Description of Steps
The identified stakeholders for the proposed change in AMRTC included hospital leadership, participating nurses, and patients (Bravi et al., 2013). The former group had the most power and influence on the project, as they were the ones allocating resources and nurses to see it done. They had a reasonably high interest in the success of the project. Nurses had a moderate-to-high power and influence over the course of the project, submitting to hospital leadership in matters of subordination, but being active with propositions and feedback as the project went on. They too had a high interest in the success of the intervention. The patients were tertiary stakeholders, as their psychological health issues prevented them from actively participating in the project. In most cases, they were considered to be recipients of care.
The implementation plan of the project had 5 stages, which included the preparation stage, the implementation stage, divided into three sub-parts, and the revision stage (Burnes & Bargal, 2017). The plan revolved around Kurt Lewinâs framework of change implementation (Burnes & Bargal, 2017), During the preparation stage, the team arranged a meeting with AMRTCâs directors and top healthcare managers, to present the project. They were, understandably, very busy, but managed to give me time for the presentation. Besides myself, there were 4 other individuals in the room, in accordance with maximum limit of 5 during the COVID-19 emergency. They reviewed the proposed plan of action and were positively predisposed to it. The council pointed out that that the entirety of AMRTC could not undergo the change at the same time without significantly inconveniencing everyone involved, but they agreed to allow for a team of nurses working with 3 patients to serve as a test group for the research, reducing its size and scope, but not altering the overall plan of action. Afterwards, the team was allowed to meet the nurse leader of the team and explain the proposition to her in detail.
The implementation stage featured three steps as indicated by the original plan. The team introduced a system of color codes: green, yellow, red, to indicate the likelihood of violence in different patients (Halter et al., 2017). Conveniently, the patients given for the team to administer featured one green, one yellow, and one red-coded patient. Based on that gradation, younger nurses within the team dealt with the green patient. They were also allowed to work with the yellow patient under the supervision of a more experienced nurse and were forbidden from interacting with the red patient.
The second step, according to the plan, was supposed to include an increase in payment for nurses due to savings achieved from retention. Because the intervention did not see as wide of a scope as initially planned, however, obtaining the funds for increasing salaries for the participant nurses proved to be impossible. As such, the second step of the stage was abandoned. The third step featured a gradual change from a 12-our shift to an 8-hour shift pattern. This was realized by allowing younger nurses to work on an 8-hour schedule, every day, with older nurses more comfortable with 12-hour shifts covering the time positions where younger nurses were not available (Banakhar, 2017). Because this practice often generated discrepancies in schedules, sometimes the younger nurses were asked to stay overtime and work 10 hours instead of 8 (Banakhar, 2017).
During the last stage, the new model was being observed for any changes that needed to be implemented. Weekly reports were delivered to the administration of the hospital for review and any recommendations they had were put into implementation. One of the more significant implementations was the increase in the number of nurses, as more became available, allowing us to switch to the 8-hour shifts instead of 10-hour shifts, which was useful for the initial purposes of the project. Also, the hospital offered a small bonus to individuals participating in the experiment, resulting in a substitute for stage 2.
Discussion of Changes
There were several changes made to the original project plan, which were motivated by AMRTCâs capacity to support the proposed changes. Namely, the intervention that was planned to encompass the entire facility or a large department within it was reduced to being tested out on a single team taking care of 3 patients. This significantly reduced the scope of the project. In addition, the proposed increase in nurse salaries as a result of improved retention was significantly curtailed due to the reduced scope of the project. Further down the line, it was partially implemented in a form of bonuses to nurses going through with the experiment. Finally, the switch to 8-hour shifts became possible only once a few more nurses joined the project, as it was impossible to schedule everyone to have 8-hour shifts appropriately otherwise.
Discussion of Barriers
The primary barriers identified during the initial meeting with senior hospital staff included the lack of staff available for the project (initial number of nurses was 5, which grew to 8 during the later stages), the lack of availability of funds, and the reduction of the initial scope of the project. The economic part of the intervention was largely based on project scope as a means of increasing retention, providing economic stimuli for the hospital to increase salaries, and to have more representation in general. Without it, it was harder to justify salary increases for a specific small group of nurses, and it was harder to switch them to an 8-hour shift. Other than that, there were no significant barriers to the intervention, as the staff of AMRTC was very forthcoming to the experiment.
Overcoming Barriers
The project had to be adjusted to respond to the changes in scope and the availability of nurses and funds. Initially, there was nothing to be done in regards to the number of patients, nurses, and material motivations to be allocated for the project, so we had to work with what we had. While applying the color-coding schematic was easy enough even on a small scale, the allocations had to be changed â for example, it was allowed for younger nurses to supervise yellow patients under the supervision of a more experienced nurse. This was done because out of 5 nurses, 3 could be classified as relatively novice. Allocating all three to tending 1 green patient would have been a waste of time for the nurses. Later on, we were given more nurses, patients, and some bonuses to imitate financial stimulation.
Finally, to compensate for a lack of participants, the transfer to an 8-hour shift had to be postponed, in favor of 10-hour shifts. This was in accordance with the initial literature-supported assessment that shorter shifts result in better retention and lesser burnout. These were the major challenges to the project that were successfully overcome either by changing the projectâs initial plan, through the assistance of AMRTC staff or both.
Identification of Interprofessional Relationships
The project received plenty of assistance from the hospital administration and staff along the way. The team had a good and mutually-beneficial interprofessional relationship with AMRTCâs director as well as the nurse leader for the nursing team. Both of them shared the views and ideas proposed in the project and did their best to support it, even though the project was curtailed in its scope as a result of strained resources for the hospital. The Directorâs contribution was in managing to allocate the team more employees and financial stimulation for nurses as the project showed to be performing well. The nurse leader, on the other hand, directly involved herself with the management of the resources available to her to make the project fit the initial plans and requirements. The adjustments to staffing in relation to color-codes as well as the switch from 8-hour shifts to 10-hour shifts were her ideas, and they worked out well. The rest of the participants were also very responsive and did their part to the best of their abilities. The team is grateful for their contribution to the project.
Discussion of Relationships
The positive attitude that both the director, the nurse leader, and the rest of the team had in relation to the project was conducive to the results achieved during its facilitation. The active participation of hospital staff coupled with their knowledge of the systemâs existing limitations and issues allowed to tailor the project to the facility, ensuring its functioning as part of the existing schedule without straining resources or reducing the overall efficiency of the ongoing operation. The receptiveness helped create a relationship of respect and trust between the parties, which contributed to the overall positive results of the project.
Discussion of Successes
The projectâs preparation phase was successful and went without substantial hitches. Although there were minor edits to be made during all steps of the way, from project conception to literature review assessment, planning, and presentation, they did not significantly alter the original idea behind the change: introducing a 3-color code for patients in AMRTC, improve nurse salaries, and switching to an 8-hour shift. Project presentation to hospital staff also went well, as they were excited to participate and assist in its implementation. Tackling the physical challenges associated with resource shortages was also done successfully, as the team was capable of adjusting the plans, goals, and scope to fit the realities and capabilities of AMRTC.
How Successes Will Inform Future Projects
Although future projects will likely involve different interventions, locations, and hospitals, there are some lessons from successful implementation of this one that could be transferred to other practices. The framework of developing the project, from its conception, to review of literature, to the creation of an action plan, and ending with a presentation to hospital staff was very useful and easy to follow. It will be utilized for the development of future projects. The development of healthy working relationships with key members of hospital staff was crucial for the continuation and adjustment of the project. Therefore, utilizing teamwork, collaboration, and clear communication in future efforts would be beneficial to future efforts as well. To summarize, having a well-tested framework to follow and engaging in cooperation and coordination with stakeholders during the project would help inform its success.
Aspects That Did Not Go as Well
Some aspects of the project did not go well, however. One of them was the inability of coordinating the development of the project beforehand with hospital officials. Most of the information about AMRTC was gathered from publicly-available sources, which did not reflect the inner workings of the organization with complete accuracy. Because of that, the action plan had to be remodeled based on feedback from hospital staff, after the presentation. Doing so significantly changed the scope of the project. Another obstacle was the lack of foresight in regards to the COVID-19 pandemic, which was one of the reasons why the project was severely curtailed in size and the number of available nurses. While AMRTC did not shut down because of COVID-19, the numbers available and the process of visitation were hampered. Since the team did not plan for such a heavy force majeure event, it significantly reduced the number of things we were allowed to do.
Understanding What Did Not Go Well
The first mistake that was made was the lack of coordination between the hospital and the team during the development part of the project. We first made the plan and then presented it to AMRTC staff. Edits were made only after we discovered that the aims and scope of the intervention were too large for them to bear, at present. Real-time feedback from various sources would have been a great help and allowed us to adjust accordingly instead of making last-minute changes. In the future, the team will rely on close coordination with the organization of interest during the development phase of the intervention. Finally, we did not account for force-majeure events. We should have developed a risk mitigation plan for such emergencies, which will be done in the future. To summarize, greater cooperation and coordination between stakeholders and researchers, as well as planning contingencies for different negative outcomes would be beneficial to the effectiveness of the project.
Explanation of How the Gap Was Bridged
Before the intervention, the problem at AMRTC involved poor retention and understaffing, which negatively impacted the overall performance of the hospital (Johnson et al., 2018). The hospital operated at half of its potential efficiency, with 110 beds available out of 200 (Minnesota Department of Human Services, 2020). Entire wings of the hospital were closed off, resulting in fewer patients being served, and a greater strain on the community that relied on AMRTC as its sole high-security facility for psychiatric patients (Minnesota Department of Human Services, 2020).
The literature reviewed in the scope of this paper instructed several approaches to improve retention. Halter et al. (2017) proposed the utilization of a three-color danger markings for the patients to outline expectations for each and utilize hospital staff precautions and resources accordingly. The idea of increasing compensation rates came from the fact that AMRTC had some of the lowest salaries for their employees in the US (âHow much,â 2020). Research advocated that increasing compensation rates would improve the hospitalâs position in the market as well as retention rates (Jansen, Hem, Dambolt & Hanssen, 2020). Finally, there was the solution of changing the schedules from 12-hour shifts to 8-hour shifts. This intervention was supported by numerous sources, namely Schroyer, Zellers and Abraham (2020), Johnson et al. (2018), Bravi et al. (2013), Banakhar(2017), and Imo (2017).
When the solution was implemented, it was done with significant alterations to the researchâs scope of practice. Although the number of participants was significantly reduced and the monetary rewards were not present until, in the later stages of the research, the nurses appreciated the changes, as they made their work safer, more rewarding, and less prone to burnout. None of the participants expressed a desire to leave the profession, including the newer nurses, which in itself may constitute a success.
Supporting the Plan (Post-Implementation)
The project provided the hospital with a working model of operation that does not require the presence of students to remain functioning. The short-term idea for the proposed solutions is to keep it as an experimental wing to receive long-term results of effectiveness while comparing them to the rest of the hospital in terms of safety, productivity, and nurse retention. Should the results be positive, AMRTC may consider expanding the program to encompass more of its members, and eventually transition to an 8-hour schedule with a higher per-hour rate of payment, as large-scale retention and savings because of such are going to be possible for a department-wide or hospital-wide intervention, achieving an economy of scale (Kossivi, Xu, & Kalgora, 2016). The solution will require staffing and budgetary adjustments to accommodate the new method of scheduling and compensating employees.
Resources for Post-Implementation
The initial project plan was meant to encompass the entire hospital. The adjusted plan involved only a small part of it (1 team). Therefore, the resources for project sustainability within a larger scope would remain similar to those projected at the start, including the following (Yuniarti & Tutiany, 2019):
- Human resources: Hospital staff, administrative staff;
- Material resources: Finances to support the changes in scheduling and compensation;
- Space resources: A meeting room and a training facility for more nurses to be acquainted with the new 3-color system.
Final estimations for post-implementational resource requirements could be
conducted along with the financial and management departments of AMRTC, as they have the concrete figures for estimations of how much will be needed to sustain a hospital-wide implementation of the changes tested out within the scope of the project.
Integrated Outcomes
The two most relevant MSN graduate outcomes from this task were the implementation of evidence-based practices as well as professional communication and collaboration. The former manifested throughout the formulation of the entirety of the project, its planning phases, presentation, and later adjustments to the realities of AMRTC. The initial study of evidence managed to provide an overarching picture of the situation in psychiatric hospitals in general, allowing to highlight some areas of potential interest that may be of concern for the organization of interest. These included poor retention, burnout, excessive scheduling, and threats to the safety of nurses at work. Further research into the organization supported these findings, indicating the poor retention of nurses as well as very high rates of patient-to-nurse violence, which resulted in boycotts and demonstrations in 2018 (Minnesota Department of Human Services, 2020). Thus, even though the team did not have any direct contact with the hospital before the meeting and presentation of the project, the identification of needs was done relatively accurately.
Further investigation of evidence and literature proposed effective solutions to the identified problems of safety, retention, and compensation. Although the scope of the project was severely limited after encountering the problems that AMRTC was facing at the moment, along with the COVID-19 situation, it was still salvageable. Additional literature search was conducted to ensure that the changes to the plan of action would not have a negative effect and would have some support with the evidence available, after which it was implemented in the project. The results were compared to similar research in the field, to see if they matched.
The second MSN outcome revolved around communication and collaboration. During the planning, formulation, and presentation part of the project, the team worked with the faculty to ensure the quality of the paper and presentation. It worked well, and such collaboration ensured that by the time the team had to present its solutions to the AMRTC staff, all major errors and inconsistencies have been polished off. Once the project entered its active phase, communication and collaboration allowed the team to work with the hospital staff to alter the project and continue its implementation in a smaller scope and format, while retaining its basic ideas and principles. The establishment of good working relations with all participants allowed for better implementation of solutions and evaluation of outcomes.
Abstract Creation
The purpose of this project is to improve nurse retention in AMRTC, which is one of the largest high-security psychiatric facilities in the US. The problems identified in the scope of the AMRTC included poor retention as a result of low payments compared to other regions within the US, poor safety and security for nurses, resulting in frequent attacks by patients, and uncomfortable scheduling of 12 hours per day, often with mandatory overtime. The plan was to introduce a 3-color patient rating system, improve salaries as a result of retention efforts saving money, and change the schedule from 12-hour shifts to 8-hour shifts.
The implementation process involved 3 stages and 5 steps in total. During the initial stage, the project was presented to hospital staff, which provided feedback, recommendations, and alterations when necessary. The second stage included 3 steps, with the nurse training, implementation of the processes, and on-site changes as per demand. The final stage included observations and final changes before the system was cemented as a new standard of practice. Due to hospital staff shortages as well as COVID-19 limitations, the scope of the project had to be shifted from one department to one nurse team. However, as it went on, AMRTC allocated more nurses and resources to participate in the project. The overall results could be considered a success, as both nursing staff and hospital administration found the practice to be an improvement to morale and retention rates over what was previously used.
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