The American Nurses Credentialing Center (ANCC) Pathway to Excellence® Program (Pathway) recognizes healthcare organizations globally that have met standards demonstrating a positive practice environment that engages and empowers nurses.1 The Pathway framework includes 6 standards depicted in Figure 1. The criteria underpinning these standards are drawn from literature demonstrating correlations between characteristics of the nursing practice environment in healthcare organizations and better outcomes for nurses, patients, and organizations as well as from environmental scanning and literature identifying emerging issues in nursing practice environments (SDC, available at https://links.lww.com/JONA/B4, lists the “Library of Pathway Associated Concepts”). Ongoing research ensures that the literature reflects continuing changes in healthcare systems and organizations, and informs revisions to the Pathway standards, introduced every 4 years. Given the breadth of topics related to positive practice environments and the Pathway standards, identifying the top research priorities is crucial to achieve 2 goals: 1) advancing research that can have the greatest impact and contribution to improving practice environments, and nurse and patient outcomes; and 2) informing nursing leaders, researchers, and funders of potential research projects to conduct and support.2

Figure 1:

ANCC Pathway to Excellence framework for positive practice environments.

This study forms the basis for a Pathway research agenda. The objective was to determine high-priority research topics identified by Pathway program appraisers and leaders in Pathway-designated organizations: chief nursing officer (CNO) and Pathway program director (PPD). Together, these are the most knowledgeable potential informants about the value of implementing Pathway standards in healthcare organizations. Their unique perspective is important in identifying the most critical areas for research investigation related to creating positive practice environments for nurses. Through a modified Delphi approach, the study coalesced consensus around the high-priority research areas from the perspective of individuals with the most experiential knowledge of the benefits and transformations introduced by adopting the Pathway standards in healthcare organizations.

Methods

This study used a common modification to the Delphi process by drawing from the literature to structure the 1st survey rather than asking only open-ended questions,3 although panelists were also invited to suggest topics thought to be missing. The 2nd survey asked panelists to rate the relative importance of research topics, including the new suggestions from the 1st survey. The 3rd survey included the research topic ratings generated by the 2nd survey to give panelists the opportunity to reassess and revise their previous ratings. Three survey rounds have frequently been found sufficient for achieving consensus.3,4 This study was reviewed by an institutional review board and determined to be exempt. There was no external funding for this study.

The Commission on Pathway to Excellence (COPE) acted as an advisory panel to assist in the development of research topics for the Pathway research priorities round 1 survey. Consisting of volunteer members appointed by the ANCC Board of Directors to represent various segments of the nursing community including practice, academia, and the community, the COPE has extensive subject matter expertise. Commission on Pathway to Excellence members also participated in the most recent literature review conducted by the Pathway program to inform revisions of the 2016 Pathway standards for the 2020 Pathway application manual.1 When all 3 survey rounds and related analyses were completed, the COPE reviewed results and suggested grouping of items and other adjustments to balance the final list of research priorities.

Survey Development

The items for the Pathway Research Priorities Survey were developed from the criteria specified in the Pathway 2020 application manual,1 which were initially drawn from literature on the relationship of practice environment characteristics to patient, nurse, and organizational outcomes as well as literature on emerging issues related to nursing practice environments. The following steps were conducted to extract a list of researchable topics.

Pathway program staff reviewed criteria for all 6 standards to brainstorm a list of researchable questions, and the research team summarized the list of 43 questions in a table of unique concepts and theoretically associated outcomes. Each of the 3 COPE Executive Committee (EC) members independently reviewed the documents and selected their own lists of top 30 items. The research team compiled the top-30 lists, clarifying items with the COPE EC, and drafted the survey. The Pathway and research teams met with the COPE EC to review the survey draft. Three volunteers from the ANCC Research Council, a voluntary advisory body, previewed the draft survey to offer feedback. Eight members of the COPE piloted the survey draft. Format

Because asking only open-ended questions in the 1st round of a Delphi survey study can generate extensive amounts of data,4,5 presenting a structured questionnaire based on existing information offers a more efficient way to begin the Delphi process.3,5 To mitigate being too narrow in scope, however, the round 1 survey also invited panelists to suggest additional research topics.6

Research topics were grouped by the 6 standards, which are familiar to the Delphi panelists of Pathway CNOs, PPDs, and appraisers, and a 7th grouping was added under the label of outcomes. A 10-point rating scale was used to provide more points of discrimination for a Delphi panel of this size. The 7 groupings were randomized in the survey to reduce possible order effects and to ensure an even number of responses for each group.

Demographics

The survey included 2 demographic questions: 1) identify your role (Pathway CNO, PPD, or appraiser); and 2) years (in 5 categories) your organization has been Pathway-designated or years you have been a Pathway appraiser. In the round 2 and 3 surveys, yes/no questions were added to confirm whether panelist submitted responses in the previous round(s).

Sample and Recruitment

A total of 393 individuals were invited to participate in the 3-round Delphi study. Invitees for the 1st 2 groups included CNOs (n = 169) and PPDs (n = 153) from each of the 171 Pathway-designated organizations located in 39 states throughout the United States. Pathway PPDs are nurses who are expected to know their own organization well and to work closely with the CNO on the organization's Pathway application. Most Pathway organizations (96%) were acute care settings averaging 79 beds with a range from 15 to 912 beds. The remaining organizations were either long-term care or ambulatory facilities.

The 3rd group, Pathway appraisers (n = 71), were representatives of the Pathway program who are selected based on education, practice setting, administrative expertise, and professional reputation. The appraisers' role is to evaluate documents submitted by applicant organizations and prepare a summary report for the COPE, which makes the final determination of designation.1 To bolster recruitment, advanced notice was emailed to the sample a few days before the initial survey invitation. The research team clearly stated the study aims and process in each survey invitation to encourage motivation to participate and to gain the continued commitment necessary to respond to 3 successive survey rounds.4

Distribution

Invitations stated that the survey was voluntary and anonymous and that no benefits, pay, or other compensation would be received for completing the survey. No survey questions were required, and consent was obtained with a yes/no question asking respondents whether they agreed to participate in the survey. No identifying information was collected about individual participants or organizations in closed-ended questions, and instructions said not to provide any identifying information in open-ended comments. Panelists were informed that study results would be reported anonymously in the aggregate.

For all 3 rounds, 2 reminders were sent to nonrespondents. The survey distribution method ensured that researchers could not link any individual respondent to his/her response. Undeliverable emails were resent from the researcher's email account along with email reminders sent blindly to the group of individuals whose initial invitations were not received.

Survey Rounds: Data Collection

The round 1 Pathway Research Priorities Web-based survey was emailed using the Alchemer survey platform to a total of 393 individuals consisting of 169 CNOs and 153 PPDs from Pathway-designated organizations, and 71 Pathway appraisers. The survey was open for 13 days in October and November 2020.

The round 2 survey was sent to the same panel with the attrition of 1 CNO who had left the organization, a total of 392 individuals. The survey was open for 16 days to account for a holiday during administration in November and December 2020. Results from round 1 were not included to avoid introducing bias related to the new items generated in round 1. The survey invitation explained4 why items were added and dropped with instruction to review the whole updated set of items carefully and rate importance for each one.

Round 3 had no attrition and again was emailed to 392 individuals in December 2020. The survey remained open for 13 days. This round included per-item statistics from round 2 results for panelists to consider as they reassessed their initial judgments.3 To reduce the number of research priorities presented in this final round, items that showed low importance or wide disagreement about importance in the round 2 analysis were eliminated6 because too many items can blur consensus.4

Data Analysis

The literature does not identify a prescriptive value for defining consensus.4,7 This study defined final consensus as 70% of responses in the 8-to-10 range of the 10-point scale. The analysis goals and decision criteria identified for each survey round of this study bolster confidence in the results.

The round 1 analyses served 2 goals: identify low-scoring items to be eliminated from the round 2 question set and summarizing new research topics suggested in round 1 to add to the round 2 survey. Only the very lowest-scoring items were eliminated at this stage to guard against prematurely removing items from the iterative survey process.4 Nine items with less than 60% of responses in the 8-to-10 range of the 10-point scale were selected to be dropped. To summarize additional research topics suggested by round 1 respondents, members of the research team first grouped similar items and then had volunteer researchers on the ANCC Research Council verify the groupings.4 From this analysis, 4 new research topics were identified and added to the round 2 survey.

The 2 goals of the round 2 analysis were to: 1) to generate the item statistics to include in the round 3 survey indicating the panelists' collective judgments; and b) to identify items, if any, that should be removed from the round 3 question set. The round 2 elimination marker was set at 50% of responses in the 8-to-10 range; however, because no scores were below this threshold, the marker was moved up to 60%. This eliminated 5 items, reducing the total number of research topics from 49 to 44.

Round 3 used the final consensus definition of 70% of responses in the 8-to-10 range. This analysis summarized statistics overall and by subgroups for CNOs, PPDs, and appraisers. Response rates were calculated for each round separately and throughout the rounds as indicated by self-reports of rounds 1 and 2 participation provided in round 3.

Results

The overall response rate was 21%, 23%, and 19% in each successive round out of the 393 total eligible participants. Of the 74 respondents in round 3, 45% were PPDs, one-third (34%) were Pathway appraisers, and the remaining 21% were Pathway CNOs. Eighty-six percent of the round 3 respondents indicated they had participated in previous rounds: 62% participated in the 1st 2 rounds, and 24% participated in either round 1 or round 2.

For round 1, the percentage of respondents rating an item an 8, 9, or 10 on a 10-point scale ranged from 37.5% to 87.8%. Of the 54 total items, 9 were below the 60.0% threshold of responses in the 8-to-10 range and thus were dropped. From the qualitative analysis of suggested research topics, 4 new items were added to the round 3 survey.

In round 2, the range of results for the 49 items tightened with the lowest item scoring 51.7% and the highest scoring 89.7%. Five research topics scored less than 60.0% and were dropped going into round 3, two of which were newly added items from respondent suggestions in round 1.

For the final round 3, 20 of the 44 items scored at or above the 70.0% threshold set for identifying Pathway research priorities. The top 2 ranking research topics received a score of 8, 9, or 10 from over 90% of participants: building and maintaining shared governance participation (91.9%) and nurse participation in performance improvement and evidence-based practice (EBP) activities (90.7%). The next 7 items were rated very important by 82.9% to 89.2% of participants, and 11 items were identified as very important research topics by 70.4% to 79.5% of respondents. See Table 1 for the full results from all rounds of the survey.

Table 1 - Delphi Results by Round: Rank Order and Percentage of Rating an Item an 8, 9, or 10 Round 1 Round 2 Round 3 Pathway Standard Research Topic Rank Rated 8-10 Rank Rated 8-10 Rank Rated 8-10 Shared decision making Building and maintaining shared governance participation 1 87.8% 1 89.7% 1 91.9% Quality Nurse participation in performance improvement and EBP activities 4 85.4% 2 87.4% 2 90.4% Outcomes Staff engagement 5 85.0% 4 83.7% 3 89.2% Safety Physical and psychological safety in the workplace 10 83.3% 8 80.9% 4 87.5% Leadership Nurse manager transitions to practice and ongoing development 19 79.0% 7 81.4% 5 86.3% Shared decision making Training in shared governance leadership for staff RNs, nurse managers, and interprofessional partners 9 83.8% 3 85.1% 6 85.9% Leadership Effective strategies used by leaders at various levels to support direct care nurses 15 80.5% 15 76.7% 7 84.7% Outcomes Healthy work environment 2 87.5% 9 80.7% 8 83.3% Professional development Training/mentoring provided by the organization 17 79.7% 25 72.4% 9 82.9% Outcomes Retention 27 72.8% 5 82.8% 10 79.5% Safety Staff-driven safety improvement practices 13 82.3% 6 82.6% 11 77.8% Professional development Transition into practice across all roles 16 80.2% 24 73.6% 12 77.8% Shared decision making Role of nurse managers in a culture of shared decision making 12 82.7% 17 76.1% 13 76.7% Well-being Reducing compassion fatigue 18 79.0% 19 75.9% 14 76.7% Well-being Measuring resilience 23 74.1% 21 75.3% 15 76.7% Leadership Strategies used by leaders to maintain the professional practice environment during uncertainty 22 75.3% 12 78.8% 16 76.1% Quality Sustainability of change projects 21 75.6% 14 77.9% 17 73.6% Safety Effective communication among healthcare professionals and with patients/families 6 84.8% 22 73.9% 18 73.2% Quality Performance improvement and EBP education and support for direct care nurses 7 84.1% 18 75.9% 19 72.2% Quality Unit-level employee engagement 14 80.7% 26 72.1% 20 70.4% Outcomes Nurse satisfaction 8 83.8% 13 78.2% 21 69.9% Leadership Leadership education and role preparation 24 74.1% 16 76.7% 22 69.4% Safety Managing unplanned events (COVID-19 is an example) 11 82.7% 11 79.5% 23 68.1% Quality Applying EBP frameworks 20 78.0% 20 75.9% 24 68.1% Outcomes Clinical outcomes 3 87.0% 10 80.5% 25 65.8% Well-being Staff engagement in well-being programs New 27 72.1% 26 64.4% Well-being Measuring well-being 29 71.6% 34 67.8% 27 62.5% Well-being Stress reduction strategies 34 69.1% 37 66.7% 28 61.6% Professional development Professional development strategies inside and outside an acute care setting 31 70.9% 38 66.3% 29 58.6% Safety How just culture principles are used to resolve issues 30 71.3% 23 73.9% 30 58.3% Shared decision making Design of interprofessional shared governance structures in varied settings 36 67.9% 35 67.8% 31 57.5% Professional development Preceptor selection criteria and education 42 65.0% 36 67.8% 32 57.1% Leadership Change management and planning for change 37 67.5% 28 72.1% 33 56.9% Quality Collaboration on quality initiatives with other staff, disciplines, and departments New 32 68.2% 34 56.9% Well-being Overcoming physical fatigue 35 68.8% 43 61.6% 35 56.5% Shared decision making Role of executive leaders in a culture of shared decision making 25 74.1% 33 67.8% 36 56.2% Leadership Leadership succession planning 41 65.4% 30 69.8% 37 54.9% Well-being Reward and recognition strategies for different generations 33 70.4% 44 60.9% 38 54.1% Professional development Staff succession planning 43 61.5% 31 68.6% 39 52.9% Shared decision making Evaluating the effectiveness of shared governance models across settings 32 70.4% 40 64.0% 40 52.1% Outcomes Turnover, including by subgroups such as unit, specialty, role (managers), 1st-year nurses, and age groups 26 73.1% 29 71.9% 41 52.1% Well-being Variety and nature of well-being programs for nurses 38 67.5% 39 64.8% 42 50.7% Professional development Preceptor burnout prevention strategies 44 61.3% 41 63.2% 43 40.8% Professional development Effective needs assessment tools 39 66.3% 42 61.6% 44 39.4% Quality Technology impact on practice New 45 59.8% Drop Outcomes Patient satisfaction 28 71.8% 46 58.6% Drop Quality Person-centered care strategies 40 66.3% 47 58.1% Drop Leadership Nurse manager span of control (number of FTEs reporting) 45 60.3% 48 55.2% Drop Professional development Evaluating learning resources New 49 51.7% Drop Outcomes Intent to stay 46 58.8% Drop Drop Outcomes Improved diversity, equity, and inclusion 47 57.7% Drop Drop Professional development Career mapping and coaching 48 57.5% Drop Drop Shared decision making Effective staff engagement in technology selection, implementation, and evaluation 49 55.7% Drop Drop Well-being Technology impact on well-being 50 52.5% Drop Drop Shared decision making Processes and support to address ethical concerns 51 51.9% Drop Drop Outcomes Business case for Pathway to Excellence credential 52 49.4% Drop Drop Leadership Applying data analytics to recruitment and hiring 53 39.7% Drop Drop Outcomes Differences by organization type (eg, teaching status, long-term care, ambulatory, acute care, home care) 54 37.5% Drop Drop

Abbreviation: FTEs, full-time equivalents.

The 20 research priorities from the results were synthesized where possible and grouped into themes, as shown in Table 2, to aid in communication and dissemination of the Pathway research agenda to nursing leadership, researchers, and funders. The final list was narrowed down to 17 research topics grouped into 4 key themes: professional practice, which includes shared governance and shared decision making; a supportive work environment; training and education; and quality and improvement.

Table 2 - Pathway to Excellence Research Agenda Professional practice Building and maintaining shared governance participation Staff engagement at all levels Role of nurse managers in a culture of shared decision making Retention Supportive work environment Physical and psychological safety in the workplace Effective strategies used by leaders at various levels to support direct care nurses Healthy work environment Measuring resilience Reducing compassion fatigue Training and education Transition into practice and ongoing development for all roles Training in shared governance leadership for staff RNs, nurse managers, and interprofessional partners Training/mentoring provided by the organization Quality and improvement Sustainability of change projects Staff-driven safety improvement practices Effective communication among healthcare professionals and with patients/families Strategies used by leaders to maintain the professional practice environment during uncertainty Support, education, and nurse participation in performance improvement and EBP activities
Discussion

The Delphi survey method was valuable in developing Pathway research priorities identified by nurses across diverse healthcare settings who represented Pathway-designated organizations and Pathway program appraisers. Elements from all 6 of the Pathway standards were identified as a top research priority in the results, indicating the importance of all the standards in creating a positive workplace environment for nursing. The results of this study are summarized in Table 2 to help nurse leaders and funders identify the most critical areas of nursing research. Focusing research resources on these areas will contribute the greatest impact on needs identified by CNOs and other nursing experts with direct experience in implementing and evaluating the Pathway standards.

The top 2 ranking research priorities were building and maintaining shared governance participation, and nurse participation in performance improvement and EBP activities, whereas many other areas were rated as important. These research priorities align with the transformational leadership approaches to promoting a culture of EBP discussed at length throughout the nursing leadership literature.8-11

Further research is needed on the impact of developing and deploying interprofessional shared governance models for healthcare leaders. Historically, shared interprofessional governance has been considered critical for agencies seeking to sustain high reliability in the offering of quality patient care services