1. Hassmiller, Susan B. PhD, RN, FAAN
  2. Bolton, Linda Burnes DrPH, RN, FAAN


An initiative to improve patient care and nursing retention.


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Eight years ago the Robert Wood Johnson Foundation (RWJF) became interested in what may become our country's worst nursing shortage. The RWJF report, published in April 2002 (available at made bold recommendations to address the shortage. To improve the quality of care in this country, it said, we will have to reinvent or redefine the role of nurses and the ways they are educated.


The RWJF also analyzed why nurses were leaving the profession and what positions they most commonly vacated. They found that most nurses were unhappy with their work environments, but the busiest turnstiles seemed to be at the doors of medical-surgical units. As a result, the RWJF asked the Institute for Healthcare Improvement (IHI) to help it devise a plan to improve hospital work environments so more nurses might come to and remain at medical-surgical units. That plan was the Transforming Care at the Bedside (TCAB) initiative.

Figure. Susan B. Has... - Click to enlarge in new windowFigure. Susan B. Hassmiller (left) and Linda Burnes Bolton

TCAB began in 2003 with a demonstration project. Nurses on one medical-surgical unit at the University of Pittsburgh Medical Center in Shadyside, Pennsylvania; Seton Northwest Hospital in Austin, Texas; and Kaiser Permanente Roseville Medical Center in California brainstormed about improving their work environments so they could spend more time at the bedside. Following the TCAB framework, they developed solutions targeting patient-centered care, value-added processes, vitality and teamwork, and safe and reliable care. Solutions-usually very simple ones-were tried in small, rapid-cycle tests of change and adopted, adapted, or abandoned.


The three-hospital demonstration project was a great success. It led to a 13-hospital demonstration. Now, only a few years later, about 160 hospitals have taken part in some aspect of an "official" TCAB program led by the RWJF, the IHI, or the American Organization of Nurse Executives. The U.S. Department of Veterans Affairs is testing its own version of TCAB this year in more than 40 hospitals. The unofficial count of hospitals that have adopted the TCAB process amounts to many hundreds in the United States and abroad.


TCAB is now a national movement to engage front-line staff in devising changes that will improve nurses' delivery of care and daily work lives. Across the country, nurses, physicians, and hospital executives are calling for their facilities to adopt TCAB to improve patient care; increase retention of staff nurses; and provide safe, reliable, patient-centered, and value-based care. Providers, patients, and administrative leaders all want to participate in a process that can both increase nurses' time for direct patient care and improve the care itself.


Many TCAB hospitals are working with schools of nursing to help them incorporate TCAB principles and processes into their curricula. These schools' graduates will help to shape how care is provided at U.S. hospitals. Nursing students are learning that nurses can be directly responsible for their work environment; they do not have to accept the status quo!


TCAB provides blueprints for eliminating the waste in care delivery, improving job satisfaction and nurse retention, enhancing communication and collaboration among team members, and improving patient care. TCAB changes how hospital executives, educational institutions, patients, physicians, and nurses organize and deliver inpatient care. It doesn't take much: being willing to listen to nurses and patients, engaging front-line staff, conducting rapid-cycle tests of change, identifying changes to adopt and spread, and aligning the aspirations of direct patient care providers with institutional goals. These little investments can achieve much for patients, staff, and society.


For a toolkit on how to implement TCAB, go to the RWJF's virtual TCAB site at