Professional Documents
Culture Documents
Patient Safety
Patient Safety
Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 Editor: Ronda G. Hughes, Ph.D., M.H.S., R.N. AHRQ Publication No. 08-0043 April 2008
Disclaimer: The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services.
This document is in the public domain and may be used and reprinted without permission, except those copyrighted materials noted for which further reproduction is prohibited without specific permission of the copyright holder. Citation of the source is appreciated.
Suggested Citation:
Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008.
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Foreword
The Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood Johnson Foundation (RWJF) are pleased to have jointly sponsored the development of this handbook for nurses on patient safety and quality. Patient Safety and Quality: An Evidence-Based Handbook for Nurses examines the broad range of issues involved in providing high quality and safe care across health care settings. We know that nurses are at the center of patient care and therefore are essential drivers of quality improvement. From the Institute of Medicines reports, including To Err is Human and Keeping Patients Safe: Transforming the Work Environment of Nurses, we know that patient safety remains one of the most critical issues facing health care today and that nurses are the health care professionals most likely to intercept errors and prevent harm to patients. For us, both at AHRQ and RWJF, improving patient safety and health care quality is embedded in our mission and at the core of what we do. We strongly believe that the safety and quality of health care in this nation is dependent upon the availability of the best research possible and on our ability to deliver the results of that research into the hands of providers, policymakers, and consumers so that all can make better decisions. We believe the result will be improved health care and safety practices, which will be manifested in measurably better outcomes for patients. Given the diverse scope of work within the nursing profession in this country, AHRQ and the RWJF expect that the research and concepts presented in the book will be used to improve health care quality by nurses in practice, nurse-educators, nurse-researchers, nursing students, and nursing leaders. The 89 contributors to this book represent a broad range of nurse-researchers and senior researchers throughout this nation. The product of this joint effort underscores the commitment of AHRQ and the RWJF to achieving a health care system that delivers higher quality care to everyone. We believe that high-quality health care can be achieved through the use of evidence and an enabled and empowered nursing workforce. We welcome written comments on this book. They may be sent to Ronda Hughes, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850.
Carolyn M. Clancy, M.D. Director Agency for Healthcare Research and Quality
Risa Lavizzo-Mourey, M.D., M.B.A. President and CEO Robert Wood Johnson Foundation
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Preface
Errors pervade our lives in our homes, on the roads, and in our places of work. Each hour of each day, patients and clinicians are affected by near errors and the consequences of adverse events. The effects of health care errors and poor quality health care have impacted all our livessometimes directly, at other times indirectly. Even during the writing of this book, many of the authors had firsthand experiences with near errors, adverse events, and a level of poorquality care that should never have been presented to any patient. Given the importance of health and health care in our lives, the purpose of this book is to bring safety and quality to the forefront in nursing. Throughout these pages, you will find peer-reviewed discussions and reviews of a wide range of issues and literature regarding patient safety and quality health care. Owing to the complex nature of health care, this book provides some insight into the multiple factors that determine the quality and safety of health care as well as patient, nurse, and systems outcomes. Each of these 51 chapters and 3 leadership vignettes presents an examination of the state of the science behind quality and safety concepts and challenges the reader to not only use evidence to change practices but also to actively engage in developing the evidence base to address critical knowledge gaps. Patient safety and quality care are at the core of health care systems and processes and are inherently dependent upon nurses. To achieve goals in patient safety and quality, and thereby improve health care throughout this nation, nurses must assume the leadership role. Despite being a relatively new field of inquiry, particularly in terms of how patient safety and quality are now defined, the need to improve the quality and safety of care is the responsibility of all clinicians, all health care providers, and all health care leaders and managers. As clinicians, we are obligated to do our best, regardless of whether we are acting as a clinician or a patient. Just as we say there are good patients and bad patients, clinicians as patients can unfortunately be considered bad patients because they may know too much, ask too many questions, or are not up-to-date on the research or current practice standards. Yet that is a mindset that must end and become a part of history, not to be repeated. Instead, nurses need to ensure that they and other team members center health care on patients and their families. All patientswhether they include ourselves, our loved ones, or the millions of our neighbors throughout this countryneed to be engaged with clinicians in their care. Each of the chapters in this book is organized with a background section and analysis of the literature. At the end of each chapter, you will find two critical components. First, there is a Practice Implications section that outlines how the evidence can be used to inform practice changes. Practice leaders and clinicians can use this information, based on the state of the science, to guide efforts to improve the quality and safety of delivering services to patients. Second, there is a Research Implications section that outlines research gaps that can be targeted by researchers and used by clinicians to inform and guide decisions for practice. Faculty and graduate students will find innumerable questions and issues that can be used to develop dissertation topics and grant applications to uncover the needed evidence. In all but a few chapters, you will find evidence tables. These tables were developed by critically assessing the literature, when possible, and present invaluable insight as to the type and quality of research that can inform practice, clarify knowledge gaps, and drive future research. As the reader will observe, the majority of patient safety and quality research presented in the evidence tables represent cross-sectional studies. In fact, 81 percent of the studies exploring the
various aspects of safety and quality employed cross-sectional study designs, predominately representing assessments at single sites of care and using qualitative surveys. This may be the byproduct of the challenges of the research process (including sources of funding) or the challenges of engaging in collaborative research. From this review of the literature, we can learn the importance of the need for longitudinal, multisite analyses to bring us forward into the next generation of evidence-based knowledge. Great is the importance of nurses being involved throughout the research process and collaborating with interdisciplinary teams throughout care settings. Then, too, it is critical that nursing leaders and managers, clinical leaders, and nurses across care settings engage in a lifelong pursuit of using data and information as well as research evidence to inform practice. Combined with experiential knowledge, analyses, and evidence, nurses will be challenged to continuously improve care processes and encourage our peers and interdisciplinary colleagues to make sure patients receive the best possible care, regardless of where they live, their race or gender, or their socioeconomic circumstances. The chapters in this book are organized into six sections. Each chapter can be read independently of the others; however, some do make reference to other chapters, and a greater understanding of the breadth and depth of patient safety and quality can be better obtained by reading the book in its entirety. Highlights from the chapters are summarized by section as follows: In Section I Patient Safety and Quality, patient safety is discussed as being foundational to quality, where nurses can be invaluable in preventing harm to patients and improving patients outcomes (chapter 1). Even though the quality and safety of health care is heavily influenced by the complex nature of health care and multiple other factors, nurses have been held accountable for harm to patients, even when other clinicians and health care providers and characteristics of the care system in which they work often havealmost without exceptiongreater roles and, in some respects, have ensured that an error would happen (chapters 2 and 3). With the many challenges facing health care today, the Institute of Medicines 11-volume Quality Chasm series brings to light the multitude of issues and factors that individuals and organizations, both within and outside of nursing and health care, need to understand and to work together to overcome (chapter 4). Moving toward and securing a culture of safety throughout health care will, by definition, acknowledge the influence of human factors in all clinicians, the results of humansystem interfaces and system factors, and will institutionalize processes and technology that will make near errors and errors very rare (chapter 5). This paradigm shift will enable nurses to think more critically and clinically (chapter 6), and to achieve greater insights as to how education, training, and experience are needed and can be leveraged to ultimately achieve high-quality care in every care setting and for all patients. To improve patient safety and quality, one needs to understand the state of the science at hand, as well as strategies that can be behind effective utilization of evidence and implementation of change, as discussed in Section II Evidence-Based Practice. It is here that one can learn that implementing evidence into practice can be accomplished though several approachesoften more than one simple intervention is possibleand by early on engaging key stakeholders to move toward adoption of change by translating research-based evidence into everyday care (chapter 7). Yet in assessing the state of the science, it becomes apparent that the majority of care afforded patients is not evidence based, emphasizing the need for health services research to examine progress toward safer and higher-quality care and to assess new and innovative practices (chapter 8). While the future of health care is uncertain, clinicians must
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continually assess, understand, and meet the needs of patients and prepare themselves to meet emerging health needs we might not expect (chapter 9). Due to innumerable pressures to improve patient safety and quality, it may be important to focus on those areas of care delivery, as discussed in Section III Patient-Centered Care, that are significantly influenced by nursing care. Providing health care is all about patients and their needs and meeting those care needs in settings where the majority of care is provided by cliniciansor, in certain circumstances, where loved ones and family members supplement nursing care or solely provide for the care needs of patients in community settings. Almost all the adverse events and less-than-optimal care afforded patients can be prevented, beginning by implementing research in practice. Situations in which failure to use evidence can be detected can include when preventable patients falls with injury occur (chapter 10), when illness-related complications are missed and lead to functional decline in the elderly (chapter 11), and when pressure ulcers develop in patients of any age (chapter 12). For nurses, ensuring and/or providing evidence-based, safe, and high-quality care become even more challenging when patients need care in their homes and subsequently rely on care rendered by family members and loved ones care that can be dependent upon the guidance of nurses (chapter 13). Not only can the resources and functionality of the community or home setting pose potential threats to the safety of patients and may relegate them to care of a lower quality, but those who care for patients may also succumb to the physical and emotional demands of providing informal care; amelioration can require broadening nursing care to caregivers (chapter 14). Nursing can also have a significant effect on the outcomes of specific groups of patients, particularly in preventing not only adverse events but the lasting effects of comorbidities and symptoms. The reason behind focusing on these specific populations is that their unique needs must not be considered less important than those of the majority. In the case of children, who are some of the most vulnerable patients due to developmental and dependency factors, it is difficult to provide safe, high-quality care that meets their unique needs. Instead, nurses need to use current best practices (chapter 15) to avert potentially lifelong comorbidities and address symptomsand develop new practices when the evidence is not available. It is also important to focus on simple strategies to prevent morbiditynot just preventing adverse eventsand ensure that patients receive preventive care services whenever possible, especially when the use of these services is supported by evidence (chapter 16). Especially for patients with moderate to severe pain, it is also important to prevent the adverse effects of their diseases and conditions by working with patients to manage their pain, promoting healing and improving function (chapter 17). And finally, in the case of potential adverse effects of polypharmacy in the elderly, nurses can also focus on simple strategies to improve adherence to intended therapies and detect unnecessary side effects, thereby improving medication safety (chapter 18). Beyond the influence of evidence on quality processes and outcomes, there are health care system and organization factors and characteristics to consider. As discussed in Section IV Working Conditions and the Work Environment for Nurses, evidence concerning the impact of health care system factors illustrates that working conditions and the work environment, which are heavily influenced by leaders, can have a greater impact on the safety and quality of health care than what an individual clinician can do. Instead of aggregating the various aspects of working conditions, the chapters in this section define and focus on specific aspects of key factors associated with patient and systems outcomes, centering on the importance of leadership. The leadership and management of health care organizations and health systems are pivotal to safer and higher quality of care because they direct and influence: which model of care is used
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to organize inpatient care services for patients (chapter 19); whether or not the organization embraces and is committed to fostering and sustaining a climate of safety and high-quality care (chapter 21); the impact of external factors, and the functionality and organization of microsystems within the context of the organization and relationships with others (chapter 22); how the specific care needs of patients are met with sufficient numbers of the right types of nurses (chapter 23 and chapter 25); how resource allocations and cost-saving strategies that involve restructuring, mergers, and organizational turbulence impact care delivery and patient outcomes (chapter 24 and chapter 29); the type of work environment that influences work stress and patient outcomes (chapter 26 and chapter 27); and how the actual physical environment and care processes influence the workload and workflow of nursing care (chapter 28, chapter 30, chapter 31). Taken together, leadership throughout organizations, led by nurse executives and influenced by physicians, is critical in determining whether or not safety and high-quality care can be achieved through daily teamwork, collaboration, and communication (chapter 20). It is because of the importance of senior nursing leadership that emphasis is put on the moral imperative that senior nursing leadership has to lead health care in the quest for safer and higher-quality care (vignette a), to demonstrate the right type of leadership (vignette b), and to excel in the right competencies (e.g., business skills and principles, communication and relationship management, and professionalism) (vignette c). Nursing leaders must actively work with and enable staff to transform the current work climate and care delivery. Section V Critical Opportunities for Patient Safety and Quality Improvement puts forth several critical opportunities that leaders and staff can work together to achieve success. In almost every care setting and situation, effective communication is essential. Not only do clinicians need to constantly communicate in a professional and technical way (chapter 32) and with team members in a way that is respectful and attuned to individual differences (chapter 33), clinicians must also ensure that the right information is communicated to next caregiver or health care provider so that the safety and quality of care is not compromised (chapter 34). Other opportunities for improvement center on the necessity to continually assess near errors and errors, not only those events that harm patients, and put in place strategies to avert the recurrence of both the near error and errors. Assessing and evaluating near errors and errors and the ability to avert the recurrence of errorsis dependent upon having information that is reported by clinicians (chapter 35), so that some errors (e.g., wrong-site surgery) never happen (chapter 36). Many initiatives to improve patient safety and health care quality have focused on medication safety. While many medication errors are prevented from harming patients because a nurse detected the error, monitoring and evaluating both near misses and adverse drug events can lead to the adoption of strategies to decrease the opportunities for errors, including unit dosing, using health information technology (chapter 37), and reconciling a patients medications (chapter 38). The nature of the work and the stress of caregiving can place nurses and patients at risk for harm. Moving patients, being in close proximity to therapeutic interventions, the implications of shift work and long work hours (chapter 39 and chapter 40), and ignoring the potential risk of injury and the impact of fatigue can increase the risk of occupational injury. It follows then that, because of the nature of the work, the proximity of nurses to patients, and the chronic and acute needs of patients, particular attention must be given to preventing health careassociated infections through known effective strategies, such as environmental cleanliness, hand hygiene,
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protective barriers (chapter 41), and strategies to address ventilator-acquired pneumonia (chapter 42). The influence of nurse practitioners and of the new generation of doctorate-level nurse clinicians has the potential of enabling significant improvements in critical opportunities for patient safety and quality improvement (chapter 43). The opportunities to demonstrate the influence of these clinical leaders is endless. The last section of this book, Section VI Tools for Quality Improvement and Patient Safety, focuses on the strategies and technologies that can be used to push health care to the next level of quality. One of the tools that can be used is quality methods, including continuous quality improvement, root cause analysis, and plan-do-study-act (chapter 44). Quality and patient safety indicators can also be used to assess performance and monitor improvement (chapter 45). These, as well as other tools, are integral in efforts to develop and demonstrate nursing excellence (chapter 46). With recent developments in information technologies, there are many potential benefits that can be afforded by these technologies that can facilitate decisionmaking, communication of patient information (chapter 47, chapter 48, chapter 49), therapeutic interventions (so long as the information technologies are used and function properly) (chapter 49), and education and training (chapter 51). All of these various issues and factors come together to define the complexity and scope of patient safety and quality care but also the necessity for multifaceted strategies to create change within health care systems and processes of care. In using evidence in practice, engaging in initiatives to continually improve quality, and striving for excellence, nurses can capitalize on the information from this book and lead health care in the direction that it should and needs to be heading to better care for the needs of patients. What it all comes down to is for us, as nurses, to decide what kind of care we would want as patients then to do all that is possible to make that happen. Today we may be doing what we can, but tomorrow we can improve. With this evidence and the call to action to nurses, in 5 years from now, headlines and research findings should carry forth the message that there are significant improvements in the quality and safety of health care throughout this nation, and it was because nurses led the way.
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Peer Reviewers
Daleen AragonOrlando Regional Healthcare, FL William BaineAHRQ, MD Mary BartonAHRQ, MD Mary BlegenUniversity of California at San Francisco, CA Barbara BradenCreighton University, NE Nancy BergstromUniversity of Texas, Houston, TX Peter BruehausVanderbilt University, TN Helen BurstinNational Quality Forum, DC Carol CainKaiser Permante, CA Carolyn ClancyAHRQ, MD Sean ClarkeUniversity of Pennsylvania, PA Marilyn ChowKaiser Permante, CA Beth Collins-SharpAHRQ, MD Kathy CrossonAHRQ, MD Linda Lindsey DavisDuke University, NC Ellen Mockus DErricoLoma Linda University, CA Joanne DischUniversity of Minnesota, MN Anita HanrahanCapital Health, Edmonton, Alberta Aparana HigginsBooz | Allen | Hamilton, NY Kerm HenricksonAHRQ, MD Judith HertzNorthern Illinois University, IL Ronda HughesAHRQ, MD Rainu KaushalHarvard-Partners, MA Ron KayeFDA, MD Marge KeyesAHRQ, MD Christine KovnerNew York University, NY Jeanette LancasterUniversity of Virginia, VA David LanierAHRQ, MD Elaine LarsonColumbia University, NY Kathy LeeUniversity of California at San Francisco, CA Michael LeonardKaiser Permante, CA Sally LuskUniversity of Michigan, MI David MeyersAHRQ, MD Jack NeedlemanUniversity of California at Los Angeles, CA D.E.B. PotterAHRQ, MD Peter PronovostJohns Hopkins University, MD Amanda RischbiethAustralia Carol RomanoDHHS/USPHS, MD Judy Sangel - AHRQ, MD Cynthia ScalziUniversity of Pennsylvania, PA Carol ScholleUniversity of Pittsburgh Medical Center Presbyterian Hospital, PA Jean Ann SeagoUniversity of California at San Francisco, CA Joan ShaverUniversity of Illinois at Chicago, IL Maria ShireyShirey & Associates, IN Jean SlutskyAHRQ, MD Kaye SpenceChildrens Hospital at Westmead, Sydney, Australia Janet TuckerUniversity of Aberdeen, United Kingdom Tasnim ViraUniversity of Toronto, Ontario Judith WarrenUniversity of Kansas, KS Jon WhiteAHRQ, MD Zane Robinson WolfLa Salle University, PA Laura ZitellaStanford University Cancer Center, CA
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Contributing Authors
Kathryn Rhodes Alden, M.S.N., R.N., I.B.C.L.C. University of North Carolina at Chapel Hill Kristine Alster, Ed.D., R.N. University of Massachusetts at Boston Lisa Antle, A.P.R.N., B.C., A.P.N.P University of Wisconsin Milwaukee College of Nursing Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N. Advances in Skin and Wound Care Jane H. Barnsteiner, Ph.D., R.N., F.A.A.N. University of Pennsylvania School of Nursing and Hospital of the University of Pennsylvania Ann Bemis, M.L.S. Rutgers, The State University of New Jersey Patricia Benner, R.N., Ph.D., F.A.A.N. Carnegie Foundation for the Advancement of Teaching Mary A. Blegen, Ph.D., R.N., F.A.A.N. School of Nursing, University of California, San Francisco Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q. College of Nursing, University of Central Florida, Orlando Carol H. Cain, Ph.D. Care Management Institute, Kaiser Permanente Pascale Carayon, Ph.D. University of Wisconsin-Madison Claire C. Caruso, Ph.D., R.N. National Institute for Occupational Safety and Health Sean P. Clarke, R.N., Ph.D., C.R.N.P., F.A.A.N. University of Pennsylvania School of Nursing Amy S. Collins, B.S., B.S.N., M.P.H. Centers for Disease Control and Prevention Karen Cox, R.N., Ph.D., C.N.A.A., F.A.A.N. Childrens Mercy Hospitals and Clinics, Kansas City, MO Leanne Currie, D.N.Sc., M.S.N., R.N. Columbia University School of Nursing Margaret J. Cushman, Ph.D.(c), R.N., F.H.H.C., F.A.A.N. University of Massachusetts at Boston Maureen Ann Dailey, R.N., M.S. Columbia University School of Nursing Elizabeth Dayton, M.A. Johns Hopkins University Andrea Deickman, M.S.N., R.N. iTelehealth Inc. Joanne Disch, Ph.D., R.N., F.A.A.N. University of Minnesota School of Nursing Molla Sloane Donaldson, Dr.P.H., M.S. M.S.D. Healthcare Nancy E. Donaldson, R.N., D.N.Sc., F.A.A.N. University of California, San Francisco, School of Nursing Carol Fowler Durham, M.S.N., R.N., University of North Carolina at Chapel Hill Victoria Elfrink, Ph.D., R.N.B.C. College of Nursing of Ohio State University and iTelehealth Inc. Carol Hall Ellenbecker, Ph.D., R.N. University of Massachusetts at Boston Marybeth Farquhar, R.N., M.S.N., C.A.G.S. Agency for Healthcare Research and Quality Kathy Fletcher, R.N., G.N.P., A.P.R.N.B.C., F.A.A.N. University of Virginia Health System
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Mary Ann Friesen, M.S.N., R.N., C.P.H.Q. Center for American Nurses, Silver Spring, MD Jeanne M. Geiger-Brown, Ph.D., R.N. University of Maryland School of Nursing Karen K. Giuliano, R.N., Ph.D., F.A.A.N. Philips Medical Systems Barbara Given, Ph.D., R.N., F.A.A.N. Michigan State University College of Nursing Ayse P. Gurses University of Minnesota-Twin Cities Saira Haque, M.H.S.A., Doctoral candidate Syracuse University Kerm Henriksen, Ph.D. Agency for Healthcare Research and Quality Ronda G. Hughes, Ph.D., M.H.S., R.N. Agency for Healthcare Research and Quality Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N. Colonel, U.S. Army (Retired) and health care consultant Meg Johantgen, Ph.D., R.N. University of Maryland School of Nursing Gail M. Keenan, Ph.D., R.N. University of Illinois, Chicago Margaret A. Keyes, M.A. Agency for Healthcare Research and Quality Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N. Rush University College of Nursing, Chicago, IL Susan R. Lacey, R.N., Ph.D. Nursing Workforce and Systems Analysis, Childrens Mercy Hospitals and Clinics, Kansas City, MO Jane A. Lipscomb, Ph.D., R.N., F.A.A.N. University of Maryland School of Nursing Carol J. Loveland-Cherry, Ph.D., R.N., F.A.A.N. University of Michigan School of Nursing Vicki A. Lundmark, Ph.D. American Nurses Credentialing Center
Courtney H. Lyder, N.D., G.N.P., F.A.A.N. University of Virginia Mary Mandeville, M.B.A. University of Illinois, Chicago Karen Dorman Marek, Ph.D., M.B.A., R.N., F.A.A.N. University of Wisconsin Milwaukee College of Nursing Diana J. Mason, R.N., Ph.D., F.A.A.N. American Journal of Nursing Margo McCaffery, R.N., F.A.A.N. Pain management consultant Pamela H. Mitchell, Ph.D., R.N., C.N.R.N., F.A.A.N., F.A.H.A. University of Washington School of Nursing Deborah F. Mulloy, M.S.N., C.N.O.R., Doctoral student University of Massachusetts at Boston School of Nursing Cindy L. Munro, R.N., A.N.P., Ph.D., F.A.A.N. Virginia Commonwealth University School of Nursing Mike R. Murphy, R.N., B.S.N., M.B.A. Synergy Health/St. Josephs Hospital Audrey L. Nelson, Ph.D., R.N., F.A.A.N. James A. Haley Veterans Hospital, Tampa, FL Michelle ODaniel, M.H.A., M.S.G., VHA West Coast Eileen T. OGrady, Ph.D., R.N., N.P. Nurse Practitioner World News and The American Journal for Nurse Practitioners Ann E. K. Page, R.N., M.P.H. Institute of Medicine Chris Pasero, R.N. Pain management consultant Emily S. Patterson, Ph.D. Cincinnati VA Medical Center and Ohio State University Nirvana Huhtala Petlick Rutgers, The State University of New Jersey Shobha Phansalkar, R.Ph., Ph.D. Harvard Medical School
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Contributing Authors
Sally Phillips, Ph.D., R.N. Agency for Healthcare Research and Quality Gail Powell-Cope, Ph.D., A.R.N.P., F.A.A.N. James A. Haley Veterans Hospital, Tampa, FL John Reiling, Ph.D., M.H.A., M.B.A., Synergy Health/St. Josephs Hospital Susan C. Reinhard, Ph.D., M.S.N., F.A.A.N. Rutgers, The State University of New Jersey Victoria L. Rich, Ph.D., R.N., F.A.A.N. University of Pennsylvania Health System Ann E. Rogers, Ph.D., R.N., F.A.A.N. University of Pennsylvania School of Nursing and University of Pennsylvania School of Medicine Alan H. Rosenstein, M.D., M.B.A. VHA West Coast Linda Samia, Ph.D., R.N. Healthy Choices for ME, MaineHealths Partnership for Healthy Aging Barbara A. Sattler, R.N., Dr.P.H., F.A.A.N. University of Maryland School of Nursing Lucy A. Savitz, Ph.D., M.B.A. Abt Associates Loretta Schlachta-Fairchild, R.N., Ph.D., F.A.C.H.E. iTelehealth Inc. Jean Ann Seago, Ph.D., R.N. School of Nursing, University of California, San Francisco Victoria L. Selby, R.N., B.S.N. University of Maryland School of Nursing Laura Senn, M.S., R.N. University of Minnesota School of Nursing
Janis B. Smith, R.N., M.S.N. Childrens Mercy Hospitals and Clinics, Kansas City, MO Elizabeth S. Soule University of Washington School of Nursing Nancy Staggers, Ph.D., R.N., F.A.A.N. University of Utah College of Nursing and School of Medicine Donald Steinwachs, Ph.D. Johns Hopkins University Patricia W. Stone, Ph.D., M.P.H., R.N. Columbia University School of Nursing Molly Sutphen, Ph.D. Carnegie Foundation for the Advancement of Teaching Marita G. Titler, Ph.D., R.N., F.A.A.N. University of Iowa Hospitals and Clinics Alison M. Trinkoff, Sc.D., R.N., F.A.A.N. University of Maryland School of Nursing Dana Tschannen, Ph.D., R.N. University of Michigan. Mary Wakefield, Ph.D., R.N., F.A.A.N. University of North Dakota, Grand Forks Charlene Weir, Ph.D., R.N. VA Geriatric Research Education and Clinical Centers, Salt Lake City, UT Nancy Wells, D.N.Sc., R.N., F.A.A.N. Vanderbilt Medical Center and Vanderbilt University School of Nursing Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q. James A. Haley Veterans Hospital, Tampa, FL Zane Robinson Wolf, Ph.D., R.N., F.A.A.N. La Salle University School of Nursing and Health Sciences Elizabeth Yakel, Ph.D. University of Michigan
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Acknowledgments
Without a doubt, this could not have been accomplished without the contribution and dedication of many people, both internally and externally to the Agency for Healthcare Research and Quality (AHRQ). A special note of gratitude is extended to each author and peer reviewer, who willingly shared their expertise and dedication to making health care better and safer. This project would not have been possible without financial support from the Robert Wood Johnson Foundation and the AHRQ, as well as the time authors committed to this project. Invaluable support was given by Carolyn Clancy, Helen Burstin, Tonya Cooper, Susan Hassmiller, David Lanier, and David Meyers throughout the 2-year process of bringing this project together. Sincere gratitude is also extended to AHRQs Office of Communications and Knowledge Transfer (OCKT), specifically Randie Siegel (project oversight), David I. Lewin (copyediting/production management), and Morgan Liskinsky (marketing plan). Further gratitude is extended to OCKTs editorial contractors (Helen Fox, Roslyn Rosenberg, and Daniel Robinson). Additional thanks go to Joy Solomita, of AHRQs Center for Primary Care, Prevenrion, and Clinical Partnerships (CP3), for all her efforts during the finalization process. Lastly, this book was dependent upon the invaluable assistance of Caryn McManus, Rene McCullough, Lynette Lilly, and other librarians throughout the country, who helped search for and retrieve thousands of articles and book chapters.
Ronda G. Hughes
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Contents
Foreword Carolyn M. Clancy, M.D., and Risa Lavizzo-Mourey, M.D., M.B.A. Preface General Overview/Executive Summary Ronda G. Hughes, Ph.D., M.H.S., R.N. List of Peer Reviewers Acknowledgments Section I: Patient Safety and Quality 1. Defining Patient Safety and Quality Care Pamela H. Mitchell, Ph.D., R.N., F.A.A.N. 2. Nurses at the Sharp End (what is an error IOM 99 and Reason) (Forthcoming) Ronda G. Hughes, Ph.D., M.H.S., R.N. 3. An Overview of To Err is Human Reemphasizing the Message of Patient Safety Molla Sloane Donaldson, Dr.P.H., M.S. 4. The Quality Chasm Series: Implications for Nursing Mary K. Wakefield, Ph.D., R.N. 5. Understanding Adverse Events: A Human Factors Framework Kerm Henriksen, Ph.D., Elizabeth Dayton, Margaret A. Keyes, M.A., Pascale Carayon, Ph.D., and Ronda G. Hughes, Ph.D., M.H.S., R.N. 6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically Patricia E. Benner, Ph.D., R.N., F.A.A.N., Molly Sutphen, Ph.D., and Ronda G. Hughes, Ph.D., M.H.S., R.N. Section II: Evidence-Based Practice 7. The Evidence for Evidence-Based Practice Implementation Marita G. Titler, Ph.D., R.N., F.A.A.N. 8. Health Services Research: Scope and Significance Donald M. Steinwachs, Ph.D., and Ronda G. Hughes, Ph.D., M.H.S., R.N. 9. Synergistic Opportunities for Enhanced Patient Safety: An Example of Connecting the Quality Improvement and Disaster Preparedness Dots (Forthcoming) Lucy Savitz, Ph.D., M.B.A., and Sally Phillips, Ph.D., R.N. Section III: Patient-Centered Care 10. Fall and Injury Prevention Leanne Currie, Ph.D., R.N. 11. Reducing Functional Decline in Hospitalized Elderly Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N., Kathy Fletcher, R.N., G.N.P., A.P.R.N.-B.C., F.A.A.N., and Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N. 12. Pressure Ulcers: A Patient Safety Issue Courtney H. Lyder, N.D., G.N.P., F.A.A.N., and Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N. 13. Patient Safety and Quality in Home Health Care Carol Hall Ellenbecker, Ph.D., R.N., Linda Samia, R.N., Margaret J. Cushman, R.N., F.H.H.C., F.A.A.N., and Kristine Alster, Ed.D., R.N.
14. Supporting Family Caregivers in Providing Care Susan C. Reinhard, Ph.D., R.N., F.A.A.N., Barbara Given, Ph.D., R.N., F.A.A.N., Nirvana Huhtula, and Ann Bemis 15. Pediatric Safety and Quality Susan Lacey, Ph.D., R.N., Janis B. Smith, R.N., M.S.N., and Karen Cox, Ph.D., R.N. 16. Prevention Safety and Quality Carol Loveland-Cherry, Ph.D., R.N., F.A.A.N. 17. Improving the Quality of Care Through Pain Assessment and Management Nancy Wells, Ph.D., Margo McCaffery, R.N., F.A.A.N., and Chris Paseo, R.N., F.A.A.N. 18. Medication Management of the Community-Dwelling Older Adult Karen Dorman Marek, Ph.D., M.B.A., R.N., F.A.A.N., and Lisa Antle, A.P.R.N., B.C., A.P.N.P. Section IV Working Conditions and the Work Environment for Nurses 19. Care Models Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N. 20. Leadership Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., Joanne Disch, Ph.D., R.N., F.A.A.N., and Laura Senn, M.S., R.N. (a) [Vignette] Transforming Health Care for Patient Safety: Nurses Moral Imperative To Lead Diana Mason, Ph.D., R.N., F.A.A.N. (b) [Vignette] Who Should Lead the Patient Quality/Safety Journey? Joane Disch, Ph.D., R.N., F.A.A.N. (c) [Vignette] Creation of a Patient Safety Culture: A Nurse Executive Leadership Imperative Victoria Rich, Ph.D., R.N., F.A.A.N. 21. Creating a Safe and High-Quality Health Care Environment Patricia W. Stone, Ph.D., R.N., Ronda G. Hughes, Ph.D., M.H.S., R.N., and Maureen Dailey, R.N., M.S. 22. What Does the IOMs Keeping Patients Safe Report Mean to Practice? Ann Page, R.N., M.P.H. 23. Patient Acuity Bonnie Jennings, D.N.Sc., R.N., F.A.A.N. 24. Restructuring and Mergers Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N. 25. Nurse Staffing and Patient Care Quality and Safety Sean P. Clarke, Ph.D., R.N., C.R.N.P., F.A.A.N., and Nancy E. Donaldson, D.N.Sc., R.N., F.A.A.N. 26. Work Stress and Burnout Among Nurses: Role of the Work Environment and Working Conditions Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N. 27. Temporary, Agency, and Other Contingent Workers Ann Page, R.N., M.P.H.
28. The Impact of Facility Design on Patient Safety (DraftDo Not Reproduce) John G. Reiling, M.H.A., M.B.A., Mike R. Murphy, R.N., B.S.N., M.B.A., and Ronda G. Hughes, Ph.D., M.H.S., R.N. 29. Turbulence Bonnie Jennings, D.N.Sc., R.N., F.A.A.N. 30. Nursing Workload and Patient SafetyA Human Factors Engineering Perspective Pascal Carayon, Ph.D., and Ayse P. Gurses, Ph.D. 31. Organizational Workflow and Its Impact on Work Quality Carol Cain, Ph.D., and Saira Haque, M.S. Section V: Critical Opportunities for Patient Safety and Quality Improvement 32. Professional Communication Jean Ann Seago, Ph.D., R.N. 33. Professional Communication and Team Collaboration (DraftDo Not Reproduce) Michelle ODaniel, Ph.D., and Alan Rosenstein, M.D. 34. Handoffs: Implications for Nurses (DraftDo Not Reproduce) Mary Ann Friesen, M.S.N., R.N., C.P.H.Q., Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q., and Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q. 35. Error Reporting and Error Disclosure (Forthcoming) Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., and Ronda G. Hughes, Ph.D., M.H.S., R.N. 36. Wrong-Site Surgery: A Preventable Medical Error (DraftDo Not Reproduce) Deborah Mulloy, M.S.N., R.N., and Ronda Hughes, Ph.D., M.H.S., R.N. 37. Medication Administration Safety (Forthcoming) Ronda G. Hughes, Ph.D., M.H.S., R.N., and Mary Blegen, Ph.D., R.N., F.A.A.N. 38. Medication Reconciliation (DraftDo Not Reproduce) Jane Barnsteiner, Ph.D., R.N. 39. Personal Safety for Nurses Alison M. Trinkoff, Sc.D., R.N., F.A.A.N., Jeanne M. Geiger-Brown, Ph.D., R.N., Claire C. Caruso, Ph.D., R.N., Jane A. Lipscomb, Ph.D., R.N., F.A.A.N., Meg Johantgen, Ph.D., R.N., Audrey L. Nelson, Ph.D., R.N., F.A.A.N., Barbara A. Sattler, Dr.P.H., R.N., F.A.A.N., and Victoria L. Selby, R.N., B.S.N. 40. The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety (DraftDo Not Reproduce) Ann E. Rogers, Ph.D., R.N., F.A.A.N. 41. Preventing Health CareAssociated Infections (DraftDo Not Reproduce) Amy Collins, M.P.H., R.N. 42. Targeting Health CareAssociated Infections: Evidence-Based Strategies (DraftDo Not Reproduce) Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N., Cindy L. Munro, R.N., A.N.P., Ph.D., F.A.A.N., and Karen K. Giuliano, R.N., Ph.D., F.A.A.N. 43. Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality (DraftDo Not Reproduce) Eileen OGrady, Ph.D., R.N., N.P.
Section VI: Tools for Quality Improvement and Patient Safety: 44. Quality Methods, Benchmarking, and Measuring Performance (CQI, TQM, FEMA, RCA) (Forthcoming) Ronda G. Hughes, Ph.D., M.H.S., R.N. 45. AHRQ Quality Indicators (DraftDo Not Reproduce) Marybeth Farquhar, R.N., M.S.N. 46. Magnet Environments for Professional Nursing Practice (DraftDo Not Reproduce) Vicki Lundmark, Ph.D. 47. Patient Safety and Health Information Technology (DraftDo Not Reproduce) Nancy Staggers, Ph.D., R.N., F.A.A.N., Charlene Weir, Ph.D., R.N., and Shobha Phansalkar, R.Ph., M.S. 48. Patient Safety, Telenursing, and Telehealth (DraftDo Not Reproduce) Loretta Schlachta-Fairchild, Ph.D., F.A.C.H.E., Victoria Elfrink, Ph.D., R.N.B.C., and Andrea Deickman, M.S.N., R.N. 49. Documentation and the Nurse Care Planning Process (DraftDo Not Reproduce) Gail Keenan, Ph.D., R.N., Elizabeth Yakel, Ph.D., and Dana Tschannen, Ph.D., R.N. 50. Patient Care Technology and Safety (DraftDo Not Reproduce) Gail Powell-Cope, Ph.D., A.R.N.P., F.A.A.N., Audrey L. Nelson, Ph.D., R.N., F.A.A.N., and Emily S. Patterson, Ph.D. 51. Enhancing Patient Safety in Nursing Education Through Patient Simulation (DraftDo Not Reproduce) Carol Fowler Durham, M.S.N., R.N., and Kathryn R. Alden, M.S.N., R.N., I.B.C.L.C.
Introduction
The goal of this chapter is to provide some fundamental definitions that link patient safety with health care quality. Evidence is summarized that indicates how nurses are in a key position to improve the quality of health care through patient safety interventions and strategies.
Quality Care
Many view quality health care as the overarching umbrella under which patient safety resides. For example, the Institute of Medicine (IOM) considers patient safety indistinguishable from the delivery of quality health care.1 Ancient philosophers such as Aristotle and Plato contemplated quality and its attributes. In fact, quality was one of the great ideas of the Western world.2 Harteloh3 reviewed multiple conceptualizations of quality and concluded with a very abstract definition: Quality [is] an optimal balance between possibilities realised and a framework of norms and values. This conceptual definition reflects the fact that quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities). Work groups such as those in the IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.4 This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. Theses standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Dsdeath, disease, disability, discomfort, and dissatisfaction5rather than more positive components of quality. The work of the American Academy of Nursing Expert Panel on Quality Health focused on the following positive indicators of high-quality care that are sensitive to nursing input: achievement of appropriate self-care, demonstration of health-promoting behaviors, healthrelated quality of life, perception of being well cared for, and symptom management to criterion. Mortality, morbidity, and adverse events were considered negative outcomes of interest that represented the integration of multiple provider inputs.6, 7 The latter indicators were outlined more fully by the National Quality Forum.8 Safety is inferred, but not explicit in the American Academy of Nursing and National Quality Forum quality indicators. The most recent IOM work to identify the components of quality care for the 21st century is centered on the conceptual components of quality rather than the measured indicators: quality care is safe, effective, patient centered, timely, efficient, and equitable. Thus safety is the foundation upon which all other aspects of quality care are built.9
Patient Safety
A definition for patient safety has emerged from the health care quality movement that is equally abstract, with various approaches to the more concrete essential components. Patient safety was defined by the IOM as the prevention of harm to patients.1 Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients.1, 10 The glossary at the AHRQ Patient Safety Network Web site expands upon the definition of prevention of harm: freedom from accidental or preventable injuries produced by medical care.11 Patient safety practices have been defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.12 This definition is concrete but quite incomplete, because so many practices have not been well studied with respect to their effectiveness in preventing or ameliorating harm. Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows:12 Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality Use of maximum sterile barriers while placing central intravenous catheters to prevent infections Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections Asking that patients recall and restate what they have been told during the informedconsent process to verify their understanding Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia Use of pressure-relieving bedding materials to prevent pressure ulcers Use of real-time ultrasound guidance during central line insertion to prevent complications Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research.12 Review of evidence to date critical for the practice of nursing can be found in later chapters of this Handbook. The National Quality Forum attempted to bring clarity and concreteness to the multiple definitions with its report, Standardizing a Patient Safety Taxonomy.13 This framework and taxonomy defines harm as the impact and severity of a process of care failure: temporary or permanent impairment of physical or psychological body functions or structure. Note that this classification refers to the negative outcomes of lack of patient safety; it is not a positive classification of what promotes safety and prevents harm. The origins of the patient safety
problem are classified in terms of type (error), communication (failures between patient or patient proxy and practitioners, practitioner and nonmedical staff, or among practitioners), patient management (improper delegation, failure in tracking, wrong referral, or wrong use of resources), and clinical performance (before, during, and after intervention). The types of errors and harm are further classified regarding domain, or where they occurred across the spectrum of health care providers and settings. The root causes of harm are identified in the following terms:8 Latent failureremoved from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources Active failuredirect contact with the patient Organizational system failureindirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factors Technical failureindirect failure of facilities or external resources Finally, a small component of the taxonomy is devoted to prevention or mitigation activities. These mitigation activities can be universal (implemented throughout the organization or health care settings), selective (within certain high-risk areas), or indicated (specific to a clinical or organizational process that has failed or has high potential to fail).
nurse and physician cognitive diagnostic and treatment decisions, more effective diagnostic and therapeutic processes, and better nursing surveillance.19, 20 Further, when we consider the key role of communication or communication lapses in the commission of error, the role of nursing as a prime communication link in all health care settings becomes evident. The definition of error chain at PSNet clearly indicates the role of leadership and communication in the series of events that leads to patient harm. Root-cause analyses of errors provide categories of linked causes, including (1) failure to follow standard operating procedures, (2) poor leadership, (3) breakdowns in communication or teamwork, (4) overlooking or ignoring individual fallibility, and (5) losing track of objectives.21 This evidence was used in developing the cause portion of the National Quality Forums patient safety taxonomy and is further discussed in other chapters of this book.
Conclusion
Patient safety is the cornerstone of high-quality health care. Much of the work defining patient safety and practices that prevent harm have focused on negative outcomes of care, such as mortality and morbidity. Nurses are critical to the surveillance and coordination that reduce such adverse outcomes. Much work remains to be done in evaluating the impact of nursing care on positive quality indicators, such as appropriate self-care and other measures of improved health status.
Author Affiliation
Pamela H. Mitchell, Ph.D., R.N., C.N.R.N., F.A.A.N., F.A.H.A., associate dean for research, professor of biobehavioral nursing and health systems, and Elizabeth S. Soule Distinguished Professorship of Health Promotion at the University of Washington School of Nursing. E-mail: [email protected].
References
1. Aspden P, Corrigan J, Wolcott J, et al., eds. Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2004. Adler M, Goman W. Quality. In: Adler M, Goman W, eds. The great ideas: a syntopicon of great books of the Western world. Chicago: Encyclopedia Britannica; 1952:p. 513-6. 7. 3. Harteloh PPM. The meaning of quality in health care: a conceptual analysis. Health Care Analysis 2003; 11(3):259-67. Lohr K, Committee to Design a Strategy for Quality Review and Assurance in Medicare, eds. Medicare: a strategy for quality assurance, Vol. 1. Washington, DC: National Academy Press; 1990. 8. 5. Lohr KN. Outcome measurements: concepts and questions. Inquiry 1988; 25(1):37-50. Mitchell PH, Lang NM. Framing the problem of measuring and improving healthcare quality: has the Quality Health Outcomes Model been useful? Med Care 2004; 42:II4-11. Mitchell PH, Heinrich J, Moritz P, et al. Outcome measures and care delivery systems: Introduction and purposes of the conference. Medical Care 1997; 35(11):NS1-5. National Quality Forum. National consensus standards for nursing-sensitive care: an initial performance measure set. Washington, DC: National Quality Forum; 2004. p. 40.
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Committee on the Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press; 2001.
16. Lang N. Issues in quality assurance in nursing. Paper presented at issues in evaluation research: an invitational conference, December 10-12, 1975. Kansas City, KS: American Nurses Association; 1976. 17. Tourangeau AE, Cranley LA, Jeffs L. Impact of nursing on hospital patient mortality: a focused review and related policy implications. Qual Saf Health Care Feb 2006;15(1):4-8. 18. Mitchell PH, Lang NM. Nurse staffing: a structural proxy for hospital quality? Med Care. Jan 2004;42(1):1-3. 19. Kahn KL, Keeler EB, Sherwood MJ, et al. Comparing outcomes of care before and after implementation of the DRG-based prospective payment system. JAMA. Oct 17 1990; 264(15):1984-8. 20. Rubenstein L, Chang B, Keeler E, et al. Measuring the quality of nursing surveillance activities for five diseases before and after implementation of the DRGbased prospective payment system. Paper presented at Patient outcomes research: examining the effectiveness of nursing practice, 1992; Bethesda, MD. 21. AHRQ PSNet Patient Safety Network. Error chain. http://psnet.ahrq.gov/glossary.aspx#E. Accessed October 20, 2007.
10. Clancy CM, Farquhar MB, Sharp BA. Patient safety in nursing practice. J Nurs Care Qual Jul-Sep 2005;20(3):193-7. 11. AHRQ PSNet Patient Safety Network. Patient safety. http://psnet.ahrq.gov/glossary.aspx#P. Accessed October 20, 2007. 12. Shojania KG, Duncan BW, McDonald KM, et al., eds. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment No. 43 (Prepared by the University of California at San Francisco-Stanford Evidence-based Practice Center under Contract No. 290-97-0013). Rockville, MD: Agency for Healthcare Research and Quality; July 2001. AHRQ Publication No. 01-E058, Summary. 13. National Quality Forum. Standardizing a patient safety taxonomy: a consensus report. Washington, DC: National Quality Forum; 2006. 14. Nightingale F. In: Goldie SM, ed. "I have done my duty: Florence Nightingale in the Crimean War, 1854-56. Manchester: Manchester University Press; 1987. 15. Wandelt MA. Definitions of words germane to evaluation of health care. NLN Publ. 1976(151611):57-8.
Background
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.
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. 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 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 nursings 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 ones predilection toward engaging in other unsafe actions. Workarounds 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 difficult14 (p. 52). Halbesleben and colleagues15
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. 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
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.3739 Classifications or categorizations of errors have been based on types of adverse events,4042 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 nurses 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 Since the publication of the IOMs 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 Foundationhave 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 challenge60 (p. 289), in part because of
the resource requirements, the complex nature of changing practice, and the influences of units within the whole.60
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 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 disseminated85 (p. 5267). 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, 8688 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
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 harm6 (p. 152) and produce consistent results. Accordingly, the
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 conditions91 (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 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 riskto identify both expected and unexpected risks; (2) appropriate reward systemsfor safety-related behaviors; (3) system quality standardsevidence-based practice standards; (4) acknowledgment of risk detecting and mitigating errors; and (5) flexible management modelspromoting 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 advocacy98 (p. 238). 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 functioning94 (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
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 patientcentered care, and using evidence-based practice with the objective of managing uncertainty and the goal of improvement.
competencies that reflect the nature of nursing in improving patient and systems outcomes, including evidence-based practice, patient-centered care, teamwork and collaboration, safety, quality improvement, and informatics.106 Opportunity, power, and the composition of the workforce within organizations influence what nurses are able to do and how they are able to use resources to meet patients needs. Lashinger and colleagues76, 107109 have found that the empowerment of staff nurses increased with greater responsibilities associated with job advancements and was related to the nurses commitment to the organization, burnout, job autonomy, their ability to participate in organizational decisionmaking, as well as job strain and work satisfaction.110 Because work environment factors influence the perceptions of nurses as being supported in their work, having a sense of accomplishment,111 and being satisfied with their work, it is important to empower staff to manage their own work, collaborate in effective teams,112 and practice nursing in optimal conditions.113 Professional empowerment in the workplace is derived from competence and interactions with colleagues and other clinicians within organizationsand with patientsas well as by demonstrating knowledge and gaining credibility.114 For nurses, structural empowerment can have a direct effect on their experience of providing care in their work environment.115 Models of care, such as a professional practice model, not only can improve work satisfaction, but they can facilitate patient and nursing outcomes.116
Patient-Centered Care
In Crossing the Quality Chasm, the IOM recommended that all health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States7 (p. 39). For this recommendation to be realized, the IOM asserted that health care would have to achieve six aims: to be safe, effective, patientcentered, timely, efficient, and equitable. The IOM also asserted that health care for the 21st century would need to be redesigned, ensuring that care would be based on a continuous healing relationship, customized inclusion of patient needs and values, focused on the patient as the source of control, and based on shared knowledge and the free flow of information. Patientcentered care would improve health outcomes and reduce or eliminate any disparities associated with access to needed care and quality.117119 Patient-centered care is considered to be interrelated with both quality and safety.7 The role of patients as part of the team can influence the quality of care they receive120, 121 and their outcomes.122, 123 The IOM recommended that clinicians partner with patients (and the patients family and friends, when appropriate)124 to realize informed, shared decisionmaking, improve patient knowledge, and inform self-management skills and preventive behaviors. Patients seek care from competent and knowledgeable health professionals to meet their physical and emotional needs. Within this framework, the clinicians recommendations and actions would be customized to the patient and informed by an understanding of the patients needs, preferences, knowledge and beliefs,125 and when possible, would enhance the patients ability to act on the information provided. It follows then that an effective clinician-patient partnership would include informed, shared decisionmaking and development of patient knowledge and skills needed for self-management of chronic conditions. Patients and families have been and are becoming more involved in their care. Findings from several studies have indicated that patients who are involved with their care decisions and
management have better outcomes than those patients who are not,126, 127 although some researchers indicate that the evidence concerning the impact of patient-centered care is variable.128 Patient self-management, particularly for chronic conditions, has been shown to be associated with improvements in quality of life129 and health status, decreased utilization of services,130 and improved physical activity.131, 132 The Chronic Care Model developed by Wagner and colleagues133135 similarly emphasized the importance of actively engaging patients in achieving substantial improvements in care. Patient-centeredness is increasingly recognized as an important professional evolution124 and holds enormous promise for improving the quality and safety of health care. Yet, patient-centered care has not become the standard of care throughout care systems and among all clinicians as recommended by the IOM.7, 136 For patientcentered care to become the standard care process, care processes would need to be redesigned and the roles of clinicians would need to be modified137, 138 to enable effective teamwork and collaboration throughout care settings.
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surgical errors)152 and higher mortality.153 Poor teamwork as well as disrespectful, rude, and insulting behaviors have no place in health care and can potentially increase unsafe practices.154 156 In a comparison of medicine to aviation, physicians were found to be significantly more supportive of hierarchical models of practice, where junior physicians would not question their seniors.152 Hierarchical structures have been found to have an adverse influence on communication among team members and patient outcomes.157, 158 Nursings participation in teams is further limited under a hierarchical, mechanistic structure when nurses focus on tasks.159 Other barriers that have been found to inhibit the effectiveness of nurses in teams were their perceptions of teamwork, having different teamwork skills, and the dominance of physicians in team interactions.160 When physicians view hospitals as a platform[s] for their work and do not see themselves as being part of [the] larger organization1 (p. 144), physicians may not only thwart the work of nurses, but the organizations efforts to improve the quality and safety of care. When anyone within organizations exhibit intimidating or disruptive behaviors and when there are inappropriate hierarchies, breakdowns in teamwork, and loss of trust, decreased morale and turnover are expected among staff; patients can expect to be harmed and will likely seek care elsewhere.1, 161163 The work environment, communication and collaboration among clinicians, and decisionmaking are also linked to leadership and management within health care organizations.164166 Some authors have argued that performance of organizations and the use of evidence in practice were factors dependent upon leadership, particularly among middle/unitbased clinical management.167169 The personality and attitudes of leaders has been shown to have an impact on safety170, 171 and on perceptions about how safety is managed.172 Visible, supportive, and transformational nursing leadership to address nursing practice and work environment issues is critical as is nursing and medical leadership to ensure that the work environment supports caregivers and fosters collaborative partnerships. However, giving encouragement is not generally stated as a high-priority role of health care supervisors. Traditionally, technical skills and productivity on the job were aspects that received the supervisor's primary focus. However, there is a growing appreciation that encouragement is a transformational leadership technique that is related to productivity on the job and to quality work. Use of encouragement is a leadership technique that fits in today's people-oriented work climate.1
Evidence-Based Practice
Evidence should be used in clinical decisionmaking whenever possible. The need for improving quality using evidence was described by Steinberg and Luce as the recognition that there is much geographic variation in the frequency with which medical and surgical procedures are performed, the way in which patients with a given disease are managed, patient outcomes, and the costs of care, which cannot be explained by differences in patients demographic or clinical characteristics173 (p. 80). Indeed, findings from research continue to provide information that illustrates that only some patients are receiving the recommended quality of care,117, 174176 and errors continue to adversely impact patient outcomes. Steinberg and Luce go on to state that there is strong evidence that much of the care that is being provided is inappropriate (that is, likely to provide no benefit or to cause more harm than good) and that there are indications that many patients are not receiving beneficial services173 (p. 80). Some examples of these concerns are associated with determining health care interventions and
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medication safety. Patients can be harmed if their symptoms and needs are not assessed accurately,177 if the wrong type of intervention is selected,178180 and if patients do not receive information they need to manage their care.181 Certain types of medication errors, such as the wrong drug, wrong dose,182 and polypharmacy,183 threaten the quality of therapeutic interventions and the safety of patient care by aggravating the patients preintervention health status. Another reason that health care quality needs to improve and be based on evidence is continuously rising health care costs173 (p. 80). In a country that spends more per capita than anywhere else in the world, patients do not necessarily have better outcomes.184 Often without knowing it, clinicians have one of the greatest roles in controlling (or increasing) the cost of health care. What type of care is given to patients is sensitive to clinicians (e.g., nurses and physicians) as well as organizational structures, policies, and resources. The skill mix and number of nurses has been found to be associated with adverse events, longer lengths of stay in hospitals, and higher health care costs.185187 Findings from research have indicated that understaffing is associated with an increase in errors and adverse events, such as medication errors, pressure ulcers, health care associated infections, and increased mortality rates in hospitalized patients. 86, 185, 188195 To address workforce shortages, organizations have used financial and shift work incentives, used part-time workers, and improved the image and job satisfaction, among other things.196, 197 All of these strategies increase the cost of health care. The combined concern about the growing cost of care and the effects of poor-quality care on patients has resulted in action by the Centers for Medicare and Medicaid Services (CMS) and other insurers to put in place financial penalties for hospitals that have preventable events, such as readmission, never events (e.g., wrong-site surgery), health care associated infections,198 pressure ulcers, and patient falls with injury. These financial penalties reflect policy based on research that has indicated a significant association between nurse staffing and adverse patient outcomes,185, 187, 192 and quality measures that have been put forth as being sensitive to nursing care.199, 200 Adverse patient outcomes are also sensitive to the care directed by physicians, even when physicians and hospitals have a financial incentive to provide specific elements of quality care. This was recently found in a comparison of treatments and outcomes for 5 conditions at 54 hospitals participating in a Medicare pay-for-performance pilot program to the treatments and outcomes at 446 hospitals not participating in the program. The researchers in this investigation found the financial incentive of pay-for-performance was not associated with significant improvement in quality of care or outcomes.201 Because health care costs are expected to continue to increase, it is important to ensure that costs of health care are not unnecessarily high and that patients receive quality care and are not exposed to preventable adverse events. Nurse leaders and clinical practitioners should be required to be actively engaged with other clinicians and leaders in assessing and monitoring the care of patients and their outcomes, as well as in driving quality improvement efforts to prevent the reoccurrence of these high-risk adverse events. However, not all evidence is equal. It can be based on research that is not generalizable to other settings and populations173, 202, 203 and may be difficult to translate into practice without further testing and the development of guidelines.203 Even when research is available, it is often not used in practice,204, 205 and adapting the research to practice can be challenging because of numerous barriers and deficits of facilitators to change.206, 207 A systematic review of interventions aimed at increasing the use of evidence in practice found that greater success was achieved when clinicians were involved in education about and in intervention strategies that
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were centered on using evidence in practice with local opinion leaders and multidisciplinary teams. The investigators further asserted that to effectively use research in practice, nurses should use the right evidence to inform and evaluate practice change interventions, longitudinally assess the effects of the intervention using the measures for multiple outcomes, and use a methodologically rigorous approach to design the implementation and evaluation of the intervention.208 Evidence-based practice has been defined as using data and information, often from diverse sources, to guide practice. When evidence is available, clinicians must locate and then consider the generalizability of its findings and usability in the practice setting. Randomized controlled trials (RCTs) have been considered the best standard for clinical practice, but they are not available for many common clinical situations and are generalizable only to the population studied during the trial. Clinicians use a broad range of practice knowledge, especially when evidence is not available. Sandars and Heller209 proposed using the concept of knowledge management, which involves generating research-based evidence, synthesizing the evidence base, communicating that knowledge, and applying it to care processes. Another option would be to employ quality improvement methods, such as Plan-Do-Study-Act, to inform practice.50 Horn and Gassway210 proposed using practice-based evidence for clinical practice improvement that is based on the selection of clinically relevant alternative interventions, includes a diverse study population from heterogeneous practice settings, and utilizes data about a broad range of health outcomes.210 Thus, when evidence is not available, clinicians should use their experience and data and information from other forms of inquiry.
A Culture of Safety
The IOM encouraged the creation of cultures of safety within all health care organizations.6 A safety culture is defined as the product of the individual and group values, attitudes, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organizations health and safety [programs]211 (p. 2). An organizations culture is based on its history, its mission and goals, and its past and current leadership. Gadd and Collins211 found that organizations with a positive safety culture were characterized by communication guided by mutual trust, shared perceptions of the importance of safety, and confidence that error-preventing strategies would work. The terms culture and climate have been used interchangeably. Organizational climate refers to the atmosphere of aggregate attitudes and perceptions of how individuals feel about their places of work, which are associated with both individual and team motivation and satisfaction. The climate within an organization represents a moveable set of perceptions related to conditions within the workplace,212 which can be changed by the values, attributes, skills, actions, and priorities of organization leaders and mangers. A safety climate is a type of organizational culture and is the result of effective interplay of structure and processes factors and the attitude, perception, and behavior of staff related to safety. A climate of safety is represented by employee perceptions of: the priority of safety within the work environment on their unit and across the organization, and is influenced by management decisions; safety norms and expectations; and safety policies, procedures, and practices within the organization.211 It follows then that the higher the safety culture, the safer and better the quality of care. When researchers compared the safety cultures of hospitals to the aviation industrywhich has been associated with high safety culturesthey found that the safety climate in hospitals was
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worse; and within hospitals, the safety culture was worse in operating rooms and emergency departments.213, 214 The perceptions of safety within a hospital have been found to be more positive among leaders and managers than among those directly involved in care;215 nurses reported the lowest numbers for a safety culture.216 Hospital staff have been found to understand the importance of safety in their work and their role in patient safety, and to judge patient safety according to their perception of workplace safety and leadership commitment.217 The perceptions of hospital staff of the patient safety culture have also been found to be associated with empowerment (e.g., being able to practice nursing optimally) and characteristics of Magnet hospitals.113 Additionally, more errors were found in organizations and units with poor safety cultures. In fact, some researchers found that the safety climate predicted the occurrence of medication errors, that the level of safety was associated with the unit-specific and hospital-wide climates, and that a positive safety climate in a unit could compensate for the detrimental effects of a low hospital-wide climate.218 Developing and transitioning to a culture of safety requires strong, committed leadership by executives, hospital boards, and staff.5 According to the IOM, the essential elements of an effective safety culture include the commitment of leadership to safety and empowering and engaging all employees in ongoing vigilance through communication, nonhierarchical decisionmaking, constrained improvisation, training, and rewards and incentives.1 The Association of Operating Room Nurses issued guidance about creating such a patient safety culture, emphasizing the necessity of the following components: (1) a reporting culture, (2) a flexible culture, (3) a learning culture, (4) a wary culture, and (5) a just culture.219 Yet, it should be understood that changing the culture within an organization is difficult and can happen only over time.2, 5 Throughout time, nurses have frequently been treated differently if they were involved in an error/adverse event, being at the sharp end of blame because they can stand between errors.220, 221 Thus, for nurses to not be at the sharp end of blame, it is important for organizational leaders and managers to establish a just culture that values reporting, where errors can be reported without fear of retribution;222-224 where staff can trust leaders to make a distinction between blameless and blameworthy; and where the organization seeks to ferret out the root causes of that error, focusing on systems and process factors. Just as important, organizational leaders, managers, and staff need to learn from the continuous assessment of safety culture and make efforts to continually improve organizational performance4, 5 and demonstrate success in safety improvements.215 If an organizations culture is based on secrecy, defensive behaviors, professional protectionism, and inappropriate deference to authority, the culture invites threats to patient safety and poor-quality care.225 Several factors can impede the development of a culture of safety, including (1) a clinicians tendency to view errors as failures that warrant blame, (2) the focus of nurse training on rules rather than knowledge, (3) punishing the individual rather than improving the system,226, 227 and (4) assuming that if a patient was not injured, that no action is required.227 Each of these factors stems from organizations and the people in them having unrealistic expectations of clinical perfection, refusing to accept the fallibility of humans, and discounting the benefit of effective multidisciplinary teams.1, 151 Changing an organizations culture of safety should begin with an assessment of the current culture, followed by an assessment of the relationship between an organizations culture and the health care quality228, 229 and safety within the organization. Several tools have been developed to measure the safety culture within organizations to inform specific interventions and opportunities for improvement. They have focused on dimensions of a patient safety climate, including
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leadership and management (e.g., personality and attitudes), teamwork, communication, staffing, attitudes/perceptions about safety, responses to error, policies, and procedures. Some of these tools could be used for individual or team assessment, or to compare organization-wide perceptions or unit-specific perceptions.230 A recent tool that was developed can be used to differentiate patient from staff safety and types of clinicians.218 Another of these tools (www.ahrq.gov/qual/hospculture/#toolkit) developed for AHRQ has been used to compare safety cultures among hospitals.
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errors and near misses, and (3) be better at diminishing patient harm if an error occurs. For these reasons, changes to the error-producing structural factors of an organization by themselves do not lead to expected improvements in quality.246, 247 Several organizations have reported difficulties in improving patient safety because of the need for transparency in reporting on performance measures, lack of standardization and functionality of information technology, and no clear pathway identified for improvement.248 Other difficulties could be associated with the results of the improvement initiative itself. For example, the introduction of computerized provider order entry systems for medication therapy prevented some errors from happening (e.g., related to illegible handwriting), but introduced other errors that might have been avoided with better implementation strategies.249 There are many change strategies, from single focus to multifaceted, that have centered on a structural approach and have been used successfully to create quality and patient safety improvements. One approach would be to implement bundles of evidence-based interventions to simultaneously improve multiple outcomes,207 using health information technology when possible. Other strategies have focused on the components of the change process that need to be addressed. Caramanica and colleges250 asserted that a successful quality improvement strategy was based on the alignment of the goals of the organization with goals for quality and patient safety improvement, collaboration using interdisciplinary teams, applying evidence-based practice, and monitoring and assessing excellence. Quality improvement strategies that align with the values and beliefs of individuals and build on current processes can determine the pace and diffusion of change.251 As discussed in chapter 44, Quality Methods, Benchmarking, and Measuring Performance, many organizations have used the Plan-Do-Study-Act approach to implement change, particularly rapid-cycle improvement. A similar strategy used the ReachEffectiveness-Adoption-Implementation-Maintenance framework to translate research into practice.252 The Department of Veterans Affairs has approached patient safety improvement by targeting key strategies, including leaders creating an environment of acceptance, establishing clear goals, creating a fair system that does not focus on blame, creating a transparent system for decisionmaking, facilitating root-cause analysis, requiring leadership and management to be visibly involved, and evaluating performance.253, 254 While organizations characteristics differ, as do characteristics of leaders and managers, success can be realized through continuous improvement with careful attention to finding a balance that avoids so much change that change fatigue results.255 The IOM asserted that improvements must target organizational factors by using information technologies, developing effective teams, standardizing procedures with evidence, and using data and information to monitor performance.7 Focusing on the role, the influence, and the complexity of health care systems by thinking about the big picture involves understanding how a specific issue or outcome of concern interacts with numerous factors, both within and external to the system. In doing so, it may be more feasible to solve recurring problems with ineffective processes and poor outcomes, even when previous attempts have failed.256 In the case of medication safety, efforts to significantly reduce medication administration errors must also consider errors associated with prescribing, transcribing, and dispensing errors, as well as errors associated with health information technologies, product labeling,257 therapeutic consistency across care settings (e.g., medication reconciliation), and miscommunication of drug allergies. For health care systems and organizations to improve safety and quality, they need to learn to improve existing knowledge and processes, understand what is and is not working well, and both adopt and discover better ways to improve patient outcomes.258
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Organizational changes should be targeted using multifaceted strategies and interventions that focus on redesigning structural factors (e.g., staffing levels, roles and responsibilities of nurses, etc.), revising policies and procedures,259 and using multidisciplinary teams.260 Because the factors and issues involved in patient safety and quality improvement are complex, mirroring the complexity of health care systems, no one single intervention will accomplish performance goals and standards. Using a systematic approach to changing practice based on evidence when possible is required to improve patient safety and contribute to the evidential knowledge base and generalizability that can be used eventually for purposes of diffusion.261 Improving the quality and safety of health care may require the use of mixed or multiple methodologies to continually monitor and evaluate the impact and performance, because no one single method would be expected to be appropriate for the depth and breadth of change interventions.262264 Change can be slow because it is a process that involves many people and issues. Efforts to improve quality and safety need champions throughout the key areas within the organization as well as executive and midlevel managers.70, 259 Champions can also be found among individuals for whom adverse events have had incredible impact on their lives.265 It would follow then that when an opportunity is present to adopt new knowledge and evidence into practice, that individual professionals and professional groups (particularly the doctors) have the power to impede or to facilitate the diffusion process168 (p. 50). Adoption of new knowledge and evidence for change is a process that needs leadership involvement and support, fostering effective relationships and enabling action, utilizing ongoing monitoring and evaluation, and demonstrating flexibility according to findings from evaluation and changing needs.254, 258 Yet the effect of this could be mitigated by the commitment and direction of senior leadership, who co-lead/co-coach with clinical leaders266 to use evidence in practice, and to continuously evaluate progress and make changes accordingly, to therefore improve organizational performance and patient outcomes.267 For changes of care processes that support safe and quality care to be effective, interventions must not be first-order, short-term problem-solving that offers quick fixes but not lasting change. Instead, second-order problem-solving should be used, where the underlying causes and processes are examined.268 Even when processes and procedures have changed and demonstrated positive effects on patient outcomes, there is a concern about sustainability over time because the tendency of health care providers to deliberately deviate from the new standard of practice may be unavoidable.95 Ongoing monitoring and management of these new processes and procedures is required.95 How do you institutionalize change? Change initiatives are successful when they are built on the current way of doing things,251 are visible and have positive outcomes, are consistent with employees values and beliefs, are manageable,269 and are generalizable to the organization.270
Practice Implications
To bring the effects of the sharp end away from nurses and put them squarely on the shoulders of health care organizations and systems, there needs to be significant changes in how health care is structured and how it is delivered to patients. While the roles and responsibilities of nurses have changed over the years, including risk management, quality assurance, case management, clinical trials coordinator, and patient care manager among numerous others,271 the diversity of skills, roles, and training272 places nurses in critical positions to lessen the
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incidence of variation by collecting and assessing data, working with interdisciplinary teams, examining performance, and driving evidence-based practice. From the literature reviewed in this chapter, there are key strategies that can be used to effect change, and subsequently, the quality and safety of care will be improved. The major factor in creating improvement is understanding and accounting for the complexity of health care organizations, health care systems, care processes, and patient needs. To begin, senior nurse leaders need to work with staff to identify and prioritize areas and establish goals to address the issues that are associated with poor-quality and unsafe care. Executive leadership and managers need to be committed to investing both their time and resources to improving the safety and quality of care. As organizations begin plans and reassess the need for changes, nurses will need to be proactive in redesigning care models and redefining the work of nurses,273 whether the initiatives will initially impact only a single unit or group of clinicians, or are aimed at being systemwide. Furthermore, efforts to improve quality and safety must have involvement and commitment from all stakeholders. The foundation of quality and safety improvement initiatives needs to be centered on systems factors, not individuals. Nurse leaders, colleagues, and State boards of nursing registration should understand the significant impact of systems factors in any instance when individual culpability is sought, particularly when appraising and disciplinary action is unfortunately taken against an individual clinician (e.g., State boards of licensure and malpractice cases). The responsibility of nurse leaders and State boards of nursing is to determine when errors and adverse events result from deliberate malfeasance as opposed to a mixture of systems factors. Without considering the nature and effect of systems factors, action taken against an individual would not appear to be evidence-based and latent factors will continue, waiting to ensnare another nurse. To improve patient safety and the quality of care, it is important to determine the best strategy and be willing to alter the strategy if necessary to create change. Not all strategies that have been successful in other organizations will be successful in your organization; some interventions have too small a sample size or information about them to be considered as a possible strategy in your organization. As an initiative is implemented, it could be that what was thought to have been generalizable needs to be tailored to the unique characteristics of your organization. Change initiatives should be either evidence based or based on data and information internal to your organization (e.g., incident reports), and should address measures to evaluate improvements in patient safety and quality.199, 274 Throughout the process of implementing changes, it is important for data and information to be continually monitored and assessed to track performance. It is only through strategic decisions and interventions that the sharp end held against nursing will transition to the organizations in which nurses work.
Research Implications
The nurses role in and ability to change patient safety and quality improvement within health care systems is a relatively new field of research, but consideration must be given to more than 60 years of nursing research that has implications for both safety and quality processes and nursing, patient, and organizational outcomes. Future research will need to better define the theoretical foundations behind the relationships between organizational systems factors, clinical processes, and patient safety and quality outcomes. It is also important for future research to focus on improving and widening the assessment of the impact of patient safety and quality
18
improvements on the incidence of the broad array of errors that can and do occur in nurses work environments. For example, leaders and clinicians need to understand the association between an organizations culture of safety and patient outcomes as well as how nurses can influence executives to lead working environment improvements. In addition, and probably more important, future research needs to address how research and evidence can be translated into and become the new standard of practice, avoiding the lengthy process now involved, which could take as long as 10 to 17 years.275
Conclusion
Everything about health care is complex. There are complex care processes, complex health care technologies, complex patient needs and responses to therapeutic interventions, and complex organizations. There are tremendous opportunities and challenges in improving the quality and safety of health care, but the majority require purposeful redesign of health care organizations and processes. Organizations that are committed to high-quality and safe care will not place nurses at the sharp end of care, but will focus on system improvements. Recognizing the complexity of care and how several factors combine at a specific time and result in errors and adverse events, organizations, leaders, and clinicians will dedicate themselves to using data and evidence and to continuously improve the quality and safety of care, even when there are complex challenges.
Author Affiliation
Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: [email protected].
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195. Blegen MA, Vaughn T, Vojir CP. Nurse staffing levels: impact of organizational characteristics and registered nurse supply. Health Services Research 2008;43(1 Part I):154-173. 196. Bradshaw L. A service in crisis? Reflections on the shortage of nurse in the British National Health Service. J Nurs Manag 1999;7(3):129-32. 197. Buerhaus PI, Staiger DO, Auerbach DI, et al. Implications of an aging registered nurse workforce. JAMA 2000;283(22):2948-54. 198. Centers for Medicare and Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Fed Regist 2007;72(162):47129-8175. 199. National Quality Forum (NQF). National voluntary consensus standards for nursing-sensitive care. Washington, DC: NQF; 2004. Available at www.qualityforum.org/pdf/nursing-quality/ txNCFINALpublic.pdf. Accessed December 5, 2008. 200. Needleman J, Kurtzman ET, Kizer KW. Performance measurement of nursing care: state of the science and the current consensus. Med Care Res Rev 2007;64(2 Suppl):10S-43S. 201. Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA 2007;297(21):2372-80. 202. Green LW, Glasgow RE. Evaluating the relevance, generalization, and applicability of research. Eval Health Prof 2006;29(1):126-53. 203. Mendelson D, Carino TV. Evidence-based medicine in the United Statesde rigueur or dream differed? Health Aff 2005;24(1):133-136. 204. Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997;157(4):408-16. 205. Livesey EA, Noon JM. Implementing guidelines: what works. Arch Dis Child 2007;92:ep129-34. 206. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients care. Lancet 2003;362:1225-30. 207. Litch B. How the use of bundles improves reliability, quality and safety. Healthcare Exec 2007;22(2):13-18. 208. Thompson DS, Estabrooks CA, Scott-Findlay S, et al. Interventions aimed at increasing research use in
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233. Longo DR, Hewett JE, Schubert S. Rural hospital patient safety systems implementation in two states. J Rural Health 2007;23(3):189-97. 234. Morrissey J. Patient safety proves elusive. Five years after the publication of the IOMs To Err Is Human, theres plenty of activity on patient safety, but progress is another matter. Mod Healthc 2004;34(44):6-7, 24-5, 28-32. 235. Beauregard K. Patient safety, elephants, chickens, and mosquitoes. Plast Surg Nurs 2006;26(3):123-5;quiz 126-7. 236. Bleich S. Medical errors: five years after the IOM report. Issue Brief (Commonwealth Fund) 2005;830:115. 237. Scalise D. 5 years after IOM the evolving state of patient safety. Hosp Health Netw 2004;78(10):59-62. 238. Wachter R. Encourage case-based discussions of medical errors. AHA News 2004 February:14. 239. Ambalberti R, Auroy Y, Berwick D, et al. Five systems barriers to achieving untrasafe health care. Ann Intern Med 2005;142:756-64. 240. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Impact of the Leapfrog Groups intensive care unit physician staffing standard. J Crit Care 2007a;22(2): 89-96. 241. Pronovost PJ, Thompson DA, Holzmueller CG, et al. The organization of intensive care unit physician services. Crit Care Med 2007b;35(10):2256-61. 242. Angus DC, Shorr AF, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med 2006;34(4):1016-24. 243. Parshuram CS, Kirpalani H, Mehta S, et al. In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units. Crit Care Med 2006;34(6):1674-8. 244. Morjikian RL, Kimball B, Joynt J. Leading change: the nurse executives role in implementing new care delivery models. J Nurs Adm 2007;37(9):399-404. 245. Pronovost P, Wu AW, Dorman T, et al. Building safety into ICU care. J Crit Care 2002;17(2):78-85. 246. Blumenthal D, Kilo CM. A report card on continuous quality improvement. Milbank Q 1998;76(4):625-48, 511.
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Introduction
On November 29, 1999, the Institute of Medicine (IOM) released a report called To Err is Human: Building a Safer Health System.1 The IOM released the report before the intended date because it had been leaked, and one of the major news networks was planning to run a story on the evening news.2 Media throughout the country recognized this opportunity for a headline story describing a very large number of hospital deaths from medical errors possibly as great as 98,000 per year. The problem in other care settings was unknown, but suspected to be great. The search was on to find out who was to blame and how to fix the problem. Congressional hearings were subsequently held. Governmental agencies, professional groups, accrediting organizations, insurers, and others quickly responded with plans to define events and develop reporting systems. Health care organizations were put on the defensive. Recognizing that individual accountability is necessary for the small proportion of health professionals whose behavior is unacceptable, reckless, or criminal, the public held organizational leadership, boards, and staff accountable for unsafe conditions. Yet imposing reporting requirements and holding people or organizations accountable do not, by themselves, make systems safer. What was often lost in the media attention to hospital deaths from medical errors cited by To Err is Human was the original intent of the IOM Committee on Quality Health Care in America, which developed the report. That committee believed it could not address the overall quality of care without first addressing a key, but almost unrecognized component of quality; which was patient safety. The committees approach was to emphasize that error that resulted in patient harm was not a property of health care professionals competence, good intentions, or hard work. Rather, the safety of caredefined as freedom from accidental injury3 (p. 16)is a property of a system of care, whether a hospital, primary care clinic, nursing home, retail pharmacy, or home care, in which specific attention is given to ensuring that well-designed processes of care prevent, recognize, and quickly recover from errors so that patients are not harmed. This chapter focuses on the principles described in the IOM report, many of which can be mapped to what are now called safe practices4 and all of which are valuable guides. This chapter is not intended to address the growing body of evidence; rather, the chapter summarizes the starting pointthe IOM recommendations based on the literature and the knowledge of the committee members who developed the report.
actions to prevent error) has the greatest potential effect, just as in preventive public health efforts. The IOM committee recognized that simply calling on individuals to improve safety would be as misguided as blaming individuals for specific errors. Health care professionals have customarily viewed errors as a sign of an individuals incompetence or recklessness. As a result, rather than learning from such events and using information to improve safety and prevent new events, health care professionals have had difficulty admitting or even discussing adverse events or near misses, often because they fear professional censure, administrative blame, lawsuits, or personal feelings of shame. Acknowledging this, the report put forth a four-part plan that applies to all who are, or will be, at the front lines of patient care; clinical administrators; regulating, accrediting, and licensing groups; boards of directors; industry; and government agencies. It also suggested actions that patients and their families could take to improve safety. The committee understood that need to develop a new field of health care research, a new taxonomy of error, and new tools for addressing problems. It also understood that responsibility for taking action could not be borne by any single group or individual and had to be addressed by health care organizations and groups that influence regulation, payment, legal liability, education and training, as well as patients and their families. The report called on Congress to create a National Center for Patient Safety within the Agency for Healthcare Research and Quality, to develop new tools and patient care systems that make it easier to do things right and harder to do things wrong. This handbook is a direct result of the implementation of those recommendations.
done more slowly and sequentially, are perceived as more difficult, and require conscious attention. Examples include making a differential diagnosis and readying several types of surgical equipment made by different manufacturers. Errors here are due to misinterpretation of the problem that must be solved and lack of knowledge. Keeping in mind these two different kinds of tasks is helpful to understanding the multiple reasons for errors and is the first step in preventing them. People make errors for a variety of reasons that have little to do with lack of good intention or knowledge. Humans have many intellectual strengths (e.g., large memory capacity and an ability to react creatively and effectively to the unexpected) and limitations (e.g., difficulty attending carefully to several things at once and generally poor computational ability, especially when tired).12 Improving safety requires respecting human abilities by designing processes that recognize human strengths and weaknesses. There are many opportunities for individuals to prevent error. Some actions are clinically oriented and evidence-based: communicating clearly to other team members, even when hierarchies and authority gradients seem to discourage it; requesting and giving feedback for all verbal orders; and being alert to accidents waiting to happen. Other opportunities are broader in focus or address the work environment and may require clinical leadership and changing the workplace culture: simplifying processes to reduce handoffs and standardizing protocols; developing and participating in multidisciplinary team training; involving patients in their care; and being receptive to discussions about errors and near misses by paying respectful attention when any member of the staff challenges the safety of a plan or a process of care. However, large, complex problems require thoughtful, multifaceted responses by individuals, teams, and organizations. That is, preventing errors and improving safety require a systems approach to the design of processes, tasks, training, and conditions of work in order to modify the conditions that contribute to errors. Fortunately, there is no need to start from scratch. The IOM report included some guidance based on what was known at the time, and other specific evidence has accumulated since then that can be put in practice today. Designing for safety requires a commitment to safety, a thorough knowledge of the technical processes of care, an understanding of likely sources of error, and effective ways to reduce errors.
departments where there is little time to react to unexpected eventsand consequences can be very serious. Although most early studies focused on the hospital setting, medical errors present a problem in all settings, including outpatient surgical centers, physician offices and clinics, nursing homes, and the home, especially when patients and families are asked to use increasingly complicated equipment. Patients should not be harmed by the health care system that is supposed to help them, but the solution does not lie in assigning blame or urging health professionals to be more careful. In what seems to be a simple example, an ICU nurse was wheeling a patient on a gurney to radiology when his knee struck a fire extinguisher hanging on the wall, resulting in the patient needing extra care. In response, the nurse may have been scolded by her supervisor and told to be more careful, or punished in some other way; everyone would feel the problem had been solved. Yet, would that make the hospital safer? Would it prevent other events that are similar but slightly different in circumstances from happening with other staff and patients in other units? The answer is an emphatic no. Improving safety, arises from attention to the often multiple latent factors that contribute to errors and in some cases, to injury. In the above example, such factors included: 1) the nurse having to move the patient herself because transport had never arrived; 2) a change in hospital policy, so that only one instead of two people guide gurneys; 3) the failure to mount the fire extinguisher in a recessed niche; 4) the decision to transport a seriously ill patient rather than having mobile equipment come to him, requiring extra handoffs and opportunities for injury; and 5) poor gurney design, making steering difficult, and possibly still other factors.
Part 3: Role of Consumers, Professionals, and Accreditation Groups The IOM believed that fundamental change would require pressure and incentives from many directions, including public and private purchasers of health care insurance, regulators (including the Food and Drug Administration), and licensing and certifying groups. A direct result was the announcement of new standards on safety from the Joint Commission and a report, Safe Practices for Better Health Care. A Consensus Report, by the National Quality Forum.10 Part 4: Building a Culture of Safety The IOM urged health care organizations to create an environment in which safety becomes a top priority. This report stressed the need for leadership by executives and clinicians and for accountability for patient safety by boards of trustees. In particular, it urged that safety principles known in other industries be adopted, such as designing jobs and working conditions for safety; standardizing and simplifying equipment, supplies and processes; and avoiding reliance on memory. The report stressed medication safety in part because medication errors are so frequent11 and in part because a number of evidenced-based practices were already known and needed wider adoption. Though at the time of publication, the levels of evidence for each category varied, the members of the committee believed that all were important places to begin to improve safety. The committee recognized that some actions could be taken at the national level as described in the recommendations contained in Parts 13. Yet if patient safety were really to improve, the committee knew it would take far more than reporting requirements and regulations. Creating and sustaining a culture of safety (Part 4) is needed, which would require continuing local action by thousands of health care organizations and the individuals working in these settings at all levels of authority. Hospital leadership must provide resources and time to improve safety and foster an organizational culture that encourages recognition and learning from errors. A culture of safety cannot develop without trust, keen observation, and extensive knowledge of care processes at all levels, from those on the front lines of health care to those in leadership and management positions.
1. User-Centered Design
Understanding how to reduce errors depends on framing likely sources of error and pairing them with effective ways to reduce them. The term user-centered design builds on human strengths and avoids human weaknesses in processes and technologies.12 The first strategy of user-centered design is to make things visibleincluding the conceptual model of the processso that the user can determine what actions are possible at any moment, for example, how to return to an earlier step, how to change settings, and what is likely to happen if a step in a process is skipped. Another principle is to incorporate affordances, natural mappings, and constraints into health care. Although the terms are strange, their meaning can be surprisingly easily applied to common everyday tasks, both in and out of the workplace.
An affordance is a characteristic of equipment or workspace that communicates how it is to be used, such as a push bar on an outward opening door that shows where to push or a telephone handset that is uncomfortable to hold in any but the correct position. Marking the correct limb for before surgery is an affordance that has been widely adopted. Natural mapping refers to the relationship between a control and its movement, for example, in steering a car to the right, one turns the wheel right. Other examples include using louder sound or a brighter light to indicate a greater amount. Constraints and forcing functions guide the user to the next appropriate action or decision. A constraint makes it hard to do the wrong thing. A forcing function makes it impossible to do the wrong thing. For example, one cannot start a car that is in gear. Forcing functions include the use of special luer locks for syringes and indwelling lines that have to be matched before fluid can be infused, and different connections for oxygen and other gas lines to prevent their being inadvertently switched. Removing concentrated potassium chloride from patient units is a (negative) forcing function because it should never be administered undiluted, and preparation should be done in the pharmacy.
discharged shortly after surgery and knows nothing about sterile technique or the design of the device. Another ubiquitous example is the warnings and dosage information on medication bottles, which many patients cannot understand how to apply.
Conclusion
Now, 7 years after the release of To Err is Human, extensive efforts have been reported in journals, technical reports, and safety-oriented conferences. That literature described the magnitude of problems in a variety of care settings, the efforts to make change, and the results of those efforts in improving patient safety. Many of those studies are referenced and discussed throughout this book. Other authors have written incisively about what progress has and has not been made in the past 7 years and the challenges in creating cultures of safety.20, 21 The greatest challenge we all face is to learn, use, and share better information about how to prevent harm to patients. 8
Author Affiliation
Molla Sloane Donaldson, Dr.P.H., M.S., principal, M.S.D. Healthcare; e-mail: [email protected].
References
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, Institute of Medicine; 1999. News Release: Medical Errors Report for Immediate Release, Nov. 29, 1999, National Academy of Sciences. Preventing Death and Injury from Medical Errors Requires Dramatic, System-Wide Changes. Reason JT. Human Error. New York, NY: Cambridge University Press; 1990. Safe Practices for Better Health Care. Fact Sheet. AHRQ Publication No. 04-P025, March 2005. Agency for Healthcare Research and Quality, Rockville, MD. Executive Summary of the National Quality Forums report, Safe Practices for Better Healthcare: A Consensus Report is available at www.ahrq.gov/qual/nqfpract.htm. The Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event. http://www.jointcommission.org/SentinelEvents/ [accessed October 31, 2006]. Cook RI, Woods D, Miller C. A tale of two stories: contrasting views of patient safety. Chicago: National Patient Safety Foundation; 1998. Reason J. Human error: models and management. BMJ. 2000;320:768-70. Leape LL. Error in medicine JAMA, 1994;272 (23):1851-57. Haberstroh CH. Organization, design and systems analysis. In Handbook of Organizations. J. J. March, ed. Chicago: Rand McNally; 1965. 12. Norman DA. The Design of Everyday Things. New York: Doubleday/Currency; 1988. 13. Leape LL, Kabcenell A, Berwick DM, et al. Reducing Adverse Drug Events. Boston: Institute for Healthcare Improvement; 1998. 14. Savitz LA, Jones CB, Bernard S. Quality indicators sensitive to nurse staffing in acute care settings. Hendriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Vol. 4, Programs, Tools & Products. AHRQ Publication No. 05-0021-4. Rockville, MD: Agency for Healthcare Quality and Research, 2005; p.375-85. 15. Clarke SP, Aiken LH. More nursing, few deaths. Qual Saf Health Care, 2006; 15:2-3. 16. Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Affairs, 2006; 25(1):204-11. 17. Cook RI. Two Years Before the Mast: Learning How to Learn About Patient Safety. Presented at Enhancing Patient Safety and Reducing Errors in Health Care. Rancho Mirage, CA, November 810; 1998. 18. Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA, 2005; 293(10):1261-3. 19. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA, 2005; 293(10):1223-38. 20. Leape LL, Berwick DM. Five years after To Err is Human. What Have We Learned? JAMA 2005; 293: 2384-90. 21. Wachter RM. The end of the beginning: patient safety five years after To Err is Human. Health Affairs, 2004; 30 (Web Exculsive): W4 534-43.
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Three comparisons of Nightingales concerns and recommendations with those expressed in the IOM reports illustrate similar problem identification as well as a shared view regarding the building blocks essential to creating solutions. First, in her publication, Notes on Hospitals, 4 Nightingale identified the paradox of the problem at hand: In practice a hospital may be found only to benefit a majority, and to inflict suffering on the remainder (p. 20). Well over a century later, To Err Is Human says, a person should not have to worry about being harmed by the health system itself2 (p. 5). Nightingale goes on to say, Even admitting to the full extent the great value of hospital improvements of recent years, a vast deal of suffering, and some at least of the mortality, in these establishments is avoidable4 (p. 3). Similarly, To Err Is Human notes, A substantial body of evidence points to medical errors as a leading cause of death and injury2 (p. 26). Finally, in a search for solutions and with an eye toward measurement, developing evidence, public reporting, and linking payment with quantifiable performance, Nightingale advances4 (p. 3), It is impossible to resist the conviction that the sick are suffering from something quite other than the disease inscribed on their bed ticketand the inquiry arises in the mind, what can be the cause? Related to this, To Error Is Human notes, Sufficient attention must be devoted to analyzing and understanding the causes of errors in order to make improvements2 (p. 87). In addition, the report notes, Group purchasers have the ability to consider safety issues in their contracting decisions2 (p. 152). As is evident in the similarity of statements between Nightingale and the IOM, concerns about medical error and compromises in patient safety bridge a significant passage of time. It is difficult not to speculate about what safety in health care would look like today had Nightingales calls to action been heeded. Rather than lagging behind, health care in the 21st century might have been the leader in safety among high-risk industries such as aviation and nuclear power production. Instead, clinicians, policymakers, and many others search for safety and quality lessons to apply in health care delivery from these and other high-risk but safer industries. Irony exists in that these industries, nonexistent during Nightingales time, have made substantially more progress than health care in creating safe environments.
To Err Is Human: Building a Safer Health System, 20002 Crossing the Quality Chasm, 20013 Leadership by Example: Coordinating Government Roles in Improving Health Care Quality, 20025 Fostering Rapid Advances in Health Care: Learning From Systems Demonstrations, 20026 Priority Areas for National Action: Transforming Health Care Quality, 2003 Health Professions Education: A Bridge to Quality, 2003
8 7
Patient Safety: Achieving a New Standard for Care, 20039 Keeping Patients Safe: Transforming the Work Environment of Nurses, 200410 Quality Through Collaboration: The Future of Rural Health Care, 200411 Preventing Medication Errors: Quality Chasm Series, 200612 Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series, 200613
This section focuses on nursing implications associated with selected issues, concepts, findings, and recommendations specifically embedded in 4 of the 11 reports: To Err Is Human, Crossing the Quality Chasm, Health Professions Education: A Bridge to Quality, and Quality Through Collaboration: The Future of Rural Health Care (often referred to as the rural report). The identified nursing implications in these four reports give a sense of the relevance and utility of these reports to the nursing discipline. The first two reports discussed in this chapter established the scope of the problems associated with compromises in quality of health care and offered a framework for addressing those problems. The third report, on health professions education, described the critical role health professions education plays in facilitating or impeding the delivery of consistent, high-quality health care. The nursing profession, central to health care delivery, is a pivotal audience for this report. The Future of Rural Health Care addresses the long-standing lack of attention brought to rural health care quality in spite of the fact that between one-fourth and one-fifth of the population resides in rural America. This report sheds light on the unique features of rural health care and tailored approaches to addressing quality shortcomings. Particularly relevant to nurses, however, is that The Future of Rural Health Care introduced innovative approaches that move beyond health care and focus on the quality of the health of populations. Whether viewed from a rural or urban context, the latter orientation is an important focus for nurses to consider in their future work and research.
were reviewed and established the evidence base for the IOMs Committee on Quality of Health Care in America determination that error is a cause of very significant and widespread injury and mortality. Many of the research studies focused on activities that incorporated nursing functions such as medication processes. Additionally, a number of the reviewed studies helped to illuminate the predeterminants of error. Due to the dearth of evidence to serve as the basis for some of the conclusions and recommendations in this report, the IOM acknowledged that current understanding of the epidemiology of errors was fragmented. Calls for research efforts were evident throughout the report. Research and analysis are not luxuries in the operation of safety systems. They are essential steps in the effective redesign of systems2 (p. 181). Clearly there is opportunity for nurse researchers, along with others, to make significant and important contributions to address this knowledge deficit with needed evidence. In addition to increasing awareness of the scope and significance of medical errors, a set of strategies and recommendations were advanced to encourage patient safety and quality improvement. Major emphasis is placed on (1) the essential role of leadership in addressing errors, (2) the need for and structure of error reporting systems, (3) the development of performance standards, and (4) recommendations regarding elements key to safety design in health care systems. The committee producing the report devoted considerable attention to making the case that perfection based on human performancewhile a long-standing expectation of the work of nurses, physicians, and othersis both faulty and dangerous. In reorienting expectations from a focus on individuals to a focus on systems, the report clearly and firmly stated that to eliminate the source of a vast majority of errors and near misses, health care systems must be designed to make it very hard for nurses and others to make errors. This orientation runs directly counter to long-held views by both the public and health care providers themselves: that mistakes are solely the result of individual provider actions and that blame should be assigned accordingly. The report refocused attention on the need to construct systems that make it easy for nurses and others to engage in safe practices and difficult to execute actions that are unsafe.
of accrediting bodies, such as the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]). The Joint Commission National Patient Safety Goals (NPSGs) are very prescriptive and explicit in their impact on aspects of nursing practice. For example, the Joint Commissions safety goals include standardizing handoff communications, including an opportunity to ask and respond to questions, and a goal to encourage the active involvement of patients and their families in the patients care as a patient safety strategy14 (e.g., patient- and family-centered care). External drivers also include steps being taken by the Centers for Medicare and Medicaid Services to link reporting performance on quality indicators with payment. These payment changes reward hospitals that publicly report their performance on a predetermined set of quality indicators, many of which are directly or indirectly influenced by nursing actions. Private sector entities such as insurance companies are moving in similar directions. The intense interest in aligning payment with performance (i.e., health sector income and patient outcome) has significant implications for nursing. Put simply, maintaining and strengthening the financial health of hospitals and other segments of the health care delivery system is linked in no small part to the practice of nursing in these facilities. Consequently, alignment of reimbursement with quality is redirecting the attention of health care administrators. To the extent that research continues to link nursing practices, staffing, and other characteristics (e.g., educational background and number of hours worked) to the quality of patient care, nursing will be positioned to receive considerably more attention from health care system leadership. Recognizing that more could be done to improve patient outcomes the report called for the incorporation of patient safety considerations into clinical practice guidelines, as well as the development of guidelines specifically focused on patient safety. Particular attention is paid to the need for engaging interdisciplinary approaches to guideline development. Nurses expertise and functions clearly overlap with a number of other disciplines in particular content areas (e.g., mental health care and critical care). This overlap makes this recommendation difficult to pursue, but appropriate to nursing as well as other disciplines. Nursing education, as well as State and national nursing organizations, can expand efforts to engage interdisciplinary partners in developing shared academic curricula and conference and meeting content. Additionally, nurse clinicians, researchers, and others should further the development of safety aspects of clinical guidelines development in concert with representatives of other health care disciplines. Another report recommendation called for professional organizations to firmly commit to an agenda focused on patient safety, with specific efforts targeted toward health professions education. Efforts can emerge through curriculum development, the inclusion of safety content on conference agendas, and ongoing in-service education. Various nursing organizations have responded to aspects of this recommendation. However, in light of many competing priorities, expanding and sustaining this focus over time and across multiple venues will challenge nurses and the nursing profession. The final external driver addressed in the report addressed whether or not the public is engaged in safety improvement efforts. Professional organizations, particularly those that represent nurses, can help to accomplish this by working with both the public and policymakers. Some national nursing organizations already have made safety part of their public policy agenda (e.g., the Association of Operating Room Nurses). Nevertheless, there is substantial work that could occur to create new efforts that educate and engage the broader public in health care safety activities. As a profession, nursing commands considerable trust from the American public. Also, nursing places high value on the importance of educating individuals, families, and communities
about health and health care in order to fully engage them as partners in their health. Consequently, nurses are particularly well positioned to engage in the challenging work of assisting the public to understand both the complexity of patient safety and error, and the actions they can engage in to help ensure they receive safe health care. Individual nurses can engage this type of effort in concert with other health team members. This work can also be done through nursing organizations and in tandem with insurers, employers, and others who recognize the pivotal role health care consumers can play in ensuring the delivery of safe care.
adverse events such as cardiac or respiratory arrest.15 With the help of nursing knowledge and research, other equally important high-impact care processes will be developed over time. Principle 5: Creating a learning environment addresses the extremely complex work of changing organizational and academic cultures so that error is viewed as an opportunity to learn. A learning environment does not seek to fix blame, but ensures that reporting systems have well-developed approaches for communicating how identified problems will be addressed. Also important, given the historical power gradient among nurses and physicians and others, is the free flow of information without the inhibiting hierarchies.2 Learning environments ensure that all staff have high comfort levels in communicating any and all safety concerns. Some of the most complex patient safety work involves creating organizational cultures and expectations that embrace these features. Redesigning the education of the next generation of nurses so they are capable of maximizing their contributions in these environments is a necessary component. Nurse leaders should play key roles in ensuring that patient safety programs inside health care organizations are highly visible, implement nonpunitive reporting processes, and incorporate safety principles into daily practice, all of which are called for in the recommendations of To Err Is Human. The second report, Crossing the Quality Chasm, describes at greater length the use of internal and external approaches to meaningfully improve the quality of health care.
United States.3 (p. 39). In contemplating this statement, nurses might ask what the collective contribution of nursing is and should be to achieving this purpose. How do we pursue this goal? How do we know whether we and other stakeholders in the U.S. health care system are making progress toward achieving it? The Quality Chasm report adds more specificity to this recommendation by setting out six aims (see Table 2). To achieve the aims of the purpose statement articulated above, the Quality Chasm report suggests that these six aims should be the focus of nurses and other clinicians, and should be pursued in all health care settings.
Table 2. IOMs Six Aims for Improving Health Care Quality
Aim 1. Safe care 2. Effective care 3. Patient-centered care 4. Timely care 5. Efficient care 6. Equitable care Description Avoiding injuries to patients Providing care based on scientific knowledge Providing respectful and responsive care that ensures that patient values guide clinical decisions Reducing waits for both recipients and providers of care Avoiding waste Ensuring that the quality of care does not vary because of characteristics such as gender, ethnicity, socioeconomic status, or geographic location.
Illustrations of the relevance and integral nature of nursing to achieving these aims are illustrated below. Aim 1Safe Care The Quality Chasm noted, The health care environment should be safe for all patients, in all of its processes, all of the time. This standard of safety implies that organizations should not have different, lower standards of care on nights and weekends or during times of organizational change3 (p. 45). Recognizing the particular danger that handoffs can pose to patients, the report notes that handoffs are frequently the first place where patient safety is compromised. Clearly, part and parcel of the work of nurses are the transactions that occur among nurses and others as information, components of care processes, and patients themselves are handed off to others. Nursing work is punctuated by patient transfers from one environment to another (e.g., inter- and intra-institutional transfers of patients), from shift to shift, or communication from one clinician to another (e.g., information given by a nurse to different physical therapists caring for the same patient). Moreover, because of their ongoing contact with patients and their families, nurses are in pivotal positions to both inform and incorporate the observations and concerns of these individuals into creating safe care environments. To do so require nurses to consider all information conveyed to them by patients and family members and to encourage that communication. Aim 2Effective Care The provision of effective nursing care rests on the development and use of nursing evidence, as well as evidence produced by other disciplines with relevance to nursing practice. Effective care is based on evidence derived from four types of research: laboratory experiments, clinical trials, epidemiological research, and outcomes research, including case reports.3 Outcomes research, critical to improving care quality, uses information about how well interventions work on a large, generalizable scale. Nurse researchers engage in all four types of research, and each
type is capable of informing aspects of care delivery and care quality. Nevertheless, there is a paucity of research to undergird the application of many interventions, nursing and non-nursing alike. Looking to the future, the Quality Chasm report suggests that the knowledge base about effective care and its use in health settings will constantly expand through improved methods of accessing, summarizing and assessing information and making it available at the point of care for the patient3 (p. 48), Already, information technology systems in some health care settings provide immediate access to clinical guidelines, step-by-step approaches to procedures, and other information that is based on research evidence or, in its absence, expert judgment. In addition to expecting the further development of and adherence to an evidence base, the Quality Chasm report also highlights the importance of nurses and other clinicians systematically and continually reviewing the outcomes of the care that they provide. Currently, care results are rolled up and reflected in overall performance indicators for nursing homes and hospitals. With some exceptions, there is relatively limited information that is currently collected, assessed, and fed back to nurses to help them better understand their individual impact on care quality and thereby assist them in improving their performance. Clearly, efforts that have resulted in the development of nursing indicators are a step in this direction. This is one more important area in which nurses can engage to further the quality improvement agenda. Aim 3Patient-Centered Care Aspects of patient-centered nursing care have long been incorporated in nursing education programs. However, the meaning of the term has evolved and the extent to which it is met is variable. Gerteis and colleagues16 put forward a set of dimensions of patient-centered care, including respect for patients values, preferences, and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support; and involvement of family and friends. Considerable nursing and other research remains to be done to better delineate the outline of this concept and strategies for addressing it. A related concept, population-centered care, is discussed extensively in the IOM report Quality Through Collaboration: The Future of Rural Health. This important concept has even less evidence-based approaches to help guide its achievement. Aim 4Timely Care Timeliness of care delivery is often compromised, almost regardless of where a consumer comes in contact with health care. From emergency rooms to schools, nurses see first hand the difficulties in providing timely access to care. Timeliness is compromised when patients needing immediate medical attention find themselves in overcrowded emergency rooms, or individuals without health insurance are delayed in accessing health care or there is a lack of available clinicians. Delays like these are too often the norm. Many factors, both internal and external to the care environment, impact timeliness. Internal to delivery systems, analyzing and refining the actual design of effective processes is overlooked. Instead, the blunt instrument used to drive timeliness is often the expectation for nurses and other clinicians to do more and, in some cases, faster. This approach itself can, at times, compromise care quality. Efforts to improve timeliness are multifaceted. One of the essential tools to address parts of this challenge is technology. The expanded use of call-a-nurse lines, e-mail exchanges between clinicians and patients, and consumer access to telemedicine applications linking rural and urban facilities, are part of the developing technology-based toolkit needed to increase timely access to care.
Aim 5Efficient Care Efficiency is not necessarily a hallmark of the U.S. health care system. In fact, some quality experts indicate that adding more financial resources to the health care delivery system is highly inefficient, given the high level of waste in current practices. Since nurses are on the front lines of health care, nurses are well positioned to work within their institutions at the local level as well as through their associations at the national level to develop and promote agendas designed to increase efficiency, ultimately making better use of the significant financial resources currently directed to health care. Additionally, nurse researchers can play an exceedingly important role in achieving efficiency. For example, Naylor17 found that elderly patients receiving a comprehensive intervention delivered by advanced practice nurses (APNs) in the hospital and followed in the home significantly decreased expensive hospitalizations. APN care resulted in average per capita expenditures of $6,152 compared to the control group expenditure of $9,618. As a result, efforts are underway to help move this intervention into the broader practice environment. As the growth in health care expenditures continues to rise nationally, public policymakers, insurers, and others will be far more open to nursing practice models as well as other strategies that help to rein in high costs while sustaining or improving care quality. Efforts toward achieving this aim provide new opportunities for nurses to create models that maximize the contribution of nursing care and innovation in quality improvement. Aim 6Equitable Care Equity refers to universal access to health care services.3 Challenges surrounding equity are reflected in disparities in health care by ethnic and socioeconomic groups, lack of health insurance or underinsurance, and geographic inequity that influences the services available. Equity as an aim tied to geographic access is discussed later in this section on the IOM report, Quality Through Collaboration: The Future of Rural Health Care.
New Rule3
Care based on continuous healing relationships Customization based on patient needs and values The patient as the source of control Shared knowledge and free flow of information
10
Current Approach
Decisionmaking is based on training and experience Do no harm is an individual responsibility Secrecy is necessary The system reacts to needs Cost reduction is sought Preference is given to professional roles over the system
New Rule3
Evidence-based decisionmaking Safety as a system property The need for transparency Anticipation of needs Continuous decrease in waste Cooperation among clinicians
As with the aims for improvement, implementing this entire set of rules in the redesign of health care systems has implications for nursing practice, education, and research. While nursing can be considered in the context of each of the current and new rules, only a few of the rules are discussed here in order to illustrate their relevance to nursing. For example, operationalizing the first new rule, care based on continuous healing relationships, focuses on ensuring that patients have the care they need when they need it. Continuity and coordination should trump fragmented, disconnected care efforts. Conceivably, this rule could directly influence where, how, and when nursing care is available to patients. Moreover, the Internet is likely to play a pivotal role in its application. Another example, the third rulethe patient is the source of controlis designed to facilitate decisionmaking by patients rather than authoritarian or paternalistic decisionmaking by health care providers. While often considered in the context of physician-patient communication, this rule has implications for the approaches nurses bring to patient engagement. However, in addition to individual nurse efforts to incorporate this orientation into patient care, major system-level changes will be needed to allow patients to exercise their preferred degree of control. Such system-level redesign, particularly as it relates to nurse-patient interactions, will benefit from nursing input. Regarding new rule four, shared knowledge and free flow of information, Quality Chasm cited evidence that giving patients access to their own health and clinical information improves care processes and health outcomes. Clearly, electronic personal health records and Web-based information have considerable potential to enhance patient knowledge and stimulate healthy behavior. However, there is limited information about how nurses can help patients to fully harness these information resources. Nurses can lead efforts to make these rules actionable across health systems, particularly as they influence the redesign of nursing practice, the nursepatient relationships, the relationships between nurses and other disciplines, and the relationship of nurses to care processes. Additionally, these expectations should be incorporated into nursing curricula to ensure that nurses are able to engage and support the refinement and application of important features of redesigned health care systems. In the process, nurses learn not just the changes necessary for improving quality of care, but also the skills and knowledge essential to fully participate in the change process associated with quality improvement efforts. Deploying these rules requires the participation of virtually all stakeholders. Nursing is clearly a key partner in the convening of health profession associations as well as key industry and quality organization representatives to lead this transformation, expand the research underlying the rules, and develop an agenda to examine progress and next steps related to actions supporting the application of this rules set. A total of 7 years has passed since the release of the
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Quality Chasm report. No doubt progress in health care redesign vis--vis the rules set has occurred during this time. However, there is considerably more work to be done in each of these areas.
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Competency 1Provide patient-centered care The report noted that patient-centered care includes knowledge of shared responsibility between patients and caregivers; communication approaches that allow patient access to information and achieve patient understanding; consideration of patients individuality, values, and needs; and focus on the use of related population-based strategies to improve appropriate use of health services. The Health Professions Education report cites research related to some of these characteristics. For example, findings indicated that patients who were involved in decision making about their care have higher functional status, better outcomes, and lower costs.8 Additionally, health systems need to be analyzed to determine the extent to which the systems facilitate or constrain the deployment of skills and knowledge associated with this competency. Competency 2Work in interdisciplinary teams Interdisciplinary teams have been shown to enhance quality and lower costs. Substantially more research is needed to determine characteristics that facilitate team effectiveness, as well as the development of successful academic models capable of teaching and testing these performance attributes. Challenging the development of interdisciplinary educational content and the use of this competency in practice is the absence of a common language across disciplines, politics, and turf battles among the professions. Berwick captured the essence of interdisciplinary practice in a statement he offered in the development of the Health Professions Education report when he said8 (p. 56), System-mindedness means cooperation. It means asking yourself not what are the parts of me, not what do I do, but what am I part of? For health professions educators, including nursing faculty, a corollary may be how do we help students acquire knowledge about their chosen profession as well as knowledge about how to effectively function in interprofessional teams of which they are destined to become part? Questions for nurse educators include how well are we instilling this competency in students and, how do we know? Interdisciplinary approaches to research on the set of five competencies may be viewed as too challenging to build in academic environments. Yet it may be in this confluence of ideas, philosophies, and approaches that nurse researchers and others are better able to understand, test, and design interdisciplinary practices. In fact, the hard work of interdisciplinary practice may best be modeled through interdisciplinary education and research efforts that begin in academic environments. The culture of many academic environments, however, does not yet value the production of interdisciplinary education or research partnerships. Competency 3Employ evidence-based practices The IOM describes evidence-based practice as the integration of research evidence, clinical expertise, and patient values in making decisions about the care of individual patients. Each of these sources may be contributing factors relevant to decision making regarding patient care. In terms of the implications of this competency for nurses, the report indicated that the following knowledge and skills were necessary: knowing how to find the best sources of evidence, formulating clear clinical questions, and determining when and how to integrate new findings into practice. This knowledge requires bridging content between traditional nursing research courses and clinical courses. The Health Professions Education report noted that the evidence base for nursing and other disciplines is markedly limited, and the availability of data that captures information around nursing interventions in administrative and clinical records for research purposes is minimal. Some nurse researchers and nursing organizations are playing pivotal roles in attempting to address this deficit.
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Competency 4Apply quality improvement The science of quality improvement is expanding rapidly, and the competency of nurses to apply this science is important. Through academic and continuing education opportunities, nurses need to be competent in measuring quality of care, assessing and benchmarking practices to identify improvement opportunities, designing and testing interventions, identifying hazards and errors in care, implementing safety design principles such as standardization and human factors training, and participating as a member of interdisciplinary teams8 (p. 59). A major challenge is the lack of quality improvement content expertise across faculty. Deans, other administrators, and faculty leaders need to focus on acquiring this expertise for their faculty as well as incorporating it into nursing education curricula, including clinical coursework. Competency 5Utilize informatics Health care informatics relates to the application of information technology (IT) systems to problems in health care and includes an array of applications from order entry to decision support systems. Research findings indicate that IT applications can enhance patient safety by standardizing, flagging errors, and eliminating handwritten data, among other functions.8 Utilizing informatics can influence knowledge management, communication, and decisionmaking. Educational programming to target facets of this competency have increased in health care environments as well as in academic programs. However, considerable work remains to be done to prepare nurses to fully harness informatics to ensure safety and enhance care quality. Not the least of this work is the analysis of environmental attributes that contribute to successful informatics applications. Much work remains in terms of teaching the five competencies in nursing education programs, applying the competencies in nursing practice, and focusing on the competencies through nursing research. The Health Professions Education report gives extensive consideration to the purposes and limitations of accreditation, certification, and licensure and the relationship of these oversight processes to clinician competence and patient outcomes. Currently, most of these oversight processes do not address nurses knowledge of any of the five competency areas. As with other disciplines, actually demonstrating competency is generally not part of the ongoing oversight of individual nurses. This report suggested that hard work on the part of oversight bodies (e.g., developing assessment tools) must be done to assure the public that nurses maintain minimum levels of competence throughout their careers.8 There is tremendous pressure on academic programs to ensure that students acquire other essential core content, making the addition of expectations such as those expressed in Health Professions Education difficult to accommodate. Nevertheless, the case is made. The inadequacy of educational preparation is reflected in the lack of skills and knowledge applied in current nursing practice. This report asserts, The extent to which health professionals are implementing these competency areas does not meet the health care needs of the American public8 (p. 67).
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important to nurses and others: that is, there is a paucity of research available on the quality of rural health care. As with urban health care, the limited rural research that does exist indicates variability of care quality.11 This circumstance underscores the need for nurses and others with interest and expertise in rural health to further expand knowledge in this largely ignored area. One particular area needing nursing inquiry is the extent to which rural health care delivery reflects activity and progress toward achieving the six aims for improvement. A unique contribution of the Future of Rural Health report is the application of the six aims to improve not just care quality delivered in health care organizations, as has been discussed in earlier reports, but also to target efforts that can improve the quality of health in the general population. Nurses in rural communities can be pivotal in helping to build a local community focus on both the quality of health and the quality of health care. The report provides illustrative examples of the application of each of the six aims and community level interventions to achieve those aims. Much of the work of targeting efforts toward improving the quality of population health will involve nurses and other leaders in rural health care settings working with community leaders in local schools, government, and other sectors. How to effectively engage this collective focus to advance population health should be a priority research area. As with most of the reports in the IOM Quality Chasm series, the theme of leadership emerged in The Future of Rural Health. In this case, particular attention is given to the need for rural health system leaders to embrace and drive quality improvement within their organizations as well as the need to engage larger issues of population health quality. An identified strength of many rural communities is the familiarity that people have with each other and the various local community sectors. Also, often typical of rural communities is the orientation and practice of engaging across sectors to achieve community-level outcomes. This characteristic can help to facilitate new efforts around building quality into population health.11 The Future of Rural Health report pivots from the major components of the Crossing the Quality Chasm report and frames the issues in a rural context. For example, priority issues such as information technology applications, quality improvement infrastructure components, workforce considerations, and the aims for improvement are all viewed through the prism of a rural context. In addition, The Future of Rural Health cited relevant rural examples of each of the six aims, considering them in the context of the community as well as the context of health care delivery. Measures of the safety aim included measuring community characteristics such as occupational accident rates in rural areas and toxic environmental exposure/risk from pesticides. Brief discussions focused on community-level strategies for improving safety, effectiveness in community health improvement, and community-centered care that reflects responsiveness to the aggregated needs, values, and other characteristics of the local community. Clearly, the broadened application of the six aims for improvement in a rural community context offers an area for research and reconfigured interdisciplinary efforts that include stakeholders outside of traditional health care settings. The community-level application of the six aims, revamped to consider unique characteristics of urban areas, also should be highly relevant to urban communities and populations. Too frequently, research conducted on quality and safety interventions in urban health care settings has been directly generalized to the often very different environments, staffing mix, and patient populations found in rural health care settings. For example, deploying rapid response teams in rural areas needs to take into consideration the different staff mix available on site in rural settings. Relevant research on functions common to rural health care settings is extremely limited. For example, there is minimal nursing research on the processes involved in patient
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stabilization and transfer. This is a set of activities common to rural hospitals but far less frequently performed in urban hospitals. Research on patient outcomes associated with these processes is virtually nonexistent. More efforts need to be directed toward developing and determining relevant rural knowledge and tools, appropriate performance measures, and the development of data feedback capabilities. To begin to fill knowledge gaps and improve health care quality and population health, access to the science of quality improvement and acquiring related expertise is pivotal. This includes acquiring competence in evaluating, adopting, and adapting this new knowledge area for application in rural environments.18 In addition to identifying gaps in research knowledge and new framing of aims for application to quality improvement in rural population health, the Future of Rural Health report also addressed internal and external drivers of quality improvement specific to rural health systems. For example, unlike most urban hospitals, which are reimbursed through the prospective payment system, a large subset of rural hospitals are designated as critical access hospitals. These hospitals receive cost-based reimbursement, and there are currently no requirements linking Medicare payment to reporting on quality indicators, as is the case with prospective payment system hospitals. The report states that no providers, rural or urban, should be excluded from public reporting. However, mechanisms for linking cost-based reimbursement to quality indicators and eventually patient outcomes need to be developed for rural health care facilities. Additionally, determining how best to report and assign meaning to data extracted from small numbers of patient encounters remains a challenge. In terms of drivers internal to rural health care settings, the job design of nurse leaders typically requires them to manage multiple roles and expectations. For example, frequently, the nurse responsible for quality assurance and improvement in a facility carries many other responsibilities as well. Given the limited numbers of nurses and other personnel in rural communities, efficiently acquiring and applying quality improvement knowledge and related skills can be particularly challenging. Conversely, because health care providers tend to be relatively few in number, information and new care approaches are often rapidly diffused throughout small rural facilities. The report devoted significant attention to characteristics essential to the rural health care workforce. Building on the Health Professions Education report, The Future of Rural Health noted that the five identified competencies are all relevant to rural health care, but the applications may be different. Interdisciplinary teams may consist of individuals geographically separated, but who share involvement in the ongoing care of individuals. Electronic intensive care units are an example. Under these circumstances, applying team concepts may have special ramifications for nurses and others. While research findings from some of these practices indicated markedly improved patient morbidity and mortality, there was virtually no research base on which to guide the configuration and deployment of these types of teams. The Future of Rural Health also advocated for educational preparation that includes ruralrelevant practice knowledge and rural clinical experience. The role of rural consumers in acquiring quality care is also discussed, with attention given to the fact that their role in managing their health may be operationalized differently compared to their urban counterparts given resource availability, etc. For example, access to certain clinicians, including home health nurses and diabetes nurse educators, may be enabled through Web and other technology applications. Yet minimal study of the quality of these encounters has been undertaken. Although technology offers the promise of linking sparsely populated areas to health care services, there is a digital divide between rural and urban areas across the country. To the extent
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that electronic connectivity is essential for care continuity, special effort needs to be made to overcome these challenges. Public policy is and will continue to play a major role in bridging this divide, offering nurses another area to engage in issues concerning rural access to quality health care.
Future Directions
In summary, the Quality Chasm series of reports emphasized a number of key attributes of the architecture needed to build a safe, consistently high-performing health care system. Expressed throughout the reports were serious concerns about the status of contemporary health care. Essential features of high-quality care systemssuch as workforce competencies, effective application of internal and external drivers, progress toward achieving the six identified aims for improvement, and the application of a set of rules to systems redesignare far from where they should be. The Quality Chasm series called for leadership in education, practice, and research to drive needed change. The series called for major overhaul of not just the organizations in which health care providers work, but the education of health care providers themselves. The series made a special effort to recognize the unique needs of specific populations, such as those in rural communities or those with mental health problems, and recommended approaches to more effectively deliver quality care to those populations. Based on the challenges and recommendations set forth, it is clear that significant work remains to be done. Specific to the nursing profession, nurse educators, clinicians, and researchers need to help build state-of-the-art and state-of-the-science approaches for redesigning nursing care processes, using information technology between nurses and patients and nurses and other clinicians; acquiring, managing, and appropriately applying new knowledge and skills; preparing nurses to function effectively in teams; and evaluating nurses performance in this regard. Regardless of the settings in which nurses practice, much more effort must be devoted to care coordination for individuals with chronic conditions, while diligently measuring both performance and outcomes. Nurses have a substantive and essential role in helping to apply the quality framework articulated in the IOM Quality Chasm series. And nurses clearly have a role in developing additional approaches and new features to the quality agenda. Active engagement in patient safety and quality improvement efforts is relevant to all nurses. Unlike the minimal progress from Nightingales time until now, hopefully future nurses will be able to reflect back to the beginning of the 21st century and determine that nursing made significant strides. They will see improvement in both the quality of health and health care quality due to an improved role of nurses in providing quality care.
Research Implications
Every report in the Quality Chasm series calls for specific, targeted research to further develop the evidence base related to quality care. Research targeting quality improvement has been supported and implemented by various stakeholders, ranging from health profession organizations to Federal agencies to health providers themselves. Findings and implications are being applied in a variety of ways, from changing internal drivers of quality such as work structure (e.g., rapid response teams) to altering external drivers of quality (e.g., paying providers for performance based on evidence-based quality indicators). While nurses have been part of many of the research activities, significant research remains to be done.
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The following is a compilation of some of the exemplar areas of research derived from the four reports reviewed in this section. These research areas are both relevant to nursing and are areas for which nursings contribution is important. The role of leaders in addressing errors and designing safety and quality into health care systems is a common thread throughout the IOM Quality Chasm report series. Currently, the work design of practice in clinical settings introduces significant potential for executing unsafe actions. This is particularly relevant to nursing, given that much of the care delivered in health systems is nursing care. Research Focus: Identify how to effectively lead, design, test, and change safety structures and processes in health systems, in addition to researching the safety of structures and processes themselves (e.g., effective strategies for teaching and achieving consistent application of the Situation-Background-Assessment-Recommendation [SBAR] model of communication.) Research is needed that continues the work of determining high-risk structures, functions, and processes in various types of health care delivery settings, focusing on ways to make unsafe nursing activity and practices extremely difficult to carry out (e.g., identify potentially unsafe work-arounds). Design research to test the effectiveness of simulated team approaches to care processes that move beyond established simulations, such as responding to cardiac arrest. Public, standardized reporting of serious medical errors is recommended, and a number of States have implemented error reporting systems. Recently, Federal legislation related to reporting errors has been enacted. Research Focus: Policy research should determine effective means for conveying public information in ways that facilitate consumer choice of care settings and drive quality improvement at the level of care delivery. Encourage health care consumers to actively participate in ensuring the delivery of safe care. Research Focus: Determine effective strategies to inform and engage consumers in ways that help ensure their receipt of safe, high-quality care. Nurses, working with other stakeholders such as insurers and employers, should test messages and delivery structures designed to ensure that consumers receive safe care; for example, develop strategies for consumers to use when (1) querying clinicians about self-care processes, (2) making informed choices about health care interventions, (3) designing Web-based support groups for geographically dispersed consumers with chronic conditions. Using external factors such as paying for quality performance can drive quality improvement. Examples exist of health systems that have tested the intervention of using payment incentives to improve performance (e.g., Premier demonstration project funded by the Centers for Medicare & Medicaid Services). Research Focus: Successful pay-for-performance models should be replicated. To facilitate this initiative, research that isolates nursing characteristics contributing to performance improvement will be useful to informing dissemination and efficient adoption of these models. Creating learning environments is a prerequisite to systemwide delivery and improvement of care quality. Research Focus: Test approaches to construct and sustain organizational cultures oriented toward safe and high-quality care. This focus includes altering power gradients in clinical settings to ensure free flow of information and testing approaches to educating teams of health profession students in academic settings to maximize communication, problem identification, and systemwide corrections.
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Even when evidence exists regarding effective approaches to care delivery, this information is not consistently applied. Research Focus: Research is needed to determine communication approaches and incentives that encourage behavior change and the adoption of evidence-based approaches to nursing care. The Quality Chasm report series proposes a set of new rules to guide health care systems, including rules such as the need for transparency, anticipation of patient needs, and the patient as the source of control. Research Focus: More research is needed to assist with effective application of each of the new rules. For example, nurse researchers could consider how to restructure care relationships and processes to determine how to move from a system that reacts to patient needs to one that anticipates patient needs. Population-centered care is a concept central to The Future of Rural Health: In this report the six aims for improvement discussed in many of the other IOM reports were considered in a population rather than a health care system context. However, an evidence base needs to be developed to better understand how to construct this concept for the purpose of improving health and health care. Research Focus: Significant research is needed to understand possible benefits as well as clarify population-centered care as a means to improve population health. A key area of focus is to determine how to effectively engage rural stakeholderscommunity leaders, educational leaders, and representatives from other sectorsto achieve measurable improvements in population health. Additionally, inquiry regarding the extent to which rural health care delivery systems reflect progress toward achieving the six aims for improvement is very limited. For example, minimal research exists on the process of patient stabilization and transfer from rural hospital emergency rooms to other facilities, and yet this is a common function of many rural facilities. The Future of Rural Health discusses the importance of linking facilities and providers across geographic distances as a means to build efficient quality improvement infrastructure. Connecting clinicians using IT to provide access to locally unavailable care has been implemented in terms of telemental health, e-Intensive Care, and other IT-based services. Research Focus: Patient outcomes associated with some technology-based interventions (e.g., e-intensive care units) have been evaluated, but very little is known about how to guide the configuration and deployment of these virtual teams, the members of which exist at geographic distance from each other. Access to home health nurses, diabetes nurse educators, and others may be enabled through the Web and other technology applications, but the associated costs, patient outcomes, etc., are not yet well established through a body of research. Fairly limited efforts have been undertaken to support these technology-based interventions through payment methods as opposed to time-limited grant funding. The Health Professions Education report advances five competencies considered essential to the ability of providers to deliver high-quality care. Research Focus: Educational research is needed to determine how to facilitate learning and adequately assess each of the core competencies in health profession students across disciplines (e.g., utilize evidence-based practices).
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Author Information
Mary Wakefield, Ph.D., R.N., F.A.A.N. Associate Dean for Rural Health and Director, Center for Rural Health; School of Medicine and Health Sciences; University of North Dakota; Grand Forks, ND. E-mail: [email protected].
References
1. The Presidents Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality first: better health care for all Americans. Washington, DC: U.S. Government Printing Office; 1998. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. Nightingale F. Notes on hospital. London: John W. Parker and Son, West Strand; 1859. Institute of Medicine. Leadership by example: coordinating government roles in improving health care quality. Washington, DC: National Academies Press; 2002. Institute of Medicine. Fostering rapid advances in health care: learning from systems demonstrations. Washington, DC: National Academies Press; 2002. Institute of Medicine. Priority areas for national action: transforming health care quality. Washington, DC: National Academies Press; 2003. Institute of Medicine. Health professions education: a bridge to quality. Washington, DC: National Academies Press; 2003. Institute of Medicine. Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2003. Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press; 2004. 16. 15. 11. Institute of Medicine. Quality through collaboration: the future of rural health. Washington, DC: National Academies Press; 2005. Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academies Press; 2006. Institute of Medicine. Improving the quality of health care for mental and substance-use conditions: quality chasm series. Washington, DC: National Academies Press; 2006. Joint Commission on Accreditation of Healthcare Organization. National patient safety goals [Online]. 2005 May. Available at: http://www.jointcommission.org/PatientSafety/Natio nalPatientSafetyGoals/06_npsg_facts. Accessed May 3, 2006. Berwick DM, Calkins DR, McCannon CJ, et al. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. In: Institute for Healthcare Improvement [Online]. 2006 Jan. Available at: http://www.ihi.org/IHI/Topics/ Improvement/ImprovementMethods/Literature/10000 0LivesCampaignSettingaGoalandaDeadline.html. Accessed May 2, 2006. Gerteis M, Edgman-Levitan S, Daley J. Through the patients eyes. Understanding and promoting patientcentered care. San Francisco, CA: Jossey-Bass; 1993. Naylor M. Making the business case for the APN care model. Report to the Commonwealth Fund; Oct. 2003. Coburn AF, Wakefield M, Casey M, et al. Assuring rural hospital patient safety: what should be the priorities? J Rural Health, 2004 Fall;20:314-26.
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Introduction
In addition to putting the spotlight on the staggering numbers of Americans that die each year as a result of preventable medical error, the Institute of Medicines (IOMs) seminal report, To Err is Human: Building a Safer Health System, repeatedly underscored the message that the majority of the factors that give rise to preventable adverse events are systemic; that is, they are not the result of poorly performing individual nurses, physicians, or other providers.1 Although it was not the intent of To Err is Human to treat systems thinking and human factors principles in great detail, it cited the work of many prominent human factors investigators and pointed out the impressive safety gains made in other high-risk industries such as aviation, chemical processing, and nuclear power. One of the beneficial consequences of the report is that it exposed a wide audience of health services researchers and practitioners to systems and human factors concepts to which they might not otherwise have been exposed. Similarly, the report brought to the attention of the human factors community serious health care problems that it could address. Today, both health care and human factors practitioners are venturing beyond their own traditional boundaries, working together in teams, and are benefiting from the sharing of new perspectives and clinical knowledge. The purpose of the present chapter is to further this collaboration between health care and human factors, especially as it is relevant to nursing, and continue the dialog on the interdependent system factors that underlie patient safety.
that shape their activities may or may not be a good fit for their strengths and limitations. When these system factors and the sensory, behavioral, and cognitive characteristics of providers are poorly matched, substandard outcomes frequently occur with respect to effort expended, quality of care, job satisfaction, and perhaps most important, the safety of patients. Many nursing work processes have evolved as a result of local practice or personal preference rather than through a systematic approach of designing a system that leads to fewer errors and greater efficiency. Far too often, providers and administrators have fallen into a status quo trap, doing things simply because they always have been done that way. Human factors practitioners, on the other hand, take into account human strengths and weaknesses in the design of systems, emphasizing the importance of avoiding reliance on memory, vigilance, and followup intentionsareas where human performance is less reliable. Key processes can be simplified and standardized, which leads to less confusion, gains in efficiency, and fewer errors. When care processes become standardized, nurses have more time to attend to individual patients specialized needs, which typically are not subject to standardization. When medical devices and new technology are designed with the end user in mind, ease of use and error detection or preventability are possible, in contrast to many current opaque computer-controlled devices that prevent the provider from understanding their full functionality. The field of human factors does not focus solely on devices and technology. Although human factors research emerged during World War II as a result of equipment displays and controls that were not well suited to the visual and motor abilities of human operators, each subsequent decade of human factors work has witnessed a broadening of the human performance issues considered worthy of investigation. More recently, a number of human factors investigators with interests in health care quality and safety advocated addressing a more comprehensive range of sociotechnical system factors, including not only patients, providers, the tasks performed, and teamwork, but also work environments or microsystems, organizational and management issues, and socioeconomic factors external to the institution.47 One of the lessons stemming from a systems approach is that significant improvements in quality and safety are likely to be best achieved by attending to and correcting the misalignments among these interdependent levels of care. Managing the system interdependencies of care, as evidenced by continued major breakdowns such as inadequate transitions of patient care, is a major challenge faced by providers and their human factors partners alike.
Understanding Systems
At a very basic level, a system is simply a set of interdependent components interacting to achieve a common specified goal. Systems are such a ubiquitous part of our lives that we often fail to recognize that we are active participants in many systems throughout the day. When we get up in the morning, we are dependent on our household systems (e.g., plumbing, lighting, ventilation) to function smoothly; when we send our children off to school, we are participants in the school system; and when we get on the highway and commute to work, we are participants (and sometimes victims) of our transportation system. At work, we find ourselves engaged simultaneously in several systems at different levels. We might report to work in a somewhat self-contained setting such as the intensive care unit (ICU) or operating room (OR)what human factors practitioners refer to as microsystemsyet the larger system is the hospital itself, which, in turn, is likely to be just one facility in yet a larger health care system or network, which in itself is just one of the threads that make up the fabric of our broader and quite diffuse national health care system. The key point is that we need to recognize and understand the functioning of the many systems that we are part of and
how policies and actions in one part of the overall system can impact the safety, quality, and efficiency of other parts of the system. Systems thinking has not come naturally to health care professionals.8 Although health care providers work together, they are trained in separate disciplines where the primary emphasis is the mastery of the skills and knowledge to diagnose ailments and render care. In the pursuit of becoming as knowledgeable and skillful as possible in their individual disciplines, a challenge facing nursing, medicine, and the other care specialties is to be aware of the reality that they are but one component of a very intricate and fragmented web of interacting subsystems of care where no single person or entity is in charge. This is how the authors of To Err is Human defined our health system:1 Health care is composed of a large set of interacting systemsparamedic, and emergency, ambulatory, impatient care, and home health care; testing imaging laboratories; pharmacies; and so forththat are coupled in loosely connected but intricate network of individuals, teams, procedures, regulations, communications, equipment, and devices that function with diffused management in a variable and uncertain environment. Physicians in community practice may be so tenuously connected that they do not even view themselves as part of the system of care. A well-known expression in patient safety is that each system is perfectly designed to achieve exactly the results that it gets. It was made popular by a highly respected physician, Donald Berwick of the Institute of Healthcare Improvement, who understands the nature of systems. If we reap what we sow, as the expression connotes, and given that one does not have to be a systems engineer to understand systems, it makes sense for all providers to understand the workings of the systems of which they are a part. It is unfortunate that today one can receive an otherwise superb nursing or medical education and still receive very little instruction on the nature of systems that will shape and influence every moment of a provider's working life.
and the organization alike. The similarity among these independently derived models is quite striking, in that they are all sociotechnical system models involving technical, environmental, and social components.
Table 1. Sociotechnical System Models
Authors Henriksen, Kaye, Morisseau 19934 Elements of Model Individual characteristics Nature of the work Physical environment Human-system interfaces Organizational/social/environmental Management Patient characteristics Task factors Individual factors Team factors Work environment Organizational and management factors People (disciplines) Tools and technology Physical environment Organizational goals Care processes
Vincent 19985
individuals who were involved in events leading up to a mishap and those who are called upon to investigate it after it has occurred is knowledge of the outcome. Investigators have the luxury of hindsight in knowing how things are going to turn out; nurses, physicians, and technicians at the sharp end do not. With knowledge of the outcome, hindsight bias is the exaggerated extent to which individuals indicate they could have predicted the event before it occurred. Given the advantage of a known outcome, what would have been a bewildering array of nonconvergent events becomes assimilated into a coherent causal framework for making sense out of what happened. If investigations of adverse events are to be fair and yield new knowledge, greater focus and attention need to be directed at the precursory and antecedent circumstances that existed for sharp end personnel before the mishap occurred. The point of investigating preventable adverse health care events is primarily to make sense of the factors that contribute to the omissions and misdirected actions when they occur.11, 12 This in no way denies the fact that well-intended providers do things that inflict harm on patients, nor does it lessen individual accountability. Quite simply, one has to look closely at the factors contributing to the adverse event and not just the most immediate individual involved. In addition to hindsight bias, investigations of accidents are also susceptible to what social psychologists have termed the attribution error.13 Human observers or investigators tend to make a fundamental error when they set out to determine the causal factors of someones mistake. Rather than giving careful consideration to the prevailing situational and organizational factors that are present when misfortune befalls someone else, the observer tends to make dispositional attributions and views the mishap as evidence of some inherent character flaw or defect in the individual. For example, a nurse who administers the wrong medication to an emergency department (ED) patient at the end of a 10-hour shift may be judged by peers and the public as negligent or incompetent. On the other hand, when misfortune befalls individuals themselves, they are more likely to attribute the cause to situational or contextual factors rather than dispositional ones. To continue with the example, the nurse who actually administered incorrect medication in the ED may attribute the cause to the stressful and hurried work environment, the physicians messily scribbled prescription, or fatigue after 10 intense hours of work.
inappropriate actions before they lead to undesirable consequences. In some unkind environments, it may not be possible to reverse the inappropriate actions, while in others it may not be possible to foresee the undesirable consequences. Rasmussens unkind work environment is quite similar to Perrows notion of tightness of coupling in complex systems.15 Perrows analysis of system disasters in high-risk industries shifts the burden of responsibility from the front-line operator of the system to actual properties of the system. Using the concepts of tightness of coupling and interactive complexity, Perrow focuses on the inherent characteristics of systems that make some industries more prone to accidents.15 Tightness of coupling refers to dependencies among operational sequences that are relatively intolerant of delays and deviations, while interactive complexity refers to the number of ways system components (i.e., equipment, procedures, people) can interact, especially unexpectedly. It is the multiple and unexpected interactions of malfunctioning parts, inadequate procedures, and unanticipated actionseach innocuous by themselvesin tightly coupled systems that give rise to accidents. Such accidents are rare but inevitable, even normal, to use Perrows terminology. By understanding the special characteristics of highrisk systems, decisionmakers might be able to avoid blaming the wrong components of the system and also refrain from technological fixes that serve only to make the system riskier.
In brief, many adverse events result from this unique interaction or alignment of several necessary but singly insufficient factors. Weaknesses in these factors typically are present in the system long before the occurrence of an adverse event. All that is needed is for a sufficient number to become aligned for a serious adverse event to occur.
Source: Reason J, Carthey J, deLeval M. Diagnosing vulnerable system syndrome: An essential prerequisite to effective risk management. Qual Health Care, 2001; 10(Suppl. II):ii21-ii25. Reprinted with permission of the BMJ Publishing Group.
The distinction made by Reason between latent conditions and active errors, shown along the left margin of Figure 1, also is very important.11, 17 In health care, active errors are committed by those providers (e.g., nurses, physicians, technicians) who are in the middle of the action, responding to patient needs at the sharp end.18 Latent conditions are the potential contributing factors that are hidden and lie dormant in the health care delivery system, occurring upstream at the more remote tiers, far removed from the active end. These latent conditionsmore organizational, contextual, and diffuse in nature or design relatedhave been dubbed the blunt end.18 The distinction between latent conditions and active errors is important because it allows us to clearly see that nurses, who have the greatest degree of patient contact, are actually the last line of defense against medical error (and hence the most vulnerable). As such, nurses can inherit the less recognized sins of omission and commission of everyone else who has played a role in the design of the health care delivery system. Reason perhaps makes this point best:10 Rather than being the main instigators of an accident, operators tend to be inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding a final garnish to a lethal brew whose ingredients have already been long in the cooking. The human factors framework outlined here allows us to examine a wide range of latent conditions that are part of the health care sociotechnical system in which providers reside.
Individual Characteristics
Figure 1 identifies individual characteristics as a first-tier factor that has a direct impact on provider performance and whether that performance is likely to be considered acceptable or substandard. Individual characteristics include all the qualities that individuals bring with them to the jobthings such as knowledge, skill level, experience, intelligence, sensory capabilities, training and education, and even organismic and attitudinal states such as alertness, fatigue, and motivation, just to mention a few. The knowledge and skills that health 8
care providers develop prior to employment through accredited training programs is fundamental to their ability to perform their work. At the same time, organismic factors such as fatigue resulting from long hours and stress can influence the ability of providers to apply their specialized knowledge optimally. Communication ability and cultural competency skills should also be included at this level. Fortunately, few critics would argue that the skills and abilities mentioned here are unimportant in having an impact on optimal health care delivery and outcomes.
Human-System Interfaces
The human-system interface refers to the manner in which two subsystems typically human and equipmentinteract or communicate within the boundaries of the system. This is shown as a third-tier factor in Figure 1. Nurses use medical devices and equipment extensively and thus have plentiful first-hand experience with the poor fit that frequently exists between the design of the devices' controls and displays and the capabilities and knowledge of users. One approach for investigating the mismatches between devices and people is to recognize there is an expanding progression of interfaces in health care settings, each with their own vulnerabilities and opportunities for confusion.26, 27 Starting at the very center with the patient, a patient-device interface needs to be recognized. Does the device or accessory attachment need to be fitted or adapted to the patient? What physical, cognitive, and affective characteristics of the patient need to be taken into account in the design and use of the device? What sort of understanding does the patient need to have of device operation and monitoring? With the increasing migration of sophisticated devices into the home as a result of strong economic pressures to move patients out of hospitals as soon as possible, safe home care device use becomes a serious challenge, especially with elderly patients with comorbidities who may be leaving the hospital sicker as a result of shorter stays, and where the suitability of the home environment may be called into question (e.g., home caregivers are also likely to be aged, and the immediate home environment layout may not be conducive to device use). In brief, the role of the patient in relation to the device and its immediate environment necessitates careful examination. At the same time, the migration of devices into the home nicely illustrates the convergence of several system factorshealth care economics,
shifting demographics, acute and chronic needs of patients, competency of home caregivers, supportiveness of home environments for device usethat in their collective interactivity and complexity can bring about threats to patient safety and quality of care. Providers of care are subject to a similar set of device use issues. Human factors practitioners who focus on the provider (user)device interface are concerned about the provider's ability to operate, maintain, and understand the overall functionality of the device, as well as its connections and functionality in relation to other system components. In addition to controls and displays that need to be designed with human motor and sensory capabilities in mind, the device needs to be designed in a way that enables the nurse or physician to quickly determine the state of the device. Increasing miniaturization of computer-controlled devices has increased their quality but can leave providers with a limited understanding of the full functionality of the device. With a poor understanding of device functionality, providers are at a further loss when the device malfunctions and when swift decisive action may be critical for patient care. The design challenge is in creating providerdevice interfaces that facilitate the formation of appropriate mental models of device functioning and that encourage meaningful dialogue and sharing of tasks between user and device. Providers also have a role in voicing their concerns regarding poorly designed devices to their managers, purchasing officers, and to manufacturers. The next interface level in our progression of interfaces is the microsystem-device interface. At the microsystem level (i.e., contained organizational units such as EDs and ICUs), it is recognized that medical equipment and devices frequently do not exist in standalone form but are tied into and coupled with other components and accessories that collectively are intended to function as a seamless, integrated system. Providers, on the other hand, are quick to remind us that this is frequently not the case, given the amount of time they spend looking for appropriate cables, lines, connectors, and other accessories. In many ORs and ICUs, there is an eclectic mix of monitoring systems from different vendors that interface with various devices that increases the cognitive workload placed on provider personnel. Another microsystem interface problem, as evidenced by several alerts from health safety organizations, are medical gas mix-ups, where nitrogen and carbon dioxide have been mistakenly connected to the oxygen supply system. Gas system safeguards using incompatible connectors have been overridden with adapters and other retrofitted connections. The lesson for providers here is to be mindful that the very need for an adaptor is a warning signal that a connection is being sought that may not be intended by the device manufacturer and that may be incorrect and harmful.28 Yet other device-related concerns are sociotechnical in nature, and hence we refer to a sociotechnical-device interface. How well are the technical requirements for operating and maintaining the device supported by the physical and socio-organizational environment of the user? Are the facilities and workspaces where the device is used adequate? Are quality assurance procedures in place that ensure proper operation and maintenance of the device? What sort of training do providers receive in device operation before using the device with patients? Are chief operating officers and nurse managers committed to safe device use as an integral component of patient safety? As health information technology (HIT) plays an increasing role in efforts to improve patient safety and quality of care, greater scrutiny needs to be directed at discerning the optimal and less-than-optimal conditions in the sociotechnical environment for the intelligent and proper use of these devices and technologies.
10
number of years. More recently, the health care profession has begun to appreciate the relationship between the physical environment (e.g., design of jobs, equipment, and physical layout) and employee performance (e.g., efficiency, reduction of error, and job satisfaction). The third tier in Figure 1 also emphasizes the importance of the physical environment in health care delivery. There is a growing evidence base from health care architecture, interior design, and environmental and human factors engineering that supports the assertion that safety and quality of care can be designed into the physical construction of facilities. An extensive review by Ulrich and colleagues29 found more than 600 studies that demonstrated the impact of the design of the physical environment of hospitals on safety and quality outcomes for patients and staff. A diverse range of design improvements include better use of space for improved patient vigilance and reduced steps to the point of patient care; mistake proofing and forcing functions that preclude the initiation of potentially harmful actions; standardization of facility systems, equipment, and patient rooms; in-room placement of sinks for hand hygiene; single-bed rooms for reducing infections; better ventilation systems for pathogen control; improved patient handling, transport, and prevention of falls; HIT for quick and reliable access to patient information and enhanced medication safety; appropriate and adjustable lighting; noise reduction for lowering stress; simulation suites with sophisticated mannequins that enable performance mastery of critical skills; improved signage; use of affordances and natural mapping; and greater accommodation and sensitivity to the needs of families and visitors. Reiling and colleagues30 described the design and building of a new community hospital that illustrates the deployment of patient safety-driven design principles. A basic premise of sound design is that it starts with a thorough understanding of user requirements. A focus on the behavioral and performance requirements of a building's occupants has generally been accepted in architecture since the early 1970s.3133 Architects have devised methodsnot dissimilar to function and task analysis techniques developed by human factors practitionersthat inventory all the activities that are performed by a building's occupants as well as visitors. Table 2 lists just a small sample of questions that need to be asked.34, 35
Table 2. Determining Activities Performed by Building Occupants and Visitors
Who will be using the facility? What are the characteristic activities of user groups? What can be learned about the extent, time of occurrence, and duration of anticipated activities? What are the relationships and exchanges between building dwellers and visitors? How many people will be moving about within the facility, for what purpose, and how frequently? What are the demographics (e.g., age, gender) and special characteristics of building users? What user groups require special equipment, fixtures, furnishings, placement, signage, safety features, and security components? What spaces are needed to support user activities? What special provisions are needed in these spaces to ensure safety and quality of the services rendered? How can the spaces be designed to facilitate human performance on the required tasks?
11
What are the recommended circulation patterns for facilitating information, equipment, and supply flow between spaces? What are the design provisions for advances in health information technology? What space adjacency requirements exist? What provisions with respect to user groups need to be made for temperature, humidity, ventilation, illumination, noise, distraction, hazards, and climatic conditions?
Given the vast amounts of time spent on hospital units and the number of repetitive tasks performed, nurses as an occupational group are especially sensitive to building and workplace layout features that have a direct bearing on the quality and safety of care provided. When designing workplaces in clinical settings, human capabilities and limitations need to be considered with respect to distances traveled, standing and seated positions, work surfaces, the lifting of patients, visual requirements for patient monitoring, and spaces for provider communication and coordination activities. Traveling unnecessary distances to retrieve needed supplies or information is a waste of valuable time. Repetitious motor activity facilitates fatigue. Information needed by several people can be made easily accessible electronically, communication and coordination among providers can be maximized by suitable spatial arrangements, and clear lines of sight where needed can be designed for monitoring tasks. At the time of this chapters writing, the U.S. hospital industry is in the midst of a major building boom for the next decade, with an estimated $200 billion earmarked for new construction. Nursing has an opportunity to play a key role in serving on design teams that seek to gain a better understanding of the tasks performed by provider personnel. By employing the accumulating evidence base, hospitals can be designed to be more effective, safe, efficient, and patient-centered. Or they can be designed in a way that repeats the mistakes of the past. Either way, the physical attributes that hospitals take will impact the quality and safety of health care delivery for years to come.
Organizational/Social Environment
As shown in the third tier of Figure 1, the organizational/social environment represents another set of latent conditions that can lie dormant for some time; yet when combined with other pathogens (to use Reason's metaphor10), can thwart the system's defenses and lead to error. Adverse events that have been influenced by organizational and social factors have been poorly understood due, in large part, to their delayed and dormant consequences. These are the omnipresent, but difficult to quantify factorsorganizational climate, group norms, morale, authority gradients, local practicesthat often go unrecognized by individuals because they are so deeply immersed in them. However, over time these factors are sure to have their impact. In her analysis of the Challenger disaster, Vaughn36 discovered a pattern of small, incremental erosions to safety and quality that over time became the norm. She referred to this organizational/social phenomenon as normalization of deviance. Disconfirming information (i.e., information that the launch mission was not going as well as it should) was minimized and brought into the realm of acceptable risk. This served to reduce any doubt or uneasy feelings about the status of the mission and preserved the original belief that their systems were essentially safe. A similar normalization of deviance seems to have happened in health care with the benign acceptance of shortages and adverse working conditions for nurses. If a hospital can get by with fewer and fewer nurses and other needed resources without the occurrence of serious adverse consequences, these unfavorable conditions may
12
continue to get stretched, creating thinner margins of safety, until a major adverse event occurs. Another form of organizational fallibility is the good provider fallacy.37, 38 Nurses as a group have well-deserved professional reputations as a result of their superb work ethic, commitment, and compassion. Many, no doubt, take pride in their individual competence, resourcefulness, and ability to solve problems on the run during the daily processes of care. Yet, as fine as these qualities are, there is a downside to them. In a study of hospital work process failures (e.g., missing supplies, malfunctioning equipment, incomplete/inaccurate information, unavailable personnel), Tucker and Edmondson39 found that the failures elicited work-arounds and quick fixes by nurses 93 percent of the time, and reports of the failure to someone who might be able to do something about it 7 percent of the time. While this strategy for problem-solving satisfies the immediate patient care need, from a systems perspective it is sheer folly to focus only on the first-order problem and do nothing about the second-order problemthe contributing factors that create the first-order problem. By focusing only on first-order fixes or work-arounds and not the contributing factors, the problems simply reoccur on subsequent shifts as nurses repeat the cycle of trying to keep up with the crisis of the day. To change this shortsightedness, it is time for nurse managers and those who shape organizational climate to value some new qualities. Rather than simply valuing nurses who take the initiative, who roll with the punches while attempting quick fixes, and who otherwise stay in their place, it is time to value nurses who ask penetrating questions, who present evidence contrary to the view that things are alright, and who step out of a traditionally compliant role and help solve the problem-behind-the-problem. Given the vast clinical expertise and know-how of nurses, it is a great loss when organizational and social norms in the clinical work setting create a culture of low expectations and inhibit those who can so clearly help the organization learn to deliver safer, higher quality, and more patient-centered care.
Management
Conditions of poor planning, indecision, or omission, associated with managers and those in decisionmaking positions, are termed latent because they occur further upstream in Figure 1 (tier four), far away from the sharp-end activities of nurses and other providers. Decisions are frequently made in a loose, diffuse, somewhat disorderly fashion. Because decisionmaking consequences accrue gradually, interact with other variables, and are not that easy to isolate and determine, those who make organizational policy, shape organizational culture, and implement managerial decisions are rarely held accountable for the consequences of their actions. Yet managerial dictum and organizational practices regarding staffing, communication, workload, patient scheduling, accessibility of personnel, insertion of new technology, and quality assurance procedures are sure to have their impact. As noted earlier, providers are actually the last line of defense, for it is the providers who ultimately must cope with the shortcomings of everyone else who has played a role in the design of the greater sociotechnical system. For example, the absence of a serious commitment to higher quality and safe care at the management level is a latent condition that may become apparent in terms of adverse consequences only when this error of judgment aligns itself with other system variables such as overworked personnel, excessive interruptions, poorly designed equipment interfaces, a culture of low expectations, and rapid-paced production schedules for treating patients. Compared to providers, managers and decisionmakers are much better positioned to actually address the problems-behind-the-problem and be mindful of the interdependencies of care. Managers and decisionmakers have the opportunity to work across organizational units
13
of care and address the discontinuities. With perhaps a few exceptions, there is very little evidence that managers and leaders actually spend much time in attending to the complex interdependencies of care and areas of vulnerability in their institutions. While they may not have the same clinical know-how as sharp end personnel, they certainly have the corporate authority to involve those with clinical expertise in needed change efforts. Thus, a new role for health care leaders and managers is envisioned, placing a high value on understanding system complexity and focusing on the interdependenciesnot just the components.38 In this new role, leaders recognize that superb clinical knowledge and dedication of providers is no match for the toll that flawed and poorly performing interdependent systems of care can take. In brief, they aim to do something about the misalignments.
14
Unlike other sectors of the economy, health care remained untouched for too long by advances in information technology (except, perhaps, for billing purposes). That is no longer the case, given the recent implementation of electronic health records, computer physician order entry systems, barcoding systems, and other technologies by early adopters. However, lofty expectations that usher in new technology are quickly dampened by unintended consequences.41, 42 One of the early lessons learned is that successful implementation involves more than just technical considerationsthe nature of clinical work, the design of well-conceived interfaces, workflow considerations, user acceptance and adoption issues, training, and other organizational support requirements all need to be taken into account. Still another external development that will likely have an impact on clinical practice in the years to come is the passage of the Patient Safety and Quality Improvement Act of 2005. It provides confidentiality protections and encourages providers to contract with patient safety organizations (PSOs) for the purpose of collecting and analyzing data on patient safety events so that information can be fed back to providers to help reduce harm to patients. With the confidentiality protections mandated by the act, providers should be able to report patient safety events freely without fear of reprisal or litigation. Finally, given the availability of numerous medical Web sites and a national press network sensitized to instances of substandard clinical care and medical error, today's patients are better informed and a bit less trusting with respect to their encounters with the health system.
15
Explanation/Implication for Nursing When things go wrong, less reliable organizations find convenient ways to circumscribe and limit the scope of the problem. They simplify and do not spend much energy on investigating all the contributing factors. Conversely, HROs resist simplified interpretations, do not accept conventional explanations that are readily available, and seek out information that can disconfirm hunches and popular stereotypes. Nurses who develop good interpersonal, teamwork, and critical-thinking skills will enhance their organization's ability to accept disruptive information that disconfirms preconceived ideas.
Sensitivity to operations
Workers in HROs do an excellent job of maintaining a big picture of current and projected operations. Jet fighter pilots call it situational awareness; surface Navy personnel call it maintaining the bubble. By integrating information about operations and the actions of others into a coherent picture, they are able to stay ahead of the action and can respond appropriately to minor deviations before they result in major threats to safety and quality. Nurses also demonstrate excellent sensitivity to operations when they process information regarding clinical procedures beyond their own jobs and stay ahead of the action rather than trying to catch up to it.
Commitment to resilience
Given that errors are always going to occur, HROs commit equal resources to being mindful about errors that have already occurred and to correct them before they worsen. Here the idea is to reduce or mitigate the adverse consequences of untoward events. Nursing already shows resilience by putting supplies and recovery equipment in places that can be quickly accessed when patient conditions go awry. Since foresight always lags hindsight, nursing resilience can be honed by creating simulations of care processes that start to unravel (e.g., failure to rescue).
Deference to expertise
In managing the unexpected, HROs allow decisions to migrate to those with the expertise to make them. Decisions that have to be made quickly are made by knowledgeable front-line personnel who are closest to the problem. Less reliable organizations show misplaced deference to authority figures. While nurses, no doubt, can cite many examples of misplaced deference to physicians, there are instances where physicians have assumed that nurses have the authority to make decisions and act, resulting in a diffusion of responsibility. When it comes to decisions that need to be made quickly, implicit assumptions need to be made explicit; rules of engagement need to be clearly established; and deference must be given to those with the expertise, resources, and availability to help the patient.
It should be noted that not everyone in health care has been receptive to comparisons between health care delivery and the activities that take place in other high-risk industries such as aircraft carrier operations or nuclear power. Health care is not aviation; it is more complex and qualitatively different. While all of this may be true, it probably also is true that health care is the most poorly managed of all the high-risk industries and very late in coming to recognize the importance of system factors that underlie adverse events. The one thing that the other high-risk industries clearly have in common with health care is the human component. Sailors that work the decks of aircraft carriers have the same physiologies as those who work the hospital floor. They get fatigued from excessive hours of operation in the same way as those who occupy the nurses station. When the technology and equipment they 16
use is poorly designed and confusing to use, they get frustrated and make similar types of mistakes as those in health care who have to use poorly designed medical devices. When the pace of operations pick up and they are bombarded with interruptions, short-term memory fails them in exactly the same way that it fails those who work in hectic EDs and ICUs. They respond to variations in the physical environment (e.g., lighting, noise, workplace layout) and to social/organizational pressures (e.g., group norms, culture, authority gradients) in a very similar fashion to those in health care who are exposed to the same set of factors. While the nature of the work may be dramatically different, the types of system factors that influence human performance are indeed very similar. The take-home message of all this is that the human factors studies that have been conducted in the other high-risk industries are very relevant to health care, and nursing in particular, as we continue to learn to improve the skills, processes, and system alignments that are needed for higher quality and safer care.
Conclusion
The complex and demanding clinical environment of nurses can be made a bit more understandable and easier in which to deliver care by accounting for a wide range of human factors concerns that directly and indirectly impact human performance. Human factors is the application of scientific knowledge about human strengths and limitations to the design of systems in the work environment to ensure safe and satisfying performance. A human factors framework such as that portrayed in Figure 1 helps us become aware of the salient components and their relationships that shape and influence the quality of care that is provided to patients. The concept of human error is a somewhat loaded term. Rather than falling into the trap of uncritically focusing on human error and searching for individuals to blame, a systems approach attempts to identify the contributing factors to substandard performance and find ways to better detect, recover from, or preclude problems that could result in harm to patients. Starting with the individual characteristics of providers such as their knowledge, skills, and sensory/physical capabilities, we examined a hierarchy of system factors, including the nature of the work performed, the physical environment, human-system interfaces, the organizational/social environment, management, and external factors. In our current fragmented health care system, where no single individual or entity is in charge, these multiple factors seem to be continuously misaligned and interact in a manner that leads to substandard care. These are the proverbial accidents in the system waiting to happen. Nurses serve in a critical role at the point of patient care; they are in an excellent position to not only identify the problems, but to help identify the problems-behind-the-problems. Nurses can actively practice the tenets of high-reliability organizations. It is recognized, of course, that nursing cannot address the system problems all on its own. Everyone who has a potential impact on patient care, no matter how remote (e.g., device manufacturers, administrators, nurse managers), needs to be mindful of the interdependent system factors that they play a role in shaping. Without a clear and strong nursing voice and an organizational climate that is conducive to candidly addressing system problems, efforts to improve patient safety and quality will fall short of their potential.
17
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Chapter 6. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically
Patricia Benner, Ronda G. Hughes, Molly Sutphen
Background
This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinicians ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.
Critical Thinking
Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years.1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based.2 A more expansive general definition of critical thinking is . . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations.3 There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice4 (p. 268). Scheffer and Rubenfeld5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition: Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge6 (Scheffer & Rubenfeld, p. 357).
The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as: the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research7 (p. 8). These concepts are furthered by the American Association of Colleges of Nurses definition of critical thinking in their Essentials of Baccalaureate Nursing: Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity8 (p. 9). Course work or ethical experiences should provide the graduate with the knowledge and skills to: Use nursing and other appropriate theories and models, and an appropriate ethical framework; Apply research-based knowledge from nursing and the sciences as the basis for practice; Use clinical judgment and decision-making skills; Engage in self-reflective and collegial dialogue about professional practice; Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals; 8 Engage in creative problem solving (p. 10). Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable. Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practiceall distinct from critical reflectionhave been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking. The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness.9
The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual.1012 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members. By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patients health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.
An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs. Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patients particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions. Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern19 has called excellent clinical ethical reasoning emotional reasoning in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge.19, 20 Clergy educators21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character developmentincluding emotional engagement, perception, habits of thought, and skill acquisitionas essential to the development of expert clinical reasoning, judgment, and action.10, 2224 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their disciplines tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinicians ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought. Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While
scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop yes and no judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time.25, 26
assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinicians understanding of the patients condition) fall into the Greek Aristotelian category of phronesis. Dewey32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality. In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patients condition and treatment.27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients.11, 22 Rational calculations available to technepopulation trends and statistics, algorithmsare created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinicians understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.
Thinking Critically
Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care;33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation.34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning.5 Ones ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects.3537 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking.5, 9 Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence.38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues,39 patient conditions, availability of resources,40 knowledge, and experience.41 Of these, experience has been shown to enhance nurses abilities to make quick decisions42 and fewer decision errors,43 support the identification of salient cues, and foster the recognition and action on patterns of information.44, 45 Clinicians must develop the character and relational skills that enable them to perceive and understand their patients needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to 6
pay attention and intelligently discern changes in patients concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care. Formation of the clinicians character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes, A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated themand whether this is not the whole point of MacIntyres recipe of withdrawal, as well as of the post-modern story of dispossession11 (p. 378). Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care. Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act.46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process.11, 30, 47 In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them: Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtuesthese corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past30 (p. 207). It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many 7
aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.
Experience
One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions by the situation as it unfolds rather than by preset goals48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience.48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time.48 Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey49 notes that experience requires a prepared creature and an enriched environment. The opportunity to reflect and narrate ones experiential learning can clarify, extend, or even refute experiential learning. Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice.50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance.51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise.52 The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response: Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience In our experience we bring
nothing to a close; we are constantly learning new things from our experience this I call the interminability of all experience32 (p. 403). Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant.53 Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nursesand it could be argued experienced as wellcan use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients needs, responses, and situation,54 a process that requires critical thinking and decisionmaking.55, 56 Using guidelines also reflects ones problem identification and problemsolving abilities.56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise.39, 57 Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses thinking moves from steps and procedures (i.e., task-oriented care) toward chunks or patterns39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation.34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking.39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation.48 Expert nurses can perform highlevel care without conscious awareness of the knowledge they are using,39, 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care.39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge.59, 60 Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation.22 Some have proposed that expert nurses provide high-quality patient care,61, 62 but that is not consistently documentedparticularly in consideration of patient outcomesand a full understanding between the differential impact of care rendered by an expert nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes.63, 64 In a review of the literature on expertise in nursing, Ericsson and colleagues65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurses ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients.39
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intended to provide guidance for specific areas of health care delivery.84 The clinicianboth the novice and expertis expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.
Evaluating Evidence
Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patientsa complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient. Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patients concerns and condition and/or the clinicians understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patients concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.
Sources of Evidence
Evidence that can be used in clinical practice has different sources and can be derived from research, patients preferences, and work-related experience.85, 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and researchbased knowledge87 as well as other sources. For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studiedwhich may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment. Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patients particular pathophysiology or 11
care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patients known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patients illness and recovery, and available resources. In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinicians sense of salience in any given situation depends on past clinical experience and current scientific evidence.
Evidence-Based Practice
The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients.88, 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently. Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient.90, 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patients lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice. Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patients condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses92 and their risks.93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely.94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive. The judgment of the patients condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences.95 Nurses use knowledge from clinical experience96, 97 andalthough infrequentlyresearch.98100 Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence101 and evaluates potential discrepancies. The process of using evidence in practice involves a problem-solving approach that incorporates the best available scientific evidence, clinicians expertise, and 12
patients preferences and values102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice.103 Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice,104, 105 amount of time required to access information and determine practice implications,105107 lack of organizational support to make changes and/or use in practice,104, 97, 105, 107 and lack of confidence in ones ability to critically evaluate clinical evidence.108
To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the professions fundamental purposes.109 This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training. Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous students comments: With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasnt going to school, Id be doing it because I was told to be doing itor Id be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why Im doing it and the clinical reasons of why theyre making the decisions, and the prioritization that goes on behind it. I think thats the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand whats going on and why. The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in crossprofessional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning. Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence. Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social,
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dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.
Clinical Grasp *
Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan20 described the clinicians attempt at finding an optimal grasp or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.
Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving
Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patients responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made. We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in detective work. Students are given the daily clinical assignment of sleuthing for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the
This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard.23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.
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student whether she had asked the nurse or the patient about the dosage. Upon the students questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patients staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of critical reflection, but stays situated and engaged, ferreting out the immediate history and unfolding of events.
Clinical Forethought
Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected. Future think. Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurses attentiveness to 16
the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events. Clinical forethought about specific diagnoses and injuries. This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as obvious preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients. Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victims potential injuries, and recognizing that intubation might be needed. Anticipation of crises, risks, and vulnerabilities for particular patients. This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patients problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing lifesustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning. When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient: I was used to different equipment and didnt know how things went, didnt know their routine, really. You can explain all you want in class, this is how its going to be, but when you get there . Kim was my first instructor and my patient that she assigned me toI walked into the room and he had every tube imaginable. And so I was a little overwhelmed. Its not necessarily even that he was that critical . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I dont really feel comfortable doing it by myself, without you watching to make sure that Im flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that its all kosher and whatever. So she went through the chest tube and explained, its just bubbling a little bit and thats okay. The site, check the site. The site looked okay and that shed say if it wasnt okay, this is what it might look like . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadnt really done too much with the feeding stuff either . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was
17
clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I cant even remember but there were a lot. As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference: So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didnt tell the student to say this, but she said, I just want to tell you what I did today in clinical so you dont do the same thing, and heres what happened. Everybodys listening very attentively and they were asking her some questions. But she shared that. She didnt have to. I didnt tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them. The teachers response to this students honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on being correct prevents learning from breakdown or error and can dampen students curiosity and courage to learn experientially. Seeing the unexpected. One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical certainty associated with perceptual grasp is distinct from the kind of certainty achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to face recognition or recognition of family resemblances. This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present.111 The relationship between foreground and 18
background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected.20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.
Conclusion
Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.
Author Affiliation
Patricia Benner, R.N., Ph.D., F.A.A.N., Carnegie Foundation for the Advancement of Teaching. E-mail: [email protected]. Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: [email protected]. Molly Sutphen, Ph.D., Carnegie Foundation for the Advancement of Teaching. E-mail: [email protected].
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Background
Overview of Evidence-Based Practice
Evidence-based health care practices are available for a number of conditions such as asthma, heart failure, and diabetes. However, these practices are not always implemented in care delivery, and variation in practices abound.14 Traditionally, patient safety research has focused on data analyses to identify patient safety issues and to demonstrate that a new practice will lead to improved quality and patient safety.5 Much less research attention has been paid to how to implement practices. Yet, only by putting into practice what is learned from research will care be made safer.5 Implementing evidence-based safety practices are difficult and need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and ultimatelychanging health care cultures to be evidence-based safety practice environments.5 Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6 9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated by Nightingale,10 the nursing profession has more recently provided major leadership for improving care through application of research findings in practice.11 Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.1215 Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decisionmaking is derived principally from nonresearch evidence sources such as expert opinion and scientific principles.16 As more research is done in a specific area, the research evidence must be incorporated into the EBP.15
A recent conceptual framework for maximizing and accelerating the transfer of research results from the Agency for Healthcare Research and Quality (AHRQ) patient safety research portfolio to health care delivery was developed by the dissemination subcommittee of the AHRQ Patient Safety Research Coordinating Committee.37 This model is a synthesis of concepts from scientific information on knowledge transfer, social marketing, social and organizational innovation, and behavior change (see Figure 1).37 Although the framework is portrayed as a series of stages, the authors of this framework do not believe that the knowledge transfer process is linear; rather, activities occur simultaneously or in different sequences, with implementation of EBPs being a multifaceted process with many actors and systems.
to adopt and consistently use evidence-based research findings and innovations in everyday practice. Implementing and sustaining EBPs in health care settings involves complex interrelationships among the EBP topic (e.g., reduction of medication errors), the organizational social system characteristics (such as operational structures and values, the external health care environment), and the individual clinicians.35, 3739 A variety of strategies for implementation include using a change champion in the organization who can address potential implementation challenges, piloting/trying the change in a particular patient care area of the organization, and using multidisciplinary implementation teams to assist in the practical aspects of embedding innovations into ongoing organizational processes.35, 37 Changing practice takes considerable effort at both the individual and organizational level to apply evidence-based information and products in a particular context.22 When improvements in care are demonstrated in the pilot studies and communicated to other relevant units in the organization, key personnel may then agree to fully adopt and sustain the change in practice. Once the EBP change is incorporated into the structure of the organization, the change is no longer considered an innovation but a standard of care.22, 37 In comparison, other models of EBP (e.g., Iowa Model of Evidence-based Practice to Promote Quality of Care16) view the steps of the EBP process from the perspective of clinicians and/or organizational/clinical contexts of care delivery. When viewing steps of the EBP process through the lens of an end user, the process begins with selecting an area for improving care based on evidence (rather than asking what findings ought to be disseminated); determining the priority of the potential topic for the organization; formulating an EBP team composed of key stakeholders; finding, critiquing, and synthesizing the evidence; setting forth EBP recommendations, with the type and strength of evidence used to support each clearly documented; determining if the evidence findings are appropriate for use in practice; writing an EBP standard specific to the organization; piloting the change in practice; implementing changes in practice in other relevant practice areas (depending on the outcome of the pilot); evaluating the EBP changes; and transitioning ongoing quality improvement (QI) monitoring, staff education, and competency review of the EBP topic to appropriate organizational groups as defined by the organizational structure.15, 40 The work of EBP implementation from the perspective of the end user is greatly facilitated by efforts of AHRQ, professional nursing organizations (e.g., Oncology Nursing Society), and others that distill and package research findings into useful products and tools for use at the point of care delivery. When the clinical questions of end users can be addressed through use of existing evidence that is packaged with end users in mind, steps of the EBP process take less time and more effort can be directed toward the implementation, evaluation, and sustainability components of the process. For example, finding, critiquing, and synthesizing the evidence; setting forth EBP recommendations with documentation of the type and strength of evidence for each recommendation; and determining appropriateness of the evidence for use in practice are accelerated when the knowledge-based information is readily available. Some distilled research findings also include quick reference guides that can be used at the point of care and/or integrated into health care information systems, which also helps with implementation.41, 42
promoting and sustaining adoption of EBPs. Examples of translation studies include describing facilitators and barriers to knowledge uptake and use, organizational predictors of adherence to EBP guidelines, attitudes toward EBPs, and defining the structure of the scientific field.11, 4749 Translation science must be guided by a conceptual model that organizes the strategies being tested, elucidates the extraneous variables (e.g., behaviors and facilitators) that may influence adoption of EBPs (e.g., organizational size, characteristics of users), and builds a scientific knowledge base for this field of inquiry.15, 50 Conceptual models used in the translating-researchinto-practice studies funded by AHRQ were adult learning, health education, social influence, marketing, and organizational and behavior theories.51 Investigators have used Rogerss Diffusion of Innovation model,35, 39, 5255 the Promoting Action on Research Implementation in Health Services (PARIHS) model,29 the push/pull framework,23, 56, 57 the decisionmaking framework,58 and the Institute for Healthcare Improvement (IHI) model59 in translation science. Study findings regarding evidence-based practices in a diversity of health care settings are building an empirical foundation of translation science.19, 43, 51, 6083 These investigations and others18, 8486 provide initial scientific knowledge to guide us in how to best promote use of evidence in practice. To advance knowledge about promoting and sustaining adoption of EBPs in health care, translation science needs more studies that test translating research into practice (TRIP) interventions: studies that investigate what TRIP interventions work, for whom, in what circumstances, in what types of settings; and studies that explain the underlying mechanisms of effective TRIP interventions.35, 49, 79, 87 Partnership models, which encourage ongoing interaction between researchers and practitioners, may be the way forward to carry out such studies.56 Challenges, issues, methods, and instruments used in translation research are described elsewhere.11, 19, 49, 78, 8897
Research Evidence
What Is Known About Implementing Evidence-Based Practices?
Multifaceted implementation strategies are needed to promote use of research evidence in clinical and administrative health care decisionmaking.15, 22, 37, 45, 64, 72, 77, 79, 98, 99 Although Grimshaw and colleagues65 suggest that multifaceted interventions are no more effective than single interventions, context (site of care delivery) was not incorporated in the synthesis methodology. As noted by others, the same TRIP intervention may meet with varying degrees of effectiveness when applied in different contexts.35, 49, 79, 80, 87, 100, 101 Implementation strategies also need to address both the individual practitioner and organizational perspective.15, 22, 37, 64, 72, 77, 79, 98 When practitioners decide individually what evidence to use in practice, considerable variability in practice patterns result,71 potentially resulting in adverse patient outcomes. For example, an individual perspective of EBP would leave the decision about use of evidence-based endotracheal suctioning techniques to each nurse and respiratory therapist. Some individuals may be familiar with the research findings for endotracheal suctioning while others may not. This is likely to result in different and conflicting practices being used as people change shifts every 8 to 12 hours. From an organizational perspective, endotracheal suctioning policies and procedures based on research are written, the evidence-based information is integrated into the clinical information systems, and adoption of these practices by nurses and other practitioners is systematically promoted in the organization. This includes assuring that practitioners have the
necessary knowledge, skills, and equipment to carry out the evidence-based endotracheal suctioning practice. The organizational governance supports use of these practices through various councils and committees such as the Practice Committee, Staff Education Committee, and interdisciplinary EBP work groups. The Translation Research Model,35 built on Rogerss seminal work on diffusion of innovations,39 provides a guiding framework for testing and selecting strategies to promote adoption of EBPs. According to the Translation Research Model, adoption of innovations such as EBPs are influenced by the nature of the innovation (e.g., the type and strength of evidence, the clinical topic) and the manner in which it is communicated (disseminated) to members (nurses) of a social system (organization, nursing profession).35 Strategies for promoting adoption of EBPs must address these four areas (nature of the EBP topic; users of the evidence; communication; social system) within a context of participative change (see Figure 2). This model provided the framework for a multisite study that tested the effectiveness of a multifaceted TRIP intervention designed to promote adoption of evidence-based acute pain management practices for hospitalized older adults. The intervention improved the quality of acute pain management practices and reduced costs.81 The model is currently being used to test the effectiveness of a multifaceted TRIP intervention to promote evidence-based cancer pain management of older adults in home hospice settings. * This guiding framework is used herein to overview what is known about implementation interventions to promote use of EBPs in health care systems (see Evidence Table).
Principal Investigator: Keela Herr (R01 grant no. CA115363-01; National Cancer Institute (NCI))
computer decision-support software that integrates evidence for use in clinical decisionmaking about individual patients.40, 104, 111114 There is still much to learn about the best manner of deploying evidence-based information through electronic clinical information systems to support evidence-based care.115
Methods of Communication
Interpersonal communication channels, methods of communication, and influence among social networks of users affect adoption of EBPs.39 Use of mass media, opinion leaders, change champions, and consultation by experts along with education are among strategies tested to promote use of EBPs. Education is necessary but not sufficient to change practice, and didactic continuing education alone does little to change practice behavior.61, 116 There is little evidence that interprofessional education as compared to discipline-specific education improves EBP.117 Interactive education, used in combination with other practice-reinforcing strategies, has more positive effects on improving EBP than didactic education alone.66, 68, 71, 74, 118, 119 There is evidence that mass media messages (e.g., television, radio, newspapers, leaflets, posters and pamphlets), targeted at the health care consumer population, have some effect on use of health services for the targeted behavior (e.g., colorectal cancer screening). However, little empirical evidence is available to guide framing of messages communicated through planned mass media campaigns to achieve the intended change.120 Several studies have demonstrated that opinion leaders are effective in changing behaviors of health care practitioners,22, 68, 79, 100, 116, 121123 especially in combination with educational outreach or performance feedback. Opinion leaders are from the local peer group, viewed as a respected source of influence, considered by associates as technically competent, and trusted to judge the fit between the innovation and the local situation.39, 116, 121, 124127 With their wide sphere of influence across several microsystems/units, opinion leaders use of the innovation influences peers and alters group norms.39,128 The key characteristic of an opinion leader is that he or she is trusted to evaluate new information in the context of group norms. Opinion leadership is multifaceted and complex, with role functions varying by the circumstances, but few successful projects to implement innovations in organizations have managed without the input of identifiable opinion leaders.22, 35, 39, 81, 96 Social interactions such as hallway chats, one-on-one discussions, and addressing questions are important, yet often overlooked components of translation.39, 59 Thus, having local opinion leaders discuss the EBPs with members of their peer group is necessary to translate research into practice. If the EBP that is being implemented is interdisciplinary in nature, discipline-specific opinion leaders should be used to promote the change in practice.39 Change champions are also helpful for implementing innovations.39, 49, 81, 129131 They are practitioners within the local group setting (e.g., clinic, patient care unit) who are expert clinicians, passionate about the innovation, committed to improving quality of care, and have a positive working relationship with other health care professionals.39, 125, 131, 132 They circulate information, encourage peers to adopt the innovation, arrange demonstrations, and orient staff to the innovation.49, 130 The change champion believes in an idea; will not take no for an answer; is undaunted by insults and rebuffs; and, above all, persists.133 Because nurses prefer interpersonal contact and communication with colleagues rather than Internet or traditional sources of practice knowledge,134137 it is imperative that one or two change champions be identified for each patient care unit or clinic where the change is being made for EBPs to be enacted by direct care providers.81, 138 Conferencing with opinion leaders and change champions 6
periodically during implementation is helpful to address questions and provide guidance as needed.35, 66, 81, 106 Because nurses preferred information source is through peers and social interactions,134 137, 139, 140 using a core group in conjunction with change champions is also helpful for implementing the practice change.16, 110, 141 A core group is a select group of practitioners with the mutual goal of disseminating information regarding a practice change and facilitating the change by other staff in their unit/microsystem.142 Core group members represent various shifts and days of the week and become knowledgeable about the scientific basis for the practice; the change champion educates and assists them in using practices that are aligned with the evidence. Each member of the core group, in turn, takes the responsibility for imparting evidence-based information and effecting practice change with two or three of their peers. Members assist the change champion and opinion leader with disseminating the EBP information to other staff, reinforce the practice change on a daily basis, and provide positive feedback to those who align their practice with the evidence base.15 Using a core-group approach in conjunction with a change champion results in a critical mass of practitioners promoting adoption of the EBP.39 Educational outreach, also known as academic detailing, promotes positive changes in practice behaviors of nurses and physicians.22, 64, 66, 71, 74, 75, 77, 81, 119, 143 Academic detailing is done by a topic expert, knowledgeable of the research base (e.g., cancer pain management), who may be external to the practice setting; he or she meets one-on-one with practitioners in their setting to provide information about the EBP topic. These individuals are able to explain the research base for the EBPs to others and are able to respond convincingly to challenges and debates.22 This strategy may include providing feedback on provider or team performance with respect to selected EBP indicators (e.g., frequency of pain assessment).66, 81, 119
individual physicians practices can be effective but may be perceived as punitive; data feedback must persist to sustain improved performance; and effectiveness of data feedback is intertwined with the organizational context, including physician leadership and organizational culture.60 Hysong and colleagues67 found that high-performing institutions provided timely, individualized, nonpunitive feedback to providers, whereas low performers were more variable in their timeliness and nonpunitiveness and relied more on standardized, facility-level reports. The concept of useful feedback emerged as the core concept around which timeliness, individualization, nonpunitiveness, and customizability are important. Users of an innovation usually try it for a period of time before adopting it in their practice.22, 39, 147 When trying an EBP (piloting the change) is incorporated as part of the implementation process, users have an opportunity to use it for a period of time, provide feedback to those in charge of implementation, and modify the practice if necessary.148 Piloting the EBP as part of implementation has a positive influence on the extent of adoption of the new practice.22, 39, 148 Characteristics of users such as educational preparation, practice specialty, and views on innovativeness may influence adoption of an EBP, although findings are equivocal.27, 39, 130, 149 153 Nurses disposition to critical thinking is, however, positively correlated with research use,154 and those in clinical educator roles are more likely to use research than staff nurses or nurse managers.155
Social System
Clearly, the social system or context of care delivery matters when implementing EBPs.2, 30, 33, 39, 60, 84, 85, 91, 92, 101, 156163 For example, investigators demonstrated the effectiveness of a prompted voiding intervention for urinary incontinence in nursing homes, but sustaining the intervention in day-to-day practice was limited when the responsibility of carrying out the intervention was shifted to nursing home staff (rather than the investigative team) and required staffing levels in excess of a majority of nursing home settings.164 This illustrates the importance of embedding interventions into ongoing processes of care. Several organizational factors affect adoption of EBPs.22, 39, 79, 134, 165167 Vaughn and colleagues101 demonstrated that organizational resources, physician full-time employees (FTEs) per 1,000 patient visits, organizational size, and whether the facility was located in or near a city affected use of evidence in the health care system of the Department of Veterans Affairs (VA). Large, mature, functionally differentiated organizations (e.g., divided into semiautonomous departments and units) that are specialized, with a focus of professional knowledge, slack resources to channel into new projects, decentralized decisionmaking, and low levels of formalization will more readily adopt innovations such as new practices based on evidence. Larger organizations are generally more innovative because size increases the likelihood that other predictors of innovation adoptionsuch as slack financial and human resources and differentiationwill be present. However, these organizational determinants account for only about 15 percent of the variation in innovation adoption between comparable organizations.22 Adler and colleagues168 hypothesize that while more structurally complex organizations may be more innovative and hence adopt EBPs relatively early, less structurally complex organizations may be able to diffuse EBPs more effectively. Establishing semiautonomous teams is associated with successful implementation of EBPs, and thus should be considered in managing organizational units.168170
As part of the work of implementing EBPs, it is important that the social systemunit, service line, or clinicensures that policies, procedures, standards, clinical pathways, and documentation systems support the use of the EBPs.49, 68, 72, 73, 103, 140, 171 Documentation forms or clinical information systems may need revision to support changes in practice; documentation systems that fail to readily support the new practice thwart change.82 Absorptive capacity for new knowledge is another social system factor that affects adoption of EBPs. Absorptive capacity is the knowledge and skills to enact the EBPs; the strength of evidence alone will not promote adoption. An organization that is able to systematically identify, capture, interpret, share, reframe, and recodify new knowledge, and put it to appropriate use, will be better able to assimilate EBPs.82, 103, 172, 173 A learning organizational culture and proactive leadership that promotes knowledge sharing are important components of building absorptive capacity for new knowledge.66, 139, 142, 174 Components of a receptive context for EBP include strong leadership, clear strategic vision, good managerial relations, visionary staff in key positions, a climate conducive to experimentation and risk taking, and effective data capture systems. Leadership is critical in encouraging organizational members to break out of the convergent thinking and routines that are the norm in large, well-established organizations.4, 22, 39, 122, 148, 163, 175 An organization may be generally amenable to innovations but not ready or willing to assimilate a particular EBP. Elements of system readiness include tension for change, EBPsystem fit, assessment of implications, support and advocacy for the EBP, dedicated time and resources, and capacity to evaluate the impact of the EBP during and following implementation. If there is tension around specific work or clinical issues and staff perceive that the situation is intolerable, a potential EBP is likely to be assimilated if it can successfully address the issues, and thereby reduce the tension.22, 175 Assessing and structuring workflow to fit with a potential EBP is an important component of fostering adoption. If implications of the EBP are fully assessed, anticipated, and planned for, the practice is more likely to be adopted.148, 162, 176 If supporters for a specific EBP outnumber and are more strategically placed within the organizational power base than opponents, the EBP is more likely to be adopted by the organization.60, 175 Organizations that have the capacity to evaluate the impact of the EBP change are more likely to assimilate it. Effective implementation needs both a receptive climate and a good fit between the EBP and intended adopters needs and values.22, 60, 140, 175, 177 Leadership support is critical for promoting use of EBPs.33, 59, 72, 85, 98, 122, 178181 This support, which is expressed verbally, provides necessary resources, materials, and time to fulfill assigned responsibilities.148, 171, 182, 183 Senior leaders need to create an organizational mission, vision, and strategic plan that incorporate EBP; implement performance expectations for staff that include EBP work; integrate the work of EBP into the governance structure of the health care system; demonstrate the value of EBPs through administrative behaviors; and establish explicit expectations that nurse leaders will create microsystems that value and support clinical inquiry.122, 183, 184 A recent review of organizational interventions to implement EBPs for improving patient care examined five major aspects of patient care. The review suggests that revision of professional roles (changing responsibilities and work of health professionals such as expanding roles of nurses and pharmacists) improved processes of care, but it was less clear about the effect on improvement of patient outcomes. Multidisciplinary teams (collaborative practice teams of physicians, nurses, and allied health professionals) treating mostly patients with prevalent
chronic diseases resulted in improved patient outcomes. Integrated care services (e.g., disease management and case management) resulted in improved patient outcomes and cost savings. Interventions aimed at knowledge management (principally via use of technology to support patient care) resulted in improved adherence to EBPs and patient outcomes. The last aspect, quality management, had the fewest reviews available, with the results uncertain. A number of organizational interventions were not included in this review (e.g., leadership, process redesign, organizational learning), and the authors note that the lack of a widely accepted taxonomy of organizational interventions is a problem in examining effectiveness across studies.82 An organizational intervention that is receiving increasing attention is tailored interventions to overcome barriers to change.162, 175, 185 This type of intervention focuses on first assessing needs in terms of what is causing the gap between current practice and EBP for a specified topic, what behaviors and/or mechanism need to change, what organizational units and persons should be involved, and identification of ways to facilitate the changes. This information is then used in tailoring an intervention for the setting that will promote use of the specified EBP. Based on a recent systematic review, effectiveness of tailored implementation interventions remains uncertain.185 In summary, making an evidence-based change in practice involves a series of action steps and a complex, nonlinear process. Implementing the change will take several weeks to months, depending on the nature of the practice change. Increasing staff knowledge about a specific EBP and passive dissemination strategies are not likely to work, particularly in complex health care settings. Strategies that seem to have a positive effect on promoting use of EBPs include audit and feedback, use of clinical reminders and practice prompts, opinion leaders, change champions, interactive education, mass media, educational outreach/academic detailing, and characteristics of the context of care delivery (e.g., leadership, learning, questioning). It is important that senior leadership and those leading EBP improvements are aware of change as a process and continue to encourage and teach peers about the change in practice. The new practice must be continually reinforced and sustained or the practice change will be intermittent and soon fade, allowing more traditional methods of care to return.15
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to converse with busy clinicians about the evidence-based rationale for doing fall-risk assessment, and to help them understand that fall-risk assessment is an external regulatory agency expectation because the strength of the evidence supports this patient safety practice. Third, didactic education alone is never enough to change practice; one-time education on a specific safety initiative is not enough. Simply improving knowledge does not necessarily improve practice. Rather, organizations must invest in the tools and skills needed to create a culture of evidence-based patient safety practices where questions are encouraged and systems are created to make it easy to do the right thing. Fourth, the context of EBP improvements in patient safety need to be addressed at each step of the implementation process; piloting the change in practice is essential to determine the fit between the EBP patient safety information/innovation and the setting of care delivery. There is no one way to implement, and what works in one agency may need modification to fit the organizational culture of another context. Finally, it is important to evaluate the processes and outcomes of implementation. Users and stakeholders need to know that the efforts to improve patient safety have a positive impact on quality of care. For example, if a new barcoding system is being used to administer blood products, it is imperative to know that the steps in the process are being followed (process indicators) and that the change in practice is resulting in fewer blood product transfusion errors (outcome indicators).
Research Implications
Translation science is young, and although there is a growing body of knowledge in this area, we have, to date, many unanswered questions. These include the type of audit and feedback (e.g., frequency, content, format) strategies that are most effective, the characteristics of opinion leaders that are critical for success, the role of specific context variables, and the combination of strategies that are most effective. We also know very little about use of tailored implementation interventions, or the key context attributes to assess and use in developing and testing tailored interventions. The types of clinical reminders that are most effective for making EBP knowledge available at the point of care require further empirical explanation. We also know very little about the intensity and intervention dose of single and multifaceted strategies that are effective for promoting and sustaining use of EBPs or how the effectiveness differs by type of topic (e.g., simple versus complex). Only recently has the context of care delivery been acknowledged as affecting use of evidence, and further empirical work is needed in this area to understand how complex adaptive systems of practice incorporate knowledge acquisition and use. Lastly, we do not know what strategies or combination of strategies work for whom, in what context, why they work in some settings or cases and not others, and what is the mechanism by which these strategies or combination of strategies work. This is an exciting area of investigation that has a direct impact on implementing patient safety practices. In planning investigations, researchers must use a conceptual model to guide the research and add to the empirical and theoretical understanding of this field of inquiry. Additionally, funding is needed for implementation studies that focus on evidence-based patient safety practices as the topic of concern. To generalize empirical findings from patient safety implementation studies, we must have a better understanding of what implementation strategies work, with whom, and in what types of settings, and we must investigate the underlying
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mechanisms of these strategies. This is likely to require mixed methods, a better understanding of complexity science, and greater appreciation for nontraditional methods and realistic inquiry.87
Conclusion
Although the science of translating research into practice is fairly new, there is some guiding evidence of what implementation interventions to use in promoting patient safety practices. However, there is no magic bullet for translating what is known from research into practice. To move evidence-based interventions into practice, several strategies may be needed. Additionally, what works in one context of care may or may not work in another setting, thereby suggesting that context variables matter in implementation.80
Author Affiliation
University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care. Address correspondence to: Marita G. Titler, Ph.D., R.N., F.A.A.N., University of Iowa Hospitals and Clinics, Department of Nursing Services and Patient Care, 200 Hawkins Drive RM T10 GH, Iowa City, IA 52242-1009; e-mail: [email protected].
Search Strategy
Several electronic databases were searched (MEDLINE, CINAHL, PubMed) using terms of evidence-based practice research, implementation research, and patient safety. (The terms quality improvement or quality improvement intervention research were not used.) The Cochrane CollaborationCochrane Reviews was also searched to look for systematic reviews of specific implementation strategies, and the Journal of Implementation Science was also reviewed. I also requested the final reports of the TRIP I and TRIP II studies funded by AHRQ. Classic articles known to the author were also included in this chapter (e.g., Locock et al.123 ).
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Evidence-Based Practice Implementation
Adapted from Nieva, V., Murphy, R., Ridley, N., et al.37 Used with permission. http://www.ahrq.gov/qual/advances/
Social System
Communication Process
Communication
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Issue Related to EBP Assess the implementation methods for 4 clinical practice guidelines (CPGs) in the VA health care system.
Study Design & Study Outcome Measure(s) Survey methods with questionnaire sent to 416 quality managers, primary care administrators, or others involved with guideline implementation in primary care at 143 VA medical centers with primary care clinics (level 9). Modified Dillman method was used. Outcomes: methods used to implement guidelines (level 4).
Study Setting & Study Population Primary care clinics of VA medical centers. Study population is individual responsible for guideline implementation. 242 surveys returned from 130 hospitals. CPGs were chronic obstructive pulmonary disease (COPD), diabetes, heart failure, and major depressive disorder.
Study Intervention Total number of interventions used were counted and type of interventions used to implement CPGs were categorized as consistently effective, variably effective, and minimally effective, based on Beros categories: Consistently effective: - Forms created/revised - Computer interactive education - Internet discussion groups - Responsibilities of nonphysicians changed academic detailing Variably effective: - CPG workgroup - Clinical meetings to discuss CPG Minimally effective: - Providers receive brief summary - Providers receive CPG - Providers receive pocket guide - Storyboards - Instructional tape of CPG - Grand rounds
Key Findings Commonly used approaches were clinical meetings to discuss guidelines (variably effective/Beros classification), provider receipt of brief summary (minimally effective classification), forms created or revised (consistently effective classification), responsibilities of nonphysicians revised (consistently effective classification). Most facilities used 47 approaches. Consistently and minimally effective approaches were used most frequently. Strategies used together almost always included one consistently effective approach.
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Issue Related to EBP Describe the implementation process for the Hospital Elder Life Program (HELP)an evidence-based program for improving care of older patients.
Study Design & Study Outcome Measure(s) Qualitative analyses of implementation process at the beginning of implementation and every 6 months for up to 18 months.
Study Setting & Study Population 8 hospitals implementing HELP. In-depth, open-ended interviews were conducted by telephone with physicians, nurses, volunteers, and administrative staff involved in the HELP implementation.
Study Intervention
Key Findings Major themes in implementing the HELP program were (1) gain internal support for the program, recognizing diverse requirements and goals; (2) ensure effective clinical leadership in multiple roles; (3) integrate with existing geriatric programs to foster coordination rather than competition; (4) balance program fidelity with hospitalspecific circumstances; (5) document and publicize positive outcomes; (6) maintain momentum while changing practice and shifting organizational culture.
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Issue Related to EBP Identify key themes about effective approaches for data feedback as well as pitfalls to avoid in using data feedback to support performance improvement efforts.
Study Design & Study Outcome Measure(s) Qualitative study with open-ended interviews of clinical and administrative staff at 8 hospitals representing a range of sizes, geographical regions, and beta-blocker use rate after AMI (level 9). Outcomes = key themes in use of data feedback.
Study Setting & Study Population 8 hospitals. Interviewed physicians (n = 14), nurses (n = 15), quality management (n = 11), and administrative (n = 5) staff who were identified as key in improving care of patients with AMI.
Study Intervention Data feedback for improving performance of beta-blocker use after AMI.
Key Findings 7 major themes: Data must be perceived by physicians as valid to motivate change. It takes time to develop credibility of data within a hospital. The source and timeliness of the data are critical to perceived validity. Benchmarking improves the validity of the data feedback. Physician leaders can enhance the effectiveness of data feedback. Data feedback that profiles an individual physicians practices can be effective but may be perceived as punitive. Data feedback must persist to sustain improved performance. Effectiveness of data feedback might be intertwined with the organizational context, including physician leadership and organizational culture.
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Issue Related to EBP Evaluation of the relationship between physicians knowledge of hypertension guidelines and blood pressure (BP) control in their patients.
Study Design & Study Outcome Measure(s) Cross-sectional study of physicians knowledge about Joint National Committee (JNC) 7 hypertension guidelines (level 4). Outcomes were BP values of patients each physician treated.
Study Setting & Study Population Study setting was two academic primary care clinics located in the same academic medical center. The sample was 32 primary care physicians and 613 patients they treated. Mean age of physicians was 41 years (Standard Deviation [SD]. = 10.9), majority were men (66%).
Study Intervention Association between physician knowledge and BP control. Covariates of presence of diabetes, patient age.
Key Findings There was a strong inverse relationship between BP control rates and correct responses by physicians on the knowledge test (r = -0.524; p = .002). Strong correlation was also found between correct responses on the knowledge survey and a higher mean systolic BP (r = 0.453; p = .009). When the covariates of patient age and diabetes were added to the model, there was no longer a significant association between physician knowledge and BP control. However, the correlation (in the multivariate model) was still in the same direction; for every 5 points better on the knowledge test, there was a 16% decrease in the rate of BP control (p = .13), and for every 10 years increase in patient age, there was a 16% decrease in BP control (p = .04).
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Issue Related to EBP To determine the additive effect of additional support for organizational change techniques and chronic care management as they are added to the Health Disparities Collaborative initiatives to improve diabetes care in community health centers.
Study Design & Study Outcome Measure(s) 34 centers were randomized to a standardized intensity arm (Health Disparities Collaborative initiatives) or high intensity arm. (level 2). Outcomes included process of care measures; laboratory values based on American Diabetes Association (ADA) recommendations; and patient surveys of satisfaction with providers communication style and overall care, attitudes about interacting with providers, knowledge of ADA recommendations, and provider performance of key processes of care (levels 1 and 2).
Study Setting & Study Population 34 community health centers from the Midwest or West Central clusters that participated in the 199899 or 1999 2000 Diabetes Collaborative of the Bureau of Primary Health Care in Improving Diabetes Care Collaboratively in the Community. These centers care for the medically underserved. In the standard arm, there were 843 patients at baseline and 665 in the followup standard intensity group. 993 patients were in the high intensity arm at baseline and 818 postinterventions high intensity group. Mean age of subjects ranged from 56 to 58, a majority were female, and white.
Study Intervention All 34 centers were community health centers that are overseen by the Bureau of Primary Health Care and had participated in the Health Disparities Collaborative to improve diabetes care. Interventions included forming a QI team, adoption of the Plan-DoStudy-Act (PDSA) cycle for QI, learning sessions, data feedback, monthly teleconferences, and regional meetings over a year. The centers randomized to the standard intensity arm continued to receive quarterly data-feedback reports, conference calls with other centers, and a yearly in-person meeting with other health centers. The high intensity sites received the standard intensity interventions plus additional support in organizational change strategies, chronic care management, and strategies to engage patients in behavioral change designed to get them to be more active in their care.
Key Findings Centers in the high intensity arm showed higher rates of Hgb A1c and urine microalbumin assessment, eye exam, foot exam, dental referral, and increased prescription of home glucose monitoring postintervention as compared to the standard intensity arm. No significant differences by treatment arm were noted for patient survey data.
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Issue Related to EBP To estimate the effectiveness of persuasive interventions, restrictive interventions, and structural interventions (alone or in combination) in promoting prudent antibiotic prescribing to hospital inpatients.
Study Design & Study Outcome Measure(s) RCTs, quasi-randomized controlled trials, controlled before and after studies, and interrupted time series studies (levels 2 and 3). Outcomes were appropriate antibiotic prescribing and patient outcomes, including length of stay, inpatient mortality, and 28-day mortality (levels 1 and 2).
Study Setting & Study Population 66 studies (43 interrupted time series studies, 13 RCTs, 6 controlled before/after studies, 2 controlled clinical trials, 1 cluster clinical trial, 1 cluster randomized trial. The majority of studies (42) were from the United States. Study participants were health care professionals who prescribe antibiotics to hospitalized inpatients receiving acute care.
Study Intervention Interventions were categorized as persuasive interventions (distribution of educational materials; local consensus process; educational outreach visits; local opinion leaders; reminders provided verbally, on paper, or via the computer; audit and feedback), restrictive interventions (formulary restrictions, prior authorization requirements, therapeutic substations, automatic stop orders and antibiotic policy changes), and structural (changing from paper to computerized records, introduction of quality monitoring mechanisms).
Key Findings A wide variety of interventions has been shown to be effective in changing antibiotic prescribing for hospitalized patients. Restrictive interventions have a greater immediate impact than persuasive interventions, although their impact on clinical outcomes and longterm effects are uncertain.
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Issue Related to EBP To map research utilization as a field of study in nursing and identify the structure of this scientific community, including the current network of researchers.
Study Design & Study Outcome Measure(s) Bibliometric analysis to map the development and structure of the field. Outcomes were journal patterns of publication, country patterns of publication, author patterns of publication, references per article, co-occurrence of words, citation patterns, interdisciplinary flow of information, within field diffusion of information.
Study Setting & Study Population 630 articles (350 opinion articles, 65 conceptual articles, 112 research utilization studies, 103 research articles) published in 194 different journals.
Tested a basic and an augmented email reminder to improve evidence-based care of individuals with heart failure (HF) in home health care settings.
Prospective randomized trail with 3 groups (control, basic e-mail reminder, augmented email reminder). Outcome measures were nursing practices and patient outcomes. Level 1 outcomes.
Older adults with heart failure (n = 628; x age = 72) and nurses (n = 354; x age = 43.6; 93% female) caring for those patients. Home health care agency in a large urban setting.
Basic e-mail reminder upon patient admission to the nurses care that highlighted 6 HF-specific clinical practices for improving patient outcomes. Augmented intervention included basic e-mail reminder plus package of material for care of HF patient (medication management, prompter card for improving communication with physicians, self-care guide for patients) and followup outreach by a clinical nurse specialist (CNS) who served as an expert peer.
Key Findings On the basis of cocitation, scholars at the core of the field are Horsley, Stetler, Fun, Titler, and Goode. The field has attained a critical mass of nurse scholars and scholarly works as demonstrated by more than 60% of the references in articles are to research by nurses. Emergence of interdisciplinary collaborative groups in this field is yet evolving. Basic and augmented intervention significantly improved delivery of evidence-based care over control group; augmented intervention improved care more than basic intervention.
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Study Design & Study Outcome Measure(s) RCT, controlled clinical trial, and interrupted time series (levels 2, 3, 7). Unit of intervention was organizational, comprising nurses or groups of professionals including nurses. Outcomes = objective measures of evidencebased practice (levels 1 and 2).
Study Setting & Study Population 121 papers were identified as potentially relevant, but no studies met the inclusion criteria. After relaxing the criteria, 7 studies were included and all used a retrospective case study design (15).
Study Intervention Entire or identified component of an organizational infrastructure to promote effective nursing interventions.
Greenhalgh 22 2005
Diffusion, spread, and sustainability of innovations in the organization and delivery of health services.
Metanarrative review.
Comprehensive report of factors and strategies to promote use of innovations in health care services.
7 key topic areas addressed: characteristics of the innovation, adoption by individuals, assimilation by organizations, diffusion and dissemination, the inner context, the outer context, implementation and routinization.
Key Findings No high-quality studies that reported the effectiveness of organizational infrastructure interventions to promote evidencebased nursing practice were identified. Conceptual models that were assessed positively against criteria are briefly included in this review. Complex process requiring multiple strategies. Excellent resource of scholarly work in knowledge transfer and innovation adoption.
31
Issue Related to EBP Assess the effect of mass media on use of health services.
Study Design & Study Outcome Measure(s) RCTs, controlled clinical trials, controlled beforeand-after studies, and interrupted time series analysis (levels 2, 3, 4). Outcomes were objective measures of health services (drugs, medical or surgical procedures, diagnostic tests) by professionals, patients, or the public.
Study Setting & Study Population 26 papers reporting 20 time series and on controlled beforeand-after study met the inclusion criteria.
Study Intervention All studies relied on a variety of media, including radio, TV, newspapers, posters, and leaflets. To meet inclusion criteria, studies had to use mass media, be targeted at the population level, and aimed to promote/discourage use of evidence-based health care interventions or change public lifestyle.
Key Findings Mass media campaigns have a positive influence upon the manner in which health services are used. Mass media have an important role in influencing use of health care interventions. Mass media campaign is one of the tools that may encourage use of effective services and discourage those of unproven effectiveness.
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Issue Related to EBP Assessment of the effectiveness of guideline dissemination and implementation strategies.
Study Design & Study Outcome Measure(s) RCTs, controlled clinical trials, controlled beforeand-after studies, interrupted time series from 1966 to 1998 (levels 2, 3, 4). Outcomes were objective measures of provider behavior and/or patient outcomes (levels 1, 2).
Study Setting & Study Population Studies of guidelines aimed at medically qualified professionals. (Studies on guidelines aimed at multiple professionals were included only if results for medical professionals were reported separately or if medical professionals represented more than 50% of the targeted population.) The review included 110 clustered RCTs, 29 patient RCTs, 7 clustered controlled clinical trials, 10 patient controlled clinical trials, 40 controlled before-and-after studies, and 39 interrupted time series designs. The most common setting was primary care (39%) followed by inpatient settings (19%) and generalist ambulatory settings (19%). Other studies addressed settings across sites of care or were in a variety of other types of settings (e.g., nursing homes).
Study Intervention Interventions were educational materials, educational meetings, educational outreach, consensus, opinion leaders, patient-directed interventions, audit and feedback, reminders, other professional (marketing, mass media), financial interventions, organizational interventions, structural interventions, and regulatory interventions. Studies compared single interventions to no intervention, multifaceted interventions to no intervention, or a control receiving one or more single intervention. This systematic review compared findings from studies with a single intervention against a no-intervention control group; single interventions against an intervention control group; multifaceted interventions against nointervention control group (7 different types of comparisons); multifaceted interventions against intervention controls (4 different types of comparisons). A total of 309 comparisons were done. This systematic review also includes economic evaluations and cost analysis.
Key Findings This is a comprehensive review of implementation strategies. The reader is referred to the technology report, as a comprehensive summary of findings is beyond the scope of this chapter. Overall findings include: the overall quality of studies were poor; the majority of comparisons (86.6%) observed improvements in care; reminders are a potentially effective intervention and are likely to result in moderate improvements in care processes; educational outreach may result in modest improvements in processes of care; educational materials and audit and feedback appeared to result in modest improvements in care; multifaceted interventions did not appear to be more effective than single interventions; multifaceted interventions did not appear to increase with the number of
33
Issue Related to EBP Examine the feasibility of identifying opinion leaders using a sociometric instrument (frequency of nomination of an individual as an OL by the responder) and a selfdesignating instrument (tendency for others to regard them as influential).
Study Design & Study Outcome Measure(s) Survey. Mailed questionnaires of different professional groups. Outcomes = general and condition-specific opinion leader types classified as sociometric OLs and self-designated OLs (level 2 outcomes).
Study Setting & Study Population All general practitioners, practice nurses, and practice managers in two regions of Scotland. All physicians and surgeons and medical and surgical nursing staff in two district general hospitals and one teaching hospital in Scotland as well as Scottish obstetric and gynecology, and oncology consultants.
Key Findings The selfdesignating instrument identified more OLs. OLs appear to be condition specific.
34
Issue Related to EBP To evaluate a coordinated, multifaceted implementation intervention designed to promote evidence-based surfactant therapy.
Study Design & Study Outcome Measure(s) Cluster randomized trial with randomization at the hospital level (level 2). Outcomes were proportion of infants receiving their first dose of surfactant in the delivery room, proportion of infants treated with surfactant who received their fist dose more than 2 hours after birth, and time after birth at which the first dose of surfactant was administered; proportion of all infants who developed a pneumothorax, and proportion of all infants who died prior to discharge (levels 1 and 2).
Study Setting & Study Population 114 hospitals with membership in the Vermont Oxford Network, not participating in a formal quality improvement collaborative, with the majority of infants born in the hospital rather than transferred in and born in 1998 and 1999; received the first dose of surfactant within 15 minutes after birth. Subjects were high-risk preterm infants 23 to 29 weeks gestational age. The intervention group had 3,313 neonates and 2,726 in the comparison group.
Study Intervention The multifaceted 18month intervention included quarterly audit and feedback of data, evidence reviews, an interactive 3-day training workshop, and ongoing support to participants via conference calls and e-mail discussion.
Key Findings The proportion of infants 23 to 29 weeks gestational age receiving surfactant in the delivery room was significantly higher in the intervention than the control group for all infants (OR = 5.38). Those who received surfactant more than 2 hours after birth was significantly lower in the intervention than control group (OR = 0.35). There were no significant differences in rates of mortality or pneumothorax between groups. Infants in the intervention group received their first dose of surfactant significantly sooner after birth with a median time of 21 minutes as compared to 78 minutes in the control group (p < .001).
35
Issue Related to EBP Exploratory study of how high-performing facilities and low-performing facilities differ in the way they use clinical data for feedback purposes.
Study Design & Study Outcome Measure(s) Descriptive, qualitative, cross-sectional study. Subjects were interviewed using a semistructured interview format (level 4). Outcomes were participant responses to questions asking how CPGs were currently implemented at their facility, including strategies, barriers, and facilitators.
Study Setting & Study Population Study setting was 6 VA medical settings (from a pool of 15) ranked as high performing (n = 3) and low performing (n = 3) organizations with respect to 20 indicators for 6 chronic conditions treated in outpatient settings. 102 employees across 6 facilities were the subjects. Within each facility, facility leadership (n = 25), middle management (n = 34), and outpatient clinic personnel (n = 33) were interviewed.
Study Intervention No study intervention, but transcripts were analyzed using grounded theory, and passages that specifically addressed feedback of data were included in the analyses.
Key Findings High-performing institutions provided timely, individualized, nonpunitive feedback to providers, whereas low performers were more variable in their timeliness and nonpunitiveness and relied more on standardized, facility-level reports. The concept of actionable feedback emerged as the core concept around which timeliness, individualization, nonpunitiveness, and customizability are important.
36
Issue Related to EBP To determine if a systems intervention for primary care providers resulted in increased preventive screening and counseling of adolescent patients compared to usual care.
Study Design & Study Outcome Measure(s) 2 intervention outpatient pediatric clinics and 2 comparison outpatient pediatric clinics in the same health system were used to test the intervention. Level 3. Outcomes were adolescent reports of whether their provider screened and counseled them for risky behavior (tobacco, alcohol, drugs, sexual behavior, and safetyhelmet and seatbelt use). Level 2.
Study Setting & Study Population 4 outpatient pediatric clinics within Kaiser Permanente, Northern California. 76 clinicians were in the study (37 in each treatment arm). Adolescent reports of provider behavioracross all phases of the study, the intervention sample size was 1,717, and the comparison sample size was 911. Mean age of adolescents was 14.8 years (SD = 1.34). Data were collected from adolescents at baseline, following training, and following forms implementation.
Study Intervention The intervention was 2 phases. First phase was an 8-hour clinician training in adolescent preventative services based on social cognitive theory, including didactic education, discussions, demonstration role plays, and interactive role-plays at each intervention site (4 months). Second phase was implementation of screening and chart forms customized for this study (4 months). All clinicians participated in the training and the tools were implemented on a clinic-wide basis. Local opinion leaders were integrally involved in the intervention.
Key Findings Average baseline screening rates in the intervention group ranged from 42% for helmet use to 71% for tobacco use. Following training, screening rates increased significantly across all 6 target areas, ranging from 70% for helmet use to 85% for tobacco use, and remained constant during the posttools implementation phase. Counseling rates followed a similar pattern. By comparison, screening and counseling rates in the comparison group tended to remain stable across all 3 data collection points. Screening and counseling rates were significantly higher in the intervention group than the comparison group after the full implementation of the intervention; screening and counseling rates were significantly higher in the intervention than the comparison group after the training component of the intervention; screening and counseling rates
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Issue Related to EBP Assessment of the effectiveness of patient reminder and patient recall systems in improving immunization rates.
Study Design & Study Outcome Measure(s) RCTs, controlled beforeand-after studies, and interrupted time series (levels 2 and 3). Outcomes were immunization rates or the proportion of the target population up to date on recommended immunizations.
Study Setting & Study Population 43 studies. Approximately three-fourths of the studies were conducted in the United States. The majority of the studies were RCTs. Studies included children and adults and a variety of settings.
Study Intervention Reminder methods and recall systems included letters to patients, postcards, person-toperson telephone calls, autodialer, postcard and phone combination, and tracking and outreach.
Key Findings Patients receiving patient reminder and recall interventions were more likely to have been immunized or up to date on immunizations (OR = 1.70). All types of reminders and recall were found to be effective, with increases in immunization rates on the order of 5% 20%. Person-toperson telephone reminders were the most effective single approach (OR = 1.92). Letter reminders were similar to phone reminders in effectiveness (OR = 1.89). Reminder and recall interventions were effective for children and adults in all types of settings.
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Issue Related to EBP Use of audit and feedback to improve professional practice.
Design Type Systematic literature review. Metaregression along with visual and qualitative analyses. Evidence level 1 (Table 3.1).
Study Design & Study Outcome Measure(s) Randomized trails (level 2). Outcome measures = noncompliance with guideline recommendations (level 2).
Study Setting & Study Population 85 studies. 53 trials in North America, 16 in Europe, 8 in Australia, 2 in Thailand, 1 in Uganda. In most trials, the professionals were physicians; in 2 studies the providers were nurses, and 5 involved mixed providers.
Study Intervention Audit and feedback defined as any summary of clinical performance of health care over a specified period of time, delivered in written, electronic, or verbal format.
Jones 200471
An intervention study to improve pain practices (RCT). The intervention was implemented in 6 nursing homes (level 2). Outcomes = pain knowledge and attitudes of staff; pain assessment and treatment decisions based on 2 short case studies; barriers to effective pain management. Outcomes measured from questionnaires distributed to nurses and nursing assistants (level 3).
12 long-term care sites in Colorado6 in urban sites and 6 in rural sites. Nursing homes ranged in size from 65 to 150 beds.
Education for staff; resident educational video; designation of a 3member internal pain team; pain vital sign; site visits with discussion of feedback reports; pain rounds and consultations. Implementation phase lasted 9 months.
Key Findings Audit and feedback can be effective in improving professional practice with effects generally moderate. Absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low. Audit and feedback should be targeted where it is likely to effect change. No significant treatment effect for staff knowledge or staff attitudes; staff in the treatment group were 2.5 times more likely to chose an aggressive pain management strategy than those in the control group (p = .002); no significant treatment effect for decreasing barriers to pain management.
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Issue Related to EBP Testing an intervention to improve use of EBP smoking cessation guidelines.
Design Type RCT with randomization at the clinic level. Evidence level 2 (Table 3.1).
Study Design & Study Outcome Measure(s) Prospective randomized trial of 8 primary care clinics in southern Wisconsin (level 2). Outcomes included staff performance and patient quit rates (levels 1 and 2).
Study Setting & Study Population 8 communitybased clinics (6 family practice, 2 internal medicine).
Levine 200473
Test a nurseadministered, protocol-driven model for comprehensive preventive services in a low-income outpatient setting. Focus was on preventive services as recommended by the U.S. Preventive Services Task Force (USPSTF).
Controlled trial.
Controlled comparison using a convenience sample of patients within a single practice (n = 987) and a usual care group (n = 666) obtained from a random sample of households from the postal zip codes served by the same practice (level 3). Outcomes were percentage of preventive services initiated in the treatment arm versus the comparison arm (level 1).
Primary care single practice with internal medicine, family medicine, and pediatric clinics. Patients receiving care in this clinic between January and September 2001. Children = 514 (about 170 in each of 3 age groups: 02, 37, 817; 63% African American). Adults = 473 (about 170 in each age group 1849 and 5064; 130 in 65 or older; 76% African American).
Study Intervention Multimodality intervention (5 componentsdidactic and interactive education of staff, modified vital signs stamp imprinted on each encounter form, offering nicotine patches and telephone counseling, group and confidential individual feedback to providers on whether clinicians had assessed smoking status and provided cessation counseling as needed) to implement AHRQ smoking cessation guideline. Offer all identified preventive services that are needed using a nursing model under the guidance of a protocol agreed upon by the medical staff.
Key Findings Quit rates higher in experimental (E) sites at 2 and 6 months. Percentage of patients advised to quit smoking higher at E sites than control (C) sites.
Use of a nursing protocol for USPSTF recommendations was associated with a significantly higher percentage of preventive services initiated (99.6%) in the experimental arm as compared to usual care group (18.6%) (p < .001).
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Study Design & Study Outcome Measure(s) Case studies using principally qualitative methods. Outcomes = effectiveness of opinion leaders in promoting change/adoption of evidence-based practices (level 2.)
Study Setting & Study Population Variety of acute care and primary care settings. Evaluation of PACE project100 and Welsh Clinical National Demonstration Project.
Study Intervention Local opinion leaders defined as those perceived as having particular influence on the beliefs and actions of their colleagues, either positive or negative.
Key Findings Both expert and peer opinion leaders have important and distinct roles to play in promoting adoption of EBPs. Opinion leadership is part of a wider process that cannot be understood in isolation of other contextual variables with which it may interact. The value of the expert opinion leader is in the initial stages of getting an idea rolling, endorsing the evidence, and translating it into a form that is acceptable to practitioners and takes account of their local experience. Peer opinion leader influence seems to be important in mainstream implementation, providing a role model for fellow practitioners and building their confidence. The local context may modify or magnify the opinion leader influence.
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Issue Related to EBP To test the effect of a multifaceted implementation intervention for safely reducing antimicrobial prescriptions for suspected urinary tract infections in nursing home residents.
Study Design & Study Outcome Measure(s) The study design was randomization of 24 nursing homes to an intervention group or a usual care group (level 2). Main outcome measures were antimicrobials prescribed for urinary infections, total antimicrobials, hospitalizations, and deaths (level 1).
Study Setting & Study Population Free standing, community-based nursing homes with 100 or more beds in Hamilton, Ontario, region and Boise, Idaho, region were sites for the study. The numbers of residents were 2,156 in the intervention arm and 2,061 in the comparison arm.
Study Intervention Implementation of algorithms for diagnostic testing and antibiotic prescribing developed from research findings. Implementation strategies included interactive education with nurses, one-on-one meeting with physicians that see more than 80% of the patients, written materials, real-time paper reminders, and quarterly outreach visits targeted to nurses and physicians.
Key Findings The rate of antimicrobial use for suspected urinary infections was significantly lower in the treatment arm (1.17 courses of antimicrobials per 1,000 resident days) as compared to the comparison arm (1.59 per 1,000 patient days) (P = .03). The proportion of antimicrobials prescribed for suspected urinary infections were lower in the intervention arm than the comparison arm (P = .02). There was no significant difference for total antimicrobial use, rate of urine cultures obtained, overall hospitalization, or mortality.
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Issue Related to EBP To test the effectiveness of 2 implementation interventions in reducing asthma symptom days as compared to usual care.
Study Design & Study Outcome Measure(s) RTC. Outcomes were annualized asthma symptom days, asthmaspecific functional health status, and frequency of brief oral steroid bursts (level 1).
Study Setting & Study Population 42 primary care practices in 3 locales and targeted 317year-old children with mild to moderate persistent asthma enrolled in practices affiliated with managed care organizations. Among the 638 patient subjects, the mean age was 9.4 years (SD = 3.5); the majority were white (66%) and boys (60%).
Study Intervention 3 treatment arms were usual care, provider (MD, PA, NP) oriented strategy of targeted education through an on-site peer leader, and an organizational approach that combined the provider education with a nurse-run intervention (planned care arm) to better organize chronic asthma care in the primary care practice.
McDonald 75 2005
Testing of 2 computer-based reminder interventions designed to promote evidence-based pain management practices among home care nurses.
Nurses were randomly assigned to one of 3 treatment groups (control, basic e-mail reminder, augmented email reminder). Outcomes = pain management practices of nurses and patients pain (levels 1 and 2).
Home health care. Nurses were mostly female (> 90%) with an average age of 43.3 years.
Basic e-mail reminder that focused on 6 key practices (2 treatment arms) was sent to nurse every time an eligible cancer patient with pain was admitted to his/her care. Nurses in the augmented intervention group also received provider prompts, patient education material, and CNS outreach.
Key Findings Children in the planned care arm had 13.3 fewer symptoms annually (P = .02) and 39% lower oral steroid burst rate per year relative to usual care (P = .01). Those in the peer leader arm showed a 36% decrease in annualized steroid bursts per year as compared to usual care (P = .008). Improvements in asthma-specific functional status were also found for both the peer leader and planned care arm as compared to usual care. Nursing pain management practices did not differ significantly among the groups (P < .05), but pain levels were lower in the 2 treatment groups as compared to the control group. Patients treated by nurses in the augmented group had a 25% reduction in the probability of hospitalization.
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Issue Related to EBP Assess the effect of outreach visits on improving professional practice or patient outcomes.
Study Design & Study Outcome Measure(s) Randomized trials (level 2). Outcomes of provider performance (level 2).
Study Setting & Study Population 18 trials. Providers were mainly primary care physicians practicing in community settings. In 13 trials the behaviors were prescribing practices. 10 trials in North America, 4 in Europe, 2 in Indonesia, and 2 in Australia.
Study Intervention Outreach visits defined as use of a trained person who meets with providers in their practice settings to provide information with the intent of changing providers performance. The information may include feedback about performance.
OBrien 1999116
Assessment of the use of local opinion leaders on the practice of health professionals or patient outcomes.
RCTs (level 2). Outcomes were objectively measured provider performance in a health care setting or health outcomes (levels 1 and 2).
Use of providers nominated by their colleagues as educationally influential. 8 studies met inclusion criteria. A variety of patient problems were targeted.
Key Findings Positive effects on practice were observed in all studies. Only 1 study measured a patient outcome. Educational outreach visits, particularly when combined with social marketing, appear to be a promising approach to modifying health professional behavior, especially prescribing. Further research is needed to identify key characteristics of outreach visits important to success. In 3 trials that measured patient outcomes, 1 achieved an impact on practice. Only 2 trials provided strong evidence for improving performance of health care providers. Local opinion leaders may be important change agents for some problems.
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Issue Related to EBP Assess the effects of educational meetings on professional practice and health care outcomes.
Study Design & Study Outcome Measure(s) Randomized trials and well-designed quasiexperimental studies (levels 2 and 3). Outcomes were objectively measured health professional practice behaviors or patient outcomes in a setting where health care was provided (levels 1, 2, 3).
Study Setting & Study Population 32 studies met inclusion criteria with 30 RCTs. 24 studies were in North America, 2 in the United Kingdom, and 1 each in Australia, Brazil, France, Indonesia, Sri Lanka, and Zambia. Most of the study participants were physicians; 4 included nurses, and 3 other health professionals.
Study Intervention The intervention was defined as continuing education: meetings, conferences, lectures, workshops, seminars, symposia, and courses that occurred off-site from the practice setting. Education was defined as didactic (predominately lectures with Q and A), or interactive (sessions that involved some type of interaction in small, moderate, or large groups). 7 studies were didactic and 25 were interactive. Duration and frequency of the intervention varied widely.
Key Findings The few studies that compared didactic education to no intervention did not show an effect on professional practice. Studies that used interactive education were more likely to be effective in improving practice. Studies did not include information to determine what makes some interactive educational sessions more effective than others. Interactive workshops can result in moderately large changes in professional practice. Didactic education alone is unlikely to change professional practice.
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Issue Related to EBP Evaluation of the South Thames Evidence-based Practice (STEP) project.
Study Design & Study Outcome Measure(s) Each of the 9 projects followed a pretest/posttest design within a clinical audit framework over a period of 27 months (level 6). Outcomes = intermediate outcomes of uptake of change by staff and patient outcomes (levels 1 and 2).
Study Setting & Study Population 9 projects that focused on improving evidence-based nursing practices. UK sites included acute care wards, community nursing services, and longterm care. Topics were leg ulcer management, breast-feeding, pressure ulcer care, nutrition in stroke patients (n = 2), Use of functional independence measure (FIM) assessment tool, assessment of continence, assessment and transfer of older adults on discharge from hospital, family therapy in schizophrenia.
Study Intervention A 2-week training program followed by 3 monthly seminars, staff training program, active support in the practice setting.
Key Findings Intermediate outcomes improved in most projects; leaders ratings of staff adherence were moderate or better in the majority of the projects; patient outcomes improved in most projects. Organizational factors were found to have a major impact on achieving successful change in practice. Having enough staff of the right skill mix, strong leadership, supportive managers and colleagues, and organizational stability are important to successful change. Project leaders and a credible change agent who works with practitioners face-to-face to encourage enthusiastic involvement are also important.
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Issue Related to EBP Tailored interventions to address specific identified barriers to change in professional performance.
Design Type Systematic literature review with metaregression. Evidence level 1 (Table 3.1).
Study Design & Study Outcome Measure(s) RCTs (level 2). Outcomes = professional performance, patient outcomes, or both (levels 1 and 2).
Titler 200681
Testing a TRIP intervention for promoting adoption of evidence-based acute pain management practices for care of older adults hospitalized with hip fracture.
RCT with randomization at the clinic level. Evidence level 2 (Table 3.1).
Prospective randomized trial of 12 acute care hospitals in the Midwest United States (level 2). Outcomes included nurse and physician performance, patient pain levels, and cost effectiveness (levels 1 and 2).
Study Setting & Study Population 15 RCTs. 7 in primary care or community settings and health care professionals responsible for patient care. 10 in North America, 2 in the United Kingdom, 2 in Indonesia, and 1 in Norway. 12 large (n = 2), medium (n = 6), and small hospitals (n = 4) in the Midwest.
Study Intervention An intervention was defined as tailored if it was chosen after identification of barriers and to overcome those barriers.
Multifaceted intervention that addressed the characteristics of the EBP, the users, the social context of care, and communication, based on Rogers diffusion of innovation framework.
Key Findings Results were mixed with variation in the direction and size of effect. The effectiveness of tailored interventions remains uncertain, and more rigorous trials including process evaluations are needed. Acute pain management strategies improved more in the experimental than comparison group, and the TRIP intervention saved health care dollars.
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Issue Related to EBP Organizational strategies for improving professional performance, patient outcomes, and costs.
Study Design & Study Outcome Measure(s) A review of reviews that included RCTs, interrupted time series, controlled before/after studies, and prospective comparative observational studies (levels 2, 5, 6, 7). Outcomes = professional practice and patient outcomes (levels 1 and 2).
Study Setting & Study Population 36 reviews were included. A taxonomy of organizational strategies to improve patient care was developed to organize findings.
Study Intervention Revision of professional roles, multidisciplinary teams, integrated care services, knowledge management, quality management.
Key Findings Revision of professional roles can improve professional performance, while positive effects on patient outcomes remain uncertain. Multidisciplinary teams can improve patient outcomes but have primarily been tested in highly prevalent chronic diseases. Integrated care systems can improve patient outcomes and save costs; they have been extensively tested in highly prevalent chronic conditions. Professional performance and patient outcomes can be improved by implementation of computers in clinical practice settings (knowledge management). Effects of quality management on professional performance and patient outcomes remain uncertain. There is growing evidence of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited; for no strategy can
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Issue Related to EBP Usefulness of interprofessional education (IPE) interventions on professional practice and health care outcomes.
Study Design & Study Outcome Measure(s) RCTs, controlled beforeand-after studies, and interrupted time series studies (levels 2, 6, 7). Outcomes included health care outcomes (mortality rates, complication rates, readmission rates) and impact on professional practice (teamwork and cooperative practice) (levels 1 and 2).
Study Setting & Study Population 89 studies were reviewed for possible inclusion, but none met the inclusion criteria.
Study Intervention An educational intervention during which members of more than one health and/or social care profession learn interactively together for the purpose of improving collaborative practice and/or the health of patients.
Key Findings Despite finding a large body of literature on the evaluation of IPE, studies lacked the methodological rigor needed to understand the impact of IPE.
*Study design type: Use the following numbers for categories to reference the specific type of evidence (evidence level):
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Meta-analysis Randomized controlled trials Non-randomized trials Cross-sectional studies Case control studies Pretest and post-test (before and after) studies Time series studies Noncomparative studies Retrospective cohort studies Prospective cohort studies Systematic literature reviews Literature reviews, nonsystematic/narrative Quality improvement projects/research Changing practice projects/research Case series Consensus reports Published guidelines Unpublished research, reviews, etc.
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Background
The provision of high-quality, affordable, health care services is an increasingly difficult challenge. Due to the complexities of health care services and systems, investigating and interpreting the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services is key to informing government officials, insurers, providers, consumers, and others making decisions about health-related issues. Health services researchers examine the access to care, health care costs and processes, and the outcomes of health services for individuals and populations. The field of health services research (HSR) is relied on by decisionmakers and the public to be the primary source of information on how well health systems in the United States and other countries are meeting this challenge. The goal of HSR is to provide information that will eventually lead to improvements in the health of the citizenry.1 Drawing on theories, knowledge, and methods from a range of disciplines,2 HSR is a multidisciplinary field that moves beyond basic and applied research, drawing on all the health professions and on many academic disciplines, including biostatistics, epidemiology, health economics, medicine, nursing, operations research, psychology, and sociology.3 In 1979, the Institute of Medicine defined HSR as inquiry to produce knowledge about the structure, processes, or effects of personal health services4 (p. 14). This was expanded upon in 2002 by AcademyHealth, the professional organization of the HSR field, with the following definition, which broadly describes the scope of HSR: Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations.5 More specifically, HSR informs and evaluates innovations in health policy. These include changes in Medicare and Medicaid coverage, disparities in access and utilization of care, innovations in private health insurance (e.g., consumer-directed health plans), and trends among those without health insurance.610 The health care industry continues to change, and HSR examines the impact of organizational changes on access to care, quality, and efficiency (e.g., growth in for-profit hospital systems). As new diagnostic and treatment technologies are introduced, HSR examines their impact on patient outcomes of care and health care costs. The definition of HSR also highlights the importance of examining the contribution of services to the health of individuals and broader populations. HSR applied at the population level is particularly important in understanding health system performance and the impact of health policy on the publics health. In the United States, the National Healthcare Quality Report,11 National Healthcare Disparities Report,12 and Healthy People Year 201013 exemplify our
capacity for monitoring quality and assessing change. These reports tell us that the American quality of care is inconsistent and could be substantially improved. The associated cost of health care services is monitored by the Centers for Medicare & Medicaid Services (CMS). CMS reports tell us that American health care is the most expensive in the world, consuming approximately 16 percent of Americas gross domestic product.14 Beyond health policy, HSR examines the process of care and the interactions of patients and providers. For example, HSR methods have been developed to describe doctor-patient communication patterns and examine their impact on patient adherence, satisfaction, and outcomes of care.1517 Advances in HSR measurement methodologies have made possible policy innovations. Prospective payment of hospitals, nursing homes, and home health care by Medicare became possible with the development of robust case-mix measurement systems.18 CMS was able to initiate a pay-for-performance demonstration, rewarding hospitals with better quality performance, using valid and robust measures of quality.14 Innovations in health care policy are frequently made possible by advances in measurement of indicators of health system performance.
Federal agencies fund HSR. The diversification of funding comes, in part, from the recognition that HSR is important in managing health care systems, such as the Veterans Health Administration, and provides essential information on the translation of scientific discoveries into clinical practice in American communities, such as those funded by National Institutes of Health. It is estimated that total Federal funding of HSR was $1.5 billion in 2003, of which AHRQ was responsible for approximately 20 percent.24 Private funding of HSR has also grown over time. Funding by private foundations has a significant role and complements Federal funding. Among the many foundations funding HSR are the Robert Wood Johnson Foundation, Commonwealth Fund, Kaiser Family Foundation, Kellogg Foundation, and Hartford Foundation. Other private funding sources include the health care industry, for example, pharmaceutical companies, health insurers, and health care systems.
care than the majority population, even after accounting for differences in access to health services. Crossing the Quality Chasm concludes that for the American health care system to attain these goals, transformational changes are needed.25 The field of HSR provides the measurement tools by which progress toward these goals is assessed, as seen in the National Healthcare Quality Report.11 Equally important, health services researchers are developing and evaluating innovative approaches to improve quality of care, involving innovations in organization, financing, use of technology, and roles of health professionals.
care on patients. The structure, process, and outcome dimensions of quality are influenced by both internal and external factors.
Process of Care
The interactions between the health care providers and patients over time comprise the process of health care. The process of care may be examined from multiple perspectives: the sequence of services received over time, the relationship of health services to a specific patient complaint or diagnosis, and the numbers and types of services received over time or for a specific health problem. Examining the time sequence of health care services provides insights into the timeliness of care, organizational responsiveness, and efficiency. Linking services to a specific patient complaint or diagnosis provides insights into the natural history of problem presentation and the subsequent processes of care, including diagnosis, treatment, management, and recovery. Examining the natural history of a presenting health complaint across patients will reveal variations in patterns of care. For example, presenting complaints for some patients never resolve into a specific diagnosis. An initial diagnosis may change as more information is obtained. Patients may suffer complications in the treatment process. Also, the process of care may provide insights into outcomes of care (e.g., return visit for complications). Generally it is not possible to examine the process of care and determine how fully the patient has recovered prior health status by the end of the episode of treatment. For this reason, special investigations are needed to assess outcomes of care. Evaluation of the process of care can be done by applying the six goals for health care quality.25 Was the patients safety protected (i.e., were there adverse events due to medical errors or errors of omission)? Was care timely and not delayed or denied? Were the diagnosis and treatments provided consistent with scientific evidence and best professional practice? Was the care patient centered? Were services provided efficiently? Was the care provided equitable? Answers to these questions can help us understand if the process of care needs improvement and where quality improvement efforts should be directed.
Outcomes of Care
The value of health care services lies in their capacity to improve health outcomes for individuals and populations. Health outcomes are broadly conceptualized to include clinical measures of disease progression, patient-reported health status or functional status, satisfaction with health status or quality of life, satisfaction with services, and the costs of health services.
Historically, quality assessment has emphasized clinical outcomes, for example, disease-specific measures. However, disease-specific measures may not tell us much about how well the patient is able to function and whether or not desired health outcomes have been achieved. To understand the patients outcomes, it is necessary to ask patients about their outcomes, including health status, quality of life, and satisfaction with services. HSR has developed valid and robust standardized questionnaires to obtain patient-reported information on these dimensions of health outcomes. As these are more widely applied, we are learning about the extent to which health care services are improving health.
their treatments. The efficacy question is: What impact does a clinical intervention have under ideal conditions? In contrast, effectiveness research is undertaken in community settings and generally includes the full range of individuals who would be prescribed the clinical intervention. Many of these individuals will have multiple health problems and be taking multiple medications, unlike those who were recruited to the RCT. Effectiveness research is seeking to answer the question: Who will benefit from the clinical intervention among all those people in the community who have a specific health problem(s)? Both efficacy and effectiveness questions are important. Logically, effectiveness research would be conducted after finding the clinical intervention to be efficacious. However, there are many treatments for which no efficacy information exists; the treatments are accepted as common practice, and it would not be ethical to withhold treatments from a control group in an RCT. As a result, effectiveness research may not have the benefit of efficacy findings. The routine use of an RCT to evaluate efficacy began in the 1960s and is the accepted procedure for evaluating new medications. However, this standard is not applied across all health care services and treatments. Most surgical procedures are not evaluated using an RCT. Intensive care units have never been evaluated using an RCT, nor are nurse staffing decisions in hospitals or the evaluation of many medical devices. We currently accept different standards of evidence depending on the treatment technology. As a result, the level of evidence guiding clinical and public health decisionmaking varies.
The economic impact of receiving free care in one plan versus being in a plan requiring payment out-of-pocket of deductibles and co-insurance had the expected impact on utilization. Those paying a share of their medical bills utilized approximately one-third fewer doctor visits and were hospitalized one-third less frequently. The impact on 10 health measures of free health insurance versus paying a portion of medical care costs out of pocket was evaluated. The findings were that there was largely no effect on health as measured by physical functioning, role functioning, mental health, social contacts, health perceptions, smoking, weight, serum cholesterol, diastolic blood pressure, vision, and risk of dying.46 The exceptions were that individuals with poor vision improved under free care, as did low-income persons with high blood pressure. Medicare preventive services experiment. A more recent example of RCT methods applied in HSR is the Baltimore Medicare Preventive Services Demonstration. The study evaluated the impact on cost and outcomes of offering a defined preventive services package to Medicare beneficiaries. This was compared to usual Medicare coverage, which paid for few preventive services. The preventive services coverage being evaluated included an annual preventive visit with screening tests and health counseling. The physician could request a preventive followup visit during the year, which would also be covered. Medicare beneficiaries (n = 4,195) were randomized to preventive services (the intervention group) or usual care (the control group). Sixty-three percent of those in the intervention group had at least one preventive visit. Significant differences were found in health outcomes between intervention and control groups. Among the 45 percent with declining health status, as measured by the Quality of Well-Being scale,47 the decline was significantly less in the group offered preventive services. Mortality was also significantly lower in the intervention group. There was no significant impact of preventive services on utilization and cost.48
were no more effective in controlling psychotic symptoms than the first-generation drug. There was one exception, the drug Clozapine.51 Furthermore, second-generation medications showed significant side effects that can affect health outcomes. These included weight gain, metabolic changes, extrapyramidal symptoms, and sedation effects. Each medication showed a somewhat different side-effect risk profile. From a positive perspective, the findings indicated that the clinician and patient can choose any of these medications as first-line treatment except Clozapine, which is generally used for treatment-resistant cases due to more intensive clinical monitoring requirements. The ultimate choice of treatment will depend on the patients ability to tolerate side effects that vary by drug. The conduct of any RCT is resource intensive, requiring the recruitment of participants, and participants must give informed consent to be randomized. The rationale for making this investment may depend on the importance of the policy or practice issue. As shown, RCT methods can be applied to address policy and clinical care concerns with effectiveness. To the extent that the RCT includes a broad cross-section of people who would be affected by a policy or receive a clinical treatment, this methodology provides robust effectiveness findings.
variation in outcomes. Ideally, the nonequivalent group comparison makes it possible to compare the effectiveness of alternative treatments and assess the impact of poor access to care. One limitation of this methodology is the limit of current knowledge regarding all relevant disease risk factors. Even when risk factors are known, limits on data availability and accuracy of risk factor measurement have to be considered. Risk adjustment methods are also used to make cost comparisons across health care providers to determine which providers are more efficient. Instead of adjusting for disease risk factors, adjustments are made for the costliness of the patient mix (case mix) and differences in costs of labor, space, and services in the local area. Comparisons may be made to assess efficiency of providing specific services (e.g., hospitalization, office visit, or laboratory test). These comparisons would use case-mix measures that adjust for the costliness of different mixes of hospital episodes.18 Comparisons of the total cost of care for insured populations would apply case-mix measures that adjust for disease and health factors that affect total cost of care.54
10
applications of administrative data include assessing efficiency, timeliness, and equity. The limitation is that there are many health conditions and health outcomes that cannot currently be measured using administrative data. Survey questionnaires. Neither the medical record nor the administrative data capture information on the patients experience in health or patient-reported outcomes of care. Survey questionnaires are routinely used to obtain information on patient satisfaction in health plans. A widely used example is the Consumer Assessment of Healthcare Providers and Systems or CAHPS.57 Information on the impact of health conditions on health and functional status has to come from the patient. This may be obtained at the time of a visit or hospitalization. However, to assess patient outcomes of care, systematic followup of patients after the completion of treatment is generally required. This can be done using mail questionnaires, telephone interviews, or inperson interviews. The HSR field has developed health-status and quality-of-life measures that can be used no matter what health conditions the patient has.47, 5860 Numerous condition-specific measures of outcome are also used.53 Effectiveness research relies on a range of data sources. Some are routinely collected in the process of medical care and patient billing. Others may require special data collection, including medical record abstracts to obtain detailed clinical data and survey questionnaires to gain information on the patients perspective on treatment and outcomes. Efficient strategies for examining effectiveness may use administrative data to examine a limited set of data on all patients, and a statistically representative sample of patients for in-depth analysis using data from chart abstracts and survey questionnaires.
11
treatment into existing practice.62 More needs to be learned how to assist health care providers to overcome barriers to the adoption of evidence-based practices. The described data sources and methods can be applied in clinical settings to assess conformance to evidence-based quality criteria and provide feedback to clinicians. If electronic health records are available, the feedback and reminders may be directly incorporated into the medical record and seen by the clinician at the time of a visit. Intermountain Health Care utilizes its electronic health records to monitor adherence to evidence-based quality standards and to provide decision support to clinicians when seeing patients. This strategy has contributed to substantial improvements in their quality performance.63 Outcomes management system. In 1988, Paul Ellwood proposed the adoption of outcomes management system (OMS) as a method to build clinical intelligence on what treatments work, for whom, and under what circumstances.64 OMS would require linking information on the patients experience with outcomes of care and information on diagnosis and treatment that would usually come from the medical record. In 1991, the Managed Health Care Association, an employer organization, brought together a group of employers and their health plan partners who were interested in testing the OMS concept in health plans.65 To do so would require a set of methods that could be widely applied across health plans with differing information systems. The methodology chosen was for each of 16 health plans to identify all adult enrollees with at least two diagnoses of asthma over the previous 2 years. A stratified sample was chosen with half of the enrollees having more severe asthma (e.g., hospitalization or emergency room visit in the past 2 years) and the other enrollees having less severe asthma (outpatient visits only). Each adult received a questionnaire asking about their asthma treatment and health status. Followup surveys were done in each of 2 successive years to track changes over time. The findings were compared to national treatment recommendations for adult asthma.66 Across the health plans, 26 percent of severe asthmatics did not have a corticosteroid inhaler, and 42 percent used it daily, as recommended.67 Only 5 percent of patients reported monitoring their asthma using a home peak flow meter. Approximately half of adults with asthma reported having the information they needed to avoid asthma attacks, to take appropriate actions when an asthma flare-up occurs, and to adjust medications when their asthma gets worse. Health plans used the baseline findings to develop quality-improvement interventions, which varied across health plans. Followup surveys of the patient cohort provided feedback to health plans on their success in improving asthma treatment and outcomes over time.
Conclusion
This chapter has provided a definition and history of the field of health services research and discussed how this field is examining quality-of-care issues and seeking to improve quality of care. Comparisons of current practice to evidence-based standards with feedback to clinicians and the integration of patient-reported outcomes are two examples of how HSR tools can be used to provide quality-improvement information for health care organizations. These examples utilize multiple data sources, including medical records, patient surveys, and administrative data. The opportunities for nurse researchers to provide invaluable contributions to the growing field of health services research are innumerable.
12
Author Affiliations
Donald Steinwachs, Ph.D.; Director, Health Services Research and Development Center; Bloomberg School of Public Health; Johns Hopkins University; Baltimore, MD. E-mail: [email protected]. Ronda G. Hughes, Ph.D., M.H.S., R.N.; Senior Health Scientist Administrator; Center for Primary Care, Prevention, and Clinical Partnerships; Agency for Healthcare Research and Quality; Rockville, MD. E-mail: [email protected].
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15
Background
A critical element in the mission of health care organizations is high quality health care. Organizationally, the hospital enterprise is a hierarchical structure that has separate functional charges, lines of authority, and personnel resources for quality improvement and emergency management. The overall umbrella of safety and health care delivery can be viewed to encompass quality improvement and emergency preparedness, and nursing plays an integral role in ensuring continuous quality improvement. The interaction of quality improvement and emergency preparedness resources in hospital settings promises to yield a combined effect that is greater than the sum of their individual efforts to ensure patient safety and enhanced health care quality. By strengthening communication channels and fostering opportunities for collaborative project implementation across quality improvement, emergency preparedness and organizational functions can be highly synergistic.
RTI Master Task Order Contract No. 290-00-0018, L.A. Savitz, Director; 2004.
general knowledge of the hospital industrywas obtained, affording the opportunity to identify several common practices. The leadership of the administrative emergency management function in health care organizations was often former military personnel with security experience or individuals who had worked their way up through increasing responsibility in facility/environmental services. Only those organizations with the most visible commitment to emergency preparedness also had clinical champions who partnered with the administrative emergency management function. Conversely, quality management typically had clinical leaders (i.e., physicians and/or nurses) with some training or on-the-job experience in health care administration. These individuals were repeatedly trained through continuing education and professional society meetings, used a journal specifically dedicated to implementation science (visit http://www.implementationscience.com), and reinforced change management principles using the Institute for Healthcare Improvement collaborative model (visit http://www.ihi.org). A corollary for support of similar change management efforts does not exist for emergency management. However, fostering transfunctional collaboration of emergency preparedness and quality improvement is promising; both the Joint Commission (see the Joint Commissionissued, revised emergency management standards that were effective January 1, 2008 visit http://www.jcrinc.com/28380) and the American Hospital Association are working toward increasing opportunities for such dialogues. Recent experience with Hurricane Katrina has highlighted the soft underbelly of hospital preparedness and emphasized the inseparable role that emergency management plays in the overall quality and safety of health care delivery. The emergency preparedness of this country is based on a robust health care delivery system. The public expects and is entitled to receive the highest quality evidence-based care within the most efficient delivery system possible. At times of crisis be it a disaster, natural or man made, or a major infectious disease, SARS or Pandemic, the already stressed health care system operating at the margins will be challenged to deliver this level of care without concerted planning and cooperation. Nurse executives must lead a cultural shift towards using evidence-based management and clinical practices (Williams 2006) in both quality improvement and emergency preparedness. Principal team players must include nurses, who are the essential back-bone of successful change efforts in hospitals (Savitz & Kaluzny, 2000). The extent to which nursing leaders, including middle managers, can be engaged in change management activities (Dopson & Fitzgerald, 2006) for emergency preparedness will be an important investment in successful design and implementation of targeted interventions. There is not good visibility for emergency preparedness commitment on the part of clinical staff in operational areas demonstrated, for example by most staff avoiding required drills failing to see the priority from their leaders. Health system leadership can change this by appropriately acknowledging and rewarding such efforts and modeling the commitment.
role as caregivers and clinical managers. Consequently, it would be possible to link knowledgebased learning about how interventions are implemented (a.k.a., implementation science) so that advancements in our understanding are not confined to any single aspect of quality health care delivery, but are opportunities for cross-fertilization and synergy. As stated by Mittman,4 implementation science focuses on a second level of research translation where one takes evidence-established benchmarks from limited settings (i.e., level 1 translation) to practice innovations, and more broadly to disseminate that knowledge. Implementation science (or second-level research translation) is an evolving, multidisciplinary area, and the terminology has not yet been consistently established. For example, Chapter 7 (The Evidence for Evidence-Based Practice Implementation) in this Handbook discusses translation science to describe the same concept. Despite the inconsistent terminology, researchers and practitioners are committed to implementing and disseminating promising practices.
The notion of an implementation deficit between what is planned versus achieved and the challenge of effectively translating research into practice has a long-standing literature base, primarily in organizational studies and public policy analysis.6, 8, 9 In terms of nursing, the research has been inconclusive even about the evidence for specific interventions.10 A generalized conceptual model of translational implementation, based on Rogerss seminal work,6 has been incorporated into numerous change management efforts such as the RE-AIM11, 12 (Figure 2).
Intervention Characteristics
Implementation
Essential vs. Adapted Elements of Intervention Drivers/Barriers Process Redesign End-User Participation