Changing competencies in health care professions: Will your nurses be ready?

In 1999, the Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System” brought the issues of medical error and patient safety to the forefront of national concern.¹ In this report, the now popularized statistic that “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented” stimulated health care providers and purchasers into action. Problems arising from decentralized and fragmented delivery systems, inadequate safety reporting methods, and the absence of a blameless culture of learning in health care all were cited as contributing factors to preventable medical errors with resultant patient harm.     

Communicating good care: A qualitative study of what people with urological cancer value in interactions with health care providers

PurposeCommunication with health care providers is important to help meet cancer patients' information and support needs. It can significantly affect the extent to which patients feel cared for, respected and involved, and it can influence a range of cancer care processes and outcomes. This paper presents findings from a study which explored urological cancer patients' experiences of care, focussing on insights into what they appeared to value in their interactions with health care providers and why.MethodIn-depth interviews were undertaken with 20 men and 6 women with different types of urological cancer at a range of times since diagnosis. Interviews were audio-recorded, transcribed and thematically analysed using an established interpretive approach.ResultsPatients valued being treated as someone who mattered and was worthy of care; being recognised and responded to as an individual; and experiencing support for autonomy/agency. Reasons for their valuations related to the implications of communicative interactions for the ways patients thought health professionals related to them ‘as persons’. Our findings highlight the value of relational aspects of communication for: indicating to patients what clinicians think of their worth; facilitating individualised care; and enabling patients to contribute to their own care.ConclusionsEfforts to improve health care provider-patient communication should attend not only to the transfer of information about the condition and its management but to the range of features of interactions that can signal to people how health care providers relate to them as persons.     

Implementing AORN Recommended Practices for Sharps Safety

Prevention of percutaneous sharps injuries in perioperative settings remains a challenge. Occupational transmission of bloodborne pathogens, not only from patients to health care providers but also from health care providers to patients, is a significant concern. Legislation and position statements geared toward ensuring the safety of patients and health care workers have not resulted in significantly reduced sharps injuries in perioperative settings. Awareness and understanding of the types of percutaneous injuries that occur in perioperative settings is fundamental to developing an effective sharps injury prevention program. The AORN “Recommended practices for sharps safety” clearly delineates evidence-based recommendations for sharps injury prevention. Perioperative RNs can lead efforts to change practice for the safety of patients and perioperative team members by promoting the elimination of sharps hazards; the use of engineering, work practice, and administrative controls; and the proper use of personal protective equipment, including double gloving.     

Patients' and health care professionals' attitudes towards the PINK patient safety video

Rationale, aims and objectives Patients can play an important role in reducing health care harm. Finding strategies to encourage patients to take on an active role in issues related to the quality and safety of their care is therefore essential. The aim of this study was to examine patients' and health care professionals' attitudes towards a video aimed at promoting patient involvement in safety‐related behaviours. Method A within‐subjects design was used where participants were required to complete a questionnaire pre and post screening of a patient safety video. Participants are 201 patients aged 19–103 years (mean 52) and 95 health care professionals aged 23–48 years (mean 32). Main outcome measures include (i) patients' willingness to participate and perceived importance in participating in safety‐related behaviours; and (ii) health care professionals' willingness to support patient involvement. Results After watching the video patients elicited more positive attitudes towards asking doctors and nurses if they had washed their hands and notifying them about issues to do with personal hygiene. No significant effects were observed in relation to patients notifying staff if they have not received their medication or if they were in pain or feeling unwell. In relation to health care professionals, doctors and nurses were more willing to support patient involvement in asking about hand hygiene after they had watched the video. Conclusion Video may be effective at changing patients' and health care professionals' attitudes towards patient involvement in some, but not all safety‐related behaviours. Our findings suggest video may be most effective at encouraging involvement in behaviours patients are less inclined to participate in and health care professionals are less willing to support.     

Second victim phenomenon: Is ‘just culture’ a reality? An integrative review

BackgroundDespite rigorous and multiple attempts to establish a culture of patient safety and a goal to decrease incidence of patient deaths in the health care, estimations of preventable mortality due to medical errors varied widely from 44,000 to 250,000 in hospital settings. This magnitude of medical errors establishes patient safety as being at the forefront of public concerns, healthcare practice and research. In addition to the potential negative impact on patients and the healthcare system, medical errors evoke intense psychological responses in health care providers' responses that threaten their personal and professional selves, and their ability to deliver high quality patient care. Studies show half of all hospital providers will suffer from second victim phenomena at least once in their careers. Health care institutions have begun a paradigm shift from blame to fairness, referred to as ‘just culture’. ‘Just culture’ better ensures that a balanced, responsible approach for both providers who err and healthcare organizations in which they practice, and shifts the focus to designing improved systems in the workplace.ObjectivesThe aim of this review was to identify: how medical errors affect health care professionals, as second victims; and how health care organizations can make ‘just culture’ a reality.DesignAn integrative review was performed using a methodical three-step search on the concept of second victims' perceptions and responses, as well as ‘just culture’ of health care institutions.ResultsA total of 42 research studies were identified involving health care professionals: 10 qualitative studies; eight mixed-method studies; and 24 quantitative studies. Second victims' perceptions of the current ‘just culture’ included: 1) fear of repercussions of reporting medical errors as a barrier; 2) supportive safety leadership is central to reducing fear of error reporting; 3) improved education on adverse event reporting, developing positive feedback when adverse events are reported, and the development of non-punitive error guidelines for health care professionals are needed; and 4) the need for development of standard operating procedures for health care facility peer-support teams.ConclusionsSecond victims' perceptions of organizational and peer support are a part of ‘just culture’. Enhanced support for second victims may improve the quality of health care, strengthen the emotional support of the health care professionals, and build relationships between health care institutions and staff. Although some programs are in place in health care institutions to support ‘just culture’ and second victims, more comprehensive programs are needed.     

Having Their Say: Patients’ Perspectives and the Clinical Management of Diabetes

Using an illness narratives framework, we provide 1 method that health care providers can use to obtain insight into the perceptions and experiences of their patients living with diabetes. We propose that understanding patients’ cultural perspectives help explains their health behavior and can lead to more productive partnering between provider, patient, and community health resources that support adherence and improved health outcomes. We conclude with resources available to assist health care providers in their efforts to deliver culturally appropriate diabetes care and examples of culturally tailored community-based public health initiatives that have been effective in improving diabetes outcomes among African-American patients.     

PS1-51: Effect of Integrated Health Information Exchange on the Duplication of Radiological Services

Background/Aims Unnecessary duplication of diagnostic procedures such as x-rays increases healthcare costs and jeopardizes patient safety. Electronic health records (EHRs) have the potential to reduce unnecessary duplication of diagnostic studies by improving timely access to the original test results. However, when follow-up care occurs in a different institutional setting, providers may not have access to the same EHR. In such cases, electronic health information exchange (HIE) could improve the quality and timeliness of information available to the follow-up provider, thereby reducing the need to order duplicative diagnostic tests. Our primary goal in this work was to determine if members with diagnoses of bone fractures were less likely to receive follow-up x-rays when findings from the initial diagnostic imaging study were available in the electronic health record. Our secondary goal was to estimate the economic costs and patient safety repercussions of duplicate imaging studies. Methods This retrospective cohort study of Kaiser Permanent members in the Mid-Atlantic States (KPMAS) compared the rate of duplicate x-rays in patients with a diagnosis of bone fractures from the Emergency Department (ED) or from outpatient care between 2006 and 2010. We used the Medicare fee schedule to estimate costs for the total episode of care. We estimated radiation exposure by identifying all relevant radiology procedures during the two months following the index event and assigning radiation levels based on published estimates for each procedure. Results The study included approximately 50,000 patients from KPMAS with a bone fractures diagnosis. 20% of patients were initially seen in the ED, while 80% of patients were seen in outpatient care. Patients initially seen at a KPMAS outpatient facility were more likely than patients initially seen in the ED to have x-ray findings recorded in the KPMAS EHR prior to their follow-up visit. These patients were also significantly less likely to have duplicated (same or similar) radiology procedures ordered at follow-up visits. Discussion When the findings from preliminary imaging studies are available in the EHR, providers are less likely to order similar x-rays at follow-up visits. This reduction in duplicate radiology procedures significantly reduces costs and increases patient safety.     

Changing professional practice in tuberculosis care: an educational intervention

AIM: This paper describes the development and implementation of an experiential, participatory in-service education programme focusing on patient-centeredness, problem-solving and critical reflection for primary providers delivering care to tuberculosis patients in South Africa. BACKGROUND: Tuberculosis is a major contributor to the disease burden in developing countries. In South Africa, approximately 90% of tuberculosis patients are managed by nurses at the primary level. Despite efforts to improve quality of care for these patients, many fail to complete their treatment as prescribed. Poor rapport between health care providers and patients with tuberculosis is a major reason for non-adherence to treatment. Methods of improving the quality of care delivery and communication between health care providers and patients with tuberculosis is therefore a priority. DISCUSSION: The paper outlines the stages of developing and implementing the education programme and reflects on this process. Data is drawn from an in-depth qualitative evaluation of the delivery and impacts of the intervention. The approach was acceptable to health care providers and adaptable to the needs of specific clinics. Participants evaluated the educational intervention positively, noting that it facilitated critical reflection on their work; encouraged problem-solving; and heightened their awareness of communication with patients and with colleagues. However, important structural barriers to practice change were identified, including conditions of service, relations with colleagues and support from management. CONCLUSIONS: Experiential, participatory in-service education can be implemented on a large scale in primary care settings. However, the process is resource intensive and the impacts of such education may be limited by barriers at other levels of the health system.     

'Linking the orthopaedic patient with community family violence resources'

An early article on health system response to domestic abuse by Randall in JAMA stated that health providers may be the first and only professionals in a position to recognize violence in their patient's lives. Health providers see many more victims of domestic violence than they realize. In fact, victims of domestic violence will interact with their health providers for both routine and abuse-related care. Early, effective intervention can interrupt the cycle of violence, prevent more serious injuries and symptoms, prevent long-term mental health and psychiatric symptoms, and prevent abuse to children. The most important contribution health providers can make to end abuse and protect the health of its victims is to identify and acknowledge that abuse, because that alone can empower the victim to begin a progression toward safety.     

Computed Tomography in Pregnant Patients

Computed tomography (CT) is performed with increasing frequency on pregnant women. Although exposure to a single abdominal CT does not appear to increase the risk of spontaneous abortion or congenital malformations, it is thought to double the risk of childhood cancer. This article provides a general overview of radiation risks to fetuses, what patients and health care workers know and believe about these risks, how CT is currently being used in the care of pregnant patients, and how the risks associated with this use can be managed. The goal of this overview is to stimulate discussion among health care providers in diagnostic imaging, to help them deal with their patients' concerns, and to help them come to terms with their own concerns when they are called on to perform CT on pregnant women.     

Transitioning the older adult in the ambulatory care setting

Transitions between care settings are periods of vulnerability for patients. This is especially true for older adults, for whom comorbidities and functional impairments can increase the complexity of care and the need for multiple caregivers can compromise safety. Poor care transitions can result in costly hospital admissions. For this reason, leading health care organizations have initiated programs to improve the quality of transitions; however, to date, the ambulatory surgical setting has not been a focus of these initiatives. The ambulatory setting serves an increasingly complex patient population and provides the majority of elective surgeries, and adapting some of the transition tools that have been tested in other settings will benefit health care providers and patients in the ambulatory setting. Identifying periods of transition and risk, implementing electronic health records across all phases of patient care, and using evidence-based tools at each transitional stage can optimize the quality and safety of patient care.     

Hospital–community interface: A qualitative study on patients with cancer and health care providers' experiences

BackgroundPatients with cancer must deal with complex and fragmented healthcare systems in addition to coping with the burden of their illness. To improve oncology treatment along the care continuum, the barriers and facilitators for streamlined oncologic care need to be better understood.PurposeThis study sought to gain insight into the hospital–community interface from the point of view of patients with cancer, their families, and health care providers on both sides of the interface i.e., the community and hospital settings.Methods and sampleThe sample comprised 37 cancer patients, their family members, and 40 multidisciplinary health care providers. Twelve participants were interviewed individually and 65 took part in 10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative analyses were used.ResultsTwo major concepts emerged: “ambivalence and confusion” and “overcoming healthcare system barriers.” Ambiguity was expressed regarding the roles of health care providers in the community and in the hospital. We identified three main strategies by which these patients and their families overcame barriers within the system: patients and families became their own case managers; patients and health care providers used informal routes of communication; and nurse specialists played a significant role in managing care.ConclusionsThe heavy reliance on informal routes of communication and integration by patients and providers emphasizes the urgent need for change in order to improve coordinating mechanisms for hospital–community oncologic care.     

Health care and the transcendent

This paper examines the values implicit in health care providers serving dying persons. It studies why providers should form a relationship with the dying person that is more human, less mechanistic, and less directed to that person as an economic unit or as a “case” of this or that disease. Much of the literature on the dying makes such suggestions but without providing a sound foundation for them. This paper uses a suggestion made by William F. May, who argued that health care providers' relationships with those they serve ought not to be thought of as purely contractual or purely philanthropic, but rather as covenantal (i. e., as a mutual exchange of giving). He believes that such a view makes sense only if we providers see our lives as being themselves gifts—acts of grace by the Transcendent. But it may be difficult to hold on to a covenantal relationship in this sense when there is no prior sense of having already received a gift from the Transcendent. In a culture in which religious belief is often not central to the lives of many people, an appeal to God (as a symbol for the Transcendent) may not be of much help. I suggest that healthcare providers must be able to found our covenant relationships in some other language and symbols. The latter part of this paper presents an attempt to found covenant relationships with the dying in the Transcendent, without using the symbol “God.”     

Satisfied patients are also vulnerable patients--narratives from an acute care ward

Aim. To illuminate the experience of being a patient and cared for in an acute care ward. Background. Patients may be the best source of information for assessing the quality of care in acute care wards. Studies often show that patients’ satisfaction with their hospital stay is interpreted by managers and care providers as a measure for quality of care. Design. Ten patients were interviewed as part of a comprehensive investigation by four researchers into the narratives of five enrolled nurses (study No. 1 – published in Nursing Ethics 2004), five Registered Nurses (study No. 2 published in Nursing Ethics 2005) and 10 patients (study No. 3) about their experiences from an acute care ward at one university hospital in Sweden. Method. A phenomenological hermeneutical method (inspired by the French philosopher Paul Ricoeur) was conducted in all three studies. Findings. The patients are very satisfied with their treatment and care. They also tell about factors that they do not consider as optimal, but which they explain as compromises, which must be accepted as a necessary part of their stay in the ward. This study demonstrates a close connection between patient satisfaction and vulnerability. Conclusions. It is important for all health care providers not to be complacent and satisfied when patients express their satisfaction with their treatment and care. This can result in losing the focus on the patients’ vulnerability and existential thoughts and reflections which are difficult for them, and which need to be addressed. Relevance to clinical practice. The findings can be seen as a challenge for the health care providers as well as the organization to provide quality of care to patients in acute care ward. When listening to the patients’ voice it makes it easier to be aware of the content of their vulnerability.     

Safety Culture and Care: A Program to Prevent Surgical Errors

Surgical errors are under scrutiny in health care as part of ensuring a culture of safety in which patients receive quality care. Hospitals use safety measures to compare their performance against industry benchmarks. To understand patient safety issues, health care providers must have processes in place to analyze and evaluate the quality of the care they provide. At one facility, efforts made to improve its quality and safety led to the development of a robust safety program with resources devoted to enhancing the culture of safety in the Perioperative Services department. Improvement initiatives included changing processes for safety reporting and performance improvement plans, adding resources and nurse roles, and creating communication strategies around adverse safety events and how to improve care. One key outcome included a 54% increase in the percentage of personnel who indicated in a survey that they would speak up if they saw something negatively affecting patient care.     

School-age children with asthma and their parents: relationships with health care providers

Health care providers, including nurses, physicians, and other personnel, are key figures who design and implement plans of care to help families manage childhood asthma, yet families' perceptions of relationships with these professionals has received limited study. Child and parent perspectives about relationships with their health care providers emerged as themes in a study that explored responsibility sharing between school-age children with asthma and their parents (Buford, 2004). Fourteen school-age children with asthma and 14 of their parents from 11 families participated in the study. Parents and, to a lesser extent, children, described aspects of their relationships with their health care providers that were supports or barriers to asthma management. Implications for nurses and other health care providers stem from these data and include the importance for health care providers to educate themselves and their patients about state-of-the-art asthma care. Education should be directed to both parents and their children. In addition, parents need to receive education about how to coach their children because the children depend on them for information and direction. Finally, nurses and other health care providers need to listen to parents and value their input about their children's conditions.     

CA8-02: Implementing a Community Health Initiative Using the Chronic Care Model

Background/Aims Group Health, an integrated care system serving 600,000 members in Washington state, has developed a community health initiative (CHI) based on the medical home and the Chronic Care Model (expanded to emphasize community health promotion). Primary care providers want to maximize their limited time and resources for encouraging healthy behaviors but often are unaware of the full range of community services that can augment and support clinic-based care. The overall goal of the CHI is to improve health outcomes by integrating patient-centered approaches with community- based programs and services that promote better health. Methods A CHI logic model was developed that defines expected short term (phase 1), intermediate and long term outcomes for its primary audience (patients and providers), for Group Health as an organization, and for health-promoting community resources and environments. The CHI strategy involves development of a searchable, web-based database that allows providers to easily refer patients to community-based programs that promote active living, healthful eating, and effective chronic disease management. Focus groups were held with providers to determine database scope and content and secondary data were analyzed and mapped to identify where the most vulnerable populations in Group Health's service live. Results During phase 1 the database is being piloted at a Group Health clinic in a high needs area in King County, to test clinical-community linkage strategies and to set the stage for replication throughout Group Health, among safety net providers, and in the community at large. The pilot phase evaluation is primarily a process evaluation, assessing characteristics of the program that contribute to its success, the creation of linkages to community resources, participant satisfaction, recommendations for improvement, and fidelity of implementation. Discussion The interactive database shows promise as a tool for providers to engage patients in making healthy lifestyle choices and strengthening linkages between clinical practice and community resources. Piloting and evaluating the CHI will ensure the successful replication throughout Group Health, the safety net, and the broader community, and will contribute to the field by demonstrating successful linkages between primary care and community resources.     

Barriers to providing diabetes care in community health centers

OBJECTIVE: We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS: In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbA1c tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS: Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbA1c testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS: Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.