Structural Empowerment

Clinical nurses have a voice within the UT Southwestern shared governance organizational structure, built on a solid foundation of teamwork and collaboration. Shared decision-making and accountability empower nurses with a process for determining professional nursing practice. These organizational standards are developed through staff-led interdisciplinary committees, task forces, and councils to improve patient outcomes and experiences. Nurses at all levels take conscious ownership of patient care, safety, ethics, research, performance improvement, and evidence-based practice. Our shared governance structure supports the practicing nurse as a key decision-maker with a credible, sought-after perspective. This model strengthens practice by supporting relationships and partnerships among clinical areas, providing an innovative and collaborative environment to bolster our quality patient outcomes.

UTSW Shared Governance Structure

UTSW has a strong shared governance structure that includes all staff from all areas and disciplines, as reflected in the accompanying diagram.

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Certifications

UT Southwestern nurses validate their mastery of skills, knowledge, and abilities through certification and meet ongoing learning and practice requirements through recertification. The certification process assures patients and their families that the nurse caring for them has demonstrated experience, knowledge, and skill in the complex specialty of their care. Nursing certification and continuing education contribute to an environment of professionalism and a culture of retention. Certification also differentiates UT Southwestern from other health care organizations, demonstrating to consumers that we have attracted the most skilled and experienced nursing professionals. By the end of calendar year 2024, UTSW employed 2,352 specialty certified nurses.

Bar chart showing UTSW RN Certification headcount and certification count for CY 2022 and CY 2023.

Educational Levels

A significant body of research indicates that a more highly educated nursing workforce can help ensure our nation’s population has access to high-quality, patient-centered care. Having at least 80% of nurses holding a bachelor’s degree or higher was a key recommendation of the Institute of Medicine (IOM). Increasing reimbursement for nurses working on higher education has been the work of our Nurse Executive Cabinet.

Bar chart showing the number of UTSW RNs with B.S.N. or higher for CY 2022 and CY 2023.

The larger UTSW Nurse Executive Board is responsible for attaining the IOM’s 80% B.S.N. goal. As illustrated in the graph at right, we have maintained high levels of performance in this metric.

Clinical Ladder

The UT Southwestern Nursing Clinical Ladder program is committed to recognizing superior performance and rewarding nursing excellence in providing direct patient care. The newly improved program offers a unified, point-tiered system for all eligible nursing staff throughout UT Southwestern. Within the program, participants may select options unique to their individual professional development and nursing practice in areas of continuing education, quality improvement, leadership, and evidence-based practice.

The UTSW Nursing Clinical Ladder is open to all clinical nurses involved in direct patient care.

Advanced Practice Provider Incentive Program

In fiscal year 2023, the Advanced Practice Provider (APP) Clinical Ladder program was replaced with the APP Incentive Program, which incorporated operational goals in the quality and productivity domains, while keeping the professional contribution goals that were paramount to the Clinical Ladder program’s success. The APP Incentive Program was developed with feedback from APPs and key organizational stakeholders. The professional contribution domain provides an opportunity to receive an incentive from activities such as:

Involvement in quality improvement, evidence-based practice, and research projects
Serving as a podium speaker or presenting a poster abstract at a conference
Publishing in a scholarly journal or book
Supporting UTSW’s educational mission through precepting and/or teaching
Serving on UTSW, partner organization, or professional organization committees

In FY 2024, 415 advanced practice registered nurses received an incentive payment for their professional contributions to the organization and our profession. This value represents 51% of eligible APRNs at UTSW.

Initiatives to Enhance Nursing Certification

Medical-surgical certification ensures high-quality care and patient safety within surgical units. Certification programs provide health care professionals with the specialized knowledge and skills necessary to deliver optimal patient care, which in turn enhance patient outcomes and promote professional development among health care providers.

Despite recognizing the significance of medical-surgical certification, health care professionals often encounter various challenges in obtaining and maintaining certification – challenges such as limited access to educational resources, time constraints, and financial barriers, among others. Research has shown that health care professionals who hold a medical-surgical certification demonstrate higher levels of clinical competence, increased job satisfaction, and improved patient outcomes. Thus, we knew that by increasing certification rates within our surgical unit, we could enhance the overall quality of care provided to our patients. A review of certification levels within our department revealed that only 10 of our full-time nurses held a nursing certification.

Leadership recognized an opportunity to increase nurse certifications and discerned that morale and team commitment would improve as well. As noted above, several challenges historically contribute to low certification rates, including limited access to educational resources, time constraints due to demanding work schedules, and financial barriers associated with certification exam fees. The lack of medical-surgical certification among staff members may impact patient care quality and safety, potentially leading to suboptimal outcomes. The aim of this initiative was to increase our 6 Green Unit’s certified nurses from 10 to 15 by the end of FY 24.

The team came up with an action plan to increase the number of certified nurses on our unit by:

Facilitating monthly review tutorials in preparation for the exam: The review sessions were held online and in person to provide an option for the staff to attend. Staff schedules were adjusted to allow staff to attend the sessions.
Providing practice questions and reading materials: Three-item quizzes were emailed daily to staff participating in the review classes. Resource materials such as bullet point presentations and review books were made available for staff requesting to make copies for them to study.
Notifying staff of resources available, such as CEPD opportunities as they became available.
Marketing annual certification incentives offered by the organization.
Bolstering organization support: Staff who successfully passed the exam were publicly recognized by the leadership via email sent to all the unit’s staff and at staff meetings. Quarterly coaching, mentoring. and goal setting were also performed to encourage nurses to take the certification exam.

As a result of this initiative, the number of certified nurses on 6 Green increased to 19 by the end of FY 24.

The initiative to increase the medical-surgical certification rate within our surgical unit yielded promising outcomes and demonstrated the effectiveness of targeted intervention strategies in promoting professional development and enhancing patient care excellence. Through collaborative efforts and organizational support, we have made significant progress toward cultivating a culture of continuous learning and excellence within the unit.

The implementation of educational programs, flexible scheduling, and organizational support resulted in the goal this initiative was designed to achieve. Staff members actively engaged in certification preparation activities, demonstrating a commitment to advancing their clinical competence and improving patient care outcomes. Furthermore, the positive impact of the intervention extends beyond certification attainment, fostering a supportive and empowering environment where staff members feel valued, recognized, and motivated to pursue ongoing professional development opportunities. The promotion of an organizational culture that prioritizes certification achievements has contributed to a sense of pride and camaraderie within the surgical unit, strengthening team cohesion and morale.

It is essential to sustain the momentum generated by this initiative and to continue to support staff members in their pursuit of medical-surgical certification.

Contributors:

Julie Abraham, B.S.N., RN
Zehra Aziz, B.S.N., RN, CMSRN
Shari Ann Dino-VU, M.S.N., RN, CCRN, NE-BC
Beena Johnson, M.S.N., RN, RN-BC

Megan Lowe, B.S.N., RN
Nina Pacheco, B.S.N., RN, CMSRN
Asha Samuel, B.S.N., RN

Hospital and Ambulatory Clinical Education and Professional Development

The Departments of Clinical Education and Professional Development (CEPD) for hospital and ambulatory staff advance the philosophy, mission, and vision of UTSW Nursing Services. CEPD provides support to clinical staff by offering education, training, and professional development activities. This includes clinical orientation, student placement, and education on care standards and quality improvement. Our practice transition team supports and facilitates the transition to practice experience while cultivating an inclusive learning environment for our RN and PCT residents and nurse fellows. We are accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. We offer educational hours (NCPD) for events that support nursing continuing professional development and improve patient outcomes. CEPD is committed to providing clinical staff with education and resources to deliver safe, compassionate, patient-centered care in an engaging learning environment of quality, evidence-based, and professional practice.

Our commitment to excellence in education is evidenced by employing the Nursing Professional Development Practice Model (ANPD, 2016) to leverage learning to meet and exceed organizational outcomes. To meet this challenge, our Nursing Professional Development (NPD) practitioners are master’s degree level-prepared nurses and require NPD certification within 18 months of hire. The NPD practitioners operationalize environmental scanning, proactively plan educational programming, and work collaboratively with unit-based educators to meet the learning needs at the individual, unit/clinic, and organization levels.

Wellness Room in the Emergency Department

Based on the Emergency Department (ED) 2023 Glint survey results and staff evaluations, Bailey Scales, M.B.A., M.S.N., RN, Manager of Service Coordination, recognized that several staff members desired a private area to relax and decompress during busy shifts. Survey results revealed that a recent increase in patient census and acuity added mental strain to staff, creating a need for a relaxation area. This need was presented as a priority to leadership.

In October 2023, front-line staff Katherine Lucero, B.S.N., RN, and Geoffrey Ramos, B.S.N., RN, led an initiative to create a Wellness Room to increase staff satisfaction and decrease the risk of staff burnout. Glint results showed 76.5% of the 98 respondents desired such a room; additionally, 26% of the respondents asked that the room have a quiet environment and massage chair. In December 2023, the team brainstormed necessary actions. They sought and located an underutilized break-out/discussion room and requested to convert it into a Wellness Room. With leadership’s assistance, the team cleared the room and assessed it for functionality and appropriateness for the proposed Wellness Room.

Graph showing pre and post results of ED Wellness Room implementation

In January 2024, the proposed room was officially approved as the ED Wellness Room, and the team ensured the room was ready for its intended purpose, equipping it with a comfortable chair with an ottoman, a chair with an added massage cushion, a refrigerator with cold beverages and candies, and a side table that the staff could use while on break. To make it fun, the team also offered yoga session staff could participate in by signing up using the QR code available in the room (yoga mats were also conveniently placed for use). Additionally, coloring pages with markers were available to help staff relax while in the room. Communication via email regarding the Headspace app was sent, and a calendar was placed in the room for staff to update their Headspace events and any other events of their choice. Lastly, a coffee bar was added in the break room so staff could enjoy a hot coffee during their relaxation time in the Wellness Room.

Once the ED Wellness Room was implemented, staff continued to bring items to make the space welcoming to all. The room has proved to provide a private space where staff can relax and decompress during their busy shifts, promoting staff satisfaction. In October 2024, staff completed a post-survey that showed 81% of the 79 respondents saying they utilized the Wellness Room and 90% (71/79) saying that having the Wellness Room improved staff mental well-being, increasing morale. It has been evident that the Wellness Room was well received, and staff have continued to find the time to use it.

Contributors:

Tessa Clarkson, B.S.N., RN, Emergency Department Assistant Nurse Manager
Richard Fernandez, M.S.N., RN, Emergency Department Nurse Manager
Katherine Lucero, B.S.N., RN, Emergency Department Staff

Mike Mayo, M.S.N., B.S., RN, Director of Emergency Services
Geoffrey Ramos, B.S.N., RN, Emergency Department Staff
Bailey Scales, M.B.A., M.S.N., RN, Manager of Service Coordination

Expanding Telephone Triage Knowledge Through a Dual Organization Collaborative for Education and Professional Development Nursing Opportunities

At a recent American Academy of Ambulatory Care Nursing national conference, leadership from UT Southwestern and Children's Health's nurse triage call center identified a gap in professional development opportunities for telephone triage nurses. Specifically, it was found that more affordable, standardized learning opportunities were needed to address the unique needs of triage nursing across different organizations. Both teams recognized the need to enhance professional development by providing standardized, cost-effective training to improve triage skills and adherence to regulatory standards.

Leaders from both institutions collaboratively identified the need for this initiative during conference discussions, and it was clear that offering structured education could elevate the quality of telephone triage across organizations. The focus was on creating accessible training to strengthen regulatory knowledge, improve clinical decision-making, and support nurses in handling triage calls more effectively.

The project’s primary goal was to develop and implement a standardized telephone triage education symposium for nurses at UTSW and Children’s Health. This initiative aimed to provide nurses with essential skills to enhance their clinical practice, improve patient safety, and adhere to regulatory standards while managing triage calls. An additional goal was to offer these educational sessions at no cost to participants, encouraging participation and making learning accessible.

To achieve this, both organizations' leadership teams began holding monthly Zoom meetings to develop the curriculum collaboratively. More stakeholders were introduced to the project, including appropriate leadership and education/professional development staff. These meetings were used to outline content, assign responsibilities, and develop the necessary materials for an educational day. The team decided to host two sessions, each lasting four hours, with content delivered by UTSW and Children's Health employees. The joint efforts culminated in creating a shared slide deck representing both organizations.

The content focused on:

Regulatory aspects, including requirements from licensing agencies and an overview of the Texas Nurse Practice Act
Triage foundations that conduct a focused assessment, obtain a health history, and adhere to protocols
Practical applications through an "Escape Room" activity, where participants solved case scenarios
Customer service skills to address challenging or abusive callers and manage social determinants of health beyond the triage call

Nurses from UTSW and Children's Health attended the educational event, which awarded participants three hours of nursing continuing professional development (NCPD) credits.

The initiative proved highly successful, with 41 participants attending the two-day educational symposium. Participants were asked to rate their knowledge and skill improvements on a scale ranging from "Outstanding" to "Poor." Results showed overwhelmingly positive feedback, with 73.3% rating the experience as "Outstanding" and 26.7% as "Good." Participants reported significant improvements in understanding the regulatory aspects of telephone triage, including the Texas Nurse Practice Act and protocol adherence.

Additionally, 80% of participants rated their learning on customer service strategies and managing difficult calls as "Outstanding," with the remaining 20% rating it as "Good." The project also enhanced clinical decision-making and patient interaction and set a strong foundation for future improvements in telephone triage education. Plans are now in place to record the sessions, expanding access to nurses at both institutions who could not attend the in-person sessions and offering NCPD credits to a broader audience.

Contributors:

UTSW

Sheryl Bartlett, B.S.N., RN
Alicia Bossé, M.B.A., B.S.N., CMS-RN

Children’s Health

Linda Jackson, M.S.N., RN
Murray Raymond, B.S.N., RN
Tamara Siegmund, B.S.N., RN, CPN
Susan Webber, M.S.N., RN, CPN, CEN, CPEN, CCCTM

Group of nurses rounding and discussing cases

TeamSTEPPS Program to Promote Effective Communication and Team Cohesion

As a tertiary hospital, the William P. Clements Jr. University Hospital’s 5 Blue Labor and Delivery (L&D) Department’s physicians, midwives, and nursing staff care for the region’s most complex pregnancies. They also provide laboring patients, obstetric triage, and antepartum care. The department receives referrals and transfers from many outlying hospitals. Seamless coordination and communication among staff and providers are pivotal to ensuring patients and their babies receive the best care.

The arrival of new staff in L&D was a unique opportunity to significantly enhance team effectiveness and collaboration and empower the nurses to speak up. Two previous root-cause analyses on L&D highlighted the critical role of communication and hand-offs in patient care. Additionally, the nursing and physician leadership and staff from Quality and Operational Excellence identified the need to improve hand-offs and communication among providers, patients, and families, all of which underscored the importance of an interdisciplinary workshop to improve team dynamics, aligned to improve patient care and unite staff and faculty in our mission.

With this identified need, the High-Reliability Team and Simulation Lab proposed adopting the Agency for Healthcare Research and Quality’s Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training, ensuring the highest quality and effectiveness. This curriculum-based, interactive, multidisciplinary workshop promotes communication and team dynamics. The objectives of TeamSTEPPS included a discussion of sentinel events and how teamwork and communication can reduce errors or near misses and decrease patient harm. TeamSTEPPS principles, such as radical candor and just culture, were integrated to foster an environment conducive to patient safety, promoting a high-reliability organization. Strategies included assisting one another, understanding psychological safety, and promoting closed-loop communication.

Seventy-seven participants attended training in an interactive, small-group setting, wherein registered nurses, physicians, certified nurse midwives, certified registered nurse anesthetists, certified surgical technicians, and health unit coordinators participated. They completed eight sessions between late 2023 and early 2024. Classes were held in small groups, with a minimum of five participants and a maximum of 12 for each class, with two hours of nursing continuing education units offered.

Bar chart showing the TeamSTEPPS Confidence survey results

According to participants’ positive feedback, the training was successful and significantly improved their confidence. The pre- and post-course confidence survey data revealed a remarkable shift, with participants feeling more at ease recognizing changes and more empowered to voice their concerns. Most participants described the training as a “positive learning experience and an effective use of my time.” Their comments, such as “better closed-loop communication, better teamwork, and being able to speak up when I am concerned instead of remaining quiet,” underscored the program’s effectiveness. One participant’s reflection on the program’s impact, “Speaking up, not being afraid to be wrong, not being afraid to admit if I made a mistake, we are all human,” and the recognition that “disagreements are not disrespect,” further validated the program’s success. After the training, facilitators noted a significant improvement in communication and reduced interprofessional conflict. The program’s focus on open communication and respect fostered a more positive team environment and enhanced interdisciplinary collaboration.

Contributors:

Marina Flenniken, M.S.N., RNC-OB
Jamie Morgan, M.D.
Meredith Stringer, M.S.N., APRN, AGACNP-BC

Amie Swindle, M.S.N., RN, CPPS
Janine York, M.S.N., RNC-OB

Empowering Medical Providers to Provide Optimal Early Cardiac Resuscitation

The American Heart Association (AHA) developed a systematic approach to cardiopulmonary emergency and effective team communication. UT Southwestern Medical Center identified a need to improve the Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) processes during cardiac arrest events. The Code Blue Committee reviews non-ICU code events, and the High-Reliability Team (HRT) conducts mock Code Blue simulations with a high-fidelity manikin throughout the health system. Both provide information on Code Blue event opportunities for improvement.

A multidisciplinary team piloted the improvement initiative on UTSW Clements University Hospital’s Medical-Surgical units 8 Green (8G) and 10 Blue (10B). The goals were to increase staff awareness and confidence in adhering to AHA Guidelines on early defibrillation, epinephrine administration, and provision of BLS interventions within the first two minutes in 85% of witnessed cardiac arrests.

A safety plan was developed to conduct unannounced mock codes for day and night shifts in patient care areas. A simulated patient, a high manikin, was utilized, and real-time data were collected on resuscitation efforts. Before each code simulation, hospital operational leadership was made aware, and a final safety check was performed throughout the hospital. Fourth-year medical students with ACLS certification were recruited to assess each video. They rated all four videos individually using the video questionnaire based on AHA guidelines to document the pertinent times and mechanisms.

The project team completed four unannounced mock code simulations, two within each unit, one during the day shift and one at the night shift. All four events were videotaped, and real-time data were collected through the high-fidelity manikin software. Participants of the mock codes completed an anonymous survey about their confidence in starting and performing AHA best practices. In June 2024, the project team began PDSA cycle No. 2, which aims to further assess the impact of the training by conducting four unannounced mock codes on 8G and 10B. The same survey will be used again during the second PDSA cycle, ensuring a thorough evaluation process before the data are collated.

In completing a fishbone diagram, a tool to identify the root cause of a problem and brainstorm solutions, the team elected to proceed with another improvement project: improving the compression process. The HRT educated the staff on 8G and 10B, empowering them to call a code if there was no pulse and start high-quality compressions as soon as possible. Additionally, all staff practiced < 2 minutes of high-quality compressions on a simulated manikin with real-time feedback to adjust body mechanics, improving cardiopulmonary resuscitation (CPR) quality and individual confidence. As a token of appreciation to those who completed the training, staff were given a badge reel and a chance to win a prize.

Contributors: