NR 351 Discussion Nursing Roles in Quality Improvement

“Professional nurses bring a unique perspective and offer valuable skills to enhance health care quality. All health team members must be invested in developing and maintaining a culture of safety and QI” (Hood). Nurses play a vital role in all aspects of care, nurses are the frontline and with that comes huge responsibility. Nursing is probably one of the most stressful occupations and with stress comes the potential for mistakes. No one is without fault but what makes the difference is how that fault is handled, whether it is punitive response or an opportunity to learn. “An important feature of a safe organization is the creation of a “just culture.” A just culture allows frontline employees or personnel to feel comfortable disclosing errors, even one’s own error” (Fondahn, Lane, Vannucci). Even mistakes or near misses should be treated as an opportunity to reflect and learn. We are all imperfect and working in a punitive environment creates stress and the potential for increased errors. Nurses must feel empowered to take responsibility for mistakes and not feel that they will be punished. At my hospital we embrace a “just culture” and use every opportunity to huddle and review what happened, what could have happened, and what could have been done differently.

I feel that my hospital has the tools in place to create a non-punitive environment. The improvement I would like to see is something in place to help nurses work through the pressure and guilt of needing to be perfect. Any time I have ever made a mistake the guilt I feel and the “beating myself up” is more punitive then any one could impose.

Hood, L. J. (2018). Leddy & Pepper’s professional nursing ninth edition. Philadelphia: Wolters Kluwer.

Fondahn, E; Lane, M; Vannucci, A (2016). The Washington Manual of Patient Safety and Quality Improvement. Philadelphia: Wolters Kluwer.

I agree with you that nursing is one of the most stressful jobs and with increased stress comes a higher risk for potential mistakes. An environment that is non-punitive and uses mistakes and errors as a learning opportunity for everyone is a much better environment to work in. With that being said, certain mistakes can not go without punishment, however, it should not be the primary focus. At the hospital I work at, we started a “Good Catch” award. It is to allow nurses to speak up and report a near-miss or an error that was made without being punished. It is meant to help educate staff and do a root analysis to find out how the mistake happened and what can be done to fix the problem and make it safe. Those nurses that made a “good catch” report are recognized in the monthly newsletter. It has helped nurses take responsibility to speak up about near-misses or errors made and not having to worry about being punished.

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As nurses, we promote safety and improve quality by constantly “analyzing errors and designing system improvements” (Massachusetts Department Of Higher Education Nursing Core Competencies, Revised 2016). My floor is now the COVID-19 quarantine unit of the hospital and we are continually collaborating to improve upon processes aimed to prevent contaminating ourselves, patients who might not actually be infected, or anything outside of our unit. Preventing the contamination of patients involves constantly changing PPE and keeping the unit as clean as possible. Moving people, supplies, and waste, and eating, drinking, and going to the bathroom takes more thought, though. Our donning and doffing area is like a gradient of cleanliness with a tent at the end. On the other side of the tent lies the outside world. I feel like we live on an island where practically everything has to be delivered. But it’s not a Southern Caribbean island where people are happy to bring things and might even stay for lunch, it’s more of a Northern Atlantic island, in the middle of winter, where people do not want to come, usually leave supplies on the coast, and rush home. This is good though, because we want as few people as possible coming ashore.

Then there is the conservation of supplies issue. We are now confronted with the choice of conserving and waiting, or depleting PPE, to leave the area to drink, eat, and use the bathroom. Supplies are already low and according to Palmer (2020) “preparing for a worldwide pandemic, especially when you don’t know how fast it will spread or how serious its consequences will be, is one of the hardest things that healthcare workers do.” But we are really learning how to better cluster care and align the time between patients, when we already have to change PPE, with short breaks. I feel like we are going to come out of this being some of the most efficient nurses ever.

And in addition to improving the effectiveness of our unit, we exemplify adequate training with regard to the provided technology to ensure safety to both healthcare provider and receiver (Massachusetts Department Of Higher Education Nursing Core Competencies, Revised 2016). We have become very skilled at working in airborne precautions and although all hospital staff involved in direct patient care have been extensively trained in it, those who don’t frequently visit our unit need special instruction with our process of moving into and out of the quarantine area. Our solution is to always have a “specialist” appointed to the area to both assist those in need and ensure the area is adequately cleaned and stocked.

In response to the second question, I believe my workplace, promotes a very non-punitive culture of safety, where the cause of the error is more significant than the one who caused it (Barnsteiner, 2011). Earlier in my career, I once started a fentanyl drip too fast and realized it a few hours later. The rate was within the titration parameters, and although the patient was not harmed, it was still a medication error. That evening I reflected upon what had caused the error, identified how I could prevent repeating it, discussed it with my manager, and documented it on our error tracking system. Since I was very open and honest about my mistake, and I do not have a reputation for medication errors, my manager was very understanding and I was not punished because there is a balance in my workplace “between not blaming individuals for errors and not tolerating egregious behavior” Barnsteiner (2011).

References

Barnsteiner, J. (2011). Teaching the culture of safety. Online Journal of Issues in Nursing, 16(3). doi:10.3912/OJIN.Vol16No03Man05

Massachusetts Department of Higher Education Nursing Initiative. (2010). Massachusetts Nurse of the Future Nursing Core Competencies^© Registered Nurse. Retrieved from http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdfLinks to an external site.

Palmer, J. (2020). Coronavirus and preparing for the worst. Medical Environment Update, 30(4), 1-4. Retrieved from https://web-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=10&sid=97796d22-d348-4e3f-ae9b-322226ab0e2a%40sessionmgr4007

There is definitely a national shortage of PPE. Here, we were lucky enough to have a local plastics manufacturer, who produces biohazard bags for a national distributer, that was willing to alter their production to make gowns for our hospital. Also, a local distillery is now making our hand sanitizer. And yes, we are doing the same thing with the N95 masks… keeping them in paper bags and using them for a week. Also, those of us doing direct patient care are using a Controlled Air Purifying Respirator (CAPR). They have removable face shields and pads for the headband. We are reusing those, as well. The walls of our clean area are filled with bags of these items, organized by unit and specialty. Finding your bag can really take a while.

I do live in a small community and we have only had two confirmed cases of COVID-19, but we are treating all patients with respiratory issues as potentially positive, so it is still taking a toll on our supplies. For now things aren’t too bad, but the population here usually triples around Memorial Day. My hope is that we have a handle on this pandemic, and there is less travel during that time.

It is heartbreaking to see that a well-developed country like the USA is not ready to deal with an emergency such as this! Most of the facilities are conserving PPE’s, which is not in the normal standards of CDC. The virus just pounces on unsuspecting people, and some patients come to the hospital when it’s too late, forcing the doctors to make a hard decision in triaging the incoming patients.

In response to your safety questions – it is better, to be honest about the mistake than hide it! Not being honest or blaming others just creates more problems in the long run! I have had a new nurse, orienting with me, make a medication error. When I alerted her about her error, she just started blaming me for not alerting her before she gave the medication! My answer was “if you are giving medication, it is your responsibility to check the patient’s name and verify that you are giving medication to the correct patient!” Needless to say, she is no longer with us. She was let go due to many other issues that arose within the 3 weeks that she was with us! We are all humans, and mistakes occur due to multi-tasking, distractions during medication administration, etc. So if a nurse tells me that they had never made a mistake, I assume that they are not telling the truth!

“The Nurse of the Future will minimize risk of harm to patients and providers through both system effectiveness and individual performance (QSEN, 2007)”. (MAS 2016, p 43). I work on an Inpatient Adult Psych Unit: in order to be a nurse of the future, and promote patient safety and improve quality, we perform thorough mental, physical, and environmental assessments at the beginning of the shift, and as needed throughout the shift. Once I started working on the unit, I created an assessment sheet where I ask the following questions to my patients:

“How is your mood? Are you having any anxiety? If yes, what level?”

If anything is above a mild level, ask the patient if they need PRN anxiety medication at this time. Educate the patient on PRN anxiety mediation, verbally and by providing a printout for the mediation.

“Are you having any suicidal or homicidal thoughts? If yes, is it passive or active? Do you feel safe on the unit? Will you come to the staff and let us know if they feel they will act on suicidal/homicidal thoughts? Are you having auditory/visual hallucinations?”

If yes, ask the patient to describe it.

“If hearing voices, what are the voices telling you? Are they commanding in nature? Any pain? When was the last bowel movement?”

If the patient is in need of a stool softener/laxative, provide PRN stool softener/laxative, since many psych/pain medications cause constipation. If a psych patient is constipated, they might feel an increase in pain, and/or anxiety and/or depression. Ask the patient about their goal. Educate the patient to not isolate themselves, instead encourage them to attend groups during the shift.

By asking the right questions, nurses can assess the patient’s mental status and identify potential issues related to suicidal/homicidal thoughts, and hallucinations, which can progress toward the patients acting on them and hurting themselves/others. After assessing the patient, if the nurse feels that 1:1 monitoring is required, the nurse can place the patient on 1:1 and get an order from the psychiatrist. We also provide fifteen minutes safety checks for all of our patients, and 1:1 monitoring if needed for actively suicidal patients who do not feel safe on the unit. We also provide 1:1 monitoring for patients who are at a very high risk of falling.

Within inpatient health care, patient safety issues arise from what the patient creates within the environment such as violence, aggression, self-harm, or suicide. The patient is not only a risk to themselves, but also to other patients, and staff. In mental health, nurses maintain safety through adapting to a custodian role with nursing practice (Slemon et al., 2017). Safety monitoring is usually provided by a PCT/MHA on my unit. To provide continuous safety and quality care to our patients, I would suggest that PCTs/MHAs are given adequate breaks while doing 1:1 monitoring in order to reduce fatigue. This will, in turn, prevent any adverse events for the patient. Another way to provide safety is not to give 2 patients to be monitored by one PCT/MHA. In the past, due to short staffing, our staffing office pushed us to use one PCT for two psych patients. It did not work well, because, in a psych unit, patients are not bound to stay only in their room, they can go to the dining room, groups, etc. So if one patient wants to sleep in his room and one wants to watch TV in the lounge, it creates a dilemma, and can be risky on our nursing license! I had to be firm during staffing shortages and not allow the staffing office to cut our staffing!

References:

Massachusetts Department of Higher Education Nursing Core Competencies. (Revised 2016, March). Retrieved from http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdfLinks to an external site.

Slemon, A., Jenkins, E., & Bungay, V. (2017, October). Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655749/Links to an external site.

At my place of work, nurses promote patient safety and improve quality in many ways. One of the ways nurses promote patient safety and improve quality is by completing hourly rounding on patients. Nurses and nurse assistants take turns rounding on their patients to ensure their patients are being checked on every hour. They do this by asking the patient if they need anything, if they are in pain, if they need to use the bathroom, and notify the patient that they have time to help them with those things. According to a study done by Olrich (2012), “Study findings suggest hourly rounding by nursing personnel positively impacts the three variables studied: patient fall rates, call-light usage, and patient satisfaction” (p. 36). Hourly rounding is just one of the ways nurses promote safety and improve quality.

Nurses make up a large part of the health care team around the world. It seems like almost every week there is a new task that nurses are being held responsible for. Part of being responsible for these tasks includes being reprimanded if they aren’t completed. In order to improve a non-punitive culture of safety, I feel that nurses’ unions need to put a stop to more tasks being assigned to the nurse. I also feel that hospitals should allow more leeway and less punishment when nurses aren’t able to achieve certain tasks for their patients. According to the Massachusetts Nurse of the Future (2016), part of being safe is when the nurse and health care team, “recognizes the cognitive and physical limitations of human performance” (p. 42).

References:

Massachusetts Nurse of the Future Nursing Core Competencies: Registered Nurse. (Revised March 2016). Retrieved from http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly Rounding. MEDSURG Nursing, 21(1), 23-36. Retrieved from https://oce-ovid-com.chamberlainuniversity.idm.oclc.org/article/00008484-201201000-00006/HTML

NR 351 Discussion Nursing Roles in Quality Improvement