1. Brunson, Megan E. MSN, RN, CCRN-CSC, CNL

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Diffusion of innovation is widely known as a theory that explains how, why, and the rate at which new ideas are spread. It's linked to characteristics of personalities and organized by how various people accept innovation. Some of us are early adopters of technology and innovation in our personal life, but hospitals and healthcare environments inevitably seem light years behind the rest of the world. Stuck generations behind other industries, we continue to seek comfort in practicing the way things have always been. The silver lining during the COVID-19pandemic has been the explosion of innovation.

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The need to find solutions in a rapidly changing environment, be more efficient, and keep ourselves and our patients safe has made creativity a priority. This has challenged and narrowed the research-to-practice gap rather than accepting the 17-year average as inevitable.1 Formal and informal nurse leaders have answered this call. They've been bold about committing to innovation, encouraging others to act, and sharing these ideas in abundance for the benefit of others. They became early adopters by looking at others' examples, using science to drive practice decisions, employing liberating structures, and using healthy work environment standards as a foundation.2,3 Adding a culture of innovation into our daily practice can't be limited to during the pandemic. We must forge ahead with innovation as the new normal.


What held us back from innovating?

As the most high-touch, patient-centered role, nursing has been notably left behind when it comes to innovation. Nurses use countless different types of equipment, document in the electronic health record, and practice holistically, spending more time with patients than any other member of the healthcare team. Nurses have the best vantage point from every aspect of healthcare. One would think nursing would be at the forefront of innovation, but nursing and innovation aren't always talked about together. Why?


The barriers are centered around three things. First, nursing education is focused on clinical knowledge, which misses the components of development and promotion of new ideas, strategic thinking, troubleshooting, and the business analysis of what works or doesn't work. Second, nursing has been subjected to dealing with "pain points" as part of the patient care role versus being included as part of the solution. In turn, this causes workarounds to prevent patient harm but doesn't create a culture of integrating long-term innovation. The last barrier is an organizational hierarchy in which physicians have primary clinical authority and administration has a focus on design changes based on costs and metrics. Both also tend to use nurse engagement for buy-in rather than nurses' value in contributing to a solution. Although before COVID-19 there were glimmers of innovation, the pandemic has unleashed the tremendous capacity of the nursing workforce to change the ways of the past.


The silver lining: A culture of innovation

Small and big ideas, simple and complex, have been brought to the forefront by nurse leaders this past year. These innovative ideas allow for others to build on and mold them to fit into their own healthcare system, specialties, or patients. COVID-19units were resurrected in record time to meet surge capacity using evidence-based practice and deployment of all resources available. Although that's a large feat in and of itself, the innovative nature was in abundance. New problems presented themselves, unthinkable before COVID-19. Perhaps you've seen some of the ideas in the news or on social media or implemented where you're practicing.


These ideas range from 3D printing of personal protective equipment, expansive use of telehealth, headbands to prevent staff skin breakdown, digital mentors, and extensive use of simulation for the training of nurses and nursing students. These outstanding new ideas, along with the rapid advancement of previous nursing considerations to improve care, were implemented when patients and staff needed them most. Two innovations brought front and center during the pandemic are key in highlighting and understanding how nurse leaders had to navigate the unknown: the integration of families when visitation was eliminated and staffing.


Innovating to integrate families

Nurses were instantly forced to remove families from hospital environments. However, it didn't mean they should exclude them from care planning, goals of care, or being an integral part of the healthcare team. The void of a family's presence revealed the harsh reality of how imperative they are to positive patient outcomes. The American Association of Critical-Care Nurses (AACN) practice alert Family Presence: Visitation in the Adult ICU highlights the evidence showing unrestricted access and participation by families can improve safety of care and communication and enhance patient and staff satisfaction.4


Knowing this, nurse leaders deployed a designated RN to work with family members, staying with them to answer questions, keeping them safe from infection, and guiding them during the unknown. Because of this RN champion role, frontline nurses were comforted knowing families were included and considered vital members of the team and weren't forgotten because they physically couldn't be present. This was achieved by using current technology that allows for physical distancing, such as using FaceTime and including families in Zoom conference daily rounds. It isn't that this hadn't been considered before, but now it was routinely part of practice and not optional.


Innovating the art of nurse staffing

Due to the novelty of the virus, surges occurring in various parts of the country, and the high acuity of COVID-19 patients, the staffing crisis was real. Nurse leaders sought solutions quickly through new staffing models that didn't compromise care quality or limit the scope of practice. Staffing has never been a one-size-fits-all model, and the pandemic didn't alter that. In one hospital, all ICU RNs and equipment such as ventilators and I.V. medications were outside the room and medical-surgical nurses cared for patients inside the room. This allowed the qualified ICU RN to see the patient directly and make necessary changes to the pumps, medications, and monitors, and provide support for the nurses inside the room.


Another hospital implemented the Society of Critical Care Medicine tiered staffing strategy regarding resource availability within the US.5 This model didn't designate where a nurse was physically located, but rather suggested an approach using the skills of the various types of practitioners to rapidly increase the workforce when the workload is overwhelming. The tiered strategy was parallel with nurse leaders implementing and innovating how to rapidly train nurses in new care areas. They mobilized training in a variety of ways, including the use of technology with healthcare robots, QR codes for short on-demand video in-services, surge boards with specific roles and tasks listed for each team member, and high-level simulation training that was only in beta testing. These innovative staffing and training ideas have been used within the military or in short-term crises, but not on such a wide scale across the country with an unforeseeable future regarding the pandemic. This type of innovation by nurse leaders resulted in safe and expert patient care by fully embracing the possibilities of their healthcare teams.


Is innovation an activity or an impact?

One of the most important parts of implementing innovation is allowing science to drive practice. The AACN's position statement Science Must Drive Clinical Practice and Public Health Policy states that using science to drive practice takes courage, intellectual rigor, and personal responsibility.6 As innovation leaders, nurse managers must consider what innovation means to them and ask the question: Is nursing innovation an activity or an impact? A recent healthcare podcast by Becker's Hospital Review poses this question to healthcare leaders to call attention to the fact that implementing innovation isn't only a skill set, but also a mindset to drive a culture of innovation.7 As a mindset, when using science foundationally, innovation is the thoughtful integration of science to have a positive impact on outcomes.


Applying strictly the ideas, either your own or others, doesn't always equate to supporting a culture of innovation. As nurse leaders, the supportive nature of science and innovation is to lift up a system for driving excellence. This means creating a system that limits barriers, improves efficiency, and has safe and rapid deployment at the end point of care. New ideas based on research and science can be assumed to be positive, but nurse leaders must also evaluate how this affects future opportunities, delays care, increases costs, or even creates more problems or disadvantages for staff or patients.


Outside the walls of a traditional hospital setting, others are supporting the call to action in innovation by recognizing healthcare's complexity. Johnson & Johnson's Society of Nurse Scientists, Innovators, Entrepreneurs, and Leaders and the American Organization for Nursing Leadership joined forces to solicit ideas in their QuickFire Challenge, which highlights that the power of nurse-led innovation may be more critical than ever before when developing potential solutions amid a global crisis.8 These organizations understand that nurses have extensive patient experience and nurses' ideas have the potential to improve human health. And, as innovators on the front lines of healthcare, nurses have the power to profoundly change lives. Even when ideas aren't fully formed or completely thought out, there's a place to make room for innovation.


An example is a hack-a-thon event, where a group of healthcare providers work together on a collaborative project. These events are generally hosted by a tech company or organization, and several teams compete to create prototypes that innovate on a theme or improve on an existing project or idea. Healthcare and nurse hack-a-thons provide an opportunity to collaborate with others and build on collective thoughts, experience, and science acumen to push the boundaries of what currently exists. Although these all seem like activities, they're framing innovation to be evaluated regarding the impact it will have on our practice and patients and serving as a place to share and celebrate what used to be the unthinkable.


How to use liberating structures

Staying future-focused as a leader means understanding what you can and can't control in your environment. Conventional standards to implement a new process or policy may be restricting or frustrating and may result in large amounts of time lost. In addition, the initial intention may be lost and perhaps even cause unintended consequences. The uncertainty associated with COVID-19 and its impact on healthcare has given us permission to amplify innovation and remove these burdens in providing safe care for our patients and staff. A great resource for getting started is the concept of liberating structures.9 This concept is based on putting the innovative power once reserved for experts in the hands of everyone.


There are 33 liberating structures, and the collection of group processes and methods that make it easy and quick for members of a group to radically change how they interact and work together is growing. (See The 33 liberating structures.) Liberating structures are simple exercises that promote trust within the healthcare team to bring forth ideas. The purpose of these exercises and microstructures is to liberate energy, tap into collective intelligence, and stimulate creativity, which leads to better results by engaging people and unleashing the power of self-organization. Liberating structures include a whole community of users giving and getting help in all areas of industry, education, technology, and healthcare, through alternative approaches that can be used by everyone at every level, from the executive suite to grassroots organizers. No lengthy training courses or special talents are required. Liberating structures are considered a way to implement disruptive innovation, replacing the current constraining processes and barriers and lifting up others to see the possibility.


To date, liberating structures have been used in healthcare to reshape clinical rounds, reduce hospital admissions, improve access to care, prevent superbug transmission, and take on the challenges of delirium in various patient populations. A simple application is the use of liberating structures in fall reduction. In one hospital, a combination of certified nursing assistants, nurses, and charge nurses were required to attend a 1-hour interactive session in an empty patient room. The session discussion began with identifying patients at risk for falling. This was followed by the two liberating structures improv prototyping and TRIZ, in which participants rearranged the patient room and common equipment that would potentially cause a patient fall to create a space that could achieve the worst possible outcome of a patient fall.9 These reverse exercises stimulated dialogue and discussion around problem solving. During the session, participants were asked to self-reflect on patient falls they had witnessed or identified as trends and communicate what could've been done to prevent them. Following the use of the two liberating structures, the unit experienced a greater than 50% reduction in falls over a 12-month period.

The 33 - Click to enlarge in new windowThe 33 liberating structures

Another example is a Canadian hospital that used liberating structures to prevent the spread of superbugs, such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and Clostridium difficile. Deploying the liberating structures of social network webbing and appreciative interviews, they examined assumptions and visible habits of healthcare providers. Most important, a diverse mix of nonexperts from multiple roles took an active role in prevention for the first time, including housekeeping and central supply. Nursing leadership discovered that staff often go to people who have know-how, use stories to communicate what works, and persisted with a culture of telling not asking.


One liberating structure that can be used right now is called 15% solutions-implementing any first step or action that's entirely within your discretion to act upon without approval or resources from others.9 This exercise could be incorporated into every staff meeting or huddle, or even via group communication in a virtual setting. Using 15% solutions moves away from blocked thinking, negativity, and powerlessness and toward giving back control to reveal bottom-up solutions. Nurse leaders can easily implement this in the context of a specific challenge or even foreseen barriers by asking a small group, "Where's your 15%? Where do you have the discretion to act and what can you do without resources or authority to make that change?" Within this exercise, you'll see that each 15% solution adds to the understanding of the next one, forming a clear and common purpose.


Innovation isn't just a tangible item or product, it's also ideas, thoughts, and seeds of an idea planted in others. These examples are just some ways to use the 33 liberating structures. They can be used in combination, to brainstorm a single issue, or to bring clarity to challenges your team is struggling with.


Fostering a healthy work environment to leverage innovation

Foundationally, innovation must be fostered in a healthy work environment. In 2016, the AACN published the six healthy work environment standards of meaningful recognition, authentic leadership, appropriate staffing, effective decision-making, skilled communication, and true collaboration. Two of these standards are directly linked to advancing a culture of innovation: authentic leadership and effective decision-making.


Authentic leadership

Authentic leadership is defined as nurse leaders fully embracing the imperative of a healthy work environment, living it and engaging others in its achievement.3 Nurse leaders across the US were in a constant state of disruption during the start of the COVID-19 pandemic. For instance, previously, face-to-face networking was the prime way to communicate with and support patients and staff. We can see examples of nurse leader innovation in this area in the Journal of Patient Experience, including the use of dedicated email portals or drop boxes with updated clinical information, technology for staff and patient communication, COVID-19 community dashboards, and incident command centers.10 Nurse leaders implemented innovation while remaining optimistic, staying focused, and checking on patient and staff well-being.


Being an authentic leader involves active listening and mutually working with team members to objectively evaluate organizational progress and resources while also sustaining a healthy work environment. During the pandemic, nurse leaders have been more visible than ever before, creating a comfortable atmosphere where staff members can raise concerns, give timely feedback, and provide encouragement for each other in an unstable time. Nurse leaders knew that unleashing innovation at the bedside was the key to patient safety, positive outcomes, and a return on investment. This, of course, comes with taking risks and "evaluating when it's the right time for an exception to the rule."10


Effective decision-making

Effective decision-making is defined by the AACN as allowing nurses to be committed partners in making policy, directing care, and leading operations.3 In a healthy work environment, nurses are uniquely positioned to gather, filter, interpret, and transform data into meaningful information to deliver safe care. Typically, nurse leaders have the luxury of time but in the case of the pandemic, decisions had to be made rapidly based on current evidence and science. Unfortunately, the evidence and science were changing so rapidly that at times it gave rise to indecisiveness and shifting priorities. However, nurse leaders stayed grounded by keeping the patient at the center of decision-making.


One example was the expansive use of telehealth. At UCLA, a nurse leader fielding calls on a telemedicine hotline recognized the high volume of concern from people believing they had COVID-19. She quickly helped calm fears by directing people to testing sites to keep them from crowding EDs. Another example is nurse leaders who went out of their comfort zone to advocate for nurses to monitor chemotherapy administration in rural areas via telehealth to prevent patients from needing to come into a facility and risk exposure.


Decisions often come in the form of what not to do. Healthcare burdens shifted as surgeries were cancelled and visitation was limited, so nurse leaders were innovative in the use of staff. One OR placed staff in new roles; another department provided quick in-time training to avoid furloughing experienced staff. Nurse leaders also recognized that the daily routine of audits was counterproductive as daily metrics became focused on personal protective equipment supply needs, allocation of hospital beds, the number of staff exposed, and available ventilators. Community centers, convention centers, and parking lots were transformed in anticipation of patient surges. Nurses were a key in the decision-making to protect patients and staff in these alternative care areas.


Implications for nurse leaders

Nurse leaders are in the unique position to harness the nurse-patient relationship through expert knowledge. Unleashing innovation means allowing nurses to practice to their highest potential. We're called to keep the momentum of disruptive innovation front and center in various ways, including:


* sharing your ideas and listening to others' ideas even if they don't seem possible at first


* supporting others who are creative


* knowing that you don't have to be the innovator to lead innovation


* motivating others to share their ideas


* leveraging the energy in your healthcare system to build innovation


* carving out the time in your practice environment for innovation


* knowing that the best ideas can come from unexpected sources and in unexpected ways


* looking outside nursing for possible ideas that can be applied


* realizing that shifting a few grains of sand can create a landslide and change the landscape.



Be unstoppable

We don't have the option to turn away from innovation. The recent pandemic has given us the momentum to drive innovation in parallel with our practice going forward. Disruptive innovation spreads quickly when based on science and evidence. With a vast selection of liberating structures to help foster ideas and creativity, along with the foundation of a healthy work environment, nurses are unstoppable.




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