Adopt, Adapt, Abandon: What is Old is New Again

Nelson Tuazon, DNP, DBA, RN, NEA-BC, CENP, CPHQ, CPPS, CPXP, FNAP, FACHE, FAAN
Vice-President and Associate Chief Nursing Officer
University Health
District 8 Director 

A quick scan of the current nursing and healthcare literature shows that we may have to hold on to things that have gone out of style. Team nursing (Cassidy, 2020), the addition of licensed practical nurses (LPN) or licensed vocational nurses (LVN) in the staffing plans (Johnson, 2020), and the tiered-staffing model (Wells et al., 2021) reflect this paradigm shift. The pandemic provided the impetus for leaders to innovate. The innovative approaches led by nurses are well-documented (Phillips et al., 2021). We adopted emerging technology to augment resources for COVID-19 screening, patient rounding, and staff and patient communication. We adapted to new schedules, training and education methods, and workloads. We also abandoned traditional ways of socializing, meetings, and some aspects of patient care due to the disruption in the supply chain (Riera et al., 2021). As we transition to pre-pandemic conditions, we will need to adopt, adapt, and abandon again. Weston (2020) posited that the rapid changes that are evolving in the current healthcare environment require a systematic and thoughtful strategic planning process. Leaders must have a clear understanding of the confluence of emerging trends, forge a vision for a positive future, formulate a clear direction for success, and execute actions to achieve desired outcomes. Leaders must have the ability to assess their organization and provide a vision for future endeavors. It is imperative that planning for the future should not detract us from the work of the present (Ulrich, 2021).

Innovation and Leadership in the New Norm
The literature supports the assertion that successful innovation is a result of the complex interaction of various factors including organizational culture, support, and resources that are committed to innovation, leadership, and shared vision. Robust communication and staff engagement promote effective working relationships and healthy team dynamics (Lloyd et al., 2018). Leading and innovating go hand in hand. Innovations, even in small, incremental amounts, can be impactful to the individual, team, organization, and society. Transformational leaders create highly effective and efficient work climates in which quality is delivered, resilience among the team members is fostered, and employee engagement is nurtured. Transformational leadership is associated with a purposeful and intentional search for positive changes. This type of leadership is a foundational element of a culture of innovation (Frias et al., 2021). In creating a shared vision with the staff, innovators promote creativity and instill confidence that leads to higher performance. As the practice of nursing changes as a result of new inquiry and evidence, innovators must serve as mentors to others to continue to enhance patient safety, improve the quality of care, and promote exceptional care experience across the continuum (Lott et al., 2020). The pandemic put the spotlight on nursing leadership and innovation despite the limitations and barriers imposed by social and physical distancing. Nurses have remained the backbone of patient care at the bedside amidst the pandemic (Houlihan, 2020).

A Look-Back at Diffusion of Innovation
A brief review of Rogers’ Theory of Diffusion of Innovation is warranted at this time. The theory defines innovation as an idea, practice, or project that is perceived as new by an individual. There are four generally accepted elements in the diffusion of innovations. These include the 1) innovation itself, 2) communication channel, 3) time and 4) social system. The innovation itself is defined by its characteristics. The communication channels refer to the nature of the channels used to create and share information about the innovation. Time refers to the passage of time for innovation from a decision to adoption. The social system refers to the set of interrelated units involved in the joint problem-solving process to achieve the desired goal (Rogers, 2010). In some instances, the innovation may have been invented and already adopted, but if the individuals view it as new, then it may still be an innovation for these individuals. Such is the case with staffing models (Cassidy, 2020; Johnson, 2021; Wells et al., 2021).

Steps in the Rogers' Diffusion of Innovation Theory. Roger's Diffusion of Innovation has five stages. These include 1) knowledge, 2) persuasion, 3) decision, 4) implementation, and 5) confirmation. The first stage implies that the individual is exposed to the existing innovation and acquires some understanding of the mechanics of the innovation and how it functions. Persuasion indicates that the individual forms a view or opinion about the innovation based on the perceived attributes of the innovation. Decision refers to the degree of involvement of the individual in the activity that would require a choice, either to use or dismiss the innovation. During implementation, the individual has decided to adopt the innovation as the best available option. Finally, confirmation indicates that the individual looks for support in the decision to adopt the innovation.

Levels of Adopters of Innovation. There are five levels of adopters of innovation. These include a) innovators, b) early adopters, c) early majority, d) late majority, and e) laggards. It is important to note that incomplete adoption or non-adoption is not included in the classification. Only those who successfully adopted the innovation over time are included (Rogers, 2010). The innovators are the first to try the innovation, interested in new ideas, and are willing to take risks. There is very little that needs to be done to convince this group. Early adopters represent the opinion leaders, enjoy leadership roles, and embrace change. The early majority adopts innovation before the average person and needs evidence and success stories to see evidence before adopting an innovation. The late majority is skeptical of change and adopts an innovation after the majority has tried and adopted the innovation successfully. The laggards are traditionalist and conservatives and very skeptical of change. A scan of the healthcare systems shows that hospitals and healthcare systems, including Kaiser Permanente, CHI Health, and Community Hospital Corporation have implemented team nursing and have added LVNs and LPNs to their staffing plans. Many more are expected to join this cadre of innovators and early adopters.

Roles and Qualities of an Innovator
In examining healthcare innovations across practice and academia, Joseph et al. (2019) have posited that a) although often unrecognized, nurses have always been innovators; b) nurses are uniquely positioned to witness innovations because they are at the core of patient care; and c) the framework for health care innovations across practice and academic settings promotes collaboration between researchers and clinicians. Based on the scope and scale of the practice of nurses, as innovators, they function as leaders, collaborators, and mentors.

The Innovator as a Leader. One of the considerable challenges confronting the nursing profession today is the development of future nurse leaders. Leadership is not merely a set of tasks or skills, but a way of being. Nurses are uniquely positioned to advocate for change and advance health by assuming leadership roles across different settings, fields, and specialties. Emotional intelligence enables the individual to understand the complexities of emotions and they impact the work environment. Leaders with high levels of emotional intelligence demonstrate self-knowledge, empathy, self-discipline, and fortitude. Their ability to manage their own emotions makes them effective leaders. Transformational leaders are intentional in their communication style and earn the trust and respect of their employees through skillful and empathetic listening (Frias et al., 2021).

The Innovator as a Collaborator. Effective communication is one of the fundamental traits of a transformational leader and innovator. Through effective communication, the contents of a given message and how they are passed on to individuals and groups within the organization are critical in disseminating information about the innovation. The innovation process encompasses various stages from idea generation to adoption and confirmation. At every step of the way, the intended change caused by the innovation must be clearly communicated. As the individuals internalize knowledge about their team members, the organization benefits from the innovation collaboration (Mohammadi et al., 2018). Networking has been linked to innovation because of the opportunities to combine or pool intellectual resources, obtain knowledge from others, share risks, and create a synergy of talents. Innovation is influenced by organizational culture, support, and shared vision (Lloyd et al., 2018).

The Innovator as a Mentor. A mentor guides a mentee, encourages learning, assists the mentee to gain proficiency, delivers feedback and counseling, and provides emotional support. Mentoring provides a venue for nurses to assume positions of leadership in health care. Mentorship in nursing is a professional obligation, regardless of setting or specialization (Busby et al., 2020; Lott, 2020). Innovators are engaged in generating and developing new ideas, thoughts, and concepts. These creative ideas often become the basis of innovation aimed at solving problems and improving products, services, or processes. Developing a trusting and caring relationship promotes teamwork, cooperation, and mutual respect. Providing and receiving valuable feedback fuels innovation. Feedback encourages individuals to think reflectively and differently. It allows all parties to learn from the process and to establish expectations and goals based on the feedback.

Adopt, Adapt, or Abandon? What the Evidence Shows on Team Nursing
As leaders, collaborators, and mentors, nurse leaders who are planning to deploy alternate nursing care delivery models need to familiarize themselves with evidence to inform their decision. The re-introduction of team nursing to address resource capacity and increased patient acuity brought about by the pandemic has led to questions by nurses on the outcomes related to this particular nursing care delivery model. Beckett et al. (2022) conducted an integrative review to evaluate the outcomes of team nursing for patients, nurses, and organizations, compared to other models of care. These authors concluded that there was no statistically significant difference in patient outcomes between team nursing compared with other models of care. Additionally, the evidence related to nursing and organizational outcomes is conflicted. The authors also examined the impact of providing education and training on delegation and concluded that education on delegation is critical for team nursing. Education on delegation improves the knowledge of nurses on delegation, decision-making, and competency. Nurse leaders are encouraged to read Beckett et al. (2022) to inform their decision, planning, and implementation of team nursing. The authors provide additional details on patient outcomes (e.g., safety, patient satisfaction, and pain scores), nursing outcomes (e.g., RN job satisfaction, attrition and turnover, absenteeism, and stress), and organizational outcomes (e.g., cost, perceived quality of care, and length of stay).

Strategies to Stabilize the Future Nursing Workforce
The success or failure to adopt an innovation is affected by multiple factors. Rogers (2010) posited that there are five determinants or promoters of the adoption of innovation. These include relative advantage (the benefit of the innovation), compatibility (the consistency and appropriateness of the innovation), simplicity (the ease of use of the innovation), observability (the degree by which the innovation and the outcomes are detectable), and triability (the extent by which the innovation can be tested or piloted). Nurse leaders who are pioneering efforts in re-imagining workforce planning should consider these factors in redesigning and redeploying team nursing, tiered staffing, and LVNs and LPNs.

Even before the recent pandemic, staffing and concerns regarding employee well-being have been an ongoing source of angst and frustration for many nursing leaders. Nurses rose to the occasion during the pandemic by providing the much-needed complex patient care at the bedside and developing innovative approaches to surge planning and management (Houlihan, 2020; Phillips et al., 2020; Wells et al., 2021). However, the COVID-19 pandemic and its persistent residual effects have amplified and intensified the significant and tumultuous changes within the healthcare workforce, more so in the nursing workforce (Weston, 2022). The pre-pandemic issues surrounding the reduction of work hours or retirement of the baby boomers were compounded by the increasing numbers of new graduate registered nurses. These two forces created a meaningful shift in the age distribution of the nursing workforce. These resulted in an increased number of novice nurses in the workforce. To mitigate this issue, there are seven strategies that leaders can take to stabilize the future nursing workforce (Viskstis et al., 2022).

1. Prioritize professional development of RN early – leaders should engage novice nurses in professional development programs and initiatives as early as during their first 6 months as an RN.
2. Accelerate the transition to competent level – promote mastery of skills, focusing on essential skills during the orientation period.
3. Create flexible non-traditional roles and schedules – create a balance in home life and work by offering flexibility in roles, responsibilities, hours, and locations.
4. Differentiate nursing practice for experienced nurses – implement strategies that align with the competencies and expertise of nurses; implement different models of care such as team nursing.
5. Create attractive roles for support staff – Evaluate other care delivery models and supplement the workforce with other workers such as unlicensed assistive personnel; examine entry-level wages and raises.
6. Consider every travel nurse a candidate for a permanent position – develop plans to attract temporary, travel nurses to become part of the regular staff.
7.  Address downstream capacity constraints while stabilizing inpatient staffing – safeguard the allocation of nurses in all settings by ensuring that the competition for inpatient nursing labor does not impact other care settings.

Planning for the Future
The success of planning for the future nursing workforce will require commitment, collaboration, and communication. An effective strategic plan provides a roadmap for the future and clarifies the direction for the constituents and stakeholders to follow (Lal, 2020). More than ever, strategic planning amidst the uncertainties of the recent pandemic and its lingering adverse effects may be most important in stabilizing the current and future nursing workforce (Weston, 2020). These turbulent and uncertain times demand that leaders re-imagine a different strategic planning approach to address the wise use of nursing expertise and create a positive work environment for all nurses. The plan should also reflect the priorities that help advance healthcare into the future (Ulrich, 2021). To leverage the expertise of nurses, contemporary recruitment and retention strategies will be critical. Securing adequate resources for nurses will require an understanding of the economic forces that significantly affected the decisions of nurses to stay or leave their employment. It is also essential to establish the unique value of nurses in the healthcare delivery system. Creating a positive work environment will require strategies to engage and re-engage nurses, promote the nurses’ well-being, implement innovative approaches to retirements, resignations, recruitment, and onboarding, and execute programs that invest in nurse leaders (Weston, 2022).

References

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