighteen years ago, an alarming report on preventable deaths from medical errors was released by

the Institute of Medicine (IOM, 2000). That report featured the estimate that approximately 100,000 people in the United States die each year because of preventable medical errors. A subse- quent IOM report (2003) called for all health professionals to be better pre- pared to keep patients safe, focusing on five core competencies for health professions education: patient-centered care, interprofessional collaboration, evidence-based practice, quality im- provement, and informatics.

Visionary leaders in nursing educa- tion were ahead of the curve, responding to the call for safer and more effective care via the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007). In 2008, the Institute for Healthcare Improvement announced a major initiative—the Triple Aim—which focuses on “simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (Berwick, Nolan, & Whittington, 2008, p. 759). Subsequently, Bodenheimer and Sinsky (2014) proposed a fourth—a quadruple—aim to improve the work life of health care providers, both clinicians and staff.

What progress has been made during the past 19 years since the IOM report, with 10 years of QSEN education, and 9 years after the Triple Aim was launched? Improvements in some health outcomes have been reported. For instance, the United States has seen a 15% reduction in infant mortality rates compared with 2005

(Kochanek, Murphy, Xu, & Tejada-Vera, 2014). Numbers of hospital-acquired con- ditions, such as central line-associated bloodstream infections (CLABSIs), pres- sure ulcers, and falls with injuries have significantly decreased from 2010 to 2013, according to a recent report from the American Hospital Association (2015). However, in terms of better care and lower costs, we are not yet there. James (2013) has estimated annual hospital patient deaths due to preventable harm to be over 400,000 per year. Reports from consumers of health care continue to include stories of poor care experiences, including lack of compassion and frustrations in navigat- ing the complexities of the care system. Further, the aim of lower costs per capita has yet to become reality. Although an estimated 20 million people were newly insured through the Patient Protection and Affordable Care Act (ACA, 2010), political challenges to the ACA remain, including rising costs, high out-of-pocket expenses, and access to affordable insur- ance.

In the world of leadership, there is a term referred to as the sweet spot, where economic health and the common good coexist and are the keys to achieving vi- able and sustainable solutions (Savitz & Weber, 2008). Is it possible to reach the sweet spot of the Quadruple Aim? Acad- emy Health and the Robert Wood John- son Foundation are partnering to pursue this formidable aim, proposing that care delivery systems collaborate across mul- tiple sectors to provide an affordable ap- proach to improving population health (Hacker, 2017).

Are we as a profession just going to sit back and wait for that to happen? I be-

lieve that nurse educators are well posi- tioned to lead the way to this lofty sweet spot goal. Nursing schools and nurse educators already work across multiple sectors to prepare nurses at all levels, from prelicensure to doctoral education. Nurse educators are already in all settings across the care continuum as practitioners themselves and as mentors to nursing stu- dents applying theory in practice. Many, if not most, prelicensure through DNP nursing students have been well prepared with the QSEN competencies. Those at the graduate level are leading evidence- based systems improvement initiatives as a part of their practice immersion and culminating projects.

I have seen the power of what nurses can do to bring the multiple sectors to- gether in the interest of patient safety, quality, population health, and affordable care. Faculty and students have taken a Quadruple Aim approach. Working in communities and across the globe, they have engaged with community and global leaders and local health advocates, such as Promotores (lay Hispanic health advocates), to partner for better health outcomes. Faculty and students have con- ducted community needs assessments to identify health priorities. They have pro- vided health education and health screen- ing. They have applied the processes and tools of the science of improvement to community-based projects to facilitate collaboration across sectors to improve health outcomes. They have been part of teams who have provided resources that communities often cannot afford alone. They have gathered and analyzed the metrics to measure results. The response from local leaders and health advocates

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GUEST EDITORIAL

is consistently positive, acknowledging their contributions. And both students and faculty have benefitted from these practice experiences.

My greatest concern is that those who lead national associations in both education and practice have not found a way to rise above their respective self- interests with a genuine commitment to work in partnership towards the Qua- druple Aim sweet spot. Some have not yet learned what visionary 20th century organizational leadership pioneer Mary Follett Parker taught about the distinc- tion between power with versus power over (Briskin, Erickson, Ott, & Callahan, 2009). Power over depends on relation- ships of polarity, suspicion, and differ- entials in power. Power with relies on relationships of respect, stakeholder en- gagement, and multisector approaches, resulting in co-created power.

Faculty and students typically work in collaboration with their patients and families, as well as their clinical partners across sectors, to improve health care and health outcomes. That is what QSEN has taught us. Through care coordina- tion models, we typically collaborate in a power with stance to reach both optimal learning and optimal health outcomes, contribute to cost-effectiveness, and con- tribute to quality of life. Coordination of care, including patients as partners in care, is one evidence-based strategy for reaching the Triple Aim. Care coordina- tion is a philosophy and attitude as much as it is a process. We need to teach our politicians and public officials about the care coordination model and how it ad-

dresses gaps in care in order to achieve optimal health outcomes. I have seen this facilitative education around care coordi- nation take place when students and fac- ulty are present at the policy table as im- portant health care issues are addressed, specifically relating to homelessness and care for children and families who are at high risk for foster care. Conversations have moved beyond debate to generative dialogue because nurses (faculty, stu- dents, nurse leaders, and nurses as board members) have been at the table.

Faculty, students, and their precep- tors could teach many organizational and political leaders by modeling how lever- aging a power with approach is a viable pathway to the Quadruple Aim’s sweet spot. Power with is what makes clinical nurses, nurse educators, and nurse lead- ers so effective and so special. With a rising emphasis on population health, we have many more opportunities to com- municate with political leaders and other policy makers. We must believe in our- selves as leaders of the Quadruple Aim and act accordingly if we are ever going to reach the sweet spot.

Power with and power ahead. What a concept!

References American Hospital Association. (2015). Zeroing

in on the Triple Aim. Retrieved from http:// www.aha.org/content/15/brief-3aim.pdf

Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27, 759-769. doi:10.1377/ hlthaff.27.3.759

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patient requires care of the provider. Annals of Family

Medicine, 12, 573-576. doi:10.1370.afm.1713 Briskin, A., Erickson, S., Ott, J., Callanan, T.

(2009). The power of collective wisdom and the trap of collective folly. San Francisco, CA: Berrett-Koehler.

Cronenwett, L., Sherwood, G., Barnsteiner, J. Disch, J. Johnson, J., Mitchell, P., . . . War- ren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122-131. doi:10.1016/j.outlook.2007.02.006

Hacker, K. (2017, March 27). Bridging the di- vide: The sweet spot in health care and pub- lic health. [Web log post]. Retrieved from http://www.academyhealth.org/blog/2017- 03/bridging-divide-sweet-spot-health-care- and-public-health

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press. https:// doi.org/10.17226/9728

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press. https:// doi.org/10.17226/10681

James, J.T. (2013). A new, evidence-based esti- mate of patient harms associated with hospi- tal care. Journal of Patient Safety, 9, 122-128. doi:10.1097/PTS.0b013e3182948a69

Kochanek, K.D., Murphy, S.L., Xu, J., & Tejanda-Vera, B. (2014). Deaths: Final data for 2014. National Vital Statistics Reports, 65(4). Retrieved from https://www.cdc.gov/ nchs/data/nvsr/nvsr65/nvsr65_04.pdf

Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).

Savitz, A.W. & Weber, K. (2008). The sustainabil- ity sweet spot: Where profit meets the common good. In J.V. Gallos (Ed.), Business leadership: A Jossey-Bass reader (2nd ed., pp. 230-243). San Francisco, CA: John Wiley & Sons.

Jan Boller, PhD, RN Adjunct Associate Professor

College of Nursing Creighton University

The author has disclosed no potential conflicts of interest, financial or otherwise.

doi:10.3928/01484834-20171120-01

708 Copyright © SLACK Incorporated

Reproduced with permission of copyright owner. Further reproduction prohibited without permission.

Original Article

Predictors of Evidence-Based Practice Implementation, Job Satisfaction, and Group Cohesion Among Regional Fellowship Program Participants Son Chae Kim, RN, PhD • Jaynelle F. Stichler, DNS, RN, NEA-BC, FACHE, FAAN • Laurie Ecoff, RN, PhD, NEA-BC • Caroline E. Brown, DEd, CNS • Ana-Maria Gallo, PhD, CNS, RNC-OB • Judy E. Davidson, DNP, RN, FCCM

Keywords

evidence-based practice,

fellowship, EBP beliefs,

EBP implementation, job satisfaction,

group cohesion, group attractiveness

ABSTRACT Background: A regional, collaborative evidence-based practice (EBP) fellowship program utiliz- ing institution-matched mentors was offered to a targeted group of nurses from multiple local hospitals to implement unit-based EBP projects. The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model postulates that strong EBP beliefs result in high EBP implementation, which in turn causes high job satisfaction and group cohesion among nurses.

Aims: This study examined the relationships among EBP beliefs, EBP implementation, job satis- faction, group cohesion, and group attractiveness among the fellowship program participants.

Methods: A total of 175 participants from three annual cohorts between 2012 and 2014 com- pleted the questionnaires at the beginning of each annual session. The questionnaires included the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness scales.

Results: There were positive correlations between EBP beliefs and EBP implementation (r = 0.47; p <.001), as well as EBP implementation and job satisfaction (r = 0.17; p = .029). However, no statistically significant correlations were found between EBP implementation and group cohesion, or group attractiveness. Hierarchical multiple regression models showed that EBP beliefs was a significant predictor of both EBP implementation (β = 0.33; p <.001) and job satisfaction (β = 0.25; p = .011). However, EBP implementation was not a significant predictor of job satisfaction, group cohesion, or group attractiveness.

Linking Evidence to Action: In multivariate analyses where demographic variables were taken into account, although EBP beliefs predicted job satisfaction, no significant relationship was found between EBP implementation and job satisfaction or group cohesion. Further studies are needed to confirm these unexpected study findings.

BACKGROUND The adoption and implementation of evidence-based practice (EBP) in nursing and other healthcare disciplines are recog- nized as essential in ensuring optimal patient outcomes and quality of care (Aarons, Ehrhart, & Farahnak, 2014). Although EBP is considered to be the gold standard in nursing practice, the actual implementation of EBP has been inconsistent due to barriers related to nursing workload, lack of organizational support, lack of EBP knowledge and skills, and poor attitudes toward EBP (Brown et al., 2010; Ramos-Morcillo, Fernandez- Salazar, Ruzafa-Martinez, & Del-Pino-Casado, 2015; Squires, Estabrooks, Gustavsson, & Wallin, 2011). Although many hos- pitals have used professional development courses individually

to encourage nurses’ implementation of EBP through im- proved nurses’ knowledge and attitudes about EBP, successful outcomes have been elusive (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014; Pryse, McDaniel, & Schafer, 2014; Underhill, Roper, Siefert, Boucher, & Berry, 2015).

A regional, collaborative EBP fellowship program, the EBP Institute, was founded in 2006 by nurse leaders from multi- ple hospitals and academia in San Diego County, California, to promote implementation of EBP by hospital nurses. The fel- lowship program utilized institution-matched mentors to assist in executing unit-based EBP projects, and included didactic as well as interactive learning experiences in six daylong educa- tional sessions over a 9-month period. A formal graduation day

340 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article completed the learning experience, with the fellows present- ing their EBP projects in poster and podium presentations. A previous report on this program showed improvements in the participants’ knowledge, attitudes, and practice associated with EBP, as well as a reduction in barriers to EBP implementation (Kim et al., 2013).

LITERATURE REVIEW The literature is replete with evidence and opinions that ef- forts to educate nurses regarding EBP have improved nurses’ knowledge and attitudes. However, these efforts have not nec- essarily resulted in actual improvements in EBP implementa- tion, nor have they changed clinical practices (Aarons et al., 2014; Melnyk et al., 2014; Pryse et al., 2014). Although barri- ers to EBP implementation have been well-documented, some authors have also cited the importance of organizational cul- ture and leadership in reducing barriers and fostering EBP implementation.

Organizational Culture and Leadership for EBP An organizational culture that emphasizes making clinical de- cisions based on evidence is critical for improving and sus- taining safe and high-quality patient care (Melnyk, Fineout- Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010). Al- though leaders influence the organizational culture, they also play an important role in supporting implementation of EBP and other innovative practices. Supportive leaders obtain fund- ing, provide resources, allow the time necessary for nurses to engage in EBP implementation, and reward those nurses who participate in evidence-based change projects in perfor- mance evaluations (Aarons et al., 2014; Ehrhart, Aarons, & Farahnak, 2015). Ehrhart, Aarons, and Farahnak (2015) have reported that clinical nurses with the greatest clinical exper- tise and EBP knowledge were most helpful in advancing EBP skills and positive EBP attitudes among their coworkers. This finding supports the importance of mentorship in improving nurses’ knowledge, attitudes, and practice of EBP (Abdullah et al., 2014; Green et al., 2014; Magers, 2014).

Furthermore, organizations that engage in the Magnet Recognition Program have been recognized for nurse engage- ment in EBP and implementation of clinical practice changes. The Magnet journey transforms organizational cultures, and ensures leadership support and resources necessary to facili- tate nurses’ engagement in EBP (American Nurses Credential- ing Center, 2014; Black, Balneaves, Garossino, Puyat, & Qian, 2015; Wilson et al., 2015).

Educational Processes to Enhance EBP in Healthcare Settings A number of studies have described the structures, processes, and outcomes of programs to enhance nurses’ appreciation, knowledge, competencies, and practice of EBP (Kim et al., 2013; Magers, 2014; Mollon et al., 2012; Ramos-Morcillo et al., 2015; Underhill et al., 2015; Wong & Myers, 2015). Although

most EBP educational programs emphasize EBP contents re- lated to asking relevant clinical questions, and searching for and appraising forms of evidence, less emphasis is put on actual EBP implementation (Wyer, Umscheid, Wright, Silva, & Lang, 2015). The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model emphasizes EBP implementation as the final focal point of the entire model, through which all of the beneficial outcomes of EBP diffusion flow (Melnyk et al., 2010). These outcomes include benefits to patients with improved patient outcomes as well as bene- fits to nurses such as higher job satisfaction and group cohe- sion, along with lower nurse turnover, with the ultimate out- come of decreased hospital costs. Using the ARCC model to educate nurses, previous studies have reported that partici- pants’ beliefs about EBP were significantly correlated with perceived organizational culture for EBP, implementation of EBP, group cohesion, and job satisfaction (Melnyk et al., 2010; Wallen et al., 2010). However, there has not been a full ex- amination of the strength of relationships among EBP beliefs, EBP implementation, job satisfaction, and group cohesion that takes the demographic variables into account.

The purpose of the study was to examine the relation- ships among EBP beliefs, EBP implementation, job satisfac- tion, group cohesion, and group attractiveness among nurses participating in a regional, collaborative EBP fellowship pro- gram. The specific aims were to examine: (a) EBP beliefs as a predictor of EBP implementation; and (b) EBP beliefs and EBP implementation as predictors of job satisfaction, group cohe- sion, and group attractiveness above and beyond the influence of demographic variables.

METHODS Design and Participants Three annual cohorts of nurses attending the 9-month re- gional, collaborative EBP fellowship program in San Diego, California, from 2012 to 2014 were invited to participate in the study. The program attendees were selected nurses repre- senting each participating institution as a dyad of mentor and fellow. The fellows, in general, were staff nurses who would be implementing unit-based EBP projects under the mentorship of advanced practice nurses, nurse educators, or other nurses with experience in implementing EBP projects.

Instruments EBP beliefs scale. This 16-item scale measures respondents’ beliefs about the importance of EBP and their EBP competence in a five-point Likert response format, ranging from strongly disagree ( = 1) to strongly agree ( = 5). Possible total scores range from 16 to 80, with higher scores indicating stronger EBP beliefs. The internal consistency reliability was reported as Cronbach’s alpha of 0.90, and validity testing has also been reported in the previous study (Melnyk, Fineout-Overholt, & Mays, 2008). The Cronbach’s alpha for the instrument in this study was 0.87.

Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. 341 C© 2016 Sigma Theta Tau International

Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

EBP implementation scale. This 18-item scale assesses the frequency of performing EBP-related activities in the past 8 weeks (Melnyk et al., 2008). Examples of items include gener- ating a PICO question, critically appraising research evidence, and collecting data, as well as sharing EBP guidelines with oth- ers. Response options range from 0 times ( = 0) to greater than or equal to 8 times ( = 4), and the total summation score ranges from 0 to 72, with a higher score indicating greater participa- tion in EBP-related activities. The internal consistency reliabil- ity was Cronbach’s alpha of 0.96, and validity testing was also reported. The Cronbach’s alpha in this study was 0.96.

Job satisfaction scale. Respondents are asked to rate their perception of job satisfaction in a five-point Likert response format, ranging from strongly disagree ( = 1) to strongly agree ( = 5). This scale contains four items and the total summation score ranges from 4 to 20, with a higher score indicating higher job satisfaction (Mueller, Boyer, Price, & Iverson, 1994). The Cronbach’s alpha was reported as 0.88 in the previous study and it was 0.89 in this study.

Group cohesion and attractiveness scales. These are two scales that measure group cohesion and group attractiveness in a seven-point Likert response format (Good & Nelson, 1973). The four-item Group Cohesion scale rates respondents’ percep- tion about their work group’s productivity, efficiency, feeling of belongingness, and morale from very much above average ( = 1) to very much below average ( = 7). The two-item Group Attractiveness scale assesses respondents’ perception of their enjoyment in working with the group. Responses range from like/enjoy very much ( = 1) to dislike very much ( = 7). In this study, the scores were reversed so that higher scores indicate positive perceptions. The reported split-half reliabilities were 0.77 and 0.82, whereas the Cronbach’s alphas in this study were 0.90 and 0.85, respectively.

Demographic data form. General demographic information, such as age, educational background, ethnicity, years of RN experience, and nursing position, was obtained.

Data Collection Procedures This study was approved by the institutional review boards of the participating academic and healthcare institutions. A consent letter was provided to and reviewed by all potential participants. Written documentation of consent was waived, because minimal risk was involved in this study and partici- pants’ anonymity was protected. Completion of the study ques- tionnaires indicated consent to participate in the study. The participants completed the study questionnaires at the begin- ning of each 9-month program.

Data Analyses Descriptive statistics, including mean, standard deviation, fre- quency, and percentage, were calculated. Independent t-tests were performed to compare the mean scores of EBP be- liefs, EBP implementation, job satisfaction, group cohesion,

and group attractiveness between the mentors and the fel- lows. Bivariate Pearson’s correlations were performed to exam- ine the relationships among demographic variables and other variables. To examine EBP beliefs as a predictor of EBP im- plementation, the demographic variables that had significant correlations with EBP implementation were entered in the first step of the hierarchical multiple regression model. The EBP be- liefs was then entered in the second step as a predictor of EBP implementation above and beyond the demographic variables.

To examine EBP beliefs and EBP implementation as pre- dictors of job satisfaction, group cohesion, and group attrac- tiveness, the demographic variables that correlated with job satisfaction, group cohesion, or group attractiveness were en- tered in the first step of the hierarchical multiple regression models. This was followed by entry of the EBP beliefs and EBP implementation in the second step as predictors above and beyond the demographic variables. The assumptions of normality, linearity, and homoscedasticity in the hierarchical multiple regression models were met. SPSS version 21.0 (IBM SPSS Statistics, Armonk, NY) was used for data analyses and the level of significance was set at p < .05.

RESULTS Sample Characteristics A total of 175 participants (101 fellows and 74 mentors) from the three annual cohorts between 2012 and 2014 completed the questionnaires at the beginning of the program. The fellows comprised 57.7% of all participants. A majority of the partic- ipants were white (69.7%) and had graduate degrees (52%). The mean age was 42 years and average RN experience was 15 years (Table 1).

The mentors had statistically significant higher scores for EBP beliefs (66.6 vs. 59.3; p < .001) and EBP implementation (24.2 vs. 11.0; p < .001) in comparison with the fellows. How- ever, there were no statistically significant differences in job satisfaction, group cohesion, or group attractiveness between the mentors and the fellows (Table 2).

Bivariate Correlations among Demographics and Other Variables Table 3 shows that the demographic variables of being a mentor, clinical nurse specialist, nurse educator, or nurse practitioner, as well as having a graduate-level education, had statistically significant positive correlations with both EBP beliefs and EBP implementation. Length of RN experience also correlated with EBP implementation and having a graduate- level education was the only demographic variable that corre- lated with job satisfaction. None of the demographic variables had positive correlations with either group cohesion or group attractiveness.

For EBP implementation, positive correlations were ob- served with EBP beliefs (r = 0.47; p < .001) and job satisfaction (r = 0.17; p = .029). However, no statistically significant cor- relations were found between EBP implementation and group

342 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article Table 1. Demographic Characteristics (N = 175)

Total Fellows Mentors

Variables (N= 175) (n= 101) (n= 74) Cohorts

2012 cohort 42 (24.0) 20 (19.8) 22 (29.7)

2013 cohort 60 (34.3) 40 (39.6) 20 (27.0)

2014 cohort 73 (41.7) 41 (40.6) 32 (43.2)

Age, mean (year), range 42 (23-68) 39 (23-68) 46 (27-67)

Ethnicity

White (non-Hispanic) 122 (69.7) 66 (65.3) 56 (75.7)

Black 5 (2.9) 3 (3.0) 2 (2.7)

Hispanic 11 (6.3) 6 (5.9) 5 (6.8)

Asian/Pacific Islanders 29 (16.6) 19 (18.8) 10 (13.5)

Other 8 (4.5) 7 (6.9) 1 (1.4)

Educational level

Diploma/associate 8 (4.6) 8 (7.9) 0 (0.0)

Baccalaureate 76 (43.4) 70 (69.3) 6 (8.1)

Master/doctorate 91 (52.0) 23 (22.8) 68 (91.9)

Nursing position

Clinical nurse 73 (41.7) 67 (66.3) 6 (8.1)

Lead nurse 20 (11.4) 13 (12.9) 7 (9.5)

Nurse manager 12 (6.9) 1 (1.0) 11 (14.9)

CNS/nurse educator/NP 64 (36.6) 15 (14.9) 49 (66.2)

Non-nursing 6 (3.4) 5 (5.0) 1 (1.4)

RN experience, mean (year), range 15 (1, 42) 12 (1, 35) 20 (2, 42)

ANCC certification in specialty 94 (53.7) 48 (47.5) 46 (62.2)

Note. Values are expressed as n (%) unless otherwise indicated. Percentages may not add up to 100% because of missing data or rounding. ANCC = American Nurses Credentialing Center; CNS= clinical nurse specialist; NP= nurse practitioner; RN= registered nurse.

cohesion or group attractiveness. For job satisfaction, there were positive correlations with EBP beliefs (r = 0.26; p = .01) and group attractiveness (r = 0.23; p = .003). There was also a positive correlation between group cohesion and group attrac- tiveness (r = 0.49; p < .001; Table 3).

Multivariate Analysis: EBP Beliefs as a Predictor of EBP Implementation In the first step of a hierarchical multiple regression model, the demographic variables, including being a mentor, edu- cational level, years of RN experience, and nursing position accounted for 22.5% of the variance in EBP implementation

(R2 = 0.225; Table 4). The entry of the EBP beliefs in the second step increased the R2 by .075, indicating that the EBP beliefs explained a small fraction of the variance in the EBP implementation above and beyond the demographic variables (7.5%). Being a mentor (β = 0.27; p = .012) and EBP beliefs (β = 0.33; p < .001) were statistically significant predictors of EBP implementation.

Multivariate Analyses: Predictors of Job Satisfac- tion, Group Cohesion, and Group Attractiveness Table 5 shows that demographic variables in the first step of a hierarchical multiple regression model accounted for 6.2%

Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. 343 C© 2016 Sigma Theta Tau International

Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

Table 2. Comparison of Mean (± SD) of Variables Between Mentors and Fellows (N = 170)

P value

Fellows Mentors independent

(n= 98) (n= 72) (t test)

EBP beliefs 59.3 (6.38) 66.6 (6.91) < .001***

EBP implementation 11.0 (10.6) 24.2 (16.9) < .001***

Job satisfaction 16.6 (2.18) 17.0 (2.34) .215

Group cohesion 20.1 (4.39) 20.6 (4.67) .479

Group attractiveness 11.7 (1.67) 11.8 (1.83) .653

Note. ***p < 0.001. SD = standard deviation. The higher the scores, the higher the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness.

of the variance in job satisfaction (R2 = 0.062). The entry of EBP beliefs and EBP implementation in the second step in- creased the R2 by 0.050, indicating that these two variables ex- plained a small fraction of the variance in job satisfaction above and beyond demographic variables (5.0%). EBP beliefs was a statistically significant positive predictor of job satisfaction (β = 0.25; p = .011), but EBP implementation was not a predictor of job satisfaction.

For group cohesion, the demographic variables in the first step explained 1.8% of the variance of group cohesion (R2 = 0.018). The EBP beliefs and EBP implementation in the second step explained 0.2% of the variance of group cohesion (R2 = 0.002), indicating that these two variables explained only a minimal fraction of variance in group cohesion above and beyond the demographic variables.

For group attractiveness, the first entry of demographic variables accounted for 1.0% of the variance of the group at- tractiveness (R2 = 0.010). The entry of EBP beliefs and EBP implementation in the second step changed the R2 by 0.038, indicating that they explained a minimal fraction of the vari- ance in group attractiveness (3.8%). EBP implementation was a statistically significant negative predictor for group attractive- ness (β = -0.22; p = .021; Table 5).

Table 3. Bivariate Correlations Among Variables

EBP beliefs

EBP implementation

Job satisfaction

Group cohesion

Group attractiveness

Mentors 0.48*** 0.43*** 0.10 0.06 0.04

Educational level

Diploma/associate −0.19* −0.03 −0.02 −0.19* 0.01

Baccalaureate −0.43*** −0.37*** −0.15* −0.002 −0.06 Master/doctorate 0.51*** 0.38*** 0.16* 0.01 0.07

Years of RN experience 0.13 0.16* 0.02 0.04 0.04

Nursing position

Clinical nurse −0.33*** −0.28*** 0.04 −0.01 −0.07 Lead nurse −0.02 −0.001 −0.19* −0.04 −0.02 Nurse manager 0.07 −0.02 −0.07 0.11 0.04

CNS/nurse educator/NP 0.34*** 0.32*** 0.09 −0.02 0.01

EBP beliefs 1 0.47*** 0.26** −0.02 0.09

EBP implementation 0.47*** 1 0.17* −0.02 −0.11 Job satisfaction 0.26** 0.17* 1 0.09 0.23**

Group cohesion −0.02 −0.02 0.09 1 0.49***

Group attractiveness 0.09 −0.11 0.23** 0.49*** 1

Note. *p< .05; ** p< .01; *** p< .001 by Pearson’s correlations.

344 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article Table 4. Multivariate Analysis: Predictors of EBP Im- plementation

EBP implementation

Predictors B β

Step 1

Constant demographic variables a 15.4

R2 = 0.225***

Step 2

Constant −27.0 Mentor 8.25* 0.27*

EBP beliefs 0.66*** 0.33***

R2 � = 0.075***

F� (1, 160) = 17.22***

Note. *p < 0.05; *** p < 0.001. aDemographic variables of being a men- tor, educational level, years of RN experience, and nursing position were entered.

DISCUSSION The study findings indicate that EBP beliefs had a signifi- cant correlation with EBP implementation in bivariate anal- ysis, and was a positive predictor of EBP implementation in multivariate analysis. In addition, EBP beliefs showed a signif-

icant correlation with job satisfaction in bivariate analysis and was also a positive predictor of job satisfaction in multivariate analysis. These results are consistent with previous findings and support the ARCC model, which postulates that strong EBP beliefs result in high levels of EBP implementation (Melnyk et al., 2010).

Although these study findings indicate that EBP implemen- tation has some correlation with job satisfaction in a bivariate analysis, the multivariate analysis showed a surprising finding that EBP implementation was not a predictor of job satisfac- tion. In addition, EBP implementation was not a significant predictor of group cohesion or group attractiveness in mul- tivariate analyses. Furthermore, EBP implementation was a significant negative predictor of group attractiveness, indicat- ing that high levels of EBP implementation are associated with lower group attractiveness. These unexpected findings from multivariate analyses appear to conflict with the ARCC model, which postulates that high levels of EBP implementation re- sult in high job satisfaction as well as high group cohesion (Melnyk et al., 2010). However, these findings are consistent with a previous report showing no statistically significant cor- relations between EBP implementation and job satisfaction or group cohesion (Melnyk et al., 2010). Also, an interventional study of implementing the ARCC model showed no signifi- cant effect on job satisfaction, in spite of improvements in EBP implementation (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011). It is possible that these findings showing no significant relationship between EBP implementation and job satisfaction or group cohesion are due to small sample sizes, which could have prevented detection of small effects. Further studies are needed to confirm this study findings.

Table 5. Multivariate Analyses: Predictors of Job Satisfaction, Group Cohesion, and Group Attractiveness

Job satisfaction Group cohesion Group attractiveness

Predictors B β B β B β

Step 1

Constant 17.0 19.3 12.1

demographic variables a

R2 = 0.062 R2 = 0.018 R2 = 0.010 Step 2

Constant 12.2 20.9 10.2

EBP implementation 0.01 0.06 −0.01 −0.03 −0.03* −0.22 EBP beliefs 0.07* 0.25* −0.02 −0.04 0.04 0.16

R2 � = 0.050* R2 � = 0.002 R2 � = 0.038*

F� (2, 157) = 4.47* F� (2, 162) = 0.16 F� (2, 157) = 3.12*

Note. *p< 0.05. aDemographic variables of being a mentor, educational level, years of RN experience, and nursing position were entered.

Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. 345 C© 2016 Sigma Theta Tau International

Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

It was not surprising that mentors, given their longer years of RN experience, higher levels of education, and nursing positions as advanced practice nurses (clinical nurse special- ists, nurse educators, or nurse practitioners), had significantly stronger EBP beliefs and greater EBP implementation. These findings are consistent with previous reports showing that higher levels of education correlated with higher EBP be- liefs and EBP implementation (Underhill et al., 2015). It is interesting that the mentors did not have higher job satis- faction, group cohesion, or group attractiveness, in spite of having higher EBP implementation. This is consistent with the aforementioned findings from this study, as well as previ- ous reports that EBP implementation is not necessarily asso- ciated with higher job satisfaction or group cohesion (Melnyk et al., 2010).

Since its inception in 2006, our regional collaborative EBP fellowship program has been in continuous operation, and has successfully educated more than 400 nurses and nurse lead- ers from 12 local hospitals to date. With solid and consistent organizational support from local hospitals and academic insti- tutions, the fellowship program has been able to pool resources and expertise from these organizations to empower participat- ing nurses to execute unit-based EBP projects (Kim et al., 2013). The fellows and mentors, equipped with EBP knowledge and skills, along with strong EBP beliefs, become EBP champi- ons in their own hospital units and serve as role models for their colleagues (Melnyk, 2007). We believe that our regional EBP fellowship program in Southern California can serve as a template for other regional organizations to come together and collaborate in fostering EBP implementation across mul- tiple hospitals in their own regions, with the ultimate aim of improving quality of care and patient outcomes.

Limitations There are several limitations to this study. First, the study find- ings of EBP beliefs as a significant predictor of EBP implemen- tation and job satisfaction should not be taken as cause-and- effect relationships in this descriptive cross-sectional study. Second, the subjective self-reporting methods of the study questionnaire may have overestimated respondents’ percep- tions about their beliefs in the value of EBP, EBP implemen- tation, and job satisfaction. Third, the fellowship participants were selected from a group of staff nurses who had already demonstrated high motivation for EBP adoption. Due to the potential sample selection bias, the study findings may not be generalizable to other nursing staff. Fourth, although the in- struments used in this study have been validated previously, the items may not have fully captured the intended concepts. Further refinements of the instruments could show differ- ent results. Finally, even though the study population came from multiple institutions, the findings are from one region in Southern California and may not be generalizable to other regions.

Future studies are needed to conduct an interventional study to evaluate the beneficial effects of regional fellowship

programs on EBP beliefs, EBP implementation, job satisfac- tion, and group cohesion. There is a need for further empir- ical research evidence to support relationships in the ARCC model.

CONCLUSIONS The baseline data collected from the participants of a regional collaborative fellowship program involving multiple local hos- pitals and academic institutions over a 3-year period indicated that strong EBP beliefs was a positive predictor of EBP imple- mentation and job satisfaction. However, no significant rela- tionships were found between EBP implementation and job satisfaction or group cohesion when demographic variables were taken into account. Further studies are needed to evalu- ate the impact of regional collaborative fellowship programs on EBP beliefs, EBP implementation, job satisfaction, and group cohesion among the participants, as well as to generate addi- tional evidence for the ARCC model. WVN

LINKING EVIDENCE TO ACTION

� A regional, collaborative EBP fellowship program utilizing institution-matched mentors should be encouraged to advance EBP because such pro- grams may be effective in improving EBP beliefs, EBP implementation, and job satisfaction.

� Support from participating institutions is essential for the success of a regional, collaborative EBP fellowship program.

� Strong beliefs in the value of EBP appear to be associated with high levels of EBP implementation and job satisfaction among the fellowship program participants.

� No significant relationship was found between EBP implementation and job satisfaction or group cohesion when demographic variables were taken into account; further studies are needed to confirm these unexpected study findings.

Author information

Son Chae Kim, Professor, St. David’s School of Nursing, Texas State University, Round Rock, TX; Jaynelle F. Stichler, Pro- fessor Emerita, San Diego State University; Consultant, Re- search and Professional Development, Sharp Memorial Hos- pital and Sharp Mary Birch Hospital for Women & Infants, San Diego, CA; Laurie Ecoff, Director of Research, Education, and Professional Practice, Sharp Memorial Hospital, San Diego, CA; Caroline E. Brown, Research Consultant, Bonita Springs, FL; Ana-Maria Gallo, Director of Nursing Education, Research and Professional Practice, La Mesa, CA; Judy E. Davidson,

346 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article EBP/Research Nurse Liaison, University of California San Diego Health System, San Diego, CA

Address correspondence to Dr. Son Chae Kim, Professor, St. David’s School of Nursing, Texas State University, 1555 Univer- sity Blvd., Round Rock, TX 78665; [email protected]

Accepted 14 November 2015 Copyright C© 2016, Sigma Theta Tau International

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The Quadruple Aim: care, health, cost and meaning in work

Rishi Sikka,1 Julianne M Morath,2 Lucian Leape3

1Advocate Health Care, Downers Grove, Illinois, USA 2Hospital Quality Institute, Sacramento, California, USA 3Harvard School of Public Health, Boston, Massachusetts, USA

Correspondence to Dr Rishi Sikka, Advocate Health Care, 3075 Highland Avenue, Suite 600, Downers Grove, Il 60515, USA; [email protected]

Received 5 March 2015 Revised 6 May 2015 Accepted 16 May 2015

To cite: Sikka R, Morath JM, Leape L. BMJ Qual Saf 2015;24:608–610.

In 2008, Donald Berwick and colleagues provided a framework for the delivery of high value care in the USA, the Triple Aim, that is centred around three over- arching goals: improving the individual experience of care; improving the health of populations; and reducing the per capita cost of healthcare.1 The intent is that the Triple Aim will guide the redesign of healthcare systems and the transition to population health. Health systems glo- bally grapple with these challenges of improving the health of populations while simultaneously lowering healthcare costs. As a result, the Triple Aim, although ori- ginally conceived within the USA, has been adopted as a set of principles for health system reform within many organi- sations around the world. The successful achievement of the

Triple Aim requires highly effective healthcare organisations. The backbone of any effective healthcare system is an engaged and productive workforce.2 But the Triple Aim does not explicitly acknow- ledge the critical role of the workforce in healthcare transformation. We propose a modification of the Triple Aim to acknow- ledge the importance of physicians, nurses and all employees finding joy and meaning in their work. This ‘Quadruple Aim’ would add a fourth aim: improving the experience of providing care. The core of workforce engagement is

the experience of joy and meaning in the work of healthcare. This is not synonym- ous with happiness, rather that all members of the workforce have a sense of accomplishment and meaning in their contributions. By meaning, we refer to the sense of importance of daily work. By joy, we refer to the feeling of success and fulfilment that results from meaning- ful work. In the UK, the National Health Service has captured this with the notion of an engaged staff that ‘think and act in a positive way about the work they do, the people they work with and the organ- isation that they work in’.3

The evidence that the healthcare work- force finds joy and meaning in work is not encouraging. In a recent physician survey in the USA, 60% of respondents indicated they were considering leaving practice; 70% of surveyed physicians knew at least one colleague who left their practice due to poor morale.2 A 2015 survey of British physicians reported similar findings with approximately 44% of respondents reporting very low or low morale.4 These findings also extend to the nursing profession. In a 2013 US survey of registered nurses, 51% of nurses worried that their job was affect- ing their health; 35% felt like resigning from their current job.5 Similar findings have been reported across Europe, with rates of nursing job dissatisfaction ranging from 11% to 56%.6

This absence of joy and meaning experi- enced by a majority of the healthcare workforce is in part due to the threats of psychological and physical harm that are common in the work environment. Workforce injuries are much more frequent in healthcare than in other industries. For some, such as nurses’ aides, orderlies and attendants, the rate is four times the indus- trial average.7 More days are lost due to occupational illness and injury in health- care than in mining, machinery manufac- turing or construction.7

The risk of physical harm is dwarfed by the extent of psychological harm in the complex environment of the health- care workplace. Egregious examples include bullying, intimidation and phys- ical assault. Far more prevalent is the psy- chological harm due to lack of respect. This dysfunction is compounded by pro- duction pressure, poor design of work flow and the proportion of non-value added work. The current dysfunctional healthcare

work environment is in part a by-product of the gradual shift in healthcare from a public service to a business model that occurred in the latter half of the 20th

EDITORIAL

608 Sikka R, et al. BMJ Qual Saf 2015;24:608–610. doi:10.1136/bmjqs-2015-004160

century.8 Complex, intimate caregiving relationships have been reduced to a series of transactional demand- ing tasks, with a focus on productivity and efficiency, fuelled by the pressures of decreasing reimbursement. These forces have led to an environment with lack

of teamwork, disrespect between colleagues and lack of workforce engagement. The problems exist from the level of the front-line caregivers, doctors and nurses, who are burdened with non-caregiving work, to the healthcare leader with bottom-line worries and disproportionate reporting requirements. Without joy and meaning in work, the workforce cannot perform at its potential. Joy and meaning are generative and allow the best to be contributed by each individual, and the teams they comprise, towards the work of the Triple Aim every day. The precondition for restoring joy and meaning is

to ensure that the workforce has physical and psycho- logical freedom from harm, neglect and disrespect. For a health system aspiring to the Triple Aim, fulfill- ing this precondition must be a non-negotiable, endur- ing property of the system. It alone does not guarantee the achievement of joy and meaning, however the absence of a safe environment guarantees robbing people of joy and meaning in their work. Cultural freedom from physical and psychological harm is the right thing to do and it is smart economics because toxic environments impose real costs on the organisation, its employees, physicians, patients and ultimately the entire population. An organisation focused on enabling joy and

meaning in work and pursuit of the Triple Aim needs to embody shared core values of mutual respect and civility, transparency and truth telling and the safety of the workforce. It recognises the work and accom- plishments of the workforce regularly and with high visibility. For the individual, these notions of joy and meaning in healthcare work are recognised in three critical questions posed by Paul O’Neill, former chair- man and chief executive officer of Alcoa. This is an internal gut-check, that needs to be answered affirma- tively by each worker each day:2

1. Am I treated with dignity and respect by everyone, everyday, by everyone I encounter, without regard to race, ethnicity, nationality, gender, religious belief, sexual orientation, title, pay grade or number of degrees?

2. Do I have the things I need: education, training, tools, financial support, encouragement, so I can make a con- tribution this organisation that gives meaning to my life?

3. Am I recognised and thanked for what I do? If each individual in the workforce cannot answer

affirmatively to these questions, the full potential to achieve patient safety, effective outcomes and lower costs is compromised. The leadership and governance of our healthcare

systems currently have strong economic and outcome motivations to focus on the Triple Aim. They also need to feel a parallel moral obligation to the

workforce to create an environment that ensures joy and meaning in work. For this reason, we recommend adding a fourth essential aim: improving the experi- ence of providing care. The notion of changing the objective to the Quadruple Aim recognises this focus within the context of the broader transformation required in our healthcare system towards high value care. While the first three aims provide a rationale for the existence of a health system, the fourth aim becomes a foundational element for the other goals to be realised. Progress on this fourth goal in the Quadruple Aim

can be measured through metrics focusing on two broad areas: workforce engagement and workforce safety. Workforce engagement can be assessed through annual surveys using established frameworks that allow for benchmarking within industry and with non-healthcare industries.9 Measures should also be extended to quantify the opposite of engagement, workforce burn-out. This could include select ques- tions from the Maslach Burnout Inventory, the gold standard for measuring employee burn-out.10 In the realm of workforce safety, metrics should include quantifying work-related deaths or disability, lost time injuries, government mandated reported injuries and all injuries. Although these measures do not com- pletely quantify the experience of providing care, they provide a practical start that is familiar and allow for an initial baseline assessment and monitoring for improvement. The rewards of the Quadruple Aim, achieved within

an inspirational workplace could be immense. No other industry has more potential to free up resources from non-value added and inefficient production practices than healthcare; no other industry has more potential to use its resources to save lives and reduce human suffering; no other industry has the potential to deliver the value envisioned by The Triple Aim on such an audacious scale. The key is the fourth aim: creating the conditions for the healthcare workforce to find joy and meaning in their work and in doing so, improving the experience of providing care.

Contributors All authors assisted in the drafting of this manuscript.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES 1 Berwick DM, Nolan TW, Whittington J. The triple aim: care,

health and cost. Health Aff 2008;27:759–69. 2 Lucian Leape Institute. 2013. Through the eyes of the

workforce: creating joy, meaning and safer health care. Boston, MA: National Patient Safety Foundation.

3 NHS employers staff engagement. http://www.nhsemployers. org/staffengagement (accessed 4 May 2015).

4 BMA Quarterly Tracker Survey. http://bma.org.uk/working- for-change/policy-and-lobbying/training-and-workforce/

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tracker-survey/omnibus-survey-january-2015 (accessed 4 May 2015).

5 AMN Healthcare 2013 survey of registered nurses. http://www. amnhealthcare.com/uploadedFiles/MainSite/Content/ Healthcare_Industry_Insights/Industry_Research/2013_ RNSurvey.pdf (accessed 4 May 2015).

6 Aiken LH, Sermeus W, Van Den HeedeKoen, et al. Patient safety, satisfaction and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012;344:e1717.

7 US Department of Labor Bureau of Labor Statistics. Occupational injuries and illnesses (annual) news release.

Workplace injuries and illnesses 2009. 21 October 2010. http://www.bls.gov/news.release/archives/osh_10212010.htm (accessed 4 May 2015).

8 Morath J. The quality advantage, a strategic guide for health care leaders. AHA Press, 1999:225.

9 Surveys on Patient Safety Culture. Agency for Healthcare Research and Quality. http://www.ahrq.gov/professionals/quality- patient-safety/patientsafetyculture/index.html (accessed 4 May 2015).

10 Maslach C, Jackson S, Leiter M. Maslach burnout inventory manual. 3rd edn. Palo Alto, CA: Consulting Psychologists Press, 1996.

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