Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Alice R. Swan


Doctor of Nursing Practice


Healthcare is in crisis; nursing is in crisis. Patient acuity is also on the rise (Beaty, 2005). In the United States, hospital and nursing leadership are professionally bound to produce effective clinical patient outcomes. For nursing leaders, producing effective clinical outcomes requires delivering a level of patient care that is appropriate to the individual patient and in direct proportion to his or her needs. If acuity is rising and care needs are expanding, the resulting higher level of nursing care hours affects nursing budgets. If unit budgets do not flex with the patient acuity, nursing leaders are then challenged to provide the higher level-of -care required, and still maintain the budget. Moral fatigue is growing among nurses, as they are continually asked to do more with less. Nursing leaders struggle to address the plethora of related conflicting demands, including clinical excellence in patient outcomes, patient satisfaction, employee satisfaction, budget constraints, compliance with regulatory legislation, fulfillment of accreditation requirements, consumer awareness, and transparency with all interested parties. These unpredictable variables require healthcare leaders to address and effectively manage while revenue and payments continue to be reduced. The question is, “how can our current health care delivery system be revised so that all people in theUnited States have access to affordable quality health care?”

The 2008 financial crisis created the need for the hospital to re-organize the entire patient care unit structure resulting in a significant loss to the nurse manager’s patient care unit; major effects were a reduced budget, reduced bed capacity, layoff’s and elimination of shared governance. As a result, patient satisfaction and employee engagement plummeted. All resources were directed toward clinical care, to insure positive patient outcomes. A need to create a manageable nursing work environment was paramount. A systems change project (SCP) was designed that was grounded in ethical, leadership, change and nursing theories. Social justice to address health disparities was fundamental to the researcher’s ethical, professional and moral principles. The forces that influence behavior were the intended object of the work of the initiative. The project objectives were to create an effective and efficient work environment where staff had shared accountability to design system processes and where staff have what they need when they need it. The intended and measurable outcomes were to improve patient satisfaction and employee engagement. The project design used action research methodology within a participation-based framework. A unit champion model was initiated to improve unit work environment by incorporating passion and talents of the PCU staff into a staff-driven project. Each unit staff member assumed responsibility for a self-identified unit task that was over-and-above daily assignments. There were no pre-determined structures or prescribed processes for creation of the individual’s unit task.

Deliberate lack of clarity was purposeful; work would evolve as staff became engaged. The logic was simple: if authority was matched with responsibility and employees were empowered to use that authority to meet the needs of their job responsibilities, then employees would demonstrate success through participation. Economic principles were inherent in the project design. For example, return-on-investment was demonstrated by comparing the project costs, mostly in tern of labor, to a reduction in patient days.

Data analysis and evaluation included comparison of the hospital’s nationally recognized and well established annual surveys for patient satisfaction and employee engagement. The patient care unit’s 2009 surveys were compared to the respective 2010 surveys. The results were positive in both surveys; patient satisfaction and employee engagement improved statistically. In January 2010, project participation included 63 staff: 49 RNs and 14 Nursing Assistants for 75 unit champion topics compared to six staff in January 2009 when the project was initiated.

Conclusions revealed participation and trust that the process would evolve. Authentic leadership and empowerment were critical. We cannot use old methods to address current problems in health care. Recommendations included project scalability to many forums. The clinically doctorally prepared nurse and leader will assist on our journey to improve access to and completion of effective patient care and clinical outcomes for our patients, our organizations, our communities, and our nation.