2024 Pathway manual introduction

FigureThe American Nurses Credentialing Center's Pathway to Excellence® (Pathway) Framework serves as an evidence-based blueprint for establishing positive practice environments that foster nursing excellence. This framework is designed to recognize and empower nurses, enhance job satisfaction, improve employee engagement, safeguard clinician well-being, and ultimately improve patient outcomes. Especially with the current healthcare challenges and the global pandemic's emotional toll on nurses, the criticality of creating supportive practice environments and the relevance of the Pathway Framework have been amplified. Organizations that "lived Pathway" and continued to use the framework—practicing shared decision-making, recognizing nurses' contribution, and prioritizing their well-being—thrived and sustained optimum quality of patient care when others struggled. To ensure the continued relevance, effectiveness, and adaptability of the Pathway Framework, the Commission on Pathway to Excellence (COPE), the governing body of the program, and the Pathway Program Office evaluate the Elements of Performance (EOPs) and revise the criteria every 4 years. This ongoing review and periodic revision of the application requirements are essential to ensure the effectiveness and relevance of the framework in addressing the evolving needs and current challenges in the dynamic healthcare landscape. It also exemplifies a commitment to staying at the forefront of best practices. To achieve Pathway designation, organizations must demonstrate the enculturation of all criteria essential for an optimal nursing practice environment. These criteria, or EOPs, fall under six Pathway Standards: Shared Decision-Making, Leadership, Safety, Quality, Well-Being, and Professional Development (see Figure 1). To sustain designation, Pathway organizations must go through the appraisal process and meet the most up-to-date criteria every 4 years. This ongoing evaluation prevents complacency and ensures the continued focus on the standards and alignment of organizational practices with the Pathway to Excellence framework. This cyclical process also requires organizations to continually evaluate their culture and invest in the well-being and overall success of their nursing staff.Figure 1:: ANCC Pathway to Excellence® Framework for Positive Practice EnvironmentsOverview of changes Numerous enhancements were incorporated in this current revision (see Table 1).1 The number of EOPs was increased from 53 in the 2020 manual to 60 in the 2024 manual. Historically, with every manual revision, the aim is to carefully evaluate the inclusion of EOPs and, if possible, to reduce the administrative burden on organizations applying by eliminating EOPs (which results in fewer requirements) that are no longer relevant or deemed regulatory. However, in consideration of the current healthcare landscape, including additional Pathway criteria requirements was warranted to ensure that nurses at all levels feel supported. For instance, in strengthening the well-being standard, a requirement was added with a focus on supporting nurse leaders' well-being. Additional EOPs were added to emphasize assessing the effectiveness and meaningful impact of structures or processes because of literature and/or feedback to address perception gaps or other areas of disconnect. Table 1: - New and relocated concepts reflected in the 2024 application manual1 Pathway Standard New concepts 1. Shared Decision-Making Organization assesses the effectiveness of the shared decision-making structure. Direct care nurses use shared decision-making structure to plan and evaluate well-being initiatives. 2. Leadership Organization uses succession planning to develop nurses for nursing leadership roles. (moved from PS 6) 3. Safety The nursing leadership team addresses long-term staffing concerns expressed by the direct care nurses and associated strategies are communicated back to the direct care nurses. Nurse managers create a culture in which meal and rest breaks are planned and consistently taken by their direct care nurses. A culture is in place that ensures: 1) staff feel safe to report discriminatory behaviors, 2) reported concerns are addressed, and 3) follow-up is provided to the staff member(s) who reported the concerns. Direct care nurses are supported to provide safe care when assigned to an area other than their primary area. (moved from PS 6) 4. Quality Organization 1) promotes a culture of diversity, equity, inclusion, and belonging (DEIB) to optimize the nursing workforce, and 2) describes how the organization assesses the effectiveness of the associated strategies to promote DEIB. Organization encourages sharing of new ideas and supports implementation of innovation in the workplace. 5. Well-Being Organization provides opportunities to raise awareness of: 1) mental health issues prevalent among nurses, 2) available mental health services to address those issues, and 3) evidence-based strategies to enhance mental well-being during work hours. Organization creates a culture in which a nurse feels safe to self-report a medical error in the workplace. Organization uses support strategies to address the well-being needs of senior nursing leaders and nurse managers. Heathy Nurse, Healthy Nation organizational partners may submit documentation of their HealthyNurse Survey participation for credit for EOP 5.2a. 6. Professional Development Nurses are encouraged to share best practices with entities outside their organization. Education provided on respectful communication. (moved from PS4) Organizational Overview Strategies are in place to refrain from mandatory overtime for nursing staff. The organization engages newly hired nurses to the Pathway to Excellence Standards. The American Nurses Association Nursing Leadership: Scope and Standards of Practice are incorporated into the preparation and continued development of the nursing leadership team. Shared decision-making Shared decision-making, a hallmark of Pathway organizations, is the underlying principle of shared governance. Kutney-Lee and colleagues highlight how organizations that provide nurses with opportunities to be engaged are more than likely to provide better patient care and outcomes, including nursing job satisfaction.2 In addition, shared decision-making improves the work-life quality for nurses, positively influencing staff engagement, job satisfaction, and turnover, and is therefore central to most Pathway requirements.3,4 Shared decision-making processes that are deemed effective enhance healthy practice environments.5 Having shared governance structures in place doesn't guarantee that shared decision-making is being consistently practiced. This disconnect was vastly amplified during and immediately postpandemic; therefore, a new criterion has been added that requires organizations to evaluate the effectiveness of their shared decision-making structures. It's essential to conduct this ongoing assessment because when staff members feel that their voices are heard and their input in decisions that influence care delivery and the practice environment is valued, job satisfaction and staff engagement increase. The same holds true with another element: engaging nurses in planning and evaluating well-being initiatives. Including nurses in this planning and evaluation diversifies the insight and ensures that only meaningful and impactful programs are secured for the team. Likewise, interprofessional collaboration is a major focus, crucial in addressing ethical concerns, community health, and new technology. The involvement of interprofessional healthcare teams, including direct care nurses, significantly impacts various aspects of healthcare delivery and the overall organizational culture.6 Leadership Pathway organizations' leadership is committed to living the Pathway Standards and role-modeling the behavior. They foster effective collaboration and shared decision-making processes among staff. Pathway leaders actively engage direct care nurses in decisions that impact patient care, nursing practice, and the work environment. As accountable leaders, the CNOs and nurse managers are accessible and provide unwavering support to direct care nurses, especially during organizational changes. Pathway organizations offer strategies to encourage leaders to seek professional and personal growth and advancement, enhancing core knowledge and role competency through ongoing leadership development activities. Keith and colleagues illuminate how the quality of onboarding, training, and competency impacts the job satisfaction of nurse managers.7 Therefore, individualized development activities and targeted leadership development initiatives catering to individual needs equip leaders to function successfully in their roles.8 Pathway leaders intentionally seek continuous improvement obtained through feedback from colleagues and nursing staff. Because nursing leaders possess an integral role in creating and sustaining a culture of excellence, the 2024 Pathway application manual includes a stronger focus for organizations to likewise support nurse leaders' well-being. When nursing leaders' personal well-being and resilience are enhanced, they're more likely to stay in their current role and can better support their nurses, mitigating nursing staff turnover.9 For this same reason, Pathway organizations employ strategic measures to retain CNOs and nurse managers in the pursuit of a positive practice environment amid executive leadership transitions and integrate comprehensive succession planning strategies. This is especially critical for nurse managers as they embody a central role in creating and sustaining positive practice environments at the unit level, influencing the overall success of the organization. Safety Pathway organizations safeguard the physical and psychological safety of patients and staff. The concept of direct care nurses being supported to communicate concerns about long-term staffing plans was enhanced to ensure that nursing leadership both addresses the raised concern and communicates back the plan for addressing the concern. Ineffective communication among the healthcare team increases negative patient outcomes.10 It's vital when nurses express concerns that they can be confident that their concerns will be addressed; otherwise, they'll hesitate to raise concerns in the future. It isn't enough to merely listen to the nurses' concerns; it's important for their leaders to close the communication loop and convey back any associated actions or provide an explanation about why suggested changes aren't made. Taking meal and rest breaks can mitigate nurse fatigue that increases incidences of patient safety events.11 New to this standard is a requirement to ensure nurses can consistently take their meal and rest breaks. When expectations, experiences, philosophy, and values guide the team's behavior, this shows that a construct is enculturated within an organization. Nurse managers have a unique role and responsibility in setting the culture of the areas they supervise and removing barriers to enhance nurse well-being and ensure the provision of safe patient care.12 The theme of elevating the culture and effective communication continues in the safety standard new EOP that calls for a culture in which staff feel safe to report discriminatory behaviors. In the US, employees have the right, as codified in the law, to report discrimination.13 However, having the legal right alone doesn't equate to employees feeling safe to act and report discrimination to their employer.14 Effective communication promotes trust, and for a person to be courageous enough to report discrimination, they shouldn't fear retaliation but trust and have confidence that their employer will appropriately address the reported concern. Quality Diversity and inclusion were first incorporated into the organizational overview of the Pathway manual as a clarification to the 2020 Pathway manual. With the 2024 manual publication, the concept is expanded as an EOP in the quality standard for describing how the organization both promotes a culture of diversity, equity, inclusion, and belonging (DEIB) to optimize the nursing workforce and assesses the effectiveness of their DEIB strategies. An organization's commitment, culture, and structural empowerment should all align in the efforts to achieve and maintain the desired DEIB goals.15 Ensuring teams are diverse increases quality, innovation, team communications, and financial performance.16 Additionally, staff at inclusive organizations feel safe, respected, valued, authentic, involved, and able to influence decision-making.17 Staff doing the day-to-day work in healthcare are ideally positioned to notice issues and opportunities for improvement.18 The other new EOP in the quality standard calls for encouraging sharing of new ideas and supporting the implementation of innovation in the workplace. There are numerous opportunities and solutions to promote innovation in the workplace through associated reward systems, budgeting, career tracks, and reframing of workforce models.19 Well-being Because burnout negatively impacts all aspects of care, integrating innovative strategies to address stress is critical to foster staff resiliency and well-being.20 Well-being and resilience are essential components in the strategic planning efforts of Pathway organizations. Pathway organizations conduct regular employee health assessments and implement health initiatives addressing the assessment findings. Staff and leaders who work in organizations that nurture the team's personal well-being also reported the enculturation of effective interprofessional collaboration in which they feel valued and that their voices are heard.21 Well-being strategies include how nurse leaders must foster a culture of daily recognition to acknowledge nurses for their contributions. Pathway leaders integrate innovative strategies to provide meaningful recognition in a consistent and impactful way to ensure that every staff member within the organization reaps the benefits of meaningful recognition.22 Pathway organizations are also committed to promoting resilience by integrating processes that address both physical and compassion fatigue. Equally important and new to the standard is that support strategies must be in place to address the well-being of senior nursing leaders and nurse managers, so they can function at their very best to better serve and foster the health and wellness of their teams. Another concept new to the standard is that organizations must be cognizant of mental health issues prevalent among nurses and institute evidence-based strategies to enhance mental well-being during work hours, all of which are critical to ensuring staff wellness, which then translates to improved organizational outcomes. Pathway leaders also create a safe and healthy environment for the staff as well as the patients. To err is human, and fortunately for Pathway organizations, staff feel safe to report errors, and such mishaps are approached as collective learning opportunities. A punitive environment will discourage staff from owning their mistakes to preserve their personal psychological safety.23,24 Forging a culture grounded in positive and trusting relationships with the team helps create and sustain healthy work environments. Professional development The Pathway framework builds upon the premise that developing competent and collaborative staff begins with a comprehensive orientation that includes individualization of learning needs and clinical experiences. A smooth transition into practice with the support and guidance of mentors, preceptors, or other nursing experts must also be in place to nurture the value of lifelong learning and develop emerging nurse leaders. As nurses advance along this novice-to-expert continuum, new criteria within the Professional Development standard underscore the important role nurses play in advancing nursing practice through sharing of best practices outside their organization. Disseminating best practice knowledge "to advance the discipline serves to improve patient care and is a source of personal and professional achievement."25 Presenting at conferences and publishing in journals are examples of how nurses can disseminate best practices, and organizations are encouraged to foster these skills among their nursing staff. A guide toward thriving Currently, over 210 organizations spanning the care continuum have earned Pathway to Excellence designation, operating in 37 states, the District of Columbia, and 8 countries beyond the US. This widespread adoption underscores the program's universal relevance and attainability across diverse cultures and settings. The Pathway framework is increasingly becoming the "north star" for organizations addressing their current challenges. It's an evidence-based blueprint for improving the health and well-being of clinicians. The intentional addition of selected criteria is poised to enhance this global impact, playing a pivotal role in fostering positive practice environments and enabling nurses to thrive worldwide. "As a prior Chief Nursing Officer of a Pathway-designated facility, I can attest that the Pathway to Excellence Framework is needed today, more than ever. Healthcare organizations are seeking to recruit and retain a team committed to high-quality outcomes and compassionate patient care. When an organization begins their journey of adopting this framework, they are telling their team that they are willing to be bold in their efforts to shift culture to one where nurses and all healthcare providers are set up for success. The proof of the framework's impact can be seen in the over 200 global organizations who have achieved this designation, many through the COVID-19 pandemic. The ANCC Pathway to Excellence Designation is the outward sign that an organization 'gets it' and desires only the best for its staff, patients and families, community, and global healthcare."—Dr. Valerie Morrison, DBA, MSM, BSN, RN, NEA-BC, SHRM-SCP, Chair, Commission on Pathway to Excellence