Giving voice to quality and safety matters at board level: A qualitative study of the experiences of executive nurses working in England and Wales

BackgroundRecent reports into egregious failing in the quality and safety of healthcare in the UK have focussed on the ability of executive boards to discharge their duties effectively. Inevitably the role of executive nurses, whose remit frequently includes responsibility for quality and safety, has become the object of increased scrutiny. However, limited evidence exists about the experiences of the UK's most senior nurses of working at board level.ObjectiveWe aimed to generate empirical evidence on the experiences of executive nurses working at board level in England and Wales. We posed two research questions: What are the experiences of nurse executives working at board level? What strategies and/or processes do nurse executives deploy to ensure their views and concerns about quality and safety are taken into account at board level?DesignQualitative interviews using semi-structured interviews.SettingNHS England and Wales.ParticipantsPurposive sample of 40 executive board nurses.MethodsSemi-structured interviews followed by a process of thematic data analysis using NVivo10 and feedback on early findings from participants.ResultsOur findings are presented under three headings: the experiences of executive nurses working with supportive, engaged boards; their experiences of being involved with unsupportive, avoidant boards with a poor understanding of safety, quality and the executive nursing role and the strategies deployed by executive nurses to ensure that the nursing voice was heard at board. Two prominent and interrelated discursive strategies were used by executive nurses – briefing and building relationships and preparing and delivering a credible case. Considerable time and effort were invested in these strategies which were described as having significant impact on individual board members and collective board decision making. These strategies, when viewed through the lens of the concept of “groupthink”, can be seen to protect executive nurses from accusations by board colleagues of disloyalty whislt also actively restricting the development of “groupthink” within the board.Another finding of note was that executive boards may not be permanently fixed as either unsupportive or supportive as participants described how certain boards that were initially unsupportive adopted a more supportive attitude towards matters of safety and quality.ConclusionsThese highly positioned nurses can provide invaluable advice and support to boards around matters of quality and safety. However, the work of nurse executives remains an under-research area and more work is needed to better understand the ebb and flow of power and influence at play within hospital boards.     

Governance education for nurses: Preparing nurses for the future

The complexities of today's health care environment require organizational governing boards to have deeper understanding of health needs, influences, and outcomes with diverse board leadership. Nurses understand the complexities and demands of health care, but few nurses are engaged on boards of directors and many nurses feel unprepared for the governance leadership role. The nurse of the future requires governance knowledge and competencies to influence organizational policies that will improve health care outcomes and advance health promotion. Governance education is a necessary component of preparing the nurse of the future to influence health care transformation. Until nurses can confidently embrace governance leadership as a part of their professional identity, convincing and expecting non-nurse board leaders to appoint nurses to boards will continue to be a challenge. This paper describes a strategy for incorporating governance competencies into nursing curricula across all education levels by leveraging the American Hospital Association Governance Core Competencies (2009) and the Massachusetts Nurse of the Future Core Competencies©-RN (Massachusetts Department of Higher Education Nursing Initiative, 2016).     

The role of internationally educated nurses in a quality,safe workforce

Migration and globalization of the nursing workforce affect source countries and destination countries. Policies and regulations governing the movement of nurses from one country to another safeguard the public by ensuring educational comparability and competence. The global movement of nurses and other health care workers calls for quality and safety competencies that meet standards such as those defined by the Institute of Medicine. This article examines nurse migration and employment of internationally educated nurses (IENs) in the context of supporting and maintaining safe, quality patient care environments. Migration to the United States is featured as an exemplar to consider the following key factors: the impact of nurse migration on the nursing workforce; issues in determining educational comparability of nursing programs between countries; quality and safety concerns in transitioning IENs into the workforce; and strategies for helping IENs transition as safe, qualified members of the nursing workforce in the destination country.     

Why board of nursing disciplinary actions do not always yield the expected results

One of the ways boards of nursing serve to protect the public health, safety, and welfare is by removing from practice those nurses who fail to meet recognized standards of care or otherwise pose a public threat. Self-reporting and discovery through criminal background checks and reports from the court system or other regulatory bodies represent only small numbers of those disciplined. Most complaints investigated by a board are reported by nursing administrators, either chief nursing officers or nurse managers. Frequently, the reporting nurses provide the board with information from their own investigation that identifies the problem and the cause and includes supporting evidence. Based on their own independent investigation, the reporting nurses often assume that the outcome of board action is a foregone conclusion. Without understanding all of the ramifications of disciplinary processes and the requirements to protect the rights of the nurse that are guaranteed under the US Constitution, the final outcome decision can be totally different than anticipated and thus disappointing to the reporting nurse administrator. They could perceive the decision as wrong, nonsupportive, and discounting the efforts made by the reporting nurse. This unhappiness with the outcome causes vulnerability in the major reporting source to a board, namely, the relationship between the board and the nurse administrator. An initial step in mitigating this vulnerability is a better understanding by nursing administrators of the legal procedures that guide disciplinary processes and boards providing timely feedback to reporting nurses on the disposition of cases.     

Nurses and English primary care groups: their experiences and perceived influence on policy development

AIMS OF THE STUDY: To investigate the experiences and perceived influence of nurses serving on English primary care group boards. BACKGROUND: The development of the nursing workforce and nursing services in primary care have been piecemeal and nurses have not always contributed to policy development. The recent establishment of primary care groups (PCGs) in the United Kingdom (UK) potentially offers nurses the opportunity to take a concerted and strategic role in developing professional roles and planning service developments. RESEARCH METHODS: As part of a longitudinal study of a 15% random sample of English primary care groups, nurse board members were surveyed in the winter of 1999. One hundred and forty-four nurses were invited to return self-completion questionnaires. RESULTS: Completed questionnaires were returned by 106 of those invited to participate (73%). Respondents reported that combining their usual work with their role in the PCG was frequently difficult. Only 26% perceived that they had been well prepared for their new role. Compared with other board members [for example, general practitioners (GPs)], nurses perceived that their own influence was limited, with only a quarter rating the influence of nurses on decision-making as great. Most of the sample were feeding back information to other primary care and community nurses working in the locality and 52% rated communication with this wider constituency as good or better. Nurse board members were enthusiastic about their role and optimistic about the positive future impact of PCGs on health. CONCLUSIONS: PCGs are still at a relatively early stage in their development. It is still too early to assess their impact on nurses working in primary care and community settings. Board membership offers nurses a voice in local health policy development.     

Nursing Expertise in the Boardroom: NYONEL Survey Shows Progress

The New York Organization of Nurse Executives and Leaders (NYONEL) conducted a survey of the NYONEL members regarding board membership, including examining board types and characteristics and the roles of nurses on boards. The study also looked at factors contributing to nurses obtaining positions on boards. Although the results showed some encouraging results, there is a need for nursing associations at the state and national levels to continue their efforts, assisting nurses and nurse leaders to become prepared for board membership. By continuing these efforts in conjunction with the Nurses on Board Coalition activities, the number of nurses on boards could increase to well over the achieved goal of 10,000.     

Nursing law violations. A threat to competent and safe nursing practice

Nurse Practice Act violations pose threats to consumers of nursing services and lead to disciplinary actions against nurses by boards of nursing. To analyze nursing law violations, the actions and decisions of boards of nursing, and evaluate trends in negligent and unsafe nursing practice, the authors reviewed nursing law violations as well as rates of recidivism among nurses who received actions against their nursing licenses in Kentucky. The authors discuss how their findings can assist nurse administrators in investigating nurse care givers before employment and in initiating safeguards against nurse violations that affect client safety.     

The state board of nursing and its role in continued competency

Many agencies and individuals are involved with nurse competency, but within this cooperative effort, state boards of nursing have the unique role of assuring the public, through the issuance of licenses, that nurses are competent. The purpose of the board of nursing, as defined by public lawmakers, is to protect the public. There are public members on most boards. Boards of nursing are involved with nurse competency at the time of the nurse's initial entry into practice, on an ongoing basis at the time of license renewal, when the nurse reenters practice after a time of voluntary absence, and after disciplinary action of the nurse. The participation in continuing education activities is one major method for nurses to meet continued competency requirements.     

Newly trained operating room nurses’ experiences of nursing care in the operating room

There is limited research on nurses’ experiences of nursing care in the operating room. The operating room nurses’ responsibility is to ensure good nursing care before, during and after surgery. In an increasingly technological health care environment, there is always a risk of turning the focus away from nursing care towards technology and medicine. Integration of past experiences into the role as an operating room nurse becomes a challenge for those who recently worked as general nurses. The present study aimed to explore newly trained operating room nurses’ experiences of nursing care in an operating room. Semi-structured interviews were performed with ten operating room nurses with a maximum three years’ work experience from an operating room. The interviews were subjected to qualitative content analysis. The findings revealed three themes describing operating room nurses’ searching for their new role. They experienced a gap between theory and practice, felt alone and insignificant and had to find their own place. The operating room nurses’ experienced threats to safe nursing when they lacked time for the patients as well as for their own recovery, and they lacked feedback in order to improve care. They ensured security for patients by establishing one-to-one contact, protecting patients’ well-being and working in teams for the patients’ best interest, participants also focused on the task at hand instead of the patient as a person. New ways of organising work in operating units, and well-functioning teams can be a key to a successful integration of experiences from ward nurse to an operating room nurse, and provide support so that they feel more visible, at ease and safe in their new profession.     

Acute care nurses’ attitudes toward nursing students with disabilities: A focused ethnography

Discrimination towards individuals with disabilities is problematic within nursing. There have been calls to increase diversity in nursing and this includes embracing nurses with disabilities. Increasing diversity in nursing requires increasing diversity among nursing students; in this way, nurse educators are gatekeepers to the profession. Clinical education is a crucial element of nursing education, yet there have been very few studies related to the clinical education of nursing students with disabilities. There have been no studies of attitudes of acute care nurse preceptors toward students with disabilities in the United States. This gap is important as the majority of clinical experiences occur in the acute care environment. Utilizing a focused ethnography, semi-structured interviews were conducted with 20 acute care nurses with at least two years’ experience precepting students. While positive feelings about nursing students with disabilities were shared, thoughts and behavioral intentions remained negative. Six themes emerged: safety, barriers, otherness, communicating to meet needs, disclosure, and student versus colleague. Attitudinal barriers are the primary barriers faced by individuals with disabilities in becoming and practicing as nurses. Nurses in practice and education must embrace more inclusive attitudes towards individuals with disabilities.     

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.     

Assessing RN-to-RN peer review on clinical units

pfeiffer j.a., wickline m.a., deetz j. & berry e.s. (2012) Journal of Nursing Management 20, 390–400
Assessing RN-to-RN peer review on clinical units Aim The primary purpose of this study was to measure informal registered nurse (RN)-to-RN peer review (defined as collegial communication about the quality of nursing care) at the work-unit level. Methods Survey design with cluster sampling of 28 hospital or ambulatory care units (n = 541 respondents). Results were compared with existing patient safety and satisfaction data. A chi-squared test was used to compare responses against nurse characteristics. Results Nurses agreed that RN-to-RN peer review takes place on their units, but no correlation with patient safety and satisfaction data was found. Misunderstandings about the meaning of peer review were evident. Open-ended comments revealed barriers to peer review: fear of retribution, language barriers and lack of professionalism. Conclusions Nurses need clarification of peer review. Issues with common language in a professional environment need to be addressed and nurses can learn collaboration from each other’s cultures. Implications for nursing management Managers should support RN-to-RN peer review on clinical units. Methods used here may be useful to assess current departmental nurse peer review.     

Does nursing leadership affect the quality of care in the community setting?

haycock-stuart e. & kean s. (2012) Journal of Nursing Management 20, 372–381 Does nursing leadership affect the quality of care in the community setting? Aim To examine perceptions about how nursing leadership affects quality of care in the community setting. Background Quality care is considered an essential component of nursing work and recent policy has emphasized the role of leadership in meeting the quality agenda. As shifting the balance of nursing care from the hospital to the community occurs in the UK, there is an imperative to confirm more effectively the quality of care that patients and families receive from nurses working in the community. Methods A qualitative study involving community nurse leaders (n = 12) and community nurses (n = 27) in semi-structured individual interviews (n = 31) and three focus groups (n = 13). Results Tensions exist between ‘leading’ for quality care and ‘delivering’ for quality care. Organisational decision making is challenged by limited measures of quality of care in the diverse roles of community nursing. Conclusions Frontline community nurses and nurse leaders need to articulate how they intend quality of nursing care to be appreciated and actively indicate ways to show this. Implications for nursing management Mechanisms to monitor patient safety, a key aspect of the policy agenda for quality care and other technical aspects of care are important for nurse leaders to develop with frontline community nurses.     

Hospital nursing organizational factors,nursing care left undone,and nurse burnout as predictors of patient safety: A structural equation modeling analysis

BackgroundPromotion of patient safety is among the most important goals and challenges of healthcare systems worldwide in countries including China. Donabedian’s Structure-Process-Outcome model implies that patient safety is affected by hospital nursing organizational factors and nursing care process. However, studies are imperative for a clear understanding about the mechanisms by which patient safety is affected to guide practice.ObjectiveThe objective of this study was to explore the impact of hospital nursing work environment, workload, nursing care left undone, and nurse burnout on patient safety.DesignThis was a cross-sectional study conducted in 23 hospitals in Guangdong province, China in 2014. Data from nurses (n = 1542) responsible for direct care on 111 randomly sampled medical and surgical units were analyzed.MethodsWork environment was measured by the Practice Environment Scale of Nursing Work Index. Workload was measured by day shift unit patient-nurse ratio and non-professional tasks conducted by nurses. Nursing care left undone was measured by 12 items addressing necessary nursing activities. Nurse burnout was measured by the emotional exhaustion subscale of the Maslach Burnout Inventory-Human Services Survey. Patient safety was measured by three items indicating nurses’ perception of overall patient safety and nine items addressing patient adverse events. Structural equation modeling was used to examine a hypothesized model that supposed work environment and workload have both direct and indirect effects on patient safety through nursing care left undone and nurse burnout.ResultsThe findings generally supported the hypothesized model. Better work environment was associated with better patient safety both directly and indirectly. Lower workload primarily indirectly related to better patient safety. Nursing care left undone and nurse burnout were mediators negatively associated with patient safety.ConclusionsImproving work environment, increasing nurse staffing levels, and providing sufficient support for nurses to spend more time on direct patient care would be beneficial to patient safety improvement.     

Nurse leadership: making the most of community service

Nurses are expected to demonstrate professionalism through service leadership, but it is unlikely they have been prepared to understand the responsibilities associated with taking leadership roles in the community. The authors have had a variety of experiences serving on nonprofit health care boards and have obtained information about board roles and responsibilities that would be helpful for practicing nurses who want to be board members. Nurses can make vital contributions to the nonprofit sector of the nation's health care, but must know how to make wise choices to maintain their commitments. This article provides nurses with basic information about the roles and responsibilities of nonprofit board members and some lessons about board service from the authors' experiences.     

Role and Training of Emergency Department Charge Nurses: A Mixed Methods Analysis of Processes,Needs, and Expectations

IntroductionCharge nurses (CNs) are shift leaders who manage resources and facilitate patient care, yet CNs in EDs receive minimal training, with implications for patient safety and emergency nursing practice. The purpose of the study was to describe the experiences of emergency nurses related to training, preparation, and function of the CN role.MethodsAn explanatory sequential mixed methods design using survey data (n = 2579) and focus group data (n = 49) from both CN and staff nurse perspectives.ResultsParticipants reported minimal training for the CN role, with divergent understandings of role, required education and experience, the need for situational awareness, and the acceptability of the CN taking on other duties.ConclusionsThe ED CN is critical to the safety of both nursing environment and patient care. Nurses in this pivotal role do not receive adequate leadership orientation or formal training in the key areas of nurse patient assignment, communication, and situational awareness. Formal training in nurse-patient assignment, communication, and situational awareness are critical to appropriate patient care and maintenance of interprofessional trust necessary for successful execution of the CN role. ED nurse managers should advocate for this training.