In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.
Another 71% of hospitals “basically remained the same,” she said.
Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.
And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.
Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”
In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.
“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.
Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.
The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.
Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.
After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:
Teamwork: working well together in moments of crisis
Action taking: responding swiftly after identifying a complication
Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
Recognition of complications
Communication
The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.
For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.
The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.
In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.
Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.
Her group also stressed the need for more effective language in communicating concerns.
“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.
Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.
If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.
In
my nearly 20 years of experience as a registered nurse, I’ve learned that
simple steps make a significant difference. Fast-paced clinical settings make
the procedures and protocols that all medical staff are familiar with
incredibly important. Proactive steps, as simple as remembering to always wipe
down all patient areas and keep them clear of unnecessary or unused supplies,
have the ability to keep both patients and medical staff safer.
For
nurses, patient safety is fundamental to what we do. It’s the first thing that
we think about when we get up in the morning, and the last thing we think about
before we go to bed. But no matter what your role in the organization, patient
safety must be the priority.
This is especially true when caring for patients with chronic
diseases, who are at an even higher risk given their weakened immune systems. At Lung Health Institute, we
specialize in treating patients with chronic lung disease, such as COPD and emphysema,
and we’re proud to have earned The Joint Commission Gold Seal of Approval® for
ambulatory health care accreditation.
Because we are continually evaluated, this recognition reflects our longstanding
commitment to The Joint Commission’s National Patient Safety Goals focus on
identifying patients correctly, using medicines safely, preventing infection
and providing appropriate treatment.
Ensuring
that vetted protocols and procedures are in place across your organization
is the first step to providing the safest environment possible for your
patients. Formal accreditation is a great way to ensure this exists, but
you should also revisit and review your procedures regularly. Health care is dynamic, and these
processes need to constantly evolve along with the industry.
At any stage of the process in your organization, here are a few tips that nurses caring for patients with chronic disease should follow to ensure the safest environments:
Never stop learning: Best practices and industry
standards are always changing, so you should strive to stay on top of the
latest and greatest. I would recommend getting involved with local or national
nursing organizations and attending any relevant conferences.
Lend a helping hand: With more young nurses in
the field than ever before, experienced nurses need to lead by example, taking
the extra time to demonstrate the right procedures and protocols can go a long
way.
Open the doors of
communication:
Patients are often scared when in a health care setting and taking the time to
ask them questions about not only how they’re feeling physically — but mentally
— can ensure you’re adjusting treatment plans appropriately and collaborating
with physicians in real time to problem solve. A safe environment for patients
takes into account both their physical and mental health.
Slow down and think: It’s incredible how many
errors can be prevented by taking the time to think, without rushing through your
daily tasks.
Speak up: If you’ve observed standards
and protocols and think something could be done differently, say so. Real life
experiences help shape and create the best processes, and every operation is
unique and should be tailored appropriately. Following a challenging situation,
take the time to debrief with your peers — those more experienced and less
experienced than you. Talk about what happened, and how you can work together
to make it better or more efficient moving forward. Update procedures and
protocols accordingly.
From 2014 to 2017, physician burnout increased by 5% at the Massachusetts General Hospital Physicians Organization in Boston, according to a recent analysis.
Other research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The research published in JAMA found exhaustion and cynicism were the primary drivers of increased burnout at Mass General. The research was based on survey data collected from more than 1,700 physicians.
The survey data showed exhaustion increased from 52.9% in 2014 to 57.7% in 2017, and cynicism increased from 44.8% in 2014 to 51.1% in 2017.
The researchers noted that physician turnover has several costs including patient and clinician distress as well as the expense of replacing physicians, which can be as high as three times a doctor’s annual salary.
The JAMA article has several other key data points:
Early-career physicians who had less than a decade of practice experience since their training were more susceptible to burnout than veteran physicians.
The higher burnout rate in 2017 may be linked to implementation of a new electronic health record system because average time devoted to administrative tasks increased from 23.7% in 2014 to 27.9% in 2017, and increased time spent on administrative tasks was linked to higher burnout.
Several favorable working conditions were associated with lower odds of burnout: workflow satisfaction, positive relationships with colleagues, time and resources for continuing medical education, opportunities to impact decision making, and having a trusted adviser.
Addressing physician burnout
The lead author of the research, Marcela del Carmen, MD, MPH, explained that the physician group has implemented several efforts to reduce burnout.
Del Carmen’s research team also suggested that burnout prevention efforts could be tailored for early-career physicians, who reported relatively high dissatisfaction with department leadership, relationships with colleagues, quality of care delivery, control over work environment, and career fit.
“These findings point to potential opportunities in this vulnerable group to mitigate burnout, such as initiatives that promote community building and networking and harnessing effective leadership,” the researchers wrote.
As we described in Part 1 of this series, there are important ways for nurses to speak with other providers in order to keep their patients safe. Likewise, there are crucial strategies for them to use when speaking with the patients themselves.
Again, Arnold Mackles, MD, MBA, Patient Safety Consultant for Innovative Healthcare Compliance Group and member of The Sullivan Group’s RSQ® (Risk, Safety, Quality) Collaborative took time to answer questions about exactly how nurses can safely communicate with patients.
What strategies can nurses use when communicating directly with their patients in order to keep them as safe as possible?
Effective communication with patients is just as important to ensuring positive outcomes in high-risk situations. Patients seek out health care for personal and often complicated medical conditions. They can be fearful, concerned, uncomfortable, worried, or even terrified when they visit a health care facility. Be mindful of your patients’ emotions and how these emotional states will affect the way they describe their symptoms and problems, how they interact with you, and how information and instructions are received.
The following list of patient communication strategies is straightforward and can be incorporated into any conversation with a patient:
Start with a warm introduction. Some providers walk into a waiting room and introduce themselves to their patients. This makes patients feel important. It indicates that the provider is not in a rush and is taking the time to greet them rather having them ushered into an empty exam room by office staff.
Greet the patient by name. Greet patients by their formal name. “Hello Mrs. Jones, I am Cathy and I’ll be your nurse today.” If you prefer to be less formal or you know the patient well enough, use first names. By nature, people like to hear their own names. When you know and use patients’ names throughout the medical process, stronger bonds and relationships are created.
Make eye contact. This feature of a personal interaction cannot be underestimated! If you don’t make eye contact with patients, they may assume that your thoughts are elsewhere or you are not interested in their medical issue. Eye contact is a sign of confidence, and patients want to feel confident that they are in good hands.
Be engaged. Patients know when you care, patients know when you are prepared; and patients know when you are authentically engaged. Consistency of communication is an art. Whether you are stressed, fatigued, or otherwise preoccupied due to any number of reasons, you must learn the art of being consistently engaged with all patients.
Listen to and acknowledge patient concerns. It is important that you listen, understand, and acknowledge what patients are saying. Take time to ask appropriate questions to ensure that important pieces of information were not overlooked by the patient. When you take the time to listen, miscommunication is–for the most part–averted and medical errors are significantly reduced.
Avoid interrupting the patient if possible. Allow the patient to finish explaining. Physicians and nurses often interrupt patients with questions in the middle of a conversation. Let patients complete their thoughts before questioning further. If patients go off on a tangent, politely interrupt and refocus them on what needs to be communicated.
Confirm understanding via “teach-back.” Rather than asking patients if they understand their health issues, intervention plans, or any aspect of their care, it is often more efficient to use an easy technique such as “teach-back” to confirm full comprehension–have them repeat what they understood. Simply ask the patient something like: “Mrs. Jones, since you will be taking home three different medications, just to be sure you fully understand the instructions, please explain to me how and when you will take each one.”
Provide patients with written instructions. Patients are often overwhelmed with news of a diagnosis or the seemingly complex plans for home- or self-care, which includes taking medications. Preparing and distributing written instructions will help avoid misunderstanding of the treatment and follow-up plans.
What else do nurses need to know about communicating effectively to improve patient safety in high-risk situations?
Data from The Joint Commission consistently reveals that poor communication is a leading cause of medical mistakes that result in patient harm. In fact, during the years 2014 and 2015, communication was the third most frequent “root cause” of all sentinel events reviewed.
Medical errors continue to plague our health care system. Many of these mistakes cause significant patient harm and often result in malpractice litigation. Communication breakdowns, rather than a lack of provider skill and/or medical training, are responsible for far too many adverse events. The good news is that we now have simple techniques that can be easily utilized to improve nursing communication and decrease medical errors.
If you ask any nurse why they went into nursing, their response will undoubtedly have a foundation of compassion. Whether it’s an anecdote about a family member, a childhood role model, or a personal experience, a career in nursing starts by caring.
And yet, in a modern health care system burdened by precarious political conditions, technology evolving at breakneck speed, and specialties becoming super-specialties, it’s easy to lose touch with sentiment.
The onus on nursing seems to be heavier than ever, and the workload seems to focus on skills and tasks rather than human connection. Within such a context, reminding a nurse (if you can catch him or her) that they need to give report to another unit may understandably yield a frustrated grunt.
Yet despite how inconvenient, time-consuming, and even unpleasant hand-off may seem, its purpose is not to frustrate the nurse but rather to serve the patient.
Remember SBAR? Have you heard that acronym since nursing school? Health care today is filled with endless acronyms and buzzwords. SBAR and others serve as simple solutions to the impossibly complex knowledge nursing requires. Likely to many nurses’ chagrin, SBAR is evolving, and even specializing, just like nursing; now there is SHARED, PEARLS, and IPASS, to name a few.
What does compassion have to do with giving report? If every nurse gave hand-off as if the patient was their loved one, it is likely that every scratch would be scrutinized, every medication change would be reviewed in minute detail, and personal details would be emphasized (e.g., “She hates when you call her Patty. Call her Trish.”).
Giving good report is not an advanced science, but a simple art that can be mastered with a few pointers rooted in the principle of quality care:
Write pertinent information down; do not go by memory.
Do not multitask while giving or receiving report.
Be thorough; don’t assume the other nurse “should” already know something.
Whether SBAR or not, use a simple guideline to be sure you have covered all your bases.
Caring nurses are thorough nurses. If the care that attracted a nurse to the field can inform every report they give (and every other task), nursing can become even more meaningful, efficient, and effective.
