What Are Best Practices in Nursing Practice Redesign?

4 nurse executives who have transformed nursing at their respective organizations share their key tips.

Virtual nursing, the return of licensed practical nurses to acute care, and adding advanced practice nurses are among care models nurse executives are implementing as they seek to adapt to the current state of today’s healthcare environment.

HealthLeaders talked with four nurse executives who are transforming nursing care at their respective organizations and asked each one, "What are key tips you would suggest in implementing practice redesign?"
Their replies have been lightly edited for brevity and clarity.

Kit Bredimus, DNP, RN, CPEN, CNML, NE-BC, CENP, NEA-BC, FACHE, FAONL*

Chief nursing officer
Midland Memorial Hospital

The primary focus for any leader planning a practice redesign is to have strong communication. You have to build in that feedback loop and make sure you've had that communication with the staff that are going to be involved with the change to get their buy-in. A leader needs to figure out what staff think is going to work and what's not going to work.

The other part is to empower them to make change. As you trial these things, it's important to hear from staff what's working well, what's not working well, and what they would like to see tweaked. Then, have planned stages where that feedback can be implemented, versus pushing it out from the top down. That has not been successful. I've been a victim of that before, where we recognize that something sounds like a great idea, but once we roll it out, it failed, so empowering the team to own the process and the change has been what’s really worked for us.

As an aside, it’s important to recognize that anytime you're talking about a practice redesign, there's not a lot of literature out there that says, "This is a tried-and-true model. Everyone should do it because it works every time," because every situation, every organization, every community's going to be different, with different resources, constraints, and barriers. It’s important to keep that in the forefront of your mind whenever you're talking about any of these redesigns because a lot of them are unproven and you don't know if they're going to work for your organization until you try them.

That’s why it’s important to get the feedback of staff and key stakeholders—to make sure you are looking at all the variables that are specific to your unit, your area, your community.

*Bredimus is a contributor to the HealthLeaders CNO Exchange Community, an executive community for sharing ideas, solutions, and insights. Please join the community at https://www.linkedin.com/company/healthleaders-exchange/. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com

Cori Loescher, BSN, MM, RN, NEA-BC

Newly retired chief nursing officer and vice president for patient care services
Brigham and Women's Faulker Hospital

It’s never wrong to think about all the stakeholders and in this example, the immediate problem was the emergency department. If we had put just the emergency department together with that, it would have been a one-focused orientation to that group who are making choices for another person's areas, so you need to ask, "Who are the key stakeholders that need to be at the table to start to talk about this?"

At that table, it’s important to build an open mindset and a strong ability to listen to each other's issues, brainstorm things that may be completely outrageous, and listen without judgment. Then you systematically go through and vet those choices.

Another key tip is it’s important to realize testing and piloting a redesign and being willing to iterate as you learn more. And even once you've tested it and implemented it, to be willing to go back to the table and continue to improve on what you've done or what you perhaps did not anticipate was going to come forward.

Jason Gilbert, PhD, MBA, RN, NEA-BC

Executive vice president and chief nurse executive
Indiana University Health

Balancing that structure and autonomy and not waiting for the perfect model that's going to work for everyone. Care is so complex across different patient populations, and different acuity levels that we have to lead more through guiding principles and really involve the front line and the voice of the patients and families in redesign.

It's been key to equip the frontline managers with the change management tools because there is a fear of, "What if this doesn't work?" or "What are we going to have to ask the staff to do?" It’s a shift to say that we want the staff to come up with the ideas and help with the redesign.

Leverage your professional governance structures and the Magnet principles—team empowerment, continual improvement mindset, focus on quality, safety, affordability, and equity. The biggest step is to let go of the past and challenge the status quo. Ask the "why," and then help communicate the "why" with team members.

I have found that these initial pilots really work with the willing. There are many who want this change. They live with this every day, and they're frustrated, and they want to provide care in different ways. Our frontline team members see the deficiencies, so who better to be involved in the changes?

Letting go of that traditional paternalistic command-and-control models of leadership and getting into that shared leadership/professional governance mindset is the key to the future with this. The best ideas come from our front line on how we're going to change care or do things more efficiently.

Allison Dimsdale, DNP, NP-C, AACC, FAANP

Associate vice president for advanced practice
Private Diagnostic Clinic at Duke University Health System

First of all, look at where the need is. Then look at the resources that you may already have that are well-trained, that are well-ensconced within your organization, that understand how you practice. And then figure out if you can change anything about the way that they're working right now, in order to get them to the top of their scope.

Ask them, "What are you doing that you think could be done by someone else to the top of their scope?" This is a question that's being asked all over the country right now about advanced practice, but it’s also true for physicians, nurses, and medical assistants, as the nursing shortage is real.

We need to be creative about how we deploy people, and how we put them together in teams. Some of our teams use EMTs while others use athletic trainers alongside physical therapists. We’ve found that utilizing pharmacy technicians to help with some of the paperwork required by pharmaceutical companies and insurance companies can be incredibly beneficial.

Once you've figured out who you have, and how you can use them to achieve your goal, then anticipate where the barriers are going to lie, and have a ready answer for every naysayer who comes toward you with a complaint or reason why it can't work—because it's working all over the country and it's working beautifully.