Improving practice environments based on best management practices.

The challenge of getting clinicians to base their practice on research evidence, when available, is a long-standing one. In fact, when the term "evidence-based practice" is used, it often is associated only with clinical practice. However, there is an equally compelling need for health care organizations to implement evidence-based management strategies where sufficient evidence exists. After all, it is in these organizations where practice environments are created and shaped and where patient care is provided. Evidence that these organizational environments can have a major effect on both the performance and attitudes of clinicians and the health care services they deliver is growing. The notion of change in the organizational or practice environment based on evidence is not new. However, due to the pressing problems faced in many practice environments today, interest is renewed. Issues of interest include patient safety, chronic shortages of health workers of all types, high levels of dissatisfaction among health care workers, and the rapid pace of change that is present globally. As an example, evidence of high rates of dissatisfaction among nurses in a global context was reported recently in an international survey of 43,000 nurses conducted in 5 countries. Approximately 40% of the nurses reported that work-related conditions are contributing increasingly to job dissatisfaction, burnout, and intent to leave nursing. Many of the issues that contribute to these levels of dissatisfaction are not new and most are amenable to changes in the organizational environment that could be made by management (Aiken et al., 2001). An extensive body of research, within health care and the broader organizational and management sciences, has identified management practices that are consistently associated with designing and implementing effective initiatives for improvement and change. One example can be found in a recent Institute of Medicine (IOM) report that addressed nursing work environment issues from the perspective of patient safety (Page, 2004). Five management practices that are evidence-based are described. These practices have been applied unevenly in health care organizations and hold promise for improving practice environments. The evidence-based best practices identified by the IOM that are directly related to work and practice environments are: * Creating systems to balance the tension between production efficiency and reliability, such as consciously incorporating redundancy into some aspects of the work and thereby increasing reliability and safety in the organization; * Creating and sustaining trust throughout the organization so that employees feel both heard and valued; * Actively managing the change process through ongoing communication, training, and the use of measurement and feedback techniques to make adjustments during the change process if necessary; * Involving employees in decision-making around the design and flow of their work, using strategies such as those depicted by shared governance; * Creating a learning organizational environment that is always trying to acquire and manage new knowledge as well as to modify the behavior of the organization to reflect this new knowledge. Implementation of these evidence-based strategies has been consistently demonstrated to result in improved organizational outcomes, whether defined in terms of performance goals or by employees' rating their employing organizations as desirable places to work (Page, 2004). Another recent report, produced by the International Council of Nurses (ICN), focuses on evidence related to human resource management in health care organizations. …