? Creatively write about a nursing leader who greatly influenced your thoughts and nursing practice. You may choose a formal, published and well-known nursing
leader/theorist (ex: Patricia Benner, Florence Nightingale, Clara Barton, Jean Watson), or someone you identified during your journey through nursing school.
? No more than 4 and no less than 3 pages using APA, Version 6 are required.
? Use 2-4 references to support your choice, one must be from one of the class texts and one outside of class texts.
? Be sure to relate your choice to components of leadership from the course. This paper should link your opinions about this leader to nursing leadership concepts.
? Include a section that outlines how the nurse leader you?ve chosen will directly impact your nursing career.
Please link chapter 2 from Leading and Management book that I am attaching ?.
LEADING and MANAGING in NURSING Revised Reprint FIFTH edition, Patricia S. Yoder-Wise (Last published in 2014)
As well as 2-3 more additional sources that you might find or use at the end of chapter
I copied ch2 from electronic version. Some of pages messed up because of pictures or graphs. Sorry!
LEADING and MANAGING in NURSING Revised Reprint FIFTH edition, Patricia S. Yoder-Wise (Last published in 2014)
Page # 25 in the book
In any discipline, most practitioners think of a leader as someone with positional authority. Terms such as manager, director, chief, and leader convey positional
authority. In healthcare organizations, a hierarchy exists of ?who is in charge.? Realistically, however, every registered nurse is seen by law as a leader?one who has
the opportunity and authority to make changes for his or her patients. Even as far back as Florence Nightingale?s era, patient safety was important. She focused on
changing the way health care was delivered to make a difference in the outcomes of care for those who served in the Crimean War. Yet, in the United States, it was not
until the end of the twentieth century that major efforts refocused on the basic safety and quality outcomes of care for patients. This shift to being consumed with a
passion for patient safety is a hallmark of today?s healthcare delivery and the target for the care of tomorrow. This chapter provides an overview of the key thoughts
about patient safety as the basis for all aspects of leading and managing in nursing. Patient safety, and subsequently quality of care, is why the public entrusts us
with licensure and why we use our passion for caring.
OBJECTIVES ? Identify the key organizations leading patient safety movements in the United States. ? Value the need for a focus on patient safety. ? Apply the concepts
of today?s expectations for how patient safety is implemented.
TERMS TO KNOW Agency for Healthcare Research and Quality (AHRQ) DNV (Det Norske Veritas) Institute for Healthcare Improvement (IHI)
Institute of Medicine (IOM) Magnet Recognition Program? National Quality Forum (NQF) The Joint Commission
Quality and Safety Education for Nurses (QSEN) TeamSTEPPS (an AHRQ strategy to promote patient safety)
CHAPTER 2 Patient Safety
Patricia S. Yoder-Wise
26 PART 1? Core?Concepts
In Chapter 1, the concepts of leading and managing were presented. The question is, however, leading for what? No issue is more prominent in the literature or in
healthcare organizations than the concern for patient safety. Although many other aspects of health care are discussed, they all center on patient safety. Many factors
and individuals have influenced both the nursing profession?s and the public?s concerns about patient safety, but the seminal work was To Err Is Human: Building a
Safer Health System (2000), produced by the Institute of Medicine (IOM). The Web site QSEN.org shows how important patient safety is to the foundation of quality. Even
more popularized publications, such as How Doctors Think (Groopman, 2007) and The Best Practice: How the New Quality Movement is Transforming Medicine (Kenney, 2008),
show how important the basic building block of quality?patient safety?is. This focus fits well with the basic patient advocacy role that nurses have supported over
decades. Because the core of concern in any healthcare organization is safety, it also is the core for leaders and managers in nursing. Safety, and subsequently
quality, should drive such aspects of leading and managing as staffing and budgeting decisions, personnel policies and change, and information technology and
delegation decisions. Most professionals would agree that
Vickie S. Simpson, BA, BSN, RN, CCRN, CPN Dell Children?s Medical Center of Central Texas, Austin, Texas
Over the years, our hospital has focused on pressure ulcers. In 2002, for example, we reviewed literature on pediatric pressure ulcer risk assessment scales and
prevention interventions. A couple of years later, as we were doing our pediatric pressure ulcer risk policy, we realized that pressure ulcers were not tracked. So it
was impossible to determine the true incidence. Thus we instituted a tracking system. We also developed a pediatric SKIN bundle. SKIN stands for Surface selection,
Keep turning, Incontinence management, and Nutrition. Many of these efforts included broad interdisciplinary teams. For example, after moving to our new facility in
2007, we noticed a trend of pressure ulcer development in nasally intubated patients.
When a root cause analysis was completed with members of the anesthesia and respiratory therapy departments, staff in the critical care unit, and the cardiovascular
surgeon, numerous issues were identified. These issues included not purchasing arms for the new ventilators and identification of the need for a different taping
process for nasally intubated children, which was developed by our respiratory therapists. Our outcome is that now we have no pressure ulcers on nasally intubated
children in our facility. In 2009, we identified a new trend in our patient population. It was including more overweight teenagers. We had to decide what to do.
What do you think you would do if you were this nurse?
three major driving forces are behind the current emphasis on quality: IOM, the Agency for Healthcare Research and Quality (AHRQ), and The National Quality Forum
(NQF). Also, other groups such as The Joint Commission, the new accrediting organization (the Det Norske Veritas [DNV]), the QSEN Institute, and the Magnet Recognition
Program? have incorporated specific standards and expectations about safety and quality into their respective work. Additionally, specifically focused efforts such as
those of the Quality and Safety Education for Nurses (QSEN), which provides expected competencies and resources for both undergraduate and graduate nursing students on
the topics of safety and quality, and TeamSTEPPS initiatives have addressed patient safety issues. Also, the American Board of Quality Assurance and Utilization Review
Physicians provides a certification program for physicians, nurses, and other healthcare professionals. No nurse can function today without a focus on patient safety,
nor can any nurse leader or manager.
THE CLASSIC REPORTS AND EMERGING SUPPORTS
Several reports are reflective of the efforts to refocus healthcare to quality. Numerous other reports and supports exist. Table 2-1 highlights the key groups.
27CHAPTER 2 ? Patient?Safety
TABLE 2-1 MAJOR FORCES INFLUENCING PATIENT SAFETY
ELEMENT CORE RELEVANCE
IMPLICATIONS FOR LEADERS AND MANAGERS
Institute of Medicine Reports
To Err Is Human (2000): Defined the number of deaths attributed to patient safety issues.
Moved safety issues from the incident report level to an integrated patient safety report for the organization.
Crossing the Quality Chasm (2001): Identified the six major aims in providing health care (See Box 2-1)
Moved care from discipline centric foci to patient centered foci. Reinforced the disparities that occur within health care, which, in turn, led to a focus on best
practices (and reinforced the need to be patient centered). Addressed issues such as healing environments, evidence-based care and transparency, which led to a more
holistic environment that was build on evidence and that was transparent.
Health Professions Education: A Bridge to Quality (2003): Addressed the issue of silo education among the health professions in basic and continuing education (see Box
Attempted to shrink the chasm between education and practice so that interprofessional teams would work more effectively together. Increased expectation for
participation in lifelong learning.
Keeping Patients Safe: Transforming the Work Environment of Nurses (2004): Identified many past practices that had a negative impact on nurses and thus on patients
Focused on direct care nurses, supporting their involvement in decision making related to their practice. Supported the concept of shared governance. Provided a
framework for considering how nurses could determine staffing requirements. Moved the Chief Nursing Officer into the Boardroom as a key spokesperson on safety and
Improving the Quality of Health Care for Mental and Substance-Use Conditions (2005): Addressed issues related to this patient population, including those who can be
found among a general care population
Provided a focus on mental health needs of patients who were not admitted for the primary reason of mental health issues.
Preventing Medication Errors (2006): Addressed many of the issues surrounding the use of medications
Validated the complexity of providing medications to patients.
Future of Nursing: Leading Change, Advancing Health (2010): Identified 8 recommendations based on evidence that the profession must attend to. (See Box 2-3)
Created state coalitions focused on improving nursing. Created nursing/community/business coalitions to accomplish the work. Moved the issue of nurses as leaders to a
more visible level.
Agency for Healthcare Research and Quality
Federal agency devoted to improving quality, safety, efficiency, and effectiveness (2008) www.ahrq.gov
Outcomes research sections provide resources for nurses. Source of Five Steps to Safer Health Care (www.ahrq. gov/consumer/5step.htm) (See Box 2-3) Source of Stay
Healthy checklists for men and women Source of TeamSTEPPS
28 PART 1? Core?Concepts
TABLE 2-1 MAJOR FORCES INFLUENCING PATIENT SAFETY?cont?d
ELEMENT CORE RELEVANCE
IMPLICATIONS FOR LEADERS AND MANAGERS
National Quality Forum
Membership-based organization related to quality measurement and reporting www.nqf.org
Source for Centers for Medicare and Medicaid?s never events Resource for Healthcare Facilities Accreditation Program (a CMS-deemed authority) (uses NQF?s Safe
Practices) Source of nurse sensitive care standards
The Joint Commission Not-for-profit organization that accredits healthcare organizations internationally www.jointcommission.org
Focused on outcomes redirected accreditation processes and thus nurses? roles with the process Changed to unannounced visits and thus changed the way organizations
prepared for accreditation. Issues annual patient safety goals Issues sentinel event announcements
Det Norske Veritas/ National Integrated Accreditation for Healthcare Organizations
Internationally based organization that accredits many fields, including healthcare. www.dnvaccreditation.com
Based on an internationally understood set of standards known as ISO (International Organization for Standardization) Visits annually and thus changed the way
accreditation is viewed.
Quality and Safety Education for Nurses
Comprehensive resource, including references and video modules www.qsen.org
Created knowledge, skills, and attitudes for students and graduates related to safety.
Magnet Recognition Program ?
A designation build on and evolving through research. Emphasizes outcomes nursecredentialing.com/Magnet/ ProgramOverview.aspx
Created unified approaches to seek this designation Redirected focus to outcomes, including data and efforts related to patient safety
Institute for Healthcare Improvement
Independent, not- for- profit Source of TCAB (Transforming Care at the Bedside)
Provides rapid cycle change projects designed to improve care rapidly (See Theory Box)
THE INSTITUTE OF MEDICINE REPORTS ON QUALITY
Although many reports about quality and safety had been issued before 2000, To Err is Human is the report credited with causing sufficient alarm about how widespread
the issue of patient safety concerns was. When the number of deaths (98,000 annually) attributable to medical error was announced, the interest in safety intensified.
Suddenly this issue was not related to just a few isolated instances nor was it likely to diminish without some concerted action. Probably the hallmark of this
publication was the acknowledgment that errors commonly occurred because of system errors rather than individual practitioner
incompetence. This insight, that it was the system and not the practitioners that needed to be addressed, placed even more emphasis on roles such as chief medical
officers and chief nursing officers. Hospital boards that once focused almost exclusively on finances suddenly wanted more of their agendas devoted to discussions
about quality and patient safety. The call for a comprehensive approach to the issue of improving patient safety really spurred the release of a second IOM report.
This next report, Crossing the Quality Chasm, was released the subsequent year (IOM, 2001). The intent of this second book was to improve the systems within which
health care was delivered; after all, the first report identified that systems rather than
incompetent people were the major concern. The report spelled out six major aims in providing health care, as shown in Box 2-1. These aims were designed to enhance the
quality of care that was delivered. Most are well documented in the literature, and two of them seem to be receiving much attention. One, patient-centered care, has
lessened the past practices of disciplines (e.g., nursing and pharmacy) and services (e.g., orthopedics and urology) vying for control of the patient. Now, because
care is to be rendered with the patient rather than to the patient, the emphasis of care is about what is provided?not who controls the decision about care. The second
aim, equitable, has emphasized what the literature refers to as disparities and has led to thoughtful consideration of what best practices are and how they can be
provided to the masses. The report went on to acknowledge elements of care that nurses commonly value. For example, the report cited the idea of a healing environment,
individualized care, autonomy of the patient in making decisions, evidence-based decision making, and the need for transparency. Although those elements of a
healthcare delivery system might not seem so dramatic today, they were fairly revolutionary in 2001. This report also provided substantive support for the use of
information technology within health care. In addition, it provided the impetus for payment methods being based on quality outcomes and addressed the issue of
preparing the future workforce. This latter recommendation formed the basis for another IOM report, Health Professions Education: A Bridge to Quality (IOM, 2003).
Unlike the earlier reports, the Health Professions Education report emerged as the work of an invitational summit. In this report, one of the major concerns about
safety was exposed publicly, namely that we educate disciplines in silos and then expect them to function as an integrated whole. This is true of both basic and
continuing professional education. The report stated, ?All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary
team, emphasizing evidencebased practice, quality improvement approaches, and informatics? (IOM, 2003, p. 3). Box 2-2 emphasizes those five competencies about health
professional education. The idea of this report was to shrink the chasm between learning and reality so that learning was enhanced and reality was more closely aligned
with that learning. A commitment to this redirection of learning is critical for ?learning organizations,? a term coined by Peter Senge. Thus constant learning is a
commitment every healthcare professional must have. Although it is the individual?s accountability to
Knowing the relevant literature about safe patient care guides nursing practice.
30 PART 1? Core?Concepts
maintain competence and participate in learning, the organization can hinder or enhance that individual?s need to meet this expectation. Learning organizations exhibit
a positive commitment to enhance people?s learning and changing. After looking at safety, the system and core competencies of health professionals, the IOM turned its
attention to the workplace itself. As a result, many nurses think of the IOM report Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2004) as
the major impetus behind many changes that improved the working conditions for nurses. Because nurses are so inextricably linked with patients, it was logical that the
importance of the role of nurses in health care emerged as an area of focus. This report identified that nurses had lost trust in the organizations in which they
worked and that ?flattening? the organization resulted in fewer clinical leaders being available to advocate for staff and patients and to provide resources to those
delivering direct care. Further, numerous sources of unsafe equipment, supplies, and practices were discussed. Finally, so many organizations were still engaged in
punitive practices related to errors rather than redirecting attention to the broader view of the system. This report focused on direct-care nurses being able to
participate in decisions that affected them and their provision of care, which helped reinforce the ongoing work of shared governance. Addressing staffing issues was
accomplished on a broad scale. In other words, the broad processes for determining staffing requirements and how to address those were identified. Average hours per
patient day of care, staffing levels, turnover rates, public reporting about those data, support for annual and planned education, and specifics, such as handwashing
and medication administration, were addressed. Also, this report
identified the importance of governing boards understanding the issues of safety and propelled the idea of the chief nursing officer participating in board meetings in
organizations that had not already embraced this practice. Redesigning both the work of nurses and the workspace was acknowledged as critical to maximizing a positive
workforce. The more recent report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2010), also provides guidance to nursing. Although this report does
not focus specifically on quality and safety, the evidence used to build the recommendations includes much that addresses safe, quality practices. For example, the
evidence regarding the outcomes of advanced practice registered nurses shows both safety and quality in terms of care. Additionally, the call for more nurses holding
bachelors and higher degrees relates to the outcomes evident in the literature about lowered morbidity and mortality with a better prepared workforce. Each of these
reports fits within the IOM?s focus on quality and an attempt to make health care a quality endeavor. Together, these reports and others to be developed provide
direction for the delivery of care and contain implications, if not outright recommendations, for nursing. These reports form the core of the work around quality in
most organizations today. Further, they support many issues nurses have identified as key to quality care.
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
The Agency for Healthcare Research and Quality (AHRQ) is the primary Federal agency devoted to improving quality, safety, efficiency, and effectiveness of health care
(Agency for Healthcare Research and Quality [AHRQ], 2008). As seen in numerous IOM reports, recommendations about what AHRQ could do to enhance safety were prominent.
AHRQ?s website (www.ahrq.gov) is an information-rich source for providers and consumers alike. For example, several healthcare conditions are identified in the
outcomes research section. Because AHRQ maintains current information, it is a readily available source, even if the number of conditions is limited. Another example
of AHRQ?s work is the fairly well-known
BOX 2-2 COMPETENCIES OF HEALTH PROFESSIONALS
? Provide patient-centered care ? Work in interdisciplinary teams ? Employ evidence-based practice ? Apply quality improvement ? Utilize informatics
From Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press.
31CHAPTER 2 ? Patient?Safety
?Five Steps to Safer Health Care,? which is available at www.ahrq.gov/consumer/5step.htm. Nurses who work in clinics will find these steps especially helpful in
working with patients. This list identifies ways in which nurses can support people in assuming a more influential role in their own care. Further, supporting people
in assuming a larger role helps them receive care that is patient-centered. Box 2-3 lists the five steps. If a patient does not volunteer the above information, a
nurse could readily seek clarification by asking questions related to each of those items. This is an example of reinforcing work that has been judged to benefit
patients. AHRQ is also the source for the stay healthy checklists for men and women. These checklists can be useful in any clinical setting in helping people assume a
greater understanding of their own care.
for Medicare & Medicaid Services (CMS) formed its no-pay policy based on the growing work of NQF of ?never events.? In other words, CMS will no longer pay for certain
conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare
professional. The NQF brings together providers, insurers, patient groups, federal and state governments, and professional associations and purchasers, to name a few
of the groups comprising the membership. This diversity provides a venue for open discussion about healthcare quality that does not normally happen. Having the
patients? perspectives at the same time as the perspectives of the insurers and providers allows for a broad view of any issue. The Healthcare Facilities Accreditation
Program, a CMSdeemed authority, has adopted the NQF?s 34 Safe Practices. NQF refers to nurses as ?the principal caregivers in any healthcare system? (National Quality
Forum [NQF], 2008). This acknowledgment, while welcomed, is also a challenge for nurses to perform in the best manner possible to lead organizations in their quests
for quality. Through its consensus process, NQF created a list of endorsed nurse-sensitive care standards. These standards are divided among three key areas:
patientcentered outcome measures, nursing-centered intervention measures, and system-centered measures. The first group includes fall and pressure ulcer prevalence;
the second, smoking cessation programs with three diagnosis groups; and the third, skill mix, turnover rates, nursing care hours per patient day, and a practice
environment scale. Box 2-4 lists the nursesensitive care standards from 2008. These standards create a common definition of measures so that any group can collect and
report data in a manner comparable to other groups. As a result, those measures form the basis for comparison of quality.
BOX 2-3 FIVE STEPS TO SAFER HEALTH CARE
1. Ask questions if you have doubts or concerns. 2. Keep and bring a list of ALL medications you take. 3. Get the results of any test or procedure. 4. Talk to your
doctor about which hospital is best for your health needs. 5. Make sure you understand what will happen if you need surgery.
From www.ahrq.gov/consumer/5steps.htm. Retrieved May 10, 2010.
EXERCISE 2-1 Go to www.ahrq.gov/consumer and review what sources of information are available to people for whom you may provide care. Click on ?Staying Healthy,? and
then scroll to ?Preventing Disease & Improving Your Health? and click on ?Men: Stay Healthy at 50+.? Review the information there, and then use the back button to
return to the prior page and click on ?Women: Stay Healthy at 50+.? What are the differences in the checklists based on gender?
THE NATIONAL QUALITY FORUM
The National Quality Forum (NQF) is a membership-based organization designed to develop and implement a national strategy for healthcare quality measurement and
reporting. As a result, the Centers
EXERCISE 2-2 Do an online search regarding the concept of ?BSN in 10? and read the rationale behind this movement. Assume that you work in a facility that does not
provide support (time off, tuition reimbursement, recognition of educational achievement). How could you use this information to change workplace policies and
32 PART 1? Core?Concepts
The DNV work is based on a set international standards known as International Organization for Standardization (ISO).The DNV surveys its accredited organizations
annually. Because of its extensive work in other fields, the DNV employs similar approaches in health care in meeting the ISO standards.
In addition to defining competencies for prelicensure and graduate students, QSEN, which stands for Quality and Safety Education for Nurses, provides comprehensive
resources that are competency based. These resources include bibliographies and videos to enhance our understanding of quality and safety. They have no authority;
however, most educational programs subscribe to their efforts to promote both quality and safety as key elements in nursing education.
MAGNET RECOGNITION PROGRAM?
The Magnet Recognition Program? is the only national designation built on and evolving through research. This program is designed to acknowledge nursing excellence.
Through the 14 Forces of Mag netism (www.nursecredentialing.org/Magnet/ ProgramOverview/ForcesofMagnetism.aspx), organizations must demonstrate how they provide
excellence. Although each of the forces contributes to patient safety, two are specifically focused on quality: quality of care and quality improvement. In the model
created in 2008, the core of the model is empirical outcomes. Magnet?, like other organizations mentioned here, focuses on quality care
INSTITUTE FOR HEALTHCARE IMPROVEMENT
The Institute for Healthcare Improvement (IHI) is dedicated to rapidly improving care through a variety of mechanisms including rapid cycle change projects. (See the
Theory Box on p. 33.) IHI is an independent, not-for-profit organization. Working with the Robert Wood Johnson Foundation (RWJF), IHI created an
ACCREDITING BODIES (TJC AND DNV)
The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the det norske veritas (DNV), are not-for-profit
organizations. Both have deemed status from CMS, which means an organization accredited by a deemed body meets the same expectations that CMS sets. The Joint
Commission focuses on outcomes and now uses an unannounced visit approach in an attempt to be certain organizations are meeting expectations at any point in time. This
change in emphasis, from one of processes and a regular basis to one of outcomes and unannounced visits has been seem to be of value to hospitals and other
organizations as they attempt to meet high standards. TJC issues annual patient safety goals, which can be found on their web site (www.jointcommission.org).
BOX 2-4 NURSE-SENSITIVE CARE STANDARDS
Patient-Centered Outcome Measures ? Death among surgical inpatients with treatable serious complications (failure to rescue) ? Pressure ulcer prevalence ? Patient
falls ? Falls with injury ? Restraint prevalence (vest and limb) ? Urinary catheter?associated infections (CAUTI) rate for intensive care unit (ICU) patients ? Central
line catheter?associated bloodstream (CLABSI) infection rate for intensive care unit (ICU) and neonatal intensive care unit (NICU) patients ? Ventilator-associated
pneumonia (VAP) rate for intensive care unit (ICU) and neonatal intensive care (NICU) patients Nursing-Centered Intervention Measures ? Smoking cessation counseling
for acute myocardial infarction (AMI) ? Smoking cessation counseling for heart failure (HF) ? Smoking cessation counseling for pneumonia (PN) System-Centered Measures
? Skill mix ? Nursing care hours per patient day ? Practice environment scale-nursing work index (PES-NWI) ? Voluntary Turnover
Reproduced with permission from the National Quality Forum, copyright ? 2004.
33CHAPTER 2 ? Patient?Safety
innovative project called Transforming Care at the Bedside (TCAB). Although TCAB currently is applied only to medical-surgical inpatient units, it addresses safety and
reliability, care team vitality, patient-centeredness, and increased value. Spreading innovative approaches to patient safety issues is critical to achieve major
patient safety goals.
MEANING FOR LEADING AND MANAGING IN NURSING
Many of the approaches to patient safety and, before that, aviation and nuclear energy safety, consist of strategies to alert us to safety issues. For example, the use
of SBAR (See Box 2-5) and checklists are designed to decrease omission of important information and practices. These practices aren?t designed to limit a
professional?s distinctive contributions. Rather they are designed to increase the likelihood of safe practice. This concern for patient safety is not limited solely
to hospitals or to the United States, as the International Council of Nurses points out. In a position statement issued in 2013, safe staffing levels are a concern
across the globe. The document, Safe Staffing Levels: Statement of Principles, reflects principles similar to those issued by the American Nurses Asso
ciation. This global perspective about nurse staffing as an important element in safe, quality care provides a uniform approach to advocating for strategies that
increase the potential for quality outcomes. Although the errors that nurse leaders and managers make do not typically result in a patient?s morbidity or mortality, if
each decision that is not related to patient care were treated with this type of focus, we would likely make solid decisions more frequently. Often managerial and
leadership tasks, like many others we perform, are squeezed into a hectic day. By stopping to concentrate on the work before us, we increase our chances of
understanding the complexity of the situation and the ramifications of various decisions. By thinking through various scenarios, we are likely to eliminate strategies
and methods that would not meet our needs and be more likely to narrow our choices of best actions to take. Then, if after an action, we took time to review how well
some decision was enacted, we would increase our knowledge about particular types of problems and enhance our skill at making decisions. Similarly, it is possible to
look at the five core competencies defined in the 2003 IOM report and create a professional evaluation system and continuing education program. In essence, these five
core competencies could drive the personnel performance within an organization. Using some form of a chart, continuing educators could redesign organizational-
sponsored learning activities by illustrating how the proposed learning activities contribute to developing, maintaining, or enhancing the five core competencies. This
unified focus would help both the individual and the organization. Further, having geographically accessible or virtual demonstration sites would allow physicians,
nurses, and others the opportunity to
Diffusion Theory THEORY/CONTRIBUTOR KEY IDEA APPLICATION TO PRACTICE Rogers (2003) ? A process of communication about innovation to share information over time and
among a group of people. ? Allows for non-linear change. ? More complex change is less likely to be adopted. ? Early adopters serve as role models ? Engage key leaders
in a change to infuse the energy from early adopters. ? Using Twitter in the hospital culture to engage employees communicates changes quickly.
BOX 2-5 SBAR
S?Situation B?Background A?Assessment R?Recommendation
34 PART 1? Core?Concepts
demonstrate through simulation how the five core competencies relate to specific practice areas. These major overhauls of organizational systems require commitment
from the organization?s largest department?nursing. One of the challenges for nurses in any position, and especially for leaders and managers, is the task of keeping
current with the literature. For example, Hendrick et al. (2012) identify how a strategic, system-wide effort was made to address quality and safety from chief nurses
collaborating. Computer technology has allowed us to gather data, analyze it, share it with other colleagues, and read about studies through online availability. Based
on the original IOM observation that the numbers of journals, and thus articles, had multiplied dramatically over the
past decades, knowing what to read and where to search is critical. Hoss and Hanson (2008) provided a way to consider evidence available through websites. (See the
Literature Perspective below.) The challenge for competent practice today is to stay well-informed about the best evidence or best practices that exist in any practice
situation, including that of management and leadership. As the healthcare professions have focused on creating evidence about various practices, the amount of
information has become overwhelming. The Research Perspective below illustrates one study focused on a review of the impact of a comprehensive nursing approach to
patient safety. The quantity of citations reviewed, alone, illustrates the importance of nurses and patient safety.
Resource: Richardson, A. & Storr, J. (2010). Patient safety: a literative review of the impact of nursing empowerment, leadership and collaboration. International
Nursing Review. 57:12-21. doi: 10.1111/j.1466-7657.2009.00757.x The purpose of this study was to determine how and in what intensity empowerment, leadership, and
collaboration were linked to patient safety. The authors made a comprehensive study of electronic databases from 1998 to 2008. This initial search produced 1,788
articles and abstracts. Sixty five (65) articles had full text available. Specific criteria allowed an item to be included, for example the presence of one of the
terms and a measure of impact. As a result, eleven reports were studied in greater detail. All of the
papers were from English-speaking countries, with the United States most prevelant as the source (n = 7). Although limited evidence was found, this study was the
initiation of a new approach to looking at these various issues and how they interrelated. Implications for Nursing Practice Although few reports were available and
they varied in quality of contribution to understanding how empowerment, leadership and collaboration work with patient safety, one conclusion was evident. Much work
needs to be done before the relationships of these elements to patient safety can be understood. Because nurses have such intimate involvement in care, the need to
further studies in this area is great.
Resource: Hoss, B., & Hanson, D. (2008). Evaluating the evidence: Web sites. AORN Journal, 87(1), 124, 126-128, 130-132, 134-138, 140-141. The amount of evidence-based
practice-related content has grown dramatically. Thus evaluating websites for bias, validity, and patient population descriptors has become increasingly important.
Several national sources provide quality improvement data. Examples of these are the Agency for Healthcare Research and Quality, the Institute for Healthcare
Improvement, and The Joint Commission. The authors proposed three questions to evaluate websites: (1) Is the information from a recognized authority? (2) Does the
website comply with voluntary standards? (3) Who is the intended audience? Examples of recognized authorities are most
peer-reviewed journals, the Cochrane Database of Systematic Reviews, and The Virginia Henderson International Nursing Library. An example of the second is the
standards of Medline Plus, which requires meeting several criteria to have a link from its site. An example of the third is to consider what the url extension is. For
example, .com refers to commercial enterprises; .edu to educational institutions; .org to organizations (frequently professional and nonprofit societies); and .gov to
city, county, state, or federal government. Questions of validity relate to the following: Is the author biased? Is the information complete and accurate? Are the
recommendations valid? Will the information help the patient? Implications for Practice Knowing what sources provide quality information helps nurses use their time
35CHAPTER 2 ? Patient?Safety
A multidisciplinary group was formed to address the problem. Our facility did not have some of the necessary equipment such as lift equipment, adult-size positioning
devices, and beds large enough to accommodate larger patients. We purchased the necessary equipment, and we also implemented a safe patient-handling program. The
facility ?skin champions ?also developed an incontinence protocol and a friction/shear protocol. Participation by our hospital in a multisite research study on
pressure ulcer development in critically ill children has shown that our pressure ulcer incidence is significantly lower than that of other participating children?s
Success of the pediatric pressure ulcer prevention program is the result of extensive multidisciplinary collaboration?support from hospital administration, physicians,
and frontline nurses. Utilization of evidence-based practice and research has also driven successful changes in our program. The desire to continually improve pressure
ulcer prevention strategies has become the culture within our hospital. ?Vickie S. Simpson
Would this be a suitable approach for you? Why?
Creating a culture of safety is everybody?s business; and nurses, who are so integral to care, are key players in this important work. Every nurse has the
accountability to challenge any act that appears unsafe and to stop actions that do not concur with the patient?s best
interest. Being proactive is insufficient in itself; examining practices and conditions that support errors is critical, as is sharing knowledge that can redirect
care. In this challenging context, nurses continue to provide care and provide the organizational ?glue? that supports patient care being accomplished in a safe,
effective, and efficient manner.
THE EVIDENCE The Nurse-Sensitive Care Standards, developed by the National Quality Forum (2008), are conditions associated with the quality of nursing care. These form
the evidence associated with the care nurses provide. ? Death among surgical inpatients with treatable serious complications (failure to rescue) ? Pressure ulcer
prevalence ? Patient falls ? Falls with injury ? Restraint prevalence (vest and limb) ? Urinary catheter?associated infections (CAUTI) rate for intensive care unit
(ICU) patients ? Central line catheter?associated bloodstream (CLABSI) infection rate for intensive care unit (ICU) and neonatal intensive care unit (NICU) patients
? Ventilator-associated pneumonia (VAP) rate for intensive care unit (ICU) and neonatal intensive care (NICU) patients ? Smoking cessation counseling for acute
myocardial infarction (AMI) ? Smoking cessation counseling for heart failure (HF) ? Smoking cessation counseling for pneumonia (PN) ? Skill mix ? Nursing care hours
per patient day ? Practice environment scale-nursing work index (PES-NWI) ? Voluntary turnover
NEED TO KNOW NOW ? Know how to retrieve literature related to best practice and evidence in your area of practice. ? Practice precautionary strategies such as the STAR
? Select workplaces based on the support for the core competencies as defined by IOM. ? Practice what to say to stop an unsafe practice.
36 PART 1? Core?Concepts
Agency for Healthcare Research and Quality (AHRQ). AHRQ mission. Retrieved December 1, 2008, from www.ahrq.gov/. Det Norske Veritas (DNV). Managing risk to improve
patient safety. Retrieved September 23, 2009, from www.dnv.us/ consulting/generalindustries/publicsector/ Managingrisktoimprovepatientsafety.asp. Henderson, A. L.,
Batcheller, J., Ellison, D. A., Janik, A. M., Jeffords, N. B., Miller, L., Perlich, B. L., Stafflileno, G., Storm, M., & Williams, C. (2012). The Ascension Health
experience: maximizing the chief nursing officer role in a large, multihospital system to advance patient care quality and safety. Nursing Administration Quarterly,
36(4), 277-288. Hoss, B., & Hanson, D. (2008). Evaluating the evidence: Web sites. AORN Journal, 87(1), 124-141. Institute for Healthcare Improvement. SBAR technique
for communication: a situational briefing model. Retrieved July 26, 2013 from https://www.ihi.org/knowledge/Pages/Tools/
SBARTechniqueforCommunicationASituationalBriefing Model.aspx Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Washington, DC:
National Academy Press. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy
Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press. Institute of Medicine (IOM). (2004).
Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press. Institute of Medicine (IOM). (2010). The future of nursing:
leading change, advancing health. Washington, DC: National Academy Press. International Council of Nurses. (??). Safe staffing levels: statement of principles. Geneva,
CH: The Council. Lee, C. (2009). The new hospital accreditation: Case in point. Nurse Leader, 7(5), 30-32. National Quality Forum. (2008). Nursing care quality at NQF.
Retrieved September 23, 2009, from www.qualityforum.org/ nursing. Richardson, A., & Storr, J. (2010). Patient safety: a literative review on the impact of nursing
empowerment, leadership and collaboration. International Nursing Review, 57, 12-21. Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: The Free Press.
TIPS FOR PATIENT SAFETY ? Use the STAR approach: Stop, Think, Act, Review. ? Use the IOM competencies to frame your actions. ? Keep current with the evidence and best
? Use only quality sources, especially websites. ? Read general nursing literature regarding other organizations? work related to safety.
CHAPTER CHECKLIST This chapter focused on the core of leading and managing in nursing, namely an intense passion for patients and their safety. To lead and manage
effectively, a nurse must be passionate about quality and patient safety. The nurse leader and manager, as well as followers, must be able to identify potential safety
issues, intervene quickly when a safety issue exists, and think skillfully after a safety violation so that all may learn. ? The key organizations dealing with the
patient safety movement are the following: ? The Institute of Medicine ? The Agency for Healthcare Research and Quality ? The National Quality Forum
? Accrediting Bodies ? The Joint Commission ? The DNV/NIAHOSM ? QSEN Institute ? The Magnet Recognition Program? ? The Institute for Healthcare Improvement ?
Considerable potential to capitalize on the information in the IOM reports and in evidence-based research and best practices exists. ? Keeping current with the
literature is a challenge we must meet. ? Creating a culture of safety is everyone?s job.
37CHAPTER 2 ? Patient?Safety
Agency for Healthcare Research and Quality: https:// subscriptions.ahrq.gov/service/multi_subscribe. html?code=USAHRQ. Institute for Healthcare Improvement:
www.ihi.org/ihi. Institute of Medicine: IOM news: www.iom.edu/CMS/3238.aspx. Schnall, R., Stone, P., Currie, L., Desjardins, K., John, R. M., & Bakken, S. (2008).
Development of a self-report instrument to measure patient safety attitudes, skills and knowledge. Journal of Nursing Scholarship, 40(4), 391-394. Shaffer, F. A., &
Tuttas, C. A. (2009). Nursing leadership?s responsibility for patient quality, safety and satisfaction: Current review and analysis. Nurse Leader, 7(5), 34-38.
Wagner, L. M., Capezuti, E., & Rice, J. C. (2009). Nurses? perceptions of safety culture in long-term care settings. Journal of Nursing Scholarship, 41(2), 184-192.
Walrath, J. M., & Rose, L. E. (2008). The medication administration process: Patients? perspectives. Journal of Nursing Care Quality, 23, 345-352. Wolf, D., Lehman,
L., Quinlin, R., Rosenzweig, M., Friede, S., Zullo, T., & Hoffman, L. (2008). Can nurses impact patient outcomes using a patient-centered care model? Journal of
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