An essential outcome of professional practice environments is the provision of high-quality, safe nursing care. To mitigate the quality and safety chasm, nursing leadership at St. Michael's Hospital undertook a strategic plan to enhance the nursing professional practice environment. This case study outlines the development of the strategic planning process: the driving forces (platform); key stakeholders (process and players); vision, guiding principles, strategic directions, framework for action and accountability (plan); lessons learned (pearls); and next steps to moving forward the vision, strategic directions and accountability mechanisms (passion and perseverance).

An essential outcome of professional practice environments is the provision of high-quality, safe nursing care. To mitigate the quality and safety chasm, nursing leadership at St. Michael's Hospital undertook a strategic plan to enhance the nursing professional practice environment. This case study outlines the development of the strategic planning process.

The Platform: Addressing the Safety and Quality Gap in an Academic Health Sciences Centre

The landmark Canadian Adverse Events Study highlighted the need to improve patient safety within our healthcare system. Specifically, 7.5% of hospital patients were reported to experience an adverse event, and 36.9% of these adverse events were preventable (Baker et al. 2004). Teaching hospitals were found to be at higher risk for preventable adverse events (Baker et al. 2004). This latter finding is not surprising given the increased acuity and complexity of the patients who receive care in academic health sciences centres (AHSCs). To respond to the evolving healthcare landscape, AHSCs provide learning spaces where service delivery is the platform for innovation in clinical scholarship and education. From these discoveries, new standards for the delivery of safe, high-quality healthcare occur (Institute of Medicine 2003; Nicklin et al. 2004), contributing to high-quality practice settings (College of Nurses of Ontario 2003).

Cognizant of the need for fundamental change in the organization and delivery of healthcare services to cross the "quality chasm" (Institute of Medicine 2001), St. Michael's Hospital (SMH) declared patient safety a priority in its 2004 strategic plan, Reaching New Heights. A key part of the corporate strategic plan development was the SWOT analysis that involved program- and discipline-specific input. Through hospitalwide consultation with nursing leadership, the environmental scan revealed that SMH lacked an integrated interface for nursing practice, research and education. To address this gap and achieve the hospital's vision ("Through our culture of caring and discovery, we will be the finest academic health sciences centre in Canada"), the following key priorities were established for evolving the professional practice of nursing:

  1. Articulate the future of nursing practice (over the next three to five years) through the development of a nursing strategic plan.
  2. Share collective practice expertise and support collaboration across the various programs and departments.
  3. Establish and align nursing leadership roles to support all domains of nursing.
  4. Redesign the nursing governance structure.
  5. Evolve the nursing professional care delivery model.

The Process and Players: Stakeholder Consultation and Buy-in

The evolving healthcare trends, coupled with the hospitalwide strategic plan and the priorities determined by the nursing SWOT analysis, were foundational to enhancing professional nursing practice at SMH. In March 2004, a small group was assembled (co-chairs of the Nursing Council, chief nurse executive and two healthcare consultants) to develop the planning process (Figure 1). Engaging in a strategic planning process enabled a systematic approach to developing a sustainable nursing strategic plan aligned with that of the hospital (Ingersoll et al. 2005). The group determined that an evidence-based approach involving diverse representation was integral to developing the inaugural nursing strategic plan. This approach involved analysis from a comprehensive literature review and organizational benchmarking of elements, structures and processes that enhance professional nursing practice and improve patient safety and healthcare quality. The strategic planning process and launch of the nursing strategic plan was funded through the Nursing Enhancement Fund of the Ontario Ministry of Health and Long-Term Care.

Developing the nursing strategic plan (NSP) was initiated through a series of off-site, facilitated retreats over a six-month period (June to December 2004). These retreats provided an open, safe forum for participants to bring forward their ideas and perspectives. Context-setting in the retreats included an overview of the hospitalwide strategic plan and corporate objectives (SMH chief executive officer and president); elements of clinical scholarship and academic nursing practice (dean, Faculty of Nursing, University of Toronto); professional nursing practice standards (director, practice and policy, College of Nurses of Ontario); hospital strategic plan and corporate objectives (CEO); and trends in patient safety and healthcare delivery (doctoral student specializing in patient safety research). The SWOT analysis was revisited, validated and updated through the retreat series.

Participation in the retreats included broad representation from all dimensions of professional practice including education and research (directors, resource nurses, advanced practice nurses, educators, and ); administrators (Executive Vice-President Programs and Chief Nurse Executive, Program Directors, Clinical Leader Managers, Ontario Nurses Association local president); clinical practice (staff nurses from across the programs from unit-based council chairs and nursing council); non-nursing leadership roles (Risk Management, Leadership and Staff Development, Mission and Values, and Project Gemini); and external partners (academic and community partners). Retreat participants engaged in a variety of creative exercises (visioning, brainstorming, consensus building, and priority-setting).

Deliverables from the retreats included a vision statement, guiding principles, strategic directions and supporting structures and processes. These deliverables, linked to relevant evidence from the literature and best practices from organizational benchmarking, formed the basis of the NSP draft document. In January 2005, the document was disseminated for validation and feedback throughout the corporation - beyond nursing to include other healthcare disciplines, human health resources, administration and senior management. Critical feedback was incorporated into the final document, which was officially launched during Nursing Week in May 2005. During that week, hard copies were distributed hospitalwide and an electronic copy was posted in the Strategic Planning section of SMH's website (www.st.michaelshospital.com).

The Plan: Conceptual Framing, Vision, Guiding Principles, Strategic Directions, Framework for Action and Accountability

Flowing from the hospital's strategic plan and SMH's core mission and core values, the inaugural nursing strategic plan, "Enhancing the Professional Practice of Nursing," created a blueprint for action to enhance nursing at SMH. Framing the NSP was Boyer's (1990) concept of scholarship domains: discovery, integration, application, and teaching. These four domains are essential and inseparable AHSC components, as knowledge is acquired and generated through the integration of research, synthesis, practice and teaching. Through this process, evidence-based practice and best practices develop and evolve to meet the needs of patients efficiently and effectively (Affonso 2002). Responding to the change that is required to meet future healthcare needs in an AHSC, and building on the hospital's existing foundation and rich tradition of nursing excellence, the following vision statement was developed: "Nursing excellence through our culture of caring, innovation and scholarship."

Eleven guiding principles were developed, aligned with SMH's vision, mission, core values and strategic priorities, with the aim of enhancing professional nursing services to ensure the design and delivery of safer, high-quality healthcare (Figure 2). Grounded in the vision statement and the guiding principles, five overarching strategic directions were identified as pillars that are critical to the achievement of our nursing vision (Figure 3). Each of the strategic directions has a series of objectives that provide tactical strategies to achieve nursing's vision.

A key part of operationalizing the vision and directions outlined in the nursing strategic plan is the creation of a new nursing leadership structure which will build on the work carried out by the current nursing council structure. The Nursing Leadership Council (NLC) will be the overarching decision body (referred to earlier as governance structure) for professional nursing services at SMH and will provide oversight to the implementation of the strategic plan using the recently developed accountability framework. This framework includes measures and indicators derived from a synthesis of relevant literature (Donaldson et al. 2005; Gallagher and Rowell 2003; McGillis Hall et al. 2003), key informant interviews, organizational benchmarking, accreditation patient safety criteria indicators and provincial government indicators. Both the NLC and the subcommittees (Figure 4) will be aligned with other corporate committees to ensure synergies to leverage nursing in achieving SMH's corporate goals. Key to the effectiveness of the NLC is the alignment of the front-line nurse and nursing leadership with the NLC to create the matrix for effective knowledge management and collective planning.

Anticipated outcomes associated with the NSP implementation include maximizing scope of practice, effective role integration and professional identity for nursing at SMH (Knox and Gharrity 2004). Long-term benefits include a healthier and more productive nursing workforce resulting in operational efficiencies, including reduced turnover, absenteeism, overtime and replacement costs (Waldeman et al. 2004) and the delivery of safer patient care and satisfaction (Aiken et al. 1994; CNAC 2002; Wolf et al. 2004).

The Pearls: Lessons Learned

Key lessons learned through the development of the inaugural NSP at SMH included:

  1. Linking a change agenda (enhancing professional nursing practice to meet evolving healthcare needs) to key external forces (e.g., patient safety and quality gap) and aligning a nursing discipline-specific strategic plan with key internal forces (hospital's mission, core values and corporate objectives) collectively provide a platform for action.
  2. Articulating a vision and developing guiding principles and strategic directions are essential foundational steps in the evolution of professional, academic nursing practice.
  3. Conducting extensive literature reviews and organizational benchmarking are key elements of the development, implementation and evaluation phases of new initiatives.
  4. Involving a combination of internal stakeholders (staff nurses, advanced practice nurses, clinical leader managers, program directors, other healthcare disciplines and leaders in the hospital setting) throughout the strategic planning process, balanced with external review and consultation, is an integral mix when redesigning structures (governance), roles and processes.
  5. Building a comprehensive accountability framework that is evidence-based and contextually relevant is required for ongoing monitoring and sustainability of professional practice environments.
  6. Securing funding for the strategic planning process and ongoing financial and senior management commitment is a prerequisite for achieving transformations in practice settings.
  7. Devising a communication strategy and roll-out plan through both formal (councils, committees, PDF of NSP available on website, etc.) and informal mechanisms (conversations with nurses and other colleagues) to launch the NSP.

The Passion and Perseverance: Transforming Practice Settings

The NSP is an essential step towards the transformational change required to support SMH's vision of a leading academic health science center that provides safe, quality health care. Enacting the strategic directions and the infrastructure outlined in the NSP will require investment and significant leadership across all levels and a change-management approach. Through passion and perseverance, the aim is to transform our practice settings where nurses have opportunities to participate in scholarly activities. These activities include how we investigate (research), educate (teaching and learning), manage information (informatics) and practise at the point of care (clinical services).

About the Author

Lianne Jeffs, RN, MSc
Director, Nursing/Clinical Research
St. Michael's Hospital
Toronto, ON

Jane Merkley, RN, MSc
Director, Nursing Practice and Education
Co-Chair, Nursing Council
St. Michael's Hospital
Toronto, ON

Jana Jeffrey, RN
Clinical Leader Manager
Co-Chair, Nursing Council
St. Michael's Hospital
Toronto, ON

Ella Ferris, RN, MBA
Executive Vice-President, Programs and Chief Nurse Executive
St. Michael's Hospital
Toronto, ON

Janice Dusek, RN, MS, MBA, CHE
Executive Vice-President, Programs and Chief Nurse Executive
(May 2004 - March 2006)
St. Michael's Hospital
Toronto, ON

Catherine Hunter, BScH, MBA, CMC
Management Consultant
Hunter Healthcare Consulting Inc.
Toronto, ON


The authors would like to thank the Ministry of Health and Long-Term Care for its Nursing Enhancement funding, retreat participants and guest speakers (Jeff Lozon, Dyanne Affonso and Heather Campbell), who helped shape our nursing vision, guiding principles and strategic directions and recommended aligned infrastructure at SMH.

Correspondence should be addressed to: Lianne Jeffs, email: jeffsl@smh.toronto.on.ca


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