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Mobilizing staff to participate in quality improvement initiatives amid COVID-19

Hospital finds the right mix of initiatives to engage nurses

By Rosalyn Espiritu, Susan Beswick, Murray Krock, & Sonya Canzian
September 20, 2022
During the pandemic, with restrictions on in-person meetings, nurse managers thoughtfully selected best practice guideline (BPG) nurse champions, taking into consideration their ability to work in a virtual format. Flexibility was needed in identifying a BPG focus that aligned with unit needs or pressures.

How does an organization mobilize and engage staff to participate in quality improvement and implement best practice guidelines (BPGs) amid a global pandemic? How does it do this amid increased demands on clinical care leading to staff burnout?

COVID-19 has challenged nurses and nurse leaders in various and unexpected ways over the course of the pandemic. Along with ongoing priorities of providing high-quality, safe patient care, nurse leaders are committed to creating environments that support excellence in patient and family experience while providing opportunities for professional development and career advancement.

One way St. Michael’s Hospital at Unity Health Toronto contributes to evidence-based quality care is through our Registered Nurses’ Association of Ontario (RNAO) Best Practice Spotlight Organization (BPSO) designation. St. Michael’s Hospital achieved this designation in 2012 and has implemented and sustained over 45 BPGs. We are able to sustain our designation through quality improvement initiatives led by BPG nurse champions and supported by nursing practice and education. The BPGs and quality improvement initiatives are chosen by unit leadership, in collaboration with BPG nurse champions, based on unit needs and gaps in practice.

With the competing priorities of COVID-19 in clinical care, including workload, staffing challenges and time constraints, engaging staff to participate in the implementation of BPGs was challenging for many clinical areas. This paper outlines our engagement and support strategies to enable direct care nurses to participate in quality improvement initiatives during the height of the pandemic.

We use a four-pronged approach to involve nurses in their BPG initiatives. However, with the challenges of COVID-19, we learned to make adjustments along the way to keep nurse champions engaged and feeling supported and valued throughout the process.

1)  Unit leadership
Nurse managers recruited front-line staff to become BPG nurse champions, who were selected based on their commitment to best practices in their current role; their passion for a particular BPG topic, patient population and the potential outcomes that can be achieved; and their ability to lead, coordinate and facilitate an initiative and act as a role model for positive clinical leadership.

During the pandemic, with restrictions on in-person meetings, nurse managers thoughtfully selected BPG nurse champions, taking into consideration their ability to work in a virtual format. Flexibility was needed in identifying a BPG focus that aligned with current unit needs or pressures. (In past years, areas of focus aligned with corporate priorities.) Examples of initiatives undertaken during the pandemic included:

  • The transition to virtual appointments and keeping families updated on patient status when visitor restrictions did not allow for in-person visiting
  • An initiative to encourage mothers with infants in the neonatal intensive care unit to use hand expression for inpatient breastfeeding
  • An initiative to support intra-professional collaboration to reduce sternal wound infections

Nurse managers were key to liaising with staff members, garnering their participation and reinforcing the importance of BPGs within their units. They played a vital role in supporting nurse champions with dedicated time to work on their initiatives. This time was important as it allowed nurse champions to focus on their initiatives without the distractions or stressors of their clinical work. During the most straining waves of the pandemic, when staffing shortages and increased patient volumes with high care needs became critical, nurse managers had to prioritize patient care requirements. This required more flexibility in the expectations of the scope, depth and breadth of the initiatives, with deadlines being moved, cycles of change being decreased and additional coaching being provided to nurse champions who could not attend the Communities of Practice (CoPs) meeting forums because of staffing needs.

Nurse champions were encouraged to reach out to mentors as often as needed

2) Mentorship
Each BPG nurse champion was assigned a unit mentor (e.g., nurse manager, clinical educator, clinical nurse specialist, nurse practitioner or other member of the interprofessional team) and a professional practice mentor (e.g., manager of nursing practice, manager of nursing education). Mentors were integral to keeping BPG nurse champions motivated and engaged in their initiatives, providing coaching, guidance, one-on-one consultation and encouragement throughout their journey. For most BPG nurse champions, embarking on a quality improvement initiative was a new venture and experience. Having mentors available for the nurse champions with an open-door policy to answer questions, to ensure that they were on the right track and to provide the support needed through every step of their initiative was important in ensuring that the BPG champions felt that they were not alone in the process.

During the pandemic, with most in-person meetings restricted, mentors made themselves available via email, video conferences or phone calls. Recognizing that the lack of in-person meetings could feel isolating, nurse champions were encouraged to reach out to mentors as often as needed.

Through this mentorship, BPG champions were given the opportunity to gain skills outside of their clinical work and provided with the opportunity to grow professionally. For some BPG champions, this experience allowed them to become a unit mentor themselves, and they in turn provided mentorship to future BPG nurse champions on their units.

3) Communities of Practice
We designed CoPs as virtual meeting forums for knowledge exchange, problem solving and group process. This online forum gave the nurse champions, as well as their mentors, a venue in which to share their progress related to their initiatives in a safe, supportive environment.

The first half of each forum was dedicated to roundtable discussions that gave nurse champions the opportunity to share experiences, including successes and challenges related to implementing their initiatives. The second half was focused on methodologies of quality improvement and education in support of capacity building and professional development, providing nurse champions with strategies and tools that could be applied to the implementation of their initiatives.

Each CoP forum focused on quality improvement topics delivered sequentially that assisted in informing the BPG initiative planning, implementation and sustainability. Examples of topics covered included “introduction to quality improvement,” “strategies to develop and deliver education to support change,” “sustainability in quality improvement” and “how to display data graphically.”

The CoP forums, which prior to the pandemic were in-person meetings, were held virtually to accommodate in-person meeting restrictions. Although many champions shared a preference for in-person meetings, they felt that a virtual format still allowed an opportunity to connect with their professional practice mentors and other BPG nurse champions across the hospital.

To keep the BPG champions engaged and foster a sense of camaraderie given the virtual format, breakout rooms consisting of smaller groups were created in order for them to meet with their professional practice mentors, allow for knowledge sharing and discussions and provide an opportunity for them to build relationships with one another. Creating a virtual environment where everyone feels connected and present was challenging, so aside from the breakout rooms, encouraging champions to have their cameras on allowed for the feeling of connectedness that seemed to be lacking in our current environment. Pivoting to a virtual format was exactly the adaptability needed to maintain the sense of community that was so vital and necessary for nurse champions embarking on this new journey.

4) Recognition
The St. Michael’s Hospital site of Unity Health Toronto began its BPSO candidacy period in 2009 and was successfully designated in 2012. With this comes a sense of pride in the nurses who are named BPG nurse champions, having contributed to improving the quality of patient care, and are now part of the BPSO legacy.

BPG nurse champions’ achievements are celebrated and recognized in several ways:

Engaging direct care staff with successful implementation of BPG initiatives involves a multi-pronged approach, including:

  • Support from unit leadership
  • Mentorship from unit leadership and the professional practice team
  • A safe venue to share experiences with peers, to connect and to grow professionally
  • Recognition for their hard work and successes 

This approach has allowed us to sustain our BPGs and quality improvement initiatives led by staff over the years. The keys, however, to keeping BPG nurse champions engaged in participating in quality improvement initiatives throughout the challenges of the global pandemic were as follows:

  • Flexibility and adaptability. It was important to know when and how to pivot to allow the BPG nurse champions to continue with their initiatives despite the challenges.
  • Connectedness and community. We provided a virtual format for the CoP with an opportunity for smaller breakout rooms for BPG nurse champions to connect and share their experiences, as well as encouraging champions to reach out to their mentors whenever their support was required.
  • Recognition. During the pandemic, there was never too much recognition to give. Recognizing the BPG nurse champions for all of their hard work and dedication contributed to their sense of pride in participating and being part of the BPSO legacy, especially during a global pandemic.

Despite the unique challenges and competing priorities of the COVID-19 pandemic, the BPG nurse champions were able to successfully implement many initiatives across the hospital. Their perseverance and dedication in the face of an unprecedented time demonstrated their commitment, as well as the leadership teams’ and organization’s commitment, to enhancing high-quality patient care and improving healthy work environments for nurses and their colleagues in other health disciplines.

The authors are all employed by Unity Health Toronto.
Rosalyn Espiritu, RN, MN, is an evidence-based nursing practice leader.
Susan Beswick, RN, MN, is a manager, evidence-based nursing practice.
Murray Krock RN, MN, is a senior director, nursing practice and education.
Sonya Canzian, RN, MHSc, CNN(C), is the executive vice president, clinical programs, and chief nursing and health disciplines officer.