The Exec: Fostering a Culture of Nurse Innovation Requires Intentionality

Nurses who question the status quo or seek better solutions should be celebrated, Yale New Haven Hospital's CNO says.

Yale New Haven Hospital’s strong culture of nurse innovation isn’t by accident—it’s been cultivated carefully and intentionally.

Indeed, Michele Santoro, RN, BSN, a Yale New Haven clinical nurse, was named a 2022 Magnet® Nurse of the Year because of her innovations at the New Haven, Connecticut hospital.

Ena Williams, PhD, RN, Yale New Haven’s chief nursing officer and senior vice president, spoke with HealthLeaders about how she and her colleagues have encouraged nurses to question the status quo and use their experience and skills to improve their practice to benefit patients.

This transcript has been lightly edited for clarity and brevity.

HealthLeaders: What are some innovations that have come from Yale New Haven Hospital nurses?

Ena Williams: During the pandemic, one of the first things they did was develop an innovation page on the nursing website where they could enter any issues that were impeding their ability to deliver care from a practice or a workflow perspective. Out of that came several innovations.

For example, they noticed that patients were not getting their meals in synchrony with their blood glucose testing, because patients would call for their meals at different times. But with COVID, we wanted to minimize going in and out of the room. So, within 24 hours, they had completely changed the practice of how meals were being ordered and how they were arriving to the unit. They partnered with the diabetes consultant, the dietary folks, and physicians—a real interdisciplinary team—to synchronize the testing of the blood glucose, the administration of medication, and meal delivery.

One innovation resulted in an alternative care model that stratified the nurses by color code according to their expertise, but also allowed other nurses who may not have that level of expertise to support those nurses. For example, if I'm an ICU nurse, I was a red nurse. But if I was a nurse from a step-down unit who had not delivered care to the same level of acuity as an ICU nurse but I could do 70% of what that intensive care nurse will do, I became the pink nurse.

When a nurse arrived on their unit, they wanted to know what level of competency they had and out of that came this alternative care model which has become embedded as part of the standard way we operate. When we have surges in patient volume, we can modify that model.

Ena Williams, Yale New Haven Hospital chief nursing officer and senior vice president / Photo courtesy of Yale New Haven

For example, when we had a spike in volume in the maternity space last year, nurses from medical-surgical units volunteered to go to the maternity unit and they used this model to create safety. We've used it in the emergency department and when we had a lot of pediatric RSV, so it’s an alternate staffing model that creates flexibility and elasticity in our care.

We also support nurse practitioners who care for students in what we call our school-based clinic. We fund nurse practitioners and embed them in our inner-city schools, and one of them realized that there was not a way to evaluate children and their risk for Type 1 diabetes. Because there’s a large population of African-Americans and Asians who have a high risk for diabetes, a lot of these kids would end up getting into a diabetic crisis.

So, this NP decided to start a screening process and, with grants, bought a small machine to test the A1C of the schoolchildren and worked with our pediatric primary care physicians to refer them. To date, about 25% of the school-based clinic’s population met screening criteria and had the opportunity for early interventions.

I gave you those different examples to show that innovation is not embedded in just one location. One of the most recent ones came out of our very dynamic nursing research-based program: After surgery, there has been this long, traditional belief that you should not be given water to drink for eight hours.

A group of our nurses said, “I don't know if that still stands and maybe we should challenge that.” And through their practice, they began to offer early fluids to patients post-operatively and in fact, were able to significantly reduce the post-operative nausea and vomiting that a lot of patients had.

HL: Why are nurses such natural innovators?

Williams: Nurses are problem solvers. It’s taught to us as part of our training. We’re taught to assess a situation, to use the information that we gather to come to some early conclusions about what we are seeing, hearing, feeling, sensing, touching, and then to come up with a plan—and not to just to put the plan in place but to continually evaluate that plan.

It really is a part of the way nurses practice, but what amplifies it is when you create an environment where nurses can what I call, “play in the sandbox,” where they can challenge the status quo, and say, “How can we make this better?” As nurse leaders, we emphasize that this is expected, that this is supported, and that this is validated and celebrated when those things happen.

HL: What are some specific steps that nurse leaders, in particular, can do create and then foster a culture of nurse innovation?

Williams: It is a journey, and I would encourage a nurse leader to be very patient and give themselves much grace, but you also have to be very intentional about this. You need structures, processes, and clarity, and you need to educate the community of nurses and leaders. Sometimes leaders are the toughest to let go because we think we need to own everything.

You have to be willing to truly listen and respect nurses’ voices. Sometimes they may get it wrong, and you may have to guide them a little bit, but you have to trust them. We trust our nurses to take care of the most acute patients—the sickest of the sickest—so why can't we trust them to make decisions about their practice? That's our belief here at Yale New Haven.

HL: Innovation requires a level of comfort in exploring creative solutions, risk-taking, and a willingness to fail. What are ways that nurse leaders can support these characteristics? 

Williams: By helping nurses to understand that innovation can be very simple. For example, nurses recognized that they wanted to do something when a patient on a unit is dying and one of our units decided that they were going to light a candle and put it at the desk so everyone on the unit would understand that somebody is in transition, and that there would be a level of respect, tone of voice, and support for the team that is supporting that family.

Out of that came a practice where they created a keepsake box that is now part of the supply chain at our hospital that any unit can order. Included is the candle, a poem written by a nurse that is sent to the family, a condolences card, and mementos. It came out of a nurse thinking, “How can we be respectful?” So innovation doesn’t have to be big; you can make a change where you live.

The other lesson is that it doesn’t have to be perfect because perfection can be your greatest enemy. Begin small and then pull your colleagues in. The other thing that's important is providing expertise. A nurse will have an idea, but they don't necessarily have the skill set to see it through, so providing them with individuals like nursing professional development specialist teams or even project leaders can help them to structure programs.

HL: What can a healthcare system, beyond the nurse leader, do to sustain a culture of nurse innovation?

Williams: Allow time for nurses to innovate, or to work together in teams to lead research projects. We invest in our research teams and provide funding. We also have a librarian from the Yale medical school that helps our nurses with evidence-based and research articles to help them think through issues. She’s very integrated in the work that we do, and that’s another innovation—having a librarian available to us.

It’s really about investment and framing the environment in terms of what we expect of nurses and how nurses can practice within the environment. You have to invest in the environment; it doesn't come just by chance.