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Changing a culture through Pathway to Excellence®

By: Betsy Fritz, MSN, RN, CNML, CCRN-K

Increased nurse confidence can result in improved patient outcomes.


  • Direct care nurses drive nursing excellence using Pathway standards
  • Empowering nurses to have a voice in their practice leads to improved patient care quality, staff satisfaction, and staff retention
  • Leadership support of direct care nurses leads to sustainable quality improvement and increased staff satisfaction.

August 20, 2019, was a special day for the Baylor Scott & White Medical Center–Brenham (Brenham). Months of hard work and dedication to nursing and clinical excellence culminated in a phone call from the American Nurses Credentialing Center (ANCC) telling us that we were now a Pathway to Excellence® (Pathway)–designated organization.

A little more than a year earlier, in June 2018, Brenham nursing leadership discussed the idea of Pathway designation with direct-care nurses on the nurse practice council. The nurses felt that as a small rural hospital with an average daily census of 12, this international designation of excellence was beyond something they could accomplish. The chief nursing officer, Amber Reed, MBA-HC, BSN, RN, OCN, CHPCA, explained that Pathway designation is meant for organizations that emphasize supportive practice environments, shared governance, and direct-care nurses’ voices. In other words, it’s a measure of culture, not size.

In choosing to begin their nursing excellence journey with Pathway designation, Reed and her nursing leadership team (acute-care manager Eric Roman, BSN, RN, and Pathway program and Magnet® coordinator Betsy Fritz, MSN, RN, CNML, CCRN-K [author of this article]) recognized the need to start with empowering nurses to have a voice in their practice. They decided the best way to accomplish that would be with the six Pathway standards.

Setting a standard

Following the guidance of the Pathway application manual, the team conducted an organizational self-assessment. An all-day Pathway nursing retreat was held off campus with direct-care representatives from all departments and shifts. The retreat included an introduction to Pathway designation followed by breakout sessions to review the various elements of performance and any identified gaps. At the end of the retreat, the team recognized elements within each standard that needed work and developed an action plan.

Because Pathway designation is a reflection of culture change that creates a positive practice environment, the organization worked to ensure that all nurses were supported and understood and that permanent measures were implemented to maintain the culture.

I facilitated formal and informal conversations with direct-care staff and leaders to determine bridges and barriers to success. I also oversaw the writing of the Pathway document, and Luci Bostain, MSN, RN-BC, the nurse practice council chair and direct-care nurse (assisted by six direct-care nurse leaders), collected direct-care narratives and developed strategies for sharing the Pathway document with staff.

Pathway standard 1: Shared decision-making

Although shared governance was in place at Brenham starting in 2017, it wasn’t strong. To address this weakness, Reed met with the nurse practice council (which is composed of the chair and co-chairs of each unit-based council) and nurse leaders to set expectations for participation and attendance at council meetings. Reed promised transparency and accountability with the staff in return for the same promise from them. I served as a neutral facilitator to help direct-care chairs and co-chairs develop agendas and action items for the councils. Having a nurse leader who functioned in a role of influence but not authority ensured direct-care staff felt comfortable expressing concerns without fear of retribution or judgment. In addition, I provided extensive and ongoing re-education on shared governance to all staff.

As leaders and direct-care nurses learned more about the value and importance of shared governance, we saw a significant increase in direct-care nurses elevating concerns, developing and implementing ideas for improvement, and sharing their thoughts with leadership. These successes were validated by the National Database of Nursing Quality Indicators™ (NDNQI®) RN Satisfaction Survey results for “nursing participation in hospital affairs,” which has shown consistent improvement from 2.64 in 2015 (first year of survey) to 3.26 in 2019. (The mean for Magnet-recognized organizations is 2.97.) And the survey result for the criterion “Staff nurses are involved in the internal governance of the hospital (for example, practice and policy committees)” increased from 2.47 in 2015 to 3.24 in 2019 (Magnet mean is 3.08).

Pathway standard 2: Leadership

In late 2018, after the Pathway journey had begun, several leadership changes occurred. Nurse leaders in acute care, the emergency department, women’s services, and perioperative services left the organization for other opportunities. Although assuming that the Pathway journey would come to an abrupt halt at this point would be reasonable, strong support of the chief nursing officer helped ensure that Brenham continued its march toward Pathway designation and that direct-care nurses became the true owners of the process. They participated in hiring new leaders, taking part in interviews and sharing their culture with the applicants.

Maintaining this new Pathway culture required that the new nurse leaders develop and maintain trust and transparency with staff. To model this behavior for her leaders, Reed began holding monthly “Ask Amber” breakfast meetings. Direct-care nurses received invitations at their home addresses to attend an informal breakfast conversation with Reed. Topics included organization updates, a question-and-answer period, and time to address the various rumors that abound in every healthcare organization. One nurse who attended said, “[Reed] had the guts to get in front of us and take any question and answer it honestly. I really respect that.”

Nurse managers and supervisors also increased their presence on units and spent time working beside staff so they could truly understand their concerns. The result: Staff felt valued and trusted by their leaders.

Pathway standard 3: Safety

As the Pathway journey continued, direct-care nurses became involved in organizational committees and councils, including staffing and safety councils. As in many organizations, Brenham found that some issues that should have been addressed were forgotten or ignored, which resulted in nurses creating workarounds or tolerating problems. With increased leader rounding and the “Ask Amber” breakfasts, direct-care nurses gained the confidence to raise concerns that had been overlooked and request safety features, including increased security presence and safety monitoring. In addition, nurses became outspoken advocates for patient safety and participated in all patient quality and safety reviews. This has led to multiple “Great Catch” reports, where nurses identified actual or near-miss safety events. In one instance, nurses called out a problem that affected equipment manufacturing on a national level.

Pathway standard 4: Quality

Nurses embraced the concept of working as an interprofessional team to improve patient outcomes. Before the Pathway journey, a disconnect existed between nursing and other disciplines within the organization. Reed recognized this disconnect and worked diligently to ensure that direct-care nurses had a seat at every table and created additional levels of nurse accountability, which increased their pride and confidence. (See Nurse-led success.)

Nurse-led success

Ensuring that direct-care nurses at Baylor Scott & White Medical Center–Brenham (Brenham) have a voice in solutions to improving patient care outcomes has resulted in increased nurse engagement. For example, nurses played a vital role in reducing patient falls on the acute-care unit.

In 2017, the unit experienced 18 National Database of Nursing Quality Indicators™ (NDNQI®) reportable patient falls; in 2018 it had 15, which still was unacceptable. Several fall-prevention projects had been implemented by nursing leaders with limited success. Eric Roman, BSN, RN, the unit manager, now working with Pathway to Excellence® (Pathway) knowledge, understood that resolving patient falls required nurse-led initiatives implemented by direct-care nurses. In September 2018, Roman appointed Kara Davis, BSN, RN, CMSRN, a direct-care nurse, to lead the fall-prevention initiative. Davis met with the acute-care unit council and discovered that most falls were related to patients on beds without alarms in rooms far from the nurses’ station. She developed an algorithm to assist with determining how to place patients in the unit and taught the team how to use it. In 2019, as a result of this nurse-led quality improvement project, the number of patient falls decreased to seven (a greater than 50% reduction) in 1 year.

The success of this initiative has resulted in other nurse-led outcome improvements.

  • The number of total healthcare-acquired conditions, which in fiscal year 2017 was eight, was reduced to two in 2019 and is holding steady at one in 2020.
  • Direct-care nurses working as equal partners with providers and case managers in readmission management has resulted in a reduction of all-cause readmission rates from 19.6% in fiscal year 2017 to 9.74% in 2019 and 6.25% in 2020.

Pathway standard 5: Well-being

Ensuring nurses know that they’re respected and appreciated can sometimes be easier said than done. Creating opportunities to recognize individual and department successes internally and externally and sharing recognition from patients required a commitment from nursing leaders, administration, and nurses themselves. Brenham nurses do amazing work every day, but they’re frequently reluctant to share their successes. Leadership began a dedicated push to discover and publicly recognize “Memorable Moments” (personal interactions between nurses and patients) and “Great Catches.”

Leaders also recognized that staff well-being can be directly linked to flexible scheduling. Each department worked with its unit-based council and the nurse practice council to develop flexible staffing standards that also maintain patient safety.

As a result of increased recognition and support for nurses’ well-being, Brenham’s 2019 NDNQI RN Satisfaction Survey results for “Job enjoyment” is 4.64 (Magnet mean is 4.26). In addition, RN Voluntary Retention (internal data related to staff who choose to leave the organization for other opportunities [are not laid off or fired]) improved from 72% in 2017 to 85% in 2019.

Pathway standard 6: Professional development

As nurses became more aware of their value and importance in the healthcare process, they began sharing their experiences internally and externally. For the first time, direct-care nurses submitted evidence-based practice research to multiple conferences and successfully represented the organization at the 2019 ANCC Pathway to Excellence Conference®. I mentored and supported these nurses in their professional development, providing technical knowledge and encouragement as they stepped out of their comfort zones. To support the nurses’ efforts, the organization provided them with paid time to complete their research and supported their national certification and advanced degree efforts with tuition and certification reimbursement.


Recognizing the dedication and shared commitment to excellence of their interprofessional colleagues, the Brenham nurses’ Pathway to Excellence designation celebration was presented as a facility-wide award acknowledging the hard work of all team members. In addition, the designation was acknowledged by the wider Baylor Scott & White Health system, the Brenham hospital board, and the community. This recognition has increased the organization’s visibility in the community and improved staff pride and confidence.

But Brenham’s Pathway journey didn’t end with designation. The organization’s nurses and leaders continue to focus on maintaining a culture of excellence and collaboration. The nurse practice council and unit-based councils are growing and fully supported by leadership. All nursing staff members are introduced to Pathway on their second day of orientation, and new graduate nurses are taught about Pathway designation when they enter their residency program. New nursing leaders are asked to read the Pathway to Excellence document and meet one-on-one with me to learn about the organization’s positive work environment.

Betsy Fritz is the Magnet Coordinator and Pathway Program Coordinator at Baylor Scott & White Health–College Station, in College Station, Texas.


Dans M, Pabico C, Tate M, Hume L. Understanding the new Pathway to Excellence® standards. Nurse Leader. 2017;15(1):49-52.

Fahlberg B, Toomey R. Servant leadership: A model for emerging nurse leaders. Nursing. 2016;46(10):49-52.

Pabico C, Graystone R. Comparing Pathway to Excellence® and Magnet Recognition® programs. Am Nurse Today. 2018;13(3):46-50.

Vestal K. Change fatigue: A constant leadership challenge. Nurse Leader. 2013;11(5):10-1.

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