Nurs 6051: Sharp End of Patient Care Essay

The work environment in which nurses provide care to patients can determine the quality and safety of patient care.1 As the largest health care workforce, nurses apply their knowledge, skills, and experience to care for the various and changing needs of patients. A large part of the demands of patient care is centered on the work of nurses. When care falls short of standards, whether because of resource allocation (e.g., workforce shortages and lack of needed medical equipment) or lack of appropriate policies and standards, nurses shoulder much of the responsibility. This reflects the continued misunderstanding of the greater effects of the numerous, complex health care systems and the work environment factors. Understanding the complexity of the work environment and engaging in strategies to improve its effects is paramount to higher-quality, safer care. High-reliability organizations that have cultures of safety and capitalize on evidence-based practice offer favorable working conditions to nurses and are dedicated to improving the safety and quality of care. Emphasis on the need to improve health care systems to enable nurses to not be at the “sharp end” so that they can provide the right care and ensure that patients will benefit from safe, quality care will be discussed in this chapter. Nurs 6051: Sharp End of Patient Care Essay Sample

The Everydayness of Errors
Health care services are provided to patients in an environment with complex interactions among many factors, such as the disease process itself, clinicians, technology, policies, procedures, and resources.2 When these complex factors interact, harmful and unanticipated outcomes (e.g., errors) can occur. Human error has been defined as a failure of a planned action or a sequence of mental or physical actions to be completed as intended, or the use of a wrong plan to achieve an outcome.2 By definition, errors are a cognitive phenomenon because errors reflect human action that is a cognitive activity. Near misses, or “good catches,”3 are defined as events, situations, or incidents that could have caused adverse consequences and harmed a patient, but did not.4 Factors involved in near misses have the potential to be factors (e.g., root causes) involved in errors if changes are not made to disrupt or even remove their potential for producing errors. Nurs 6051: Sharp End of Patient Care Essay Sample
Reason2 described errors as the product of either active (i.e., those that result primarily from systems factors, producing immediate events and involve operators (e.g., clinicians) of complex systems) or latent factors (i.e., factors that are inherent in the system). Latent factors (e.g., heavy workload, structure of organizations, the work environment) are embedded in and imposed by systems and can fester over time, waiting for the right circumstances to summate individual latent factors and affect clinicians and care processes, triggering what is then considered an active error (e.g., an adverse drug event). Leadership and staff within organizations essentially inherit and can create new latent factors through scheduling, inadequate training, and outdated equipment.5 Latent factors or conditions are present throughout health care and are inevitable in organizations. These factors and conditions can have more of an effect in some areas of an
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organization than others because resources can be “randomly” distributed, creating inequities in quality and safety.5 The number of hazards and risks can be reduced by targeting their root causes. In doing so, the path between active failures when the error occurred would be traced to the latent defects in the organization, indicating leadership, processes, and culture. Then, if organizational factors (e.g., latent factors) become what they should be, few active causes of accidents will come about. Nurs 6051: Sharp End of Patient Care Essay Sample
The Institute of Medicine (IOM) stated that safety was dependent upon health care systems and organizations, and patients should be safe from injury caused by interactions within systems and organizations of care.6 Organizational factors have been considered the “blunt end” and represent the majority of errors; clinicians are considered the “sharp end.” Therefore, to prevent errors, the organizations in which humans work need to be adapted to their cognitive strengths and weaknesses and must be designed to ameliorate the effects of whatever human error occurs. The most effective strategies to improve safety target latent factors within organizations and systems of care. This point is emphasized by the IOM, which further stated that the safety and quality of care would be improved by holding systems accountable, redesigning systems and processes to mitigate the effects of human factors, and using strategic improvements.7. Nurs 6051: Sharp End of Patient Care Essay Sample
According to Reason,2 a large part of mental functioning is automatic, rapid, and effortless. This automatic thinking is possible because we have an array of mental models (e.g., schemata) that are expert on some minuscule recurrent aspect of our lives (e.g., going to work). Many errors result from flaws in thinking that affect decisionmaking.8, 9 Ebright and colleagues10 assert that nurses’ ability to make logical and accurate decisions and influence patient safety is associated with complex factors, including their knowledge base and systems factors (e.g., distractions and interruptions), availability of essential information, workload, and barriers to innovation. The effects of these factors are complicated by the increasingly complex nature of nursing’s roles and responsibilities, the complex nature of preventing errors from harming patients, and the availability of resources.10
When errors occur, the “deficiencies” of health care providers (e.g., insufficient training and inadequate experience) and opportunities to circumvent “rules” are manifested as mistakes, violations, and incompetence.11, 12 Violations are deviations from safe operating procedures, standards, and rules, which can be routine and necessary or involve risk of harm. Human susceptibility to stress and fatigue; emotions; and human cognitive abilities, attention span, and perceptions can influence problem-solving abilities.2 Human performance and problem-solving abilities are categorized as skill based (i.e., patterns of thoughts and actions that are governed by previously stored patterns of preprogrammed instructions and those performed unconsciously), rule based (i.e., solutions to familiar problems that are governed by rules and preconditions), and knowledge based (i.e., used when new situations are encountered and require conscious analytic processing based on stored knowledge). Skill-based errors are considered “slips,” which are defined as unconscious aberrations influenced by stored patterns of preprogrammed instructions in a normally routine activity. Distractions and interruptions can precede skill-based errors, specifically diverting attention and causing forgetfulness.2 Rule-based and knowledge-based errors are caused by errors in conscious thought and are considered “mistakes.”13 Breaking the rules to work around obstacles is considered a rule-based error because it can lead to dangerous situations and may increase one’s predilection toward engaging in other unsafe actions. Work-arounds are defined as “work patterns an individual or a group of individuals create to accomplish a crucial work goal within a system of dysfunctional work processes that prohibits the accomplishment of that goal or makes it difficult”14 (p. 52). Halbesleben and colleagues15. Nurs 6051: Sharp End of Patient Care Essay Sample
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assert that work-arounds could introduce errors when the underlying work processes and workflows are not understood and accounted for, but they could also represent a “superior process” toward reaching the desired goal.
Clinicians’ decisionmaking and actions are also influenced by the “human condition.” Reason5, 16 asserted that because of the fallibility of the human condition, we can change the working conditions so that the potential for errors is reduced and the effect of errors that do occur is contained. Humans are limited by difficulty in attending to several things at one time, recalling detailed information quickly, and performing computations accurately.6 As discussed by Henriksen and colleagues,17 the scientific field of human factors focuses on human capabilities and limitations and the interaction between people, machines, and their work environment. The focus is on system failures, not human failures, and on meeting the needs of the humans interacting within it. Systems would be redesigned and dedicated to continuous improvement to protect against human error by employing simplification, automation, standardization of equipment and functions, and decreasing reliance on memory.18 The “work system” would account for the interrelatedness of the individual, tasks, tools and technologies, the physical environment, and working conditions.19 Conditions that make errors possible would be redesigned to reduce reliance on memory, improve information access, error-proof processes, standardize tasks, and reduce the number of handoffs.20, 21 Errors would be identified and corrected and over time there would be fewer latent failure modes and fewer errors. However, because patient outcomes are dependent upon human-controlled processes, health care settings will never be 100 percent safe. Nurs 6051: Sharp End of Patient Care Essay Sample
The IOM defined patient safety as freedom from accidental injury. 6 Adverse events are defined as injuries that result from medical management rather than the underlying disease.22, 23 While the proximal error preceding an adverse event is mostly considered attributable to human error, the underlying causes of errors are found at the system level and are due to system flaws;24 system flaws are factors designed into health care organizations and are often beyond the control of an individual.25, 26 In other words, errors have been used as markers of performance at the individual, team, or system level. Adverse events have been classified as either preventable or not,21, 27 and some preventable adverse events (fewer than one in three) are considered to be caused by negligence.28 The concept of an error being preventable has not been widely understood in its context, and definitions have been conflicting and unreliable,21, 29 partially because the source of the majority of errors have been ascribed to vague systems factors,30 and the relationship between errors and adverse events is not fully understood.30, 31
Although the true number of errors and adverse events may not be known because of underreporting, failure to recognize an error, and lack of patient harm, it is difficult to understand the pervasiveness of errors because there are differences in definitions of reportable errors and adverse events.32 Research and quality improvement initiatives have focused predominately on medication safety because of existing information systems and the potential frequency for which errors can occur. In the case of medications, the types and causes of errors describe how nurses are at the “sharp end.” Medications pose the largest source of errors, yet many do not result in patient harm.33, 34 Since errors actually occur during the process of medication therapies, the usual ‘practice’ has been to blame individuals.35, 36 A medication intervention goes from prescribing, transcribing, and dispensing to administration. Physicians are primarily responsible for prescribing medications and nurses are primarily responsible for administering medications to patients. Errors made by physicians can be intercepted by pharmacists and nurses, errors made
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by pharmacists can be intercepted by nurses, and errors made by nurses could potentially be intercepted by peers or patients.
Several classifications of health care errors have been posed.37–39 Classifications or categorizations of errors have been based on types of adverse events,40–42 incident reports,38, 39 individual blame,37 and system causes. Given what is known about error causation,1, 5, 6, 16 particularly what has been learned from root-cause analysis and failure modes and effects analysis, when errors/adverse events involve clinicians, classifications/taxonomies of errors would be centered on all the related systems factors and would consider them the major contributors of the error/adverse event.5, 16 For example, one classification of errors differentiates endogenous errors (i.e., arise within the individual or team) from exogenous errors (i.e., arise within the environment).43 Endogenous errors are generally either active or latent2 and result from departure from normative knowledge-based, skill-based, or rule-based behaviors.44
The complexity of factors involved in errors and adverse events is exemplified in medication safety. Researchers have found that between 3 percent and 5 percent,45 34 percent,46 40 percent,47 or 62 percent48 of medication errors are attributable to medication administration. For an administration error to not occur, the nurse would be at the “sharp end,” having the responsibility to intercept it. Administration errors have been found to be the result of human factors, including performance and knowledge deficiencies;49 fatigue, stress, and understaffing were found to be two major factors for errors among nurses.50 Administering medications can take up to 40 percent of the nurse’s work time,51 and medication administration errors have been found to be due to a lack of concentration and the presence of distractions, increased workloads, and inexperienced staff.48, 52, 53 If we consider what has been learned in other industries, medication administration errors would also be caused by systems factors, such as leadership not ensuring sufficient training, maldistribution of resources, poor organizational climate, and lack of standardized operating procedures.54. Nurs 6051: Sharp End of Patient Care Essay Sample
Since the publication of the IOM’s To Err Is Human,6 millions of dollars of research funds—e.g., from the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation—have been devoted to building the evidence base in patient safety research. Findings reported from the IOM and other related research is being disseminated on key aspects of patient safety. It is interesting to note that before the publication of To Err Is Human, the major focus of patient safety was on individual blame and malpractice.55 Since the publication of To Err Is Human, that has no longer been the case and there is more focus on the need to improve health care organizations,56 but the concerns associated with malpractice have not dissipated. In fact, concerns about malpractice have thwarted many patient safety improvement efforts primarily because of the need for data collection and analysis as well as performance measures to inform patient safety changes.57
The focus on the responsibilities and influences of systems does not negate the challenge of understanding error and accepting the inevitability of many errors while concurrently increasing the quality of health care. It is not possible for every aspect of health care and every setting of care to be 100 percent error free, and leaders and clinicians are challenged to define what is an acceptable level of error. Because safety is foundational to quality,58 one way to define quality is providing “the right care, at the right time, for the right person, in the right way.”59 In doing so, efforts to improve safety and quality need to address concerns with potential overuse, misuse, and underuse of health care services that can threaten the quality and safety of care delivered to patients. Since patient safety, and quality in many respects, “is a new field, identifying which safe practices are effective has presented a significant challenge”60 (p. 289), in part because of
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Nurses at the “Sharp End”
the resource requirements, the complex nature of changing practice, and the influences of units within the whole.60
The Importance of High-Performing Organizations
The quality and safety of care is associated with various factors within systems, organizations, and their work environments—the combination of which influences the type of quality and safety of care provided by nurses.1 Donabedian’s61 definition of quality of care represents the entire continuum from structure to process and to outcome. Structures, processes and outcomes are interdependent, where specific attributes of one influence another according to the strength of the relationship.61–63 When organizational structure factors support the care processes and enable teamwork, nurses are more satisfied with their jobs64, 65 and patients receive higher-quality care.65 Leaders who engage in transactional (e.g., establish trust in relationships with staff, provide structure and expectations)66, 67 and transformational leadership (e.g., develop a stronger collective identity and commitment to change)68, 69 and who view change as opportunities to learn, adapt, and improve70 organizations to improve health care quality. When teams function well and organization structure factors support their work, outcomes are better, even at institutions that have a high intensity of specialized care for those particular needs.71, 72 The effectiveness of individuals and teamwork is dependent upon leadership, shared understanding of goals and individual roles, effective and frequent communication,72-74 having shared governance,75 and being empowered by the organization.76. Nurs 6051: Sharp End of Patient Care Essay Sample
In his seminal work, Shortell asserted that the characteristics of high-performing health care organizations included “a willingness and ability to: stretch themselves; maximize learning; take risks; exhibit transforming leadership; exercise a bias for action; create a chemistry among top managers; manage ambiguity and uncertainty; exhibit a ‘loose coherence;’ exhibit a well-defined culture; and reflect a basic spirituality”77 (page 8). These organizations are engaged in continuous improvement to improve outcomes. Since then, Shortell and colleagues78 furthered his seminal work, finding that what distinguished high-performing organizations was certain key factors, such as having a quality-centered culture, reporting performance, and the ability to overcome quality improvement redesign barriers by “(1) directly involving top and middle-level leaders, (2) strategically aligning and integrating improvement efforts with organizational priorities, (3) systematically establishing infrastructure, process, and performance appraisal systems for continuous improvement, and (4) actively developing champions, teams, and staff”79 (p. 599). Nurs 6051: Sharp End of Patient Care Essay Sample
The significance of these characteristics of high-performing organizations was furthered by findings from an evaluation of 12 health care systems, where factors critical to redesigning current systems to achieve quality and safety goals and improve patient outcomes were found to be successful when there was an “(1) impetus to transform; (2) leadership commitment to quality; (3) improvement initiatives that actively engage staff in meaningful problem solving; (4) alignment to achieve consistency of organization goals with resource allocation and actions at all levels of the organization; and (5) integration to bridge traditional intra-organizational boundaries among individual components”80 (p. 309). Yet to address these factors in redesigning care systems and processes, Lucas and colleagues found that organizations needed to have “(1) mission, vision, and strategies that set its direction and priorities; (2) culture that reflects its informal values and norms; (3) operational functions and processes that embody the work done in patient care; and (4) infrastructure such as information technology and human resources that support the delivery of patient care”80 (p. 309). Nurs 6051: Sharp End of Patient Care Essay Sample
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Yet, many organizations do not meet the standards of high-reliability organizations (HROs). Reason and colleagues81 described the “vulnerable system syndrome” as a cluster of organizational pathologies that interact, making some systems more liable to unsafe practices that threaten patient safety. These pathologies (e.g., blame, denial, and the pursuit of financial excellence) are perpetuated in work environments by leaders and peers targeting individuals at the “sharp end,” simultaneously failing to question core beliefs, recognize systemic causes, or to implement systemwide reforms. Reason and colleagues further asserted that indicators of vulnerabilities of the work environment, such as a culture of individual blame, were associated with workplace cultures that influenced safety and could be categorized as (1) high reliability (where recognizing how safety can be improved is rewarded), (2) pathological (where punishment and covering up of errors/failures are pervasive and new ideas are discouraged), or (3) bureaucratic (where failures are considered isolated, systematic reforms are avoided, and new ideas are problematic). An indicator of the presence of work environment vulnerabilities and patient safety improvements could be whether or not an organization has Joint Commission accreditation.82. Nurs 6051: Sharp End of Patient Care Essay Sample
Nurses perceive multiple and complex work environment factors that influence nurse and patient outcomes, including the quality of leadership and management, staffing resources, workload,83 job stress and anxiety, teamwork, and effective communication.84 Heath and colleagues asserted that in healthy work environments, nurses “feel valued by their organization, have standardized processes in place, have staff empowerment, have strong leadership, feel a sense of community, and recognize that strategic decision-making authority [influences] how their units were run and how scarce resources were disseminated”85 (p. 526–7). Healthy work environments are also places where safe and high-quality nursing care is expected and rewarded. Healthy work environments also need to foster effective communication, collaborative relationships, and promote decisionmaking among all nurses.85 Unhealthy work environments can have adverse consequences on the quality of care delivered as well as nurses’ intention to leave the profession.1, 86–88
As proposed by Stone and colleagues,89 there are microclimates (e.g., a unit or department) that function within the larger context of the organization. These microclimates or “microsystems” have a core team of health care professionals; a defined population of patients they are responsible for; and information, staff, and health technologies that provide support to the work of the clinicians.90
Yet, the majority of this research has examined outcomes at the hospital-wide level, and not at the unit level. Since the work environment within microclimates/microsystems can be different than that found organization-wide, it would be important to focus on these subunits to support efforts to standardize common care processes, to better examine process and outcome measures and what subunit factors and organization-wide factors contribute to less-than-optimal care, to emphasize the impact of multidisciplinary teams throughout the organization, and to ascertain how lessons learned in these subunits could be applied organization-wide.90
High-Reliability Organizations. Nurs 6051: Sharp End of Patient Care Essay Sample
Inherently related to high-performing organizations, HROs are defined as organizations that function daily under high levels of complexity and hazards. Reliable organizations have “procedures and attributes that make errors visible to those working in the system so that they can be corrected before causing harm”6 (p. 152) and produce consistent results. Accordingly, the
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IOM has advocated for hospitals to transition into HROs to improve the quality and safety of care.6 In HROs, reliability and consistency are built into organizational routines where errors can have catastrophic consequences. In health care, reliability is defined as the “measurable ability of a health-related process, procedure, or service to perform its intended functions in the required time under commonly occurring conditions”91 (p. 82). Applying the theory behind high reliability organizations and normal accident theory (e.g., understanding how health system factors affect safety), patient safety improvements have been linked to high-reliability safety interventions, including double checking, and improving the validity of root-cause analyses.92
Because improving safety is complex and should be continuous,2, 4, 11 HROs continually measure their performance, learn from experience, and take action to resolve problems when they are discovered. HROs have a (1) preoccupation with avoiding failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) deference to expertise.93, 94 A preoccupation with avoiding failures is based on comprehensive error reporting, where human failure is accepted as being inevitable, and being overconfident because of successes is considered highly risky. A reluctance to simplify interpretations is supported by thoroughly examining situations. Being sensitive to operations involves being constantly concerned about the unexpected and recognizing that active errors result from latent errors in the system. Committing to resilience involves being able to identify, control, and recover from errors, as well as developing strategies to anticipate and responds to the unexpected. Having deference to expertise means that everyone is involved and decisions are made on the front line.94. Nurs 6051: Sharp End of Patient Care Essay Sample
Health care leaders and researchers have been looking to HROs in industry, such as the National Aeronautics and Space Administration, aviation, and the U.S. Postal Service,21, 94, 95 to apply their lessons learned to health care. HROs are known to approach safety from a systems perspective, involving both formal structures and informal practices, such as open inquiry and deep self-understanding that complement those structures.96 Through careful planning and design, HROs have been found to share common features: (1) auditing of risk—to identify both expected and unexpected risks; (2) appropriate reward systems—for safety-related behaviors; (3) system quality standards—evidence-based practice standards; (4) acknowledgment of risk—detecting and mitigating errors; and (5) flexible management models—promoting teamwork and decentralized decisionmaking.97 Shapiro and Jay asserted that health care organization can become HROs though “(1) attitude change, (2) metacognitive skills, (3) system-based practice, (4) leadership and teamwork, and (5) emotional intelligence and advocacy”98 (p. 238). Nurs 6051: Sharp End of Patient Care Essay Sample
Implementing quality and safety improvement strategies in organizational microclimates/microsystems, and for that matter organization-wide, should be predicated on increasing the subunits’ awareness of how they function and mindfulness of the reliability of their outcomes. Mindfulness is a “combination of ongoing scrutiny of existing expectations, continuous refinement and differentiation of expectations based on newer experiences, willingness and capability to invent new expectations that make sense of unprecedented events, and a more nuanced appreciation of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning”94 (p. 42). Mindfulness speaks to the interrelationships among processes of perception and cognition that stimulate a rich awareness of and hypervigilance for emerging factors and issues that could threaten the quality of care and enable the identification of actions that might be taken to deal with the threats to quality.94 Weick and Sutcliff94 argue that organizations can become HROs when they become 1-13
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mindful, as manifested by being preoccupied with failure, reluctant to simplify interpretations, sensitive to operations, committed to resilience, and deferent to expertise.
What Is It Going To Take To Improve the Safety and Quality of Health Care?
Changes in health care work environments are needed to realize quality and safety improvements. Because errors, particularly adverse events, are caused by the cumulative effects of smaller errors within organizational structures and processes of care, focusing on the systemic approach of change focuses on those factors in the chain of events leading to errors and adverse events.5, 99 From a systems approach, avoidable errors are targeted through key strategies such as effective teamwork and communication, institutionalizing a culture of safety, providing patient-centered care, and using evidence-based practice with the objective of managing uncertainty and the goal of improvement. Nurs 6051: Sharp End of Patient Care Essay Sample
The Right Work Environment
The major focus of the IOM’s report, Keeping Patients Safe: Transforming the Work Environment of Nurses,1 was to emphasize the dominant role of the work environment within health care organizations and the importance of the work environment in which nurses provide care to patients. Research reviewed by the IOM committee reported that nurses were dissatisfied with their work and wanted better working conditions and greater autonomy in meeting the needs of patients. The significance of these and many other findings led to the committee recommending significant changes in the way all health care organizations were structured, including “(1) management and leadership, (2) workforce deployment, (3) work processes, and (4) organizational cultures”1 (p. 48). After the release of that report, the American Association of Critical-Care Nurses (AACN) expanded upon these concepts and put forth the following standards for establishing and sustaining healthy work environments: (1) effective, skilled communication; (2) true collaboration that is fostered continuously; (3) effective decisionmaking that values the contributions of nurses; (4) appropriate staffing that matches skill mix to patient needs; (5) meaningful recognition of the value of all staff; and (6) authentic leadership where nurse leaders are committed to a healthy work environment and engage everyone.100 To achieve these standards, many organizations will need to significantly change the work environment for nurses. Nurs 6051: Sharp End of Patient Care Essay Sample
The nursing “practice environment” is defined by organizational characteristics that can either facilitate or constrain professional nursing practice.101 Changes to the nurses’ work environment need to focus on enabling and supporting nurses to provide high-quality and safe care.102 To do so, there needs to be significant changes in the way health care is organized that also address nursing workforce resources, training, and competencies. Researchers have found that nurses may experience greater professional fulfillment when strategies are implemented that promote autonomous practice environments, provide financial incentives, and recognize professional status.103 Whether because of unequal distribution of nurses or expected nursing workforce shortages with the aging of practicing nurses and faculty,104, 105 staffing shortages increase a nurse’s stress, increases their workload, and can adversely impact patient outcomes. More important, clinicians in practice will need new skills and empowerment to work effectively with colleagues within their work environments. Nurses also need to possess certain
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