Guest Editorial: New views of quality and safety offer new roles for nurses and midwives

Around the world nurses, midwives and all health professionals are developing new roles and responsibilities in improving health care. By applying the science that undergirds the approach to quality improvement and safety developed in other high performance industries, health professionals are shifting from only considering personal responsibility and accountability to systems redesign. Error reporting systems in many countries and regions allow systematic analysis of near misses as well as sentinel events so that the system can be redesigned to prevent future occurrence. Health care organizations match their quality data with benchmarks established among their peers to discover gaps in quality, create quality improvement teams to close the gap, and encourage interdisciplinary collaboration and teamwork to achieve improved outcomes. Nurses are challenged to create the educational approaches so nurses have the necessary skills and leadership opportunities, as illustrated in the Quality and Safety Education for Nurses (QSEN) project.     

Discrepant attitudes about teamwork among critical care nurses and physicians

OBJECTIVE: To measure and compare critical care physicians' and nurses' attitudes about teamwork. DESIGN: Cross-sectional surveys. SETTING: Eight nonsurgical intensive care units in two teaching and four nonteaching hospitals in the Houston, TX, metropolitan area. SUBJECTS: Physicians and nurses who worked in the intensive care units. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty subjects (90 physicians and 230 nurses) responded to the survey. The response rate was 58% (40% for physicians and 71% for nurses). Only 33% of nurses rated the quality of collaboration and communication with the physicians as high or very high. In contrast, 73% of physicians rated collaboration and communication with nurses as high or very high. By using factor analysis, we developed a seven-item teamwork scale. Multivariate analysis of variance of the items yielded an omnibus ( [7, 163] = 8.37; p <.001), indicating that physicians and nurses perceive their teamwork climate differently. Analysis of individual items revealed that relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received. CONCLUSIONS: Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other. As evidenced by individual item content, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills. These findings may be the result of the differences in status/authority, responsibilities, gender, training, and nursing and physician cultures.     

Safety Climate and Organizational Communication Satisfaction Among Korean Perianesthesia Care Unit Nurses

PurposeThis study investigated organizational communication satisfaction and safety climate among perianesthesia care unit (PACU) nurses and factors affecting safety climate.DesignA cross-sectional study of 103 registered nurses currently working in PACUs in Korea.MethodsOrganizational communication satisfaction was measured using the Communication Satisfaction Questionnaire, and safety climate was assessed using the Safety Attitudes Questionnaire-Korean version 2. Additional questions covered the demographics of the respondents and the characteristics of the hospital where they worked.FindingsFactors affecting teamwork climate included communication climate and horizontal informal communication. Safety climate was affected by media quality and organizational integration; job satisfaction by working in secondary hospitals, communication climate, and media quality; perception of management by working in public hospitals, media quality, and personal feedback; and working conditions by working in public hospitals, media quality, and personal feedback.ConclusionsThe results show that Korean PACU nurses experience poorer safety climate compared with other countries. One suggestion is to enhance nurses’ satisfaction using organizational communication (eg, by developing effective communication media that satisfy users) and to promote communication at an organizational level so that individual health care professionals are aware of their organizations’ vision and policies.     

A collaborative approach to fall prevention

Collaboration among health-care providers has emerged as a key factor in improving client care. The authors describe the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project, a nurse-led research initiative to improve fall prevention in older adults through interdisciplinary collaboration. Public health nurses and occupational therapists assessed participants before and after fall-prevention interventions and fou modest improvements in participant outcomes and reductions in modifiable risk factors. The project resulted in successful collaboration, interdisciplinary teamwork and improved service delivery to participants. Among the challenges were delayed timelines, complex issues outside the project protocol and communication difficulties. The authors, who served on the project team, make recommendations for health-care professionals interested in initiating similar projects.     

Current assessments of quality and safety education in nursing

Concerns about the quality and safety of health care have changed practice expectations and created a mandate for change in the preparation of health care professionals. The Quality and Safety Education for Nurses project team conducted a survey to assess current levels of integration of quality and safety content in pre-licensure nursing curricula. Views of 195 nursing program leaders are presented, including information about satisfaction with faculty expertise and student competency development related to 6 domains that define quality and safety content: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. With competency definitions as the sole reference point, survey respondents indicated that quality and safety content was embedded in current curricula, and they were generally satisfied that students were developing the desired competencies. These data are contrasted with work reported elsewhere in this issue of Nursing Outlook and readers are invited to consider a variety of interpretations of the differences.     

Primary Care and Behavioral Health Provider Communication: Strategy for Improvement

Limited communication between primary care and behavioral health providers was identified as a barrier to access care and effective collaborative care of patients seeking behavioral health treatment in the Matanuska-Susitna Borough, Alaska. A 1-group, pretest–posttest design, quality improvement project was created to develop and implement a standardized communication template to facilitate communication and collaboration between behavioral health and primary care providers in the project group. Relational coordination within the group as a whole improved 11.07% from pre- to postintervention. Significant cultural differences, most notably in understanding the application of Health Insurance Portability and Accountability Act, were identified between the 2 provider types.     

Partnering to Lead Change: Nurses’ Role in the Redesign of Health Care

Health care has a long-held perception of perioperative nurses as providers who advocate for patients and who carry out physician orders. According to the Institute of Medicine’s 2010 report on the future of nursing, not only must that view evolve, but nurses also must play a leading role, in partnership with physicians and other health care colleagues, if health care reform is to succeed. Several factors will prepare nurses for this new role of partnering to advance health, including advancing their formal education, developing leadership as a core competency, acquiring leadership skills, and being active in new models of leadership (ie, mentorship, volunteering, advocacy).     

Measuring and Improving Ambulatory Surgery Patients' Satisfaction

The pressure on perioperative services to improve quality for health care consumers creates both challenges and opportunities. To make positive changes, many health care organizations contract with Press Ganey (PG), which processes an extensive database of more than 9.5 million surveys annually and provides benchmark reports to same-type organizations. To measure and improve ambulatory surgery patient satisfaction at one health care network in northeastern Pennsylvania, the nursing leaders in the ambulatory surgery center and OR undertook a quality improvement project focused on educating perioperative nurses on the use of PG reports. After we reviewed the PG reports and implemented changes with nursing staff members in perioperative areas, PG patient satisfaction scores improved regarding information about delays (4.1%) and center attractiveness (0.2%).     

Integrating quality and safety education into clinical nursing education through a dedicated education unit

The Institute of Medicine and American Association of Colleges of Nursing are calling for curriculum redesign that prepares nursing students with the requisite knowledge and skills to provide safe, high quality care. The purpose of this project was to improve nursing students' knowledge of quality and safety by integrating Quality and Safety Education for Nurses into clinical nursing education through development of a dedicated education unit. This model, which pairs nursing students with front-line nursing staff for clinical experiences, was implemented on a medical floor in an acute care hospital. Prior to implementation, nurses and students were educated about the dedicated education unit and quality and safety competencies. During each clinical rotation, students collaborated with their nurses on projects related to these competencies.Students' knowledge was assessed using questions related to quality and safety. Students who participated in the dedicated education unit had higher scores than those with traditional clinical rotations. Focus groups were held mid-semester to assess nurses' perceptions of the experience. Five themes emerged from the qualitative data including thirsting for knowledge, building teamwork and collaboration, establishing trust and decreasing anxiety, mirroring organization and time management skills, and evolving confidence in the nursing role.     

Expanding the Role of Nonclinical Personnel in the OR

Ideally, quality health care should be accessible, affordable, and equitable. Working toward these goals in the OR necessitates examining and redesigning work processes and nursing workflow to make better use of the education and skills of perioperative nurses and assistive personnel. This article describes a pilot project undertaken in the OR at Massachusetts General Hospital, Boston, to identify tasks that took nurses away from direct patient care and to better incorporate assistive personnel into the workflow to increase nurses' contact with patients. The pilot program resulted in an expanded role for assistive personnel and more direct patient contact for nurses.     

Do multidisciplinary integrated care pathways improve interprofessional collaboration?

This paper reports on the evaluation stage of an action research project on interprofessional collaboration in discharge planning. Findings from interviews with health care professionals working in the acute sector had revealed concerns about discharge planning and multidisciplinary teamwork. In the United Kingdom the National Health Service (NHS) Plan has reinforced the need for an integrated approach to health care. Effective health care integration requires effective communication, teamwork and the commitment to deliver integrated care. Integrated documentation is a key strategy for enhancing interprofessional collaboration and reducing the isolation of professionals, and has been successfully implemented in a range of health care settings. Presented with the concerns about the collaborative process in discharge planning, an action research strategy was chosen to bring about change in an orthopaedic ward in one London teaching hospital. This paper will evaluate the implementation of an integrated care pathway with fractured neck of femurs in one London teaching hospital. Care pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The emphasis will be on understanding whether integrated care pathways enhance and develop interprofessional collaboration and enable effective information access and flow across the professions and the organization. The criteria for evaluation, forming the hypotheses of the study, were that interprofessional nonverbal and verbal communication would be enhanced and that interprofesisonal collaboration would increase. Methods of evaluation used were: (i) stakeholder interviews, (ii) interprofessional audit and (iii) analysis of the variances from the integrated care pathway. The evaluation revealed that although integrated care pathways led to improved outcomes for the health care trust there was little evidence to suggest that interprofessional relationships and communication were enhanced. Furthermore, key factors in discharge delays appeared to be organizational rather than professional.     

The Network for Nursing in Child Health

The Network for Nursing in Child Health was launched in 2006 building on earlier collaboration of a group of nurses in Latin America to study the needs for strengthening pediatric nursing curricula in the region. This Network is one of more than 10 specialty nursing networks being developed with support from the Pan American Health Organization (PAHO) as a mechanism for promoting collaboration and communication between nurses of different countries to improve nursing practice and health care. The initial goals of the Network for Nursing in Child Health are to share knowledge and experience related to child health nursing and to promote incorporation of guidelines related to the Integrated Management of Childhood Illnesses (IMCI) in nursing curricula. At this time, membership in the Network is open to all nurses interested in working toward the Network's objectives, although communications are in Spanish. This collaborative network demonstrates the power of nursing working in a concerted way to build on its strengths and increase the capacity of nurses and health care workers to address global health priorities related to children's health care.     

An exploration of nursing home organizational processes

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.     

Conceptualizing collaboration in nursing

Nurses practicing at every level need a clear definition of collaboration before applying the concept in daily practice. Additionally, a conceptual definition of collaboration in nursing assists nurse researchers in finding or developing instruments for measuring collaboration and attributes of collaboration, which will enhance research findings. Collaboration extends beyond communication and includes sharing, teamwork, and respect. Multiple databases including CINAHL, PubMed, and ERIC were searched using the keywords collaboration, nursing, concept analysis, sharing, respect, and teamwork. For this analysis, using Walker and Avant’s method, the conceptual definition of collaboration in nursing is an intraprofessional or interprofessional process by which nurses come together and form a team to solve a patient care or healthcare system problem with members of the team respectfully sharing knowledge and resources. Two instruments consistent with the conceptual definition of collaboration are The Mayo High Performance Teamwork Scale (MHPTS) and Team Strategies and Tools to Enhance Performance and Patient Safety (Team STEPPS) and these instruments are summarized in this study. Finally, case scenarios are given to illustrate exemplars of collaboration in clinical practice.     

Quality and Safety Education for Nurses

Quality and Safety Education for Nurses (QSEN) addresses the challenge of preparing nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work. The QSEN faculty members adapted the Institute of Medicine(1) competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics), proposing definitions that could describe essential features of what it means to be a competent and respected nurse. Using the competency definitions, the authors propose statements of the knowledge, skills, and attitudes (KSAs) for each competency that should be developed during pre-licensure nursing education. Quality and Safety Education for Nurses (QSEN) faculty and advisory board members invite the profession to comment on the competencies and their definitions and on whether the KSAs for pre-licensure education are appropriate goals for students preparing for basic practice as a registered nurse.     

Research Utilization and Interdisciplinary Collaboration in Emergency Care

OBJECTIVES: To examine perceptions of nurse-physician collaboration and research utilization in a large, county medical center with an emergency medicine (EM) residency program, to assess differences among nurses, residents, and attending physicians, and to explore the relationship between collaboration and research utilization. METHODS: A cross-sectional, exploratory, correlational design. Questionnaires measuring four aspects of collaboration-leadership, communication, problem solving, and coordination-and four aspects of research utilization-support, attitude, availability, and use-were distributed to 115 nurses, 18 attending physicians, and 33 EM residents (n = 166). A 59% response rate was achieved. RESULTS: The survey instruments demonstrated acceptable reliability at 0.70 or better Cronbach's alpha except for communication timeliness (alpha = 0.64) and predictive validity. Overall, physicians and nurses rated measures of collaboration and research favorably. However, there were significant differences (p < 0.05) between physicians and nurses on four measures of collaboration (i.e., physician leadership, communication openness within group, communication openness between groups, and problem solving within group) and research utilization (research use), with physicians holding more favorable views than nurses. Three measures of collaboration predicted 47% of the variance in research use for physicians; only one measure of collaboration was important for nurses, explaining 9.3% of the variance in research use. CONCLUSION: Interdisciplinary collaboration showed some significance in promoting research use in the ED, especially for physicians. However, nurse-physician differences in perceptions of collaboration and research use should be examined more fully.     

District continence nurses’ experiences of their continence service in primary health care

hägglund d . (2009) Journal of Nursing Management  18, 225–233
District continence nurses’ experiences of their continence service in primary health care Aim The aim of the present study was to describe district continence nurses’ experiences of providing continence services in primary care. Background It has been stated that there is too little research on the experiences of district care nurses who provide continence services. Method Twenty-two district continence nurses answered a written questionnaire containing three open-ended main questions. A qualitative content analysis method was used to analyse the texts. Results The district continence nurses’ feelings of maintaining their professionalism were promoted by scheduled patient encounters, patients who participate in assessment of urinary incontinence (UI) and functioning teamwork. The opposite situation, nurses’ feelings of having a lesser degree of professionalism, was associated with not having scheduled patient appointments, patients not participating in assessment of UI and lack of teamwork. Conclusions The district continence nurses lacked the authority to start nurse-led continence clinics because of the lack of collaborative teamwork, an organization that did not enable nurse-led scheduled appointments and nurses’ limited view of their own profession. Implications for nursing management Primary health care managers and policy-makers need to provide an environment that enables interprofessional collaboration so that nurses’ skills can be used to advance patient services; such initiatives could enable district continence nurses to reach their full potential.     

Use of problem based learning activity to improve attitudes regarding inter-professional collaborative teamwork in mental health nursing students: An evaluation study

Inter-professional collaboration results in improved processes, quality, cost-effectiveness, and outcomes in health care. Despite benefits of collaboration, little is known about effective nursing education approaches in collaboration. A pre-test, post-test brief longitudinal educational evaluation design was implemented utilizing a teamwork attitudes questionnaire to explore thirty-six Midwestern United States undergraduate nursing students' attitudes about collaborative care. An electronic educational module about collaborative nursing practice was used. Also, participants developed visual representations (maps) of collaborative care teams utilizing reverse case-study approach. The TAQ tool demonstrated significantly improved students' valuation of teamwork after the electronic module activity (t = 5.976, p = 0.000) and increased the identification of need for administrative support for effective teamwork (t = 33.53, 0.000). Collaborative team map drawings demonstrated that patient's frequently fail to identify themselves (75%) and social workers (70%) as part of their care team. Patients (58.3%) and students (77.8%) however, frequently identified family members as important to care. Further study should identify how nurses can fully engage and sustain involvement of family members and social workers in collaborative mental health care. Benefit in student nurses' attitudes about teamwork was found after a brief educational learning module about collaboration.