Quality & safety in nursing

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Readings: Chapters 8 and 9 in the textbook (3rd edition), Chapters 4 and 7 in textbook (2nd edition)
View video on “Just Culture” at: https://www.youtube.com/watch?v=5mR6e-uhR7c

Skim the following IOM reports:

Aspden, P., Wolcott, J., Bootman, J. L., & Cronenwett, L. R. (Eds.). (2007). Preventing medication
errors: Quality chasm series. http://www.nap.edu/catalog.php?record_id=11623

Frankel, Leonard, & Denham (2006). Fair and just culture, team behavior, and leadership
engagement: The tools to achieve high reliability. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/

Stead, W. W., & Lin, H. S. (Eds.). (2009). Computational technology for effective health care:
Immediate steps and strategic directions. http://www.nap.edu/catalog.php?record_id=12572

Discussion Question 2:

Do you have a “Just Culture” at your place of nursing employment?  If you do, please explain how this culture is communicated and reinforced within the workplace.  Provide an example of a situation in which “Just Culture” was evident.

If you do not have a “Just Culture” at your place of nursing employment, how might it be initiated?  Provide an example of a situation in which a “Just Culture” orientation would have been useful and effective.

A common finding in nursing informatics is that nurses develop work arounds when the technology does not work or is inadequate for documentation. 

What examples have you seen of work arounds in your practice setting?

What issues do the work arounds present for patient safety and care quality?

SECOND EDITION

Core Competencies for Nursing
Leadership and Management

INTRODUCTION TO

QUALITY AND
SAFETY EDUCATION

FOR NURSES

Editors

PATRICIA KELLY
BETH A. VOTTERO
CAROLYN A. CHRISTIE-MCAULIFFE

ISBN 978 ‑0‑8261 ‑2341‑1

11 W. 42nd Street
New York, NY 10036-8002
www.springerpub.com

INTRODUCTION TO
QUALITY AND SAFETY EDUCATION FOR NURSES
Core Competencies for Nursing Leadership and Management, SECOND EDIT ION

Editors
PATRICIA KELLY, MSN, RN
BETH A. VOTTERO, PhD, RN, CNE
CAROLYN A. CHRISTIE-MCAULIFFE, PhD, FNP

The second edition of Introduction to Quality and Safety Education for Nurses has been thoroughly updated with
an emphasis on leadership and management. The content continues to focus on knowledge and skills required
of entry-level nurses in the six Quality and Safety Education for Nurses (QSEN) domains. After heart disease
and cancer, patient safety errors rank as the third-leading cause of death in the United States. As patients’
needs have increased in complexity and inter-professional teamwork and collaboration have become essential,
only strong leadership skills can ensure high-quality and safe care. Nurses, the largest group of healthcare
professionals that spend the most time with patients, are uniquely suited to lead through effective management
and communication in this dynamic environment.

With contributions from nurses, physicians, pharmacists, librarians, attorneys, and other healthcare
professionals throughout the United States and beyond, Introduction to Quality and Safety Education for
Nurses, Second Edition underscores the inter-professional focus grounding healthcare practice today. The
updated edition includes four new chapters on implementing quality and safety initiatives from a leadership
and management perspective, and state-of-the-art information on quality improvement. Each chapter contains
learning objectives, opening scenarios, case studies, interviews, critical thinking exercises, key concepts,
clinical discussion points, review activities, NCLEX-style questions, and web resources.

New to the Second Edition:

• Increased focus on leadership and management aspects of quality and safety
• Updated information from national and state healthcare and nursing organizations
• An evolving clinical case study for application of concepts throughout the text
• Additional patient care cases and real-life examples
• Interviews with a myriad of healthcare professionals such as educators, library scientists, lawyers,

psychologists, risk managers, and many others
• Four new chapters addressing nurse leadership and management of high-quality care, legal and ethical

aspects of quality and safety, delegating patient care and setting priorities, and quality improvement project
management

Key Features:

• Helps nursing schools to fulfill accreditation standards for quality and safety curricula
• Maps the QSEN competencies for knowledge, skills, and attitudes (KSAs) for each chapter
• Includes objectives, critical thinking exercises, case studies, interviews, NCLEX-style questions, photos,

tables, suggested readings, and more in each chapter
• Provides instructor package with PowerPoint slides, Q&A, answers for case study and critical thinking

exercises, and more
• Provides knowledge for nursing education QSEN-specific courses
• KSAs throughout chapters

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Kelly_9780826123411_mech.indd 1 6/19/18 9:39 AM

INTRODUCTION TO
QUALITY AND SAFETY
EDUCATION FOR NURSES

Patricia Kelly, MSN, RN, earned her diploma in nursing from
St. Margaret Hospital School of Nursing, Hammond, Indiana;
baccalaureate in nursing from DePaul University in Chicago, Illinois;
and master’s degree in nursing from Loyola University in Chicago,
Illinois. She is Professor Emeritus, Purdue University Northwest,
Hammond, Indiana. She has worked as a staff nurse, travel nurse,
school nurse, and nurse educator. Patricia has traveled extensively in
the United States, Canada, and Puerto Rico, teaching at conferences

for the Joint Commission, Resource Applications, Pediatric Concepts, and Kaplan,
Inc. She currently teaches nationwide National Council Licensure Examination for
Registered Nurses® (NCLEX-RN®) review courses for Evolve Testing & Remediation/
Health Education Systems, Inc. (HESI), Houston, Texas. She also currently volunteers
in a level one trauma center, emergency room, Advocate Christ Medical Center, Oak
Lawn, Illinois and has been a nursing volunteer at the Old Irving Park Community
Clinic in Chicago, a free clinic for patients without healthcare insurance.

Patricia was director of quality improvement at the University of Chicago
Hospitals and Clinics. She has taught at Wesley-Passavant School of Nursing and
Chicago State University. Patricia was program director of the Associate Degree
Nursing Program and is Professor Emeritus, Purdue University Northwest, College
of Nursing, Hammond, Indiana. Patricia has taught Fundamentals of Nursing, Adult
Nursing, Nursing Leadership and Management, Nursing Issues, Nursing Trends,
Quality Improvement, and Legal Aspects of Nursing. She has been a member of Sigma
Theta Tau, the American Nurses Association, and the Emergency Nurses Association.
She is listed in Who’s Who in American Nursing, Notable American Women, and the
International Who’s Who of Professional and Business Women.

Patricia has served on the board of directors of Tri-City Mental Health Center,
St. Anthony’s Home, and the Mosby Quality Connection. She is a coeditor/author
of Introduction to Quality and Safety Education for Nurses, Core Competencies, first edi-
tion, with coeditors/authors Beth A. Vottero and Carolyn Christie-McAuliffe. Patricia
is also an editor/author of Nursing Leadership and Management, now in its third edi-
tion in the United States and Canada; Essentials of Nursing Leadership and Management
(with Janice Tazbir, coeditor/author), now in its third edition; and Nursing Delegation,
Setting Priorities, and Making Patient Care Assignments (with Maureen Marthaler, coedi-
tor/author), second edition. She contributed a chapter, “Preparing the Undergraduate
Student and Faculty to Use Quality Improvement in Practice,” in Improving Quality,
second edition, by Claire Gavin Meisenheimer. Patricia also contributed a chapter on
Obstructive Lung Disease: Nursing Management in Contemporary Medical-Surgical
Nursing by Rick Daniels. She has served as a national disaster volunteer for the American
Red Cross and has also been a team member on healthcare relief trips to Nicaragua.
Patricia has been a nurse for 50 years and currently lives in Chicago, Illinois, and in
Fort Myers, Florida. She can be reached at [email protected]

Beth A. Vottero, PhD, RN, CNE, earned a baccalaureate degree in
liberal studies with a focus in business management from the Uni-
versity of Maine at Presque Isle; a baccalaureate degree in nursing
from Valparaiso University; a master’s degree in nursing from Uni-
versity of Phoenix; and a PhD in nursing education from Capella
University. Previously, Beth taught in the undergraduate nursing at
Purdue University North Central and the graduate nursing program
at Bethel College. Beth currently is an associate professor of nursing

at Purdue University Northwest, teaching courses including Evidence-Based Practice
and Knowledge Translation at the doctoral level and Informatics and courses in the

Nurse Educator program at the graduate level. At the undergraduate level, she teaches
Quality and Safety for Professional Nursing Practice, Informatics, and Evidence-Based
Quality Improvement projects in the Capstone course.

Beth’s background includes over 18 years as a staff and charge nurse. After com-
pleting her doctorate, Beth coordinated and led a successful Magnet redesignation for
Indiana University Health La Porte Hospital in La Porte, Indiana. She brought a desire
to instill quality concepts to academia where she created an undergraduate quality
course at Purdue Northwest focused on quality and safety in healthcare. Beth is a
research associate with the Indiana Center for Evidence-Based Practice in Hammond,
Indiana, a Joanna Briggs Institute (JBI) Collaborating Center. Through this associa-
tion, she has completed systematic reviews on various topics. In collaboration with
Dr. Lisa Hopp, she assisted in developing an Evidence Implementation Workshop
to train nurses in translation science using an evidence-based quality improvement
focus. Beth is a certified Comprehensive Systematic Review Program Trainer with JBI
and conducts weeklong training for healthcare providers nationally.

Beth has published chapters in Hopp and Rittenmeyer’s Introduction to Evidence-Based
Practice: A Practical Guide for Nurses; Bristol and Zerwekh’s Essentials of E-Learning for
Nurse Educators; and has developed case studies for Zerwekh and Zerwekh’s Nursing
Today: Transitions and Trends. She has published several articles on “Teaching Informatics”
(Nurse Educator QSEN Supplement), “Conducting a Root Cause Analysis” (Nursing
Education Perspectives), and “3D Simulation of Complex Health Care Environments” (Clinical
Simulation in Nursing). Beth is an active member of the QSEN Academic Task Force with
multisite studies on quality and safety education for nurses (QSEN) teaching strategies.
As a funded researcher through Purdue University, Beth has studied factors affecting
medication errors in the clinical setting. Beth can be reached at [email protected]

Carolyn A. Christie-McAuliffe, PhD, FNP, obtained her diploma in
nursing from Crouse-Irving Memorial Hospital School of Nursing,
Syracuse, New York; a baccalaureate and master’s degree in nurs-
ing from the State University of New York, Health Science Center at
Syracuse, Syracuse, New York; and a PhD in nursing from Bingham-
ton University, Binghamton, New York. Her clinical experience has
included staff nursing, home healthcare, oncology care, and private
practice. She has functioned as an administrator primarily in clinical

research and taught at the undergraduate and graduate nursing levels at Crouse-Irving
Memorial Hospital School of Nursing, Syracuse, New York; the College of Notre Dame
of Maryland, Baltimore, Maryland; State University of New York (SUNY) Institute of
Technology, Utica, New York; and Keuka College, Keuka Park, New York. She has
implemented multiple evidence-based practice and quality assurance programs and
served as a compliance officer and Institutional Review Board chair at SUNY Institute
of Technology. Carolyn’s research interest and efforts have focused on primary preven-
tion. The majority of her publications and speaking engagements have centered on
topics of research, evidence-based practice, and leadership.

Currently Carolyn provides Integrative Medicine in her private practice in
Syracuse, NY. In addition, she runs a clinic at the Syracuse Rescue Mission where she
serves as a preceptor for undergraduate and graduate nursing students. Carolyn can
be reached at [email protected]

INTRODUCTION TO
QUALITY AND SAFETY
EDUCATION FOR NURSES
CORE COMPETENCIES FOR NURSING
LEADERSHIP AND MANAGEMENT

Second Edition

Patricia Kelly, MSN, RN

Beth A. Vottero, PhD, RN, CNE

Carolyn A. Christie-McAuliffe, PhD, FNP

Copyright © 2018 Springer Publishing Company, LLC

All rights reserved.

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ISBN: 978-0-8261-2341-1
ebook ISBN: 978-0-8261-2385-5
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Instructor’s PowerPoints: 978-0-8261-2574-3

Instructor’s Materials: Qualified instructors may request supplements by emailing [email protected]

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Library of Congress Cataloging-in-Publication Data

Names: Kelly, Patricia, 1941–editor. | Vottero, Beth A., editor. |
Christie-McAuliffe, Carolyn A., editor.

Title: Introduction to quality and safety education for nurses : core
competencies for nursing leadership and management / [edited by] Patricia
Kelly, Beth A. Vottero, Carolyn A. Christie-McAuliffe.

Description: Second edition. | New York, NY : Springer Publishing Company,
LLC, [2018] | Includes bibliographical references and index.

Identifiers: LCCN 2018012105| ISBN 9780826123411 | ISBN 9780826123855 (e-book)
Subjects: | MESH: Nursing—standards | Quality of Health Care | Patient

Safety | Safety Management | United States
Classification: LCC RT73 | NLM WY 16 AA1 | DDC 610.73071/1—dc23 LC record available at

https://lccn.loc.gov/2018012105

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Printed in the United States of America.

This book is dedicated by Patricia Kelly to her loving Dad and Mom,
Ed and Jean Kelly (Dad was a Safety Engineer at Inland Steel Company);

to her charming, wonderful fiancé, Ron Vana; to her super sisters,
Tessie Kelly Dybel and Kathy Kelly Milch; to her dear aunts and uncles,

Aunt Pat and Uncle Bill Kelly and Aunt Verna and Uncle Archie
Payne; her nephew, John Milch; her nieces, Natalie Dybel Bevil, Melissa
Milch Arredondo, and Stacey Milch Monks; her nephews-in-law, Tracy

Bevil, Peter Arredondo, and Derek Monks; her grandnephew, Brock
Bevil, and her grandniece, Reese Bevil. I love you all!

Beth Vottero would like to thank her support, her rock, and her
hero . . . her ever-patient husband Dino. Thanks also go to her

children Tom (Army Strong), Mitchell (ump extraordinaire), Micah
(King of Games), Michelle (ever-patient educator), and Trisha (the
beautiful mother); to her amazing parents Tom and Judy, Ray and
Dolly; and to her dog Ben, who sat on a chair and stared at her for

hours while she worked. To her super-human coworkers—you know
who you are and how much you motivate me.

Carolyn A. Christie-McAuliffe would like to acknowledge all
the patients she has been graced to know and work with. Her

efforts on this book are dedicated to them: for the trust and honor
they place in her; for the honesty and courage they exhibit; but

most of all, for the privilege to hear, and see, and witness healing
of mind, body, and spirit. For that privilege, she will always
feel a sense of responsibility to do what she can to facilitate

higher levels of safety and quality in healthcare.

CONTENTS

Contributors xi
Foreword xv
Mary A. Dolansky, PhD, RN, FAAN
Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN
Preface xix
Acknowledgments xxv

UNIT I. INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR
NURSES: CORE COMPETENCIES FOR NURSING LEADERSHIP AND
MANAGEMENT

1. Overview of Patient Safety and Quality of Care 3
Ronda G. Hughes

2. Quality and Safety Education for Nurses 39
Catherine C. Alexander, Gail Armstrong, and Amy J. Barton

3. Nurses as Leaders and Managers for Safe, High-Quality Patient Care 65
Carolyn A. Christie-McAuliffe

4. Quality and Safety in High-Reliability Organizations 89
Patti Ludwig-Beymer

5. Legal and Ethical Aspects of Nursing 131
Theodore M. McGinn

6. Delegation and Setting Priorities for Safe, High-Quality Nursing Care 155
Maureen T. Marthaler

UNIT II. THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS
BY NURSING LEADERS AND MANAGERS

7. Patient-Centered Care 179
Carolyn A. Christie-McAuliffe

Share Introduction to Quality and Safety Education for Nurses: Core Competencies
for Nursing Leadership and Management, Second Edition

x • CONTENTS

8. Interprofessional Teamwork and Collaboration 211
Gerry Altmiller

9. Informatics 243
Beth A. Vottero

10. Basic Literature Search Strategies 277
Kimberly J. Whalen

11. Evidence-Based Practice 305
Beth A. Vottero

12. Patient Safety 339
Christine Rovinski-Wagner and Peter D. Mills

UNIT III. NURSE LEADERSHIP AND MANAGEMENT FOR QUALITY
IMPROVEMENT

13. Essentials of Quality Improvement 375
Anthony L. D’Eramo, Melinda Davis, and Joanne Belviso Puckett

14. Tools of Quality Improvement 417
Anthony L. D’Eramo and Joanne Belviso Puckett

15. Quality Improvement and Project Management 447
Jamie L. Vargo-Warran

16. The Future Role of the Registered Nurse in Patient Safety and Quality 467
Jerry A. Mansfield, Danielle Scheurer, and Kay Burke

17. Transition from Student Nurse to Leadership and Management of
Your Future as a Registered Nurse 501
Jodi L. Boling and Patricia Kelly

Appendix A: Selected Reports of the National Academies of Sciences, Engineering,
and Medicine, Formerly the Institute of Medicine (IOM) 525

Appendix B: Prelicensure Knowledge, Skills, and Attitudes 527
Appendix C: Critical Thinking Extras 537
Glossary 547
Index 559

CONTRIBUTORS

Catherine C. Alexander, DNP, RN VA Quality Scholar, White River
Junction, Vermont, Adjunct Faculty, MGH Institute of Health Professions,
Boston, Massachusetts

Gerry Altmiller, EdD, APRN, ACNS-BC Associate Professor, Director,
QSEN Institute Regional Center at The College of New Jersey, School of
Nursing, Health, and Exercise Sciences, Ewing, New Jersey

Gail Armstrong, PhD, DNP, ACNS-BC, CNE Associate Professor,
University of Colorado College of Nursing, Aurora, Colorado

Amy J. Barton, PhD, RN, FAAN, ANEF Associate Dean for Clinical and
Community Affairs Professor, Daniel and Janet Mordecai Endowed Chair in
Rural Health Nursing, University of Colorado College of Nursing, Aurora,
Colorado

Jodi L. Boling, MSN, RN, CNS Core Faculty, American College of
Education, Indianapolis, Indiana

Kay Burke, MBA, BSN, RN, NE-BC Chief Nursing Information Officer
University of California, San Francisco Health, San Francisco, California

xii • CONTRIBUTORS

Carolyn A. Christie-McAuliffe, PhD, FNP Integrative Practitioners,
Syracuse, New York

Melinda Davis, RN, MSN, CCRN, CNL Clinical Improvement Consultant,
VHA QMS Consultative Division (10E2C3), Office of Quality, Safety and
Value, Antioch, Tennessee

Anthony L. D’Eramo, MSN, RN, CPHQ ISO Consultant, Region 1, VHA
ISO Consultation Division, Office of Quality, Safety, and Value, Coventry,
Rhode Island, Providence VA Medical Center, Providence, Rhode Island

Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN Director, Center for
Nursing Leadership, Director, Executive Doctorate of Nursing Practice,
Associate Professor, University of South Carolina, School of Nursing,
Columbia, South Carolina

Patricia Kelly, RN, MSN Professor Emerita, Purdue University Northwest,
College of Nursing, Hammond, Indiana, Faculty, Health Education Systems,
Inc. (HESI), Houston, Texas

Patti Ludwig-Beymer, PhD, RN, CTN-A, NEA-BC, CPPS, FAAN Associate
Professor, Purdue University Northwest, College of Nursing, Hammond,
Indiana

Jerry A. Mansfield, PhD, RN, NEA-BC Executive Chief Nursing Officer
and Chief Patient Experience Officer, Medical University of South Carolina,
Charleston, South Carolina

Maureen T. Marthaler, RN, MS Professor Emerita, College of Nursing,
Purdue University Northwest, Hammond, Indiana

CONTRIBUTORS • xiii

Theodore M. McGinn, JD, BBA, CPA Managing Partner Lavelle Law, Ltd.,
Adjunct Professor, The John Marshall Law School, Chicago, Illinois

Peter D. Mills, PhD, MS Director, VA National Center for Patient Safety
Field Office, Veterans Affairs Medical Center, White River Junction, Vermont
and
Adjunct Associate Professor of Psychiatry, The Geisel School of Medicine at
Dartmouth College, Hanover, New Hampshire

Joanne Belviso Puckett, EdM, RN Director, Quality and Risk Management,
USAF 48th Medical Group, Royal Air Force, Lakenheath, United Kingdom

Christine Rovinski-Wagner, MSN, ARNP National Transformational
Coach Captain, VHA Office of Veterans Access to Care, Faculty Scholar, VA
Quality Scholars Fellowship Program, White River Junction, Vermont
and
Clinical Instructor in Community and Family Medicine, The Geisel School of
Medicine at Dartmouth College, Hanover, New Hampshire

Danielle Scheurer, MD, MSCR, SFHM Hospitalist and Chief Quality
Officer, Associate Professor of Medicine, Medical University of South
Carolina, Charleston, South Carolina

Jamie L. Vargo-Warran, DM/IST, MSN, BSN, LSSGB Dean, Academic
Affairs, Chamberlain University College of Nursing, Rancho Cordova,
California

Beth A. Vottero, PhD, RN, CNE Associate Professor of Nursing, Purdue
University Northwest, College of Nursing, Research Associate, Indiana
Center for Evidence-Based Nursing Practice, Joanna Briggs Collaborating
Center, Hammond, Indiana

Kimberly J. Whalen, MLIS Associate Professor of Library Services, Health
Sciences Librarian, Valparaiso University, Valparaiso, Indiana

FOREWORD

Nurses are at the core of healthcare delivery and their role requires both competence
and leadership to ensure that high quality and safe care is provided. It is exciting to
see the publication of the second edition of Quality and Safety Education for Nurses: Core
Competencies for Nursing Leadership and Management. Based on the Quality and Safety
Education for Nurses (QSEN) competencies (Cronenwett et al., 2007) and emphasizing
leadership and management principles, this book is a valuable educational resource
that facilitates teaching contemporary nursing practice. Nursing students and fac-
ulty across the nation will benefit from the content of the book. It includes personal
interviews, essential content, and study questions that promote reflection and criti-
cal thinking. The book is an essential resource to learning and applying the QSEN
competencies.

Now is the time for nurses to have the knowledge, skills, attitudes, and leadership
to provide consistent high quality and safe care. Although there is evidence that we
have made some progress in the delivery of care (National Patient Safety Foundation,
2015) since the Institute of Medicine (IOM) report over 17 years ago (IOM, 2000, 2003),
medical error remains the third leading cause of death (Makary & Daniels, 2016).
This is due in part to the increasing complexity and dynamic nature of healthcare, the
delivery of care by interprofessional teams that demands new types of communica-
tion strategies, and the challenge of integrating informatics and the electronic health
record. The delivery of healthcare is not what it used to be and new educational strate-
gies are needed to address these changes.

The QSEN competencies were developed over 12 years ago and schools of nursing
continue to report that the QSEN competencies are not integrated into their curricu-
lum (Altmiller & Armstrong, 2017). This is concerning as 24% of NCLEX® questions
are directly related to quality and safety content. Since 2012, the QSEN Institute at the
Case Western Reserve University Frances Payne Bolton School of Nursing has contin-
ued the QSEN movement by continuing to provide resources to integrate the QSEN
competencies into the curriculum in the classroom, simulation lab, and clinical experi-
ences. The qsen.org website provides ready-to-use teaching strategies, resources, and
connections to QSEN experts. A monthly newsletter and annual conference connect
nurse educators and nurse practice leaders to ensure that nursing students are quality
and safety practice ready and that nurse preceptors and practicing nurses are ready to
role-model quality and safety standards.

xvi • FOREWORD

The QSEN movement includes a fundamental paradigm shift: a shift from nurses
not just doing their work but improving their work. This requires nurses and other
healthcare professionals to “systems think” and garner the power to change the sys-
tems in which they work (Dolansky & Moore, 2013). Systems thinking moves nurses to
not just have the knowledge and skill to deliver care to their patients (e.g., use the five
steps to safe medication administration) but to understand and value the connections of
their actions to the systems of care around them (e.g., ask how many medication errors
are occurring on my unit and what actions are being taken to reduce these errors). This
paradigm shift to systems thinking requires nurses to embrace a philosophy of con-
tinuous improvement that facilitates learning from errors and designing new ways of
providing care that ensure high quality and safe care.

Professor Emerita Patricia Kelly, Dr. Beth Vottero, and Dr. Carolyn Christie-
McAuliffe bring the QSEN core competencies alive in this introductory book to
improve student preparation. The addition of leadership and management to this
second edition of the book is important as they are important at both the front line
and the management level of patient care. Leadership and management are essential
to move from traditional nursing care to nursing care that includes systems change
to improve patient care. Leadership is the necessary ingredient to empower nurses
to stand-up and speak out and say, “I am not going to do this workaround any lon-
ger as it violates my core value of delivering high quality and safe care.” As Eleanor
Roosevelt said, “With the new day comes new strength and new thoughts.” Let us
embrace these words and move quality and safety to new heights.

Mary A. Dolansky, PhD, RN, FAAN
Associate Professor and Director of the QSEN Institute

Frances Payne Bolton School of Nursing
Case Western Reserve University

Director of Interprofessional Integration and Education
Center of Excellence in Primary Care

VA Quality Scholars Program (VAQS) Senior Nurse Fellow
Louis Stokes Cleveland VA Medical Center

REFERENCES

Altmiller, G., & Armstrong, G. (2017). National QSEN faculty survey results. Nurse Educator,
42(5S), 1–6.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J.
(2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.

Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education in nursing: The key is sys-
tems thinking. Online Journal of Issues in Nursing, 18(3), 1.

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National
Academies Press.

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National
Academies Press.

Makary, M. A., & Daniels, M. (2016). Medical error—The third leading cause of death in the US. BMJ,
353, i2139.

National Patient Safety Foundation. (2015). Free from harm: Accelerating patient safety improve-
ment fifteen years after to Err is Human. A report from an expert panel. Retrieved from
http://www.npsf.org/?page=freefromharm#form

FOREWORD

Healthcare providers and consumers of care demand excellence. When that is not
achieved, and less than optimal outcomes are realized, the competence of individual
providers pushes to the forefront of discussions, complaints, and root cause investiga-
tions. Assuming or judging individual competence is complicated, particularly when
other causes, such as organizational factors, are disregarded or not appreciated. In too
many instances, particularly when care does not meet our expectations or an adverse
event occurs, the key factors indicate troubles with the competency of not just one but
many.

With the increasing complexity of healthcare and patient needs, there is a demand
for qualified and competent healthcare providers for high-quality, safe patient care.
The attainment of nursing quality and safety competencies begins during coursework
and clinical preparation, is developed in practice, and is refined with experience. While
we may agree that all healthcare providers need to demonstrate specific competen-
cies in practice, we struggle with the definition, context, attainment, importance, and
demonstration of competencies within various healthcare environments. A common
understanding of the definitions, standards, and domains of competencies is essential
and antecedent to potential associations with understanding and improving organiza-
tional, professional, and patient outcomes.

Each day, nurses fulfill many different expectations in different contexts with
changing demands and multiple challenges. To do so, nurses apply and adapt their
competencies as part of their professional practice performance. The application and
adaptation of one’s competencies are influenced by many factors, including attitudes,
motives, and perceptions. Notwithstanding, perceptions of functioning competencies
or levels of competencies may be intertwined with the performance of other nurses
and healthcare providers. As such, there are challenges in measuring competencies
and understanding the confluence of competencies across healthcare teams. It may be
that differences in scope of practice among the professions do not necessarily indicate
discipline-specific competencies. Instead, competencies are interdependent and prac-
tice specific.

Core competencies for quality and patient safety have been defined by the Quality
and Safety Education for Nurses (QSEN) initiative, funded by the Robert Wood Johnson
Foundation, to prepare the future nursing workforce with necessary knowledge, skills,
and attitudes to be actively engaged in improving the quality and safety of health-
care. The approach in this book is based on QSEN and is structured to ensure that

xviii • FOREWORD

students will obtain the recommended competencies and knowledge necessary to provide
care that is both high quality and safe in practice. Patricia Kelly, Beth A. Vottero, and Carolyn
A. Christie-McAuliffe bring the QSEN core competencies together with leadership and
management in an introductory book to improve student preparation. It is a book that will
be an essential tool on our journey to realize the quality and safety of care we all demand.

Ronda G. Hughes, PhD, MHS, RN, CLNC, FAAN
Associate Professor/Director, Center for Nursing Leadership

College of Nursing, University of South Carolina
Member, Institute of Medicine Committee on Credentialing Research in Nursing

Editor, Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Agency for Healthcare Research and Quality

PREFACE

The 1994 Institute of Medicine (IOM) report, America’s Health in Transition: Protecting and
Improving Quality, highlighted the seriousness and pervasiveness of healthcare error rates
and their effect on patient outcomes and morbidity and mortality rates. Then, in 2000, the
IOM released the report, To Err Is Human: Building a Safer Health System. This IOM report
instantly received national attention from policymakers, healthcare providers, and con-
sumers. The IOM report stated, “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 pre-
vented.” This IOM report caused major ripples throughout the healthcare system and
highlighted the need to change how healthcare is delivered. Shockingly, recent research by
Makary and Daniel (2016) has found that more than 250,000 deaths each year are the result
of errors within healthcare. That means that after heart disease and cancer, patient safety
errors are the third leading cause of death in the United States (Makary & Daniel, 2016).

America has some of the best hospitals in the world but it is also the only large,
rich country without Universal Healthcare coverage. About half of Americans have
their health insurance provided by their employers. Healthcare costs can be financially
ruinous for others. In 2016, America spent $10,348 per person on healthcare, roughly
twice as much as the average for comparably rich countries. On average, both hospital
cost and drug prices can be 60% higher than in Europe. The American Affordable Care
Act expanded the health insurance system and cut the number of uninsured people
from 44 million to 28 million but still left a gap among people not poor enough to
qualify for Medicaid, but not rich enough to buy private insurance.

In the U.S., prices for the same service can vary enormously. Having your appen-
dix removed, for example, can cost anywhere from $1,500 to $183,000 depending
on the insurer. Add to this the fact that 9 of the 10 best-paid occupations in the U.S.
involve medicine, and we see that doctors and other healthcare providers have little
incentive to change the system.

The 2001 release of the IOM report, Crossing the Quality Chasm: A New Health System
for the 21st century, spotlighted general problems in healthcare in an attempt to close the
gap between what is known to provide quality healthcare and what is actually occur-
ring in practice. This IOM report defined six principles for healthcare: Healthcare should
be Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered (STEEEP Principles).
This IOM report also identified 10 rules for care delivery redesign (available at www.nap.
edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the). This IOM
report spawned a series of other IOM reports on priority healthcare areas, for example,

xx • PREFACE

public health; biomedical and health research; diseases; quality and patient safety; health
services, coverage, and access; select populations and health disparities; food and
nutrition; veterans’ health; healthcare workforce; environmental health; global health;
substance abuse and mental health; women’s health; aging; and education.

The IOM report, The Future of Nursing: Leading Change, Advancing Health (2011), recom-
mended that nurses practice to the full extent of their education, improve nursing edu-
cation, provide nursing leadership positions in healthcare redesign, and improve data
collection for workplace planning and policy making. This IOM report further states that
strong leadership is critical if the vision of a transformed healthcare system is to be realized.
The nursing profession must produce leaders throughout the healthcare system. Everyone
from the bedside to the boardroom must engage colleagues, subordinates, and executives
so that together they can identify and achieve common goals (Bradford & Cohen, 1998).
Nurses must understand that their leadership is as important to providing quality care as
is their technical ability to deliver care at the bedside in a safe and effective manner.

Care has been provided to patients from early history, often by religious orders.
More recently, Florence Nightingale led 38 women into Scutari Barrack Hospital in
Turkey in 1854 to manage care for British casualties of the Crimean War. She went on
to establish Saint Thomas Hospital and the Nightingale Training School for Nurses in
1860. Many other nurses have also led and managed patient care; some of them hon-
ored in the American Nurses Association Hall of Fame (see www.nursingworld.org/
Hall-of-Fame for a listing of ANA Hall of Fame inductees).

Every nurse is a nursing leader and manager, from the beginning frontline nurse
who works directly with patients and takes action to ensure their safety and care quality
to the advanced practice nurse clinician to the top federal nurse administrator in health
services, scientific and academic organizations, and public health and community-based
organizations. All of these nurses continuously demonstrate leadership and management
and work with the interprofessional team to ensure patient-centered, high quality, safe,
evidence-based care, utilizing informatics as appropriate.

The IOM reports also called for changes in how healthcare organizations provide
safe, high-quality patient care services. Currently, the IOM and many others, includ-
ing clinicians, healthcare organizations, employers, consumers, foundations, research
agencies, government agencies, and quality organizations are working to create a more
patient-centered, 21st-century healthcare system.

A primary movement for change in nursing academia toward the inclusion of more
educational information on STEEEP Principles has been the Quality and Safety Education
for Nurses (QSEN) initiative. QSEN followed the IOM lead and stated that changes in
healthcare needed to focus on the development of nursing competencies in patient-cen-
tered care, teamwork and collaboration, quality improvement, evidence-based practice,
and informatics. Because of nurses’ unique position at the sharp end, front line of care in
direct contact with patients, safety was added as a sixth QSEN competency. The QSEN
initiative convened a national panel of experts to identify the core knowledge, skills, and
attitudes (KSAs) required for each of the six competencies. Information about the KSAs
is available at qsen.org. QSEN also sponsors nursing conferences including:

• An annual QSEN Forum to attract nursing leaders in academia and practice to
share innovations and research in patient quality and safety.

• An annual Summit on Leadership and Quality Improvement to explore interprofes-
sional and frontline leadership strategies that will help to accelerate organizational
and systems cost, safety, and quality improvement performance in organizations
(qsen.org/conferences/1st-annual-summit-on-leadership-and-quality-improvement-
accelerating-change-through-positive-forms-of-leadership/).

PREFACE • xxi

Another significant movement for healthcare change comes from the Agency for
Healthcare Research and Quality (AHRQ). This agency, with funding from the Robert
Wood Johnson Foundation, published Patient Safety and Quality: An Evidence-Based
Handbook for Nurses (2008), edited by Ronda G. Hughes, to provide all nurses with evi-
dence-based techniques and interventions to improve patient outcomes. AHRQ also
provides many other resources for Quality and Patient Safety at their website.

WHY THIS BOOK, QUALITY AND SAFETY EDUCATION
FOR NURSES: CORE COMPETENCIES FOR NURSING
LEADERSHIP AND MANAGEMENT, SECOND EDITION?

The idea for this book was born when two of the editors, Patricia Kelly and Dr. Beth A.
Vottero attended the 2011 QSEN conference in Milwaukee, Wisconsin. Patricia and Beth,
both from the Chicago area, invited Dr. Carolyn A. Christie-McAuliffe, from New York,
to join them as the third editor to facilitate the development of a broad look at quality and
safety. The three coeditors experienced the rapid evolution of quality and safety infor-
mation in their clinical and academic practices and they identified the need for nursing
students to receive an understanding of quality and safety in their basic nursing prepa-
ration. The three editors believed in the need to organize existing information about
quality and safety into one basic, easily understood textbook. This need was recently
emphasized with the publication of the Makary and Daniel report (2016), mentioned
earlier. This report is shocking to us as nurses who have been delivering what we believe
is safe high-quality nursing care for a combined total from the three editors of approxi-
mately 112 years! The purpose of this book is to provide a comprehensive overview of
the essential QSEN KSAs about the six quality and safety competencies in nursing prac-
tice to beginning frontline leaders and managers of interprofessional patient care. These
frontline nursing leaders and managers use informatics and work with interprofessional
teams to deliver patient-centered, evidence-based, safe, high-quality patient care.

Many practical examples from real-life experiences are discussed in this text for stu-
dents. The contributors to this text include nurse educators, nurse faculty, nurse researchers,
library scientists, nurse administrators, nurse case managers, physicians, lawyers, nurse
quality improvement practitioners, nurse practitioners, nurse entrepreneurs, psychologists,
and others. The contributors are from all over the United States, emphasizing a broad view
of quality and safety. There are U.S. contributors from Colorado, Florida, Illinois, Indiana,
New Hampshire, New Jersey, Massachusetts, New York, Ohio, Pennsylvania, Rhode Island,
South Carolina, Vermont, and Washington, DC, as well as an international contributor.

Each chapter includes interviews with experts in their respective healthcare field
to provide an interprofessional team perspective. Interviewees include pharmacists,
nurses, lawyers, physicians, library scientists, quality improvement nurses, radiol-
ogy technologists, nurse practitioners, hospital board members, members from the
Committee of Directors for Joanna Briggs Institute, patients, and others.

An important feature of this book is the listing of QSEN competencies and the
associated KSAs found in Appendix B. Appendix B also identifies the chapter in which
the QSEN competency’s KSA information can be found in the text. This will help both
students and faculty plan for the development of KSA competency in students.

ORGANIZATION

Quality and Safety Education for Nurses: Core Competencies for Nursing Leadership and Manage-
ment, Second Edition, consists of 17 chapters. Each chapter provides nursing students and

xxii • PREFACE

beginning nurses with a background and foundational knowledge of quality and safety to
assist them in their role as sharp end, frontline leaders in today’s healthcare environment.

• Unit I, “Introduction to Quality and Safety Education for Nurses: Core Competencies
for Nursing Leadership and Management,” includes eight chapters. They are
“Overview of Patient Safety and Quality of Care,” “Quality and Safety Education
for Nurses,” “Nurses as Leaders and Managers for Safe, High-Quality Patient Care,”
“Quality and Safety in High-Reliability Organizations,” “Legal and Ethical Aspects of
Quality and Safety,” “Delegation and Setting Priorities for Safe, High-Quality Nursing
Care,” “Patient-Centered Care,” and “Interprofessional Teamwork and Collaboration.”

• Unit II, “The Use of Quality and Safety Education Concepts by Nursing Leaders
and Managers” includes four chapters. They are “Informatics,” “Basic Literature
Search Strategies,” “Evidence-Based Nursing Practice,” and “Patient Safety.”

• Unit III, “Nurse Leadership and Management for Quality Improvement,” includes
five chapters. They are “Essentials of Quality Improvement,” “Tools of Quality
Improvement,” “Quality Improvement and Project Management,” “The Future Role
of the Registered Nurse in Patient Safety and Quality,” and “Transition from Student
Nurse to Leadership and Management of Your Future as a Registered Nurse.”

CHAPTER FEATURES

Several chapter features are used throughout the text to provide the reader with a con-
sistent format for learning. Chapter features include the following:

• Photos, tables, and figures to enhance student understanding
• Healthcare or nursing quotes and interviews to illustrate the chapter content
• Objectives that state the chapter’s learning goals
• Opening Scenario, a mini entry-level clinical situation that relates to the chapter,

with two or three critical thinking questions
• Key Concepts, a listing of the primary understandings the reader is to take from

the chapter
• Key Terms, a listing of important new terms defined in the chapter and identified

within the chapter by bold type
• Clinical Discussion Points for nurses, several questions to engage students in dia-

logue (guidelines for discussion are available online)
• Review Questions, several multiple-choice and alternate-style National Council

Licensure Examination for Registered Nurses (NCLEX-RN) questions (answers to
Review Questions available online)

• Review Activities, to help students apply chapter content to patient care situations
(answers to Review Activities available online)

• Exploring Websites
• References
• Suggested Readings
• QSEN Activities

Special elements are sprinkled throughout several chapters to enhance student learn-
ing and encourage critical thinking and application of the knowledge presented. These
include the following:

• Highlights of historical nursing leaders and managers, many of them in the
American Nurses Association Hall of Fame

• Evidence From the Literature with a synopsis of key findings from nursing and
healthcare literature

PREFACE • xxiii

• Real-World Interviews with healthcare leaders and managers, including nursing staff,
clinicians, administrators, risk managers, faculty, nurses, physicians, patients, nurs-
ing assistive personnel, lawyers, pharmacists, hospital administrators, and others

• Critical Thinking Exercises regarding a safety- or quality-related issue (answers to
Critical Thinking exercises available to faculty online)

• Case Studies to provide the nursing student with a patient care situation calling
for critical thinking to solve an open-ended problem (answers to Case Study ques-
tions available to faculty online)

• Answers to all questions, opening scenarios, and QSEN activities are available to
faculty online

HIGHLIGHTS OF THE TEXT

New to the Second Edition is a robust online evolving clinical case study as an instruc-
tional supplement for faculty to guide teaching the content, with options for how to
use the case study for student learning. The content includes discussion questions for
each section of the case study or guidance for a written paper assignment. The evolv-
ing case study pulls content from the text into how to address an evidence-based qual-
ity improvement project as a new nurse.

• A strong foundation for evidence-based healthcare with attention to high quality,
safe care is emphasized throughout the text.

• Chapters include new information from national, federal, and state healthcare and
nursing organizations.

• Leadership and management for frontline nurses are highlighted throughout the
text and within each topic.

• Teamwork and interprofessional collaboration is stressed throughout the text.
• The six QSEN competencies with their KSAs are highlighted in the chapters.
• There are many critical thinking activities, case studies, and clinical discussion

points for nurses throughout the chapters.
• There is an additional set of critical thinking exercise in Appendix C (answers are

available to faculty online).

INSTRUCTOR RESOURCES

1. PowerPoint lecture slides for each chapter serve as guides for faculty presenta-
tions in the classroom. These can be obtained for qualified instructors by emailing
Springer Publishing Company.

Patricia Kelly
Beth A. Vottero

Carolyn A. Christie-McAuliffe

REFERENCES

Agency for Healthcare Research and Quality (AHRQ). (2008). Patient safety and quality: An
evidence-based handbook for nurses. AHRQ Publication No. 08–0043. Rockville, MD: Author.
Retrieved from http://www.ahrq.gov/professionals/clinicians-providers/resources/
nursing/resources/nurseshdbk/index.html

Bradford, D. L., & Cohen, A. R. (1998). Power up: Transforming organizations through shared leader-
ship. Hoboken, NJ: John Wiley & Sons.

xxiv • PREFACE

Institute of Medicine (IOM). (1994). America’s health in transition: Protecting and improving qual-
ity. Washington, DC: National Academy of Sciences. Retrieved from http://www.nap.edu/
openbook.php?record_id=9147&page=R1

Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Washington,
DC: National Academy of Sciences. Retrieved from http://www.nap.edu/openbook.
php?record_id=9728&page=R1

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st cen-
tury. Washington, DC: National Academy of Sciences. Retrieved from https://www.nap.
edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the

Makary, M., & Daniel, M. (2016). Medical error—The third leading cause of death in the U.S.
British Medical Journal, 353, i2139. doi:10.1136/bmj.i2139

Land of the free-for-all: America is a health-care outlier in the developed world. Economist. April
26th 2018, available at, https://www.economist.com/news/special-report/21740871-only-
large-rich-country-without-universal-health-care-america-health-care-outlier.

ACKNOWLEDGMENTS

A book such as this requires much effort and the coordination of many persons.
Pat, Beth, and Carolyn would like to thank all of the contributing authors for
their time and effort in sharing their knowledge gained through years of expe-
rience in both clinical and academic settings. All of the contributing authors on
both editions within tight time frames to share their expertise. Thanks also to Jane
Woodruff for her computer support and Jane A. Walker, PhD, RN, for her net-
working support.

We would like to acknowledge and sincerely thank the Springer Publishing
Company team who worked to make this book a reality. Joseph Morita, senior acqui-
sitions editor, and Chris Teja, assistant editor, are great people who worked hard to
bring the first edition of this book to publication. We would also like to acknowledge
and thank Cindy Yoo, Managing Editor, Nursing, Springer Publishing Company;
Nandhakumar Krishnan, Key Accounts Manager, DiacriTech Technologies; and
Kumeraysen Vaidhyanadhasamy, Project Manager, DiacriTech Technologies, for their
hard work on the second edition.

The three co-editors would like to thank the following nursing, medical, and
librarian authors for their contributions to the First Edition of this book:

Anne Anderson, DNP, MHSA, RN, CPHQ, NEA-BC (Winfield, Illinois)

Pauline Arnold, MSN, MSA, RN, HACP (LaPorte, Indiana)

Esther Bankert, PhD, RN

Lindsay Bonaventura, MS, RN, FNP, BC (Chesterton, Indiana)

Ashley Currier, MSN, RN, NE-BC (Chicago, Illinois)

Mary A. Dolansky, PhD, RN, FAAN (Cleveland, Ohio)

Mary Gillaspy, MLS, MS (Woodland Park, Colorado)

Corinne Haviley, RN, MS, PhD (Winfield, Illinois)

Joanne M. Joseph, PhD

Andrea Lazarek-LaQuay, MS, RN

xxvi • Acknowledgments

Karen L. McCrea, DNP, FNP-C (Washington, DC)

Francia I. Reed, MS, RN, FNP-C (Utica, New York)

Kathleen Fischer Sellers, PhD, RN (Alfred, New York)

Donna L. Silsbee, PhD, RHIA, CTR, CCS (Utica, New York)

J. Scott Thomson, MLIS, AHIP (North Chicago, Illinois)

Cibele C. Webb, MSN Ed., RN (Mishawaka, Indiana)

Patrick M. Webb, MD (LaPorte, Indiana)

Share
Introduction to Quality and Safety Education for Nurses:

Core Competencies for Nursing Leadership and
Management, Second Edition

UNIT I .
INTRODUCTION TO QUALITY AND
SAFETY EDUCATION FOR NURSES:
CORE COMPETENCIES FOR NURSING
LEADERSHIP AND MANAGEMENT

Upon completion of this chapter, the reader should be able to

1. Define quality of care and patient safety.

2. Discuss key terms used to define quality of care and patient safety.

3. Identify national healthcare organizations influencing quality and safety.

4. Discuss measuring quality and safety.

5. Discuss core measures, sentinel events, and never events.

6. Discuss healthcare quality and safety in industrialized countries.

7. Describe the costs of achieving patient safety and quality of care.

8. Describe key programs that recognize hospital excellence.

9. Discuss the influence of the Institute of Medicine’s (IOM) Quality Chasm
series of reports.

10. Discuss the role of nurses at the “sharp” end of healthcare.
11. Discuss efforts to increase healthcare transparency, improve public

reporting of healthcare, and reduce unwarranted variation in healthcare
safety and quality.

1
OVERVIEW OF PATIENT SAFETY AND
QUALITY OF CARE

Ronda G. Hughes

It is, I guess, politically correct, widely believed, that to say that American health care is the best in the
world. It’s not. (Berwick, 2009)

4 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

A
patient, Mr. R., was admitted to the hospital with uncontrollable pain from a kidney
stone. He also had a history of sleep apnea. The nursing unit was short staffed that
night and each nurse was busy, taking care of more patients than normal. Mr. R., who
was a tall, overweight, 46-year-old man, kept asking for additional intravenous pain

medication as he walked around the unit to try to ease the pain. The nurse called the physician to
increase the dose of the pain medication. The physician ordered the increase and the nurse on the
next shift proceeded to administer the higher dose without looking at how much pain medication
Mr. R. had already received in the past 12 hours, nor did the nurse look at his health history. An
hour later, Mr. R. told his nurse that he finally had some pain relief and he was going to his room
to see if he could sleep for a few hours. His nurse, busy with other patients, went to check on
Mr. R. 3 hours later. She found Mr. R. in his bed, cold to the touch with no respirations. He had
been dead for 2 hours by the time the nurse went to check on him. With the combination of what
ended up being too high of a dose of the pain medication (a medication known to be associated
with life-threatening respiratory depression), the patient’s history of sleep apnea, and the fact that
the nurse did not assess her patient during a 3-hour period, the nurse, the physician, and the
hospital were sued for malpractice by the family.

1. What should the nurse have done prior to administering the last dose of the pain
medication?

2. What should the nurse have done after administering the last dose of the pain medication?
3. What should the nurse, physician, and hospital have done to assist the nurse in avoiding

the medication error?

During the past 20 years, our nation has been focused on improving healthcare out-
comes for patients and their families through improving the quality and safety of
care. Concerns about rising healthcare costs, difficulty in accessing care, and health-
care research have highlighted the need for improving healthcare, and national initia-
tives have been implemented to accelerate change. However, improvements in quality
and safety have been slow. These improvements can be slowed by the complexity of
healthcare and the everyday challenges and opportunities of ensuring that the care
available to and accessed by patients and their families reflects high quality and is safe.
This slow improvement in quality and safety could be considered outrageous, espe-
cially considering how much is spent on healthcare in the United States, more than any
other country in the world.

Frontline bedside nurses, as well as all nurses, have a significant leadership role
to play in patient care. They have a significant influence on the incidence of patient
falls, pressure ulcers, nosocomial infections, pain management, quality improvement
(QI), and safety. Nurses influence patient satisfaction, mortality and morbidity rates,
lengths of stay, complications, and so on. When a patient is at risk for a problem, it is
often the bedside nurse who alerts the interprofessional team and begins the problem-
solving process on behalf of patients.

This chapter provides an overview of the key concepts, drivers, and strategies
for improving the quality of care and patient safety. Specifically, it begins with an
overview of key terms used to define quality of care and patient safety, followed by
key factors that influence healthcare safety and quality including the role of national
healthcare accreditation organizations. The chapter then provides an overview of
core measures, sentinel events, and never events. Since healthcare and patient safety
issues are occurring worldwide, the chapter also includes an overview of quality and
safety in industrialized countries. The chapter then provides a discussion of the costs
of achieving patient safety and quality of care, and the key programs that recognize

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 5

hospital excellence. This is followed by an overview of the influence of the Institute
of Medicine’s (IOM) Quality Chasm series of reports and how the role of nurses puts
them at the “sharp end” of healthcare in direct contact with patients. The chapter con-
cludes with an overview of efforts to increase healthcare transparency, improve public
reporting of healthcare, and reduce unwarranted variation in healthcare safety and
quality.

QUALITY OF CARE AND PATIENT SAFETY

The IOM considers patient safety both “indistinguishable from the delivery of
quality health care” (Aspden, Corrigan, Wolcott, & Erickson, 2004), and the foun-
dation of healthcare quality (Committee on the Quality of Health Care in America,
2001). Leaders in the United States have emphasized the need to redesign systems
of care to better serve patients in the complex environment of our healthcare sys-
tem. This has included efforts to inform policy through national policy reports,
such as the IOM Quality Chasm series of reports (IOM, 1999, 2001), healthcare
research and evaluation, and both federal and state policy changes to acceler-
ate safety and QIs. Federal and state regulatory agencies have implemented new
quality and safety requirements and financial penalties for poor quality care and
care that has harmed patients. There have also been several national initiatives to
improve quality and safety, such as the Institute for Healthcare Improvement’s
(IHI) Transforming Care at the Bedside (IHI, 2017a), 5 Million Lives Campaign (IHI,
2017b), and the Triple Aim (IHI, 2017c). The Centers for Medicare and Medicaid
Services (CMS) have also stopped reimbursement for extra healthcare costs associ-
ated with events that harm patients that are considered preventable. Yet, despite
these many efforts, both government agencies, such as the Agency for Healthcare
Research and Quality (AHRQ), and national healthcare quality organizations, such
as the Leapfrog Group, report that there have been some improvements in quality
and safety, but disparities and problems with quality and safety persist (AHRQ,
2011; The Leapfrog Group, 2017).

KEY TERMS USED WITH QUALITY AND SAFETY

Healthcare quality is defined as “the degree to which healthcare services for indi-
viduals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge” (IOM, 2001). High-quality
care is defined as care that is safe, timely, effective, efficient, equitable, and patient
centered (also referred to as STEEEP) with no disparities between racial or ethnic
groups (IOM, 2001). AHRQ expanded the definition of quality to include, “doing
the right thing, at the right time, in the right way, to achieve the best possible
results” (AHRQ, 2011). The IOM has recommended that quality can be improved
on four levels:

• The patient level
• The health-delivery “microsystems” level, such as a surgical team or acute-care

unit
• The organizational level, such as hospitals and healthcare systems
• The regulatory and financial environment level in which those organizations oper-

ate (IOM, 2001)

6 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Errors are defined as “an act of commission (doing something wrong) or omission
(failing to do the right thing) leading to an undesirable outcome or significant poten-
tial for such an outcome” (Wilson, Harrison, Gibberd, & Hamilton, 1999). Unfortu-
nately, most errors in healthcare are viewed as a reflection of an individual’s lack of
knowledge or skill. Thus, when an error occurs, you will see efforts to blame or pun-
ish an individual. Yet, when considering the context in which healthcare errors occur,
errors are usually a reflection of human failings within poorly designed systems. From
this systems perspective, after an error occurs, we must try to identify factors that most
likely led to the error and find solutions and changes to current healthcare processes
so that we can reduce the possibility of a recurrence of the error or reduce the impact
of the error on patients.

An adverse event, which may be considered either preventable or not, is defined as
any undesirable experience in which harm resulted to a person receiving healthcare that
“requires additional monitoring, treatment, or hospitalization, or that results in death”
(IOM, 1999). Preventable adverse events are considered to reflect care that falls below
the standard of care. Serious preventable adverse events are generally defined as an
adverse event that is preventable and results in a patient death, loss of a body part, dis-
ability, or loss of bodily function lasting for more than 7 days or still present at the time
of discharge. The U.S. Food and Drug Administration (FDA), expands this definition to
focus on any undesirable experience associated with a medical product, such as a medi-
cation or medical device. In such instances, the undesirable experience is considered an
adverse event and should be reported to the FDA when, for example, the patient:

• Dies
• Experiences a life-threatening reaction
• Has an initial or prolonged hospitalization resulting from the adverse event
• Experiences “significant, persistent or permanent change, impairment, damage or

disruption” of normal function
• Needs a “medical or surgical intervention” because of an adverse event (FDA,

2016)

When there are problems or an adverse event occurs with any medication or medical
device, health professionals and consumers/patients can report the event online
via the FDA Adverse Event Reporting System (FAERS) (www.fda.gov/Drugs/
GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/
default.htm) or MedWatch (www.fda.gov/Safety/MedWatch/default.htm). Adverse
events can also be reported to the organization where the event took place through
incident reporting systems, if appropriate, and/or to a state adverse event reporting
system or health department, depending on the state.

Sentinel events (sometimes referred to “never events” or “serious reportable
events”) are defined as any unanticipated event in a healthcare setting that reaches a
patient and results in any of the following:

• Death
• Permanent harm
• Severe temporary harm and intervention required to sustain life (The Joint

Commission [TJC], 2017a)

When a sentinel event occurs that results in death or serious physical or psychologi-
cal injury to a patient that is not related to the natural course of the patient’s illness,
it should be (but is not required to be) reported first within the organization accord-
ing to policy because these types of events, which are rare occurrences, should never

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 7

happen. There are 29 types of sentinel events/serious reportable events (the full list
is available at http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx),
including:

• Surgery on the wrong patient, at the wrong site, or a wrong procedure surgery
• Suicide in a hospital or within 72 hours of discharge
• Falls
• Delay in treatment
• Medication errors
• Surgical instrument or object left in a patient after a surgery or other procedure

(National Quality Forum [NQF], 2017)

When a sentinel event occurs, the healthcare organization is “strongly encouraged,”
but not required, to report the sentinel event to The Joint Commission (TJC) and is
“expected to conduct thorough and credible comprehensive systematic analyses (e.g.,
root cause analyses), make improvements to reduce risk, and monitor the effectiveness
of those improvements” (TJC, 2017b). Patients, family members, staff, and the media
can also report patient safety events to TJC. Note that the reporting of most sentinel
events to TJC is voluntary and represents only a small proportion of actual events
(Table 1.1).

CAUSES OF ERRORS

Everyone can make mistakes. Errors in providing healthcare to patients and their families
are caused by a variety of factors, such as incompetency, lack of education or experience,
inaccurate documentation, language barriers, fatigue, and inadequate communication
among clinicians (Weingart, Wilson, Gibberd, & Harrison, 2000). Errors are also associ-
ated with extremes of age, new procedures, urgent conditions, and the severity of the
medical condition being treated (Palmieri, DeLucia, Ott, Peterson, & Green, 2008).

NATIONAL HEALTHCARE ORGANIZATIONS INFLUENCING
QUALITY AND SAFETY

While the initial estimates in the IOM’s To Err Is Human report proclaimed that each
year there were about 98,000 preventable deaths, recent research by Makary and
Daniel (2016) has found that more than 250,000 deaths each year are the result of

TABLE 1.1 SENTINEL EVENT DATA, 2014 TO SECOND QUARTER, 2017

Retention of foreign body 400 sentinel events
Wrong-site surgery 325 sentinel events
Fall 300 sentinel events
Suicide 300 sentinel events
Delay in treatment 250 sentinel events
Operative/postoperative complication 150 sentinel events
Criminal event 100 sentinel events
Medication error 100 sentinel events
Perinatal death/injury 100 sentinel events

Numbers are approximate. The reporting of most sentinel events to TJC is voluntary.
Source: The Joint Commission. (2017). Sentinel event data general information 2Q 2017 Update. Retrieved from
www.jointcommission.org/assets/1/18/General_Information_2Q_2017.pdf

8 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

errors within healthcare. That means that after heart disease and cancer, patient
safety errors are the third leading cause of death in the United States (Makary &
Daniel, 2016). Recognizing these and other challenges within healthcare, national
healthcare organizations provide resources and incentives to improve quality of care
and patient safety.

There are three key agencies within the U.S. Department of Health and Human
Services that are influential in encouraging improvements in healthcare quality and
patient safety. These agencies include AHRQ, CMS, and FDA. The AHRQ (www.
ahrq.gov) is focused on producing evidence to make healthcare safer, higher quality,
more accessible, and equitable, and working to make sure that evidence is under-
stood and used. The CMS (www.cms.gov) has multiple roles in influencing the
quality of care and patient safety. The CMS works with both public and private
organizations to ensure quality care, promote efficient health outcomes, and make
sure that CMS policies are used by healthcare organizations and clinicians to receive
reimbursement payments for their services to improve patient outcomes. The FDA
(www.fda.gov) is responsible for protecting the public health by ensuring the safety,
efficacy, and security of human and veterinary drugs, biological products, and medi-
cal devices; and by ensuring the safety of our nation’s food supply, cosmetics, and
products that emit radiation (FDA, 2017).

Several organizations, particularly the organizations listed in the following sec-
tion, have significant roles in influencing the quality of care and patient safety. These
organizations influence healthcare safety and quality by working with government
organizations, healthcare organizations, and healthcare clinicians, as well as accredita-
tion organizations:

• The Institute for Safe Medication Practices (ISMP) is a private nonprofit
organization that leads efforts to improve how medications are used by pre-
venting medication errors and promoting safe medication use, through its
national Medication Errors Reporting Program, which collects medication error
reports from healthcare professionals, and the Medical Error Recognition and
Revision Strategies program, where ISMP works directly and confidentially
with pharmaceutical companies to prevent errors associated with confusing
or misleading medication naming, labeling, packaging, and device design
(www.ISMP.org).

• The National Academy of Medicine (NAM), formerly the IOM, provides peer-
reviewed evidence-based information and advice concerning health and health
policy issues. The NAM released a series of 11 reports on quality and patient
safety, starting with its seminal report, To Err is Human: Building a Safer Health
System (IOM, 1999), followed by Crossing the Quality Chasm (IOM, 2001). The IOM
also released the report, The Future of Nursing: Leading Change, Advancing Health,
which sets forth a series of recommendations for nursing to have a greater role in
the complex U.S. healthcare system (IOM, 2013).

• The National Quality Forum (NQF) is a private nonprofit organization that con-
ducts review processes and works with stakeholders to standardize healthcare
performance measures. NQF has certified 34 separate healthcare practices and
procedures to be effective in reducing the occurrence of adverse events. A National
Priorities Partnership, convened by the NQF, has issued sets of specific actions to
reduce healthcare costs in three important areas, i.e., avoiding hospital readmis-
sions, reducing emergency department overuse, and preventing medication errors
(www.qualityforum.org).

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 9

• IHI is a private nonprofit organization that motivates and builds the will for
change, partnering with patients and healthcare professionals to test new models
of care and ensuring the broadest adoption of best practices and effective innova-
tions (www.ihi.org).

• TJC, formerly named the Joint Commission on Accreditation of Healthcare
Organizations, is a private nonprofit organization that operates accreditation
programs for a fee to subscriber hospitals and other healthcare organizations.
Generally, TJC ensures that quality compliance requirements are met, includ-
ing core measures, safe practice measures, and process improvement efforts to
accredit a hospital. It is also known for its standards and tools aimed at ensuring
quality of care and patient safety, such as the Sentinel Event Policy, Improving the
Root Cause Analyses and Actions (RCA2) methodologies and techniques, and the
National Patient Safety Goals (www.JointCommission.org).

• The Leapfrog Group is a private nonprofit organization that collects and reports
its Leapfrog Hospital Survey on hospital performance to improve the value
of care and, through its Leapfrog Hospital Safety Grade, assigns letter grades
to hospitals based on how they perform on patient safety measures (www.
leapfroggroup.org).

• Healthcare Financial Management Association (HFMA) represents leaders in
healthcare finance with broad-based stakeholders in healthcare to provide edu-
cation and coalition building to improve healthcare through best practices and
standards. Through its Value Project, HFMA identified patient quality concerns
including “access, make my care available and affordable; safety, don’t hurt me;
outcomes, make me better; and respect, respect me as person, not a case” (HFMA,
2015; Table 1.2)

There are also some efforts to collect and provide information on performance
measurement data to consumers, physicians, and others. Data from CMS Hospital
Compare provides information on the quality of care provided to patients at hos-
pitals. The information that enables consumers to compare hospitals, which can be
accessed at, www.medicare.gov/hospitalcompare, is organized into several catego-
ries, including

• Survey of patients’ experiences (Hospital Consumer Assessment of Healthcare
Providers and Systems [HCAHPS])

• Timely and effective care
• Complications
• Readmissions and deaths
• Use of medical imaging
• Payment and value of care (CMS, 2017a)

TABLE 1.2 PATIENT QUALITY CONCERNS

ACCESS MAKE MY CARE AVAILABLE AND AFFORDABLE

Safety Do not hurt me
Outcomes Make me better
Respect Respect me as person, not a case

Source: Healthcare Financial Management Association (HFMA). (2015). Value in health care:
Current state and future directions. Westchester, IL: Healthcare Financial Management
Association. Retrieved from http://www.hfma.org/valueproject/valuesourcebook/

10 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

MEASURING QUALITY AND SAFETY

Work by the AHRQ, CMS, and NQF has led the development of measures for improv-
ing the quality of care and patient safety. Many of these measures depend on the occur-
rence of adverse patient outcomes or injury (measures of patient safety) while others
raise the standard of care by ensuring that recommended care is available and used by
all patients at the right time (measures of quality of care). When considered together,
these measures can help healthcare organizations improve the value of care they pro-
vide to all patients.

There are several examples of quality care and patient safety measures that
are used primarily in healthcare organizations, such as hospitals, nursing homes,
and outpatient clinics. The major sets of measures include the CMS Core Measures,
AHRQ Quality Indicators, AHRQ Patient Safety Indicators, NQF and American
Nurses Association (ANA) Nurse Sensitive Indicators, and the National Committee
for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set
(HEDIS) Measures (Table 1.3). Many professional organizations and other health-
care organizations also have quality of care and patient safety measures that can be
found through websites of professional organizations and in peer-reviewed journal
publications.

The case manager at a community hospital was reviewing occurrence report
data trends over the last quarter. There appeared to be an increasing trend of
patients who are not appropriate candidates for an MRI due to the patients
having implanted metal devices. The lead MRI technologist is very con-
cerned that these patients are not being correctly screened by the nurses on
the unit.
The risk manager put together an interprofessional team from the nursing, medi-
cal, and MRI departments. After reviewing the MRI screening process, it was
discovered that a new scheduling system that had been put in place in the radiol-
ogy department was so efficient at getting patients an MRI appointment, the unit
nurses did not have time to complete an MRI patient screening after the doctor
had ordered it. A new MRI screening process was immediately implemented.
The MRI order would now not be placed by the unit secretary until the RN com-
municated that the MRI patient screening was completed. Note that the problem
reported by MRI staff led to the work process change. This protected patients
from a potential injury.

1. Why is it important that patients with implants be identified on the unit by the nurse
rather than later by the MRI technologist?

2. How did the Risk Management process of reviewing the MRI screening process help
with this patient safety issue?

CASE STUDY 1.1

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 11

TABLE 1.3 EXAMPLES OF MEASURES OF PATIENT SAFETY AND MEASURES OF QUALITY
OF CARE

MEASURE SET A FEW EXAMPLES OF THE MEASURES WHERE USED

Core Measures (CMS,
2017b)

• Used to improve
quality of care for
common conditions

• www.cms.gov/
Medicare/Quality-
Initiatives-Patient-
Assessment-
Instruments/
QualityMeasures/Core-
Measures.html

• www.cms.gov/
Medicare/Quality-
Initiatives-Patient-
Assessment-
Instruments/
QualityMeasures/Core-
Measures.html

• Stroke: Received medication to
prevent blood clots

• Immunization: Assessed for flu
vaccine

• Heart failure: Received beta
blocker therapy for left ventricular
systolic dysfunction

• Age appropriate screening
colonoscopy

• Readmission: All-cause readmission
rate following elective total hip or
total knee replacement

• Hospitals
• Health plan/

integrated
delivery
systems

• Individual
clinician level

Patient Safety
Indicators (AHRQ,
2017a)

• Used to improve the
safety of inpatient care

• www.qualityindicators.
ahrq.gov/modules/
psi_overview.aspx

• Rate of pressure ulcers
• Retained surgical item or

unretrieved device fragment count
• Rate of central venous catheter-

related blood stream infections
• Rate of postoperative sepsis
• Transfusion reaction count
• Rate of accidental punctures or

lacerations
• Rate of birth trauma—injury to

neonate

Hospitals

Quality Indicators
(AHRQ, 2017b)

• Used to improve
quality of care

• qualityindicators.ahrq.
gov

Prevention Quality Indicators
• Perforated appendix admission rate
• Hypertension admission rate
• Urinary tract infection admission rate
• Uncontrolled diabetes admission rate
• Bacterial pneumonia admission rate

Hospitals

Inpatient Quality Indicators
• Hip replacement mortality rate
• Heart failure mortality rate
• Acute stroke mortality rate
• Laparoscopic cholecystectomy rate
• Hysterectomy rate

Hospitals

(continued)

12 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

CRITICAL THINKING 1.1

Each year, hospitals, healthcare systems, and healthcare providers report quality
measures to national organizations. They also use these measures to assess their overall
performance and they generally group these quality measures into several key strategic
areas:
• Quality and safety of care
• Patient satisfaction/experience
• Workforce issues

(continued)

MEASURE SET A FEW EXAMPLES OF THE MEASURES WHERE USED

Pediatric Quality Indicators
• Neonatal mortality
• Pressure ulcers
• Transfusion reactions
• Postoperative hemorrhage or

hematoma
• Postoperative respiratory failure

Hospitals

Nurse Sensitive
Indicators (ANA, 2010;
NQF, 2004)

• Used to improve the
quality of nursing care

• www.qualityforum.
org/improving_care_
through_nursing.aspx

• Falls with injury
• Nursing care hours per patient day
• Pressure ulcers
• Rate of nosocomial infections
• Staffing mix (ratios of RNs, LPNs,

and unlicensed staff)

Hospitals

HEDIS (NCQA, 2017)
• Used to measure

performance in care
and services

• www.ncqa.org/hedis-
quality-measurement/
hedis-measures

• Childhood immunizations status
• Colorectal cancer screening
• Medication management for people

with asthma
• Controlling high blood pressure
• Annual dental visit

• Outpatient
clinics and
offices

• Other
organizations
(e.g., health
insurance
company)

URAC
• Used to assess QI with

organizations
• www.urac.org/

standards-and-
measures-glance

• Patient and family member
engagement

• Effectiveness of communications
and service coordination between
providers and across providers and
their patients

• Errors and infections associated with
harm and death

• Variety of
healthcare
programs (e.g.,
healthcare
management
programs,
provider
integration and
coordination
programs)

HEDIS, Healthcare Effectiveness Data and Information Set; LPN, licensed practical nurse; URAC, Utilization Review
Accreditation Commission.

TABLE 1.3 EXAMPLES OF MEASURES OF PATIENT SAFETY AND MEASURES OF QUALITY
OF CARE (continued )

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 13

UNWANTED VARIATION IN HEALTHCARE QUALITY AND
SAFETY

Unwanted variation is variation in the use of medical care that cannot be explained on
the basis of illness, medical evidence, or patient preferences, Wennberg, as reported by
McCue (2003) has categorized four types of variation:

• Variations from the underuse of effective treatments or intervention that has been
shown in clinical studies to improve health status or quality of life, for example,
the use of beta blockers postmyocardial infarction

• Variations in outcomes attributable to the quality of care, for example, increased
mortality following surgery

• Variations from the misuse of preference-sensitive services, for example, hysterec-
tomy versus hormone treatment

• Variations from the overuse of supply-sensitive services, for example supplies that
are overused because they are easily available to patients and healthcare practition-
ers, for example, medications and various technologies

There is variation in healthcare in various areas of the United States, variation pro-
vided by different healthcare providers and agencies, and variation in services
available to different socioeconomic groups. There is also significant variation in what
healthcare providers charge for different services. Nurses and the interprofessional team
must work to reduce variation and improve healthcare service delivery to all patients.

TRANSPARENCY AND REPORTING PERFORMANCE

Healthcare clinicians, insurance companies, state and federal governments, patients and
their families, and many others have the opportunity to improve patient safety and the
quality of healthcare. National and state efforts to motivate improvements in healthcare
have included financial incentives, regulation, accreditation, and public reporting. Of
these, public reporting of performance is thought to be the best motivator for improv-
ing patient safety and quality of care. When organizations and clinicians are transpar-
ent in reporting their performance against quality measures, it is believed that they are
being accountable, that they ethically respond to failures (Leape, 2010), and that they are

CRITICAL THINKING 1.1 (continued)

• Financial performance
• Strategic sustainability and growth)

Explore one of the websites in Table 1.3 for one of the measures described there. Think
about how nurses can use these measures to improve nursing care and patient outcomes
in these five key strategic areas.

1. How can nursing care and patient outcomes be improved by reviewing
patient satisfaction measures?

2. How can nursing care and patient outcomes be improved by reviewing
quality and safety of care?

14 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

informing consumer choice (Berwick, James, & Coye, 2003). In most instances,
transparency is considered to include reporting not only the real cost of care, but
also clearly reporting information about performance failures as well as successes
(Pronovost et al., 2016). Major domains of healthcare transparency include the following:

• Clinical quality
• Resource use
• Efficiency
• Patient experience of care
• Professionalism
• Healthcare system/facility recognition and accreditations for meeting national

standards
• Financial relationship of physicians and other healthcare professionals
• Financial relationship between physicians and other healthcare professionals, and

industry
• Health insurance company processes (American College of Physicians [ACP], 2010)

Improvement of how care is delivered and improvement in patient outcomes from
care received is a labor-intensive process that uses many staff and financial resources.
Improvement processes include accurately looking at errors that occur from provid-
ing care; looking at areas where the quality of care can be improved through the early
detection, prevention, and reporting of errors; and looking at improving performance on
measures of quality care. Yet reporting errors or problems in quality of care is not straight-
forward. Federal and state governments, as well as private organizations have used man-
datory reporting systems for errors and instances of poor quality of care, yet they are
often not effective because of the fear that clinicians have of being punished, for example,
with financial fines or punitive actions. As a result, errors continue to be underreported.

In many states, when a serious preventable adverse event occurs in a healthcare
facility, for example, a hospital, nursing home, and so on, that is licensed by a state
government, the facility is required by state law to report the event to their state gov-
ernment. However, it is important to note that while the majority of states have this
requirement, not all states require this. TJC also has a voluntary reporting system.

Relatedly, it is also important to report successes and achievements in patient safety
and quality of care within an organization. For example, reports of positive nursing
sensitive indicators of high-quality care include achievement of appropriate self-care,
demonstration of health-promoting behaviors, achievement of positive health-related
quality of life, perception of being well cared for, and good symptom management.
Mortality (i.e., death), morbidity (i.e., disease), and adverse events are considered
negative outcomes by both clinicians and external organizations. Reporting successes
can be helpful in understanding if an organization or clinicians are able to sustain and
attain goals in safety and quality.

Patient safety and quality of care can improve in organizations committed to
safety and quality throughout the organization. Unfortunately, not all organizations
are committed to improving patient safety and quality. Nurses report that there is a
lack of a blame-free environment and problems with leadership support to establish
and maintaining a culture of safety (Wolf & Hughes, 2008). The barriers for attaining a
culture of safety include lack of leadership, a culture where low expectations prevail,
poor teamwork, and poor communication. Optimally, everyone, at all levels within an
organization, would work in a culture of safety where there is

• Acknowledgment of the high-risk nature of an organization’s activities and the
determination to achieve consistently safe operations

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 15

• A preoccupation with safety
• An emphasis on systems improvement to support performance
• Organizational commitment of resources and encouragement of collaboration

across ranks and disciplines to seek solutions to patient safety concerns
• Encouragement of collaboration to find solutions for patient safety problems
• Proactive reporting of unsafe conditions
• A just culture (or culture of justice) response to error, which includes frequent

debriefing and sharing of “lessons learned,” and which has an atmosphere of
teamwork within a blame-free environment with mutual respect, which enables
candid discussion among employees, where patient safety concerns are dealt with
quickly (AHRQ, 2017c)

Safety culture is generally measured by surveys of providers at all levels. Available
validated surveys include AHRQ’s Patient Safety Culture Surveys (available at psnet.
ahrq.gov/resources/resource/5333) and the Safety Attitudes Questionnaire (available
at psnet.ahrq.gov/resources/resource/3601).

THE CONSEQUENCES OF WHEN THINGS GO WRONG

Errors in healthcare that harm patients cost approximately $17.1 billion each year (Van
Den Bos et al., 2011). It has been estimated that, while hospitalized, about one in four
patients experience one or more adverse events that result in a longer hospital stay,
permanent harm, the need for a life-sustaining intervention, or death. Of these adverse
events that resulted in injury, almost half were preventable (Office of the Inspector
General [OIG], 2010).

Errors happen because of a multitude of factors, such as lack of education or expe-
rience, misdiagnosis, under-and over-treatment, urgency, and fatigue (IOM, 1999).
Patient harm during a hospitalization is also impacted by nurses. The more times a
hospitalized patient is exposed to below targeted nurse staffing levels, the greater the
risk for patient mortality (Needleman et al., 2011). While nurses are capable of prevent-
ing the majority of errors from harming a patient, all errors need to be reported (Wolf
& Hughes, 2008) by the members of the healthcare team, not just nurses. The team
needs to work together to mitigate (or minimize the amount of) the effects of an error
for the patient.

As part of national efforts to reform Medicare, and in an effort to encourage hos-
pitals to improve the quality and safety of care, CMS and many private insurance
companies require hospitals to report the occurrence of sentinel events and will apply
a financial penalty to the hospital if and when sentinel events do occur. Sentinel events
(e.g., mortality, readmissions within 30-days of discharge, and wrong-site surgery) are
considered to be preventable and should not happen. When they do happen, the hos-
pital will not be reimbursed for the cost of care associated with the cost of care for the
aftermath of the sentinel event (e.g., longer hospital stays, a corrective surgical proce-
dure) from CMS. CMS (and now many private insurance companies) will also not pay
for conditions related to Never Events, including:

• Certain serious pressure ulcers
• Acquired urinary tract infections from catheter use
• Acquired blood stream infections from catheters
• Air embolism
• Giving the wrong blood type
• Foreign objects left in surgical patients (CMS, 2008)

16 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

In some instances, errors that cause patient harm result in a medical malpractice law-
suit. Approximately $55.6 billion in 2008 or 2.4% of total U.S. healthcare spending
is estimated to be spent on medical liability. Medical liability includes items such as
malpractice payments to patients, attorneys’ fees and other legal expenses for both
sides, and defensive medicine costs, which are the costs of medical services ordered
primarily for the purpose of minimizing the physician’s liability risk (Mello, Chandra,
Gawande, & Studdert, 2010).

PROFESSIONAL RESPONSIBILITIES FOR NURSES

Nurses are key to ensuring and improving quality of care and patient safety for
patients and families, as well as for the organizations in which they work. Quality
and Safety Competencies, developed as part of the Quality and Safety Education for
Nurses (QSEN) initiative, that identify knowledge, skills, and attitudes that nursing
students should achieve as part of their prelicensure programs and be able to exem-
plify in practice. They include the following:

• Patient-centered care
• Teamwork and collaboration
• Evidence-based practice (EBP)
• QI
• Safety
• Informatics (QSEN, 2014)

It is important to understand that the best way to exemplify these six competencies in
practice is to apply each competency within the wider context of complex healthcare
systems, which has not been the traditional approach for healthcare clinicians that
have been educated to focus at the individual point of care (Dolansky & Moore, 2013).
In other words, clinicians tend to focus on the individual patient and their family, not
necessarily how that patient and their family affect and are affected by the larger popu-
lation and system of care. As such, to effectively apply each of the six competencies
within the wider context of complex healthcare systems, nurses need to think about
how performance can be measured, how the strengths of each team member can be
maximized to improve care delivery to patients and improve their outcomes, and what
can be done in the healthcare system to assure quality and safety and prevent harm
from unintended consequences from errors. To take this one step further, in some cir-
cumstances, it is important to think about how nurses can accomplish QI and patient
safety within organizations that may not truly have a culture of safety. It can be very
difficult to improve quality and patient safety within an organization that does not
have a culture of safety.

CRITICAL THINKING 1.2

In thinking about what you are learning in nursing school about patient safety and
quality of care, go to http://qsen.org/competencies/pre-licensure-ksas/ and explore the
specifics of each of the six QSEN competencies.

(continued)

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 17

PREVENTING AND RESPONDING EFFECTIVELY TO
ADVERSE EVENTS

Strategies to reduce unwarranted variation and ensure predictable and favorable
patient-care outcomes have proven successful in improving healthcare quality and
patient safety. These strategies include developing checklists and other standard-
ized tools, using best practices, and working in an organization with a culture of
safety and communication when an error does occur. Checklists have been proven
successful particularly in operating rooms and other areas where multiple tasks
need to be accomplished consistently to ensure quality and safety. Checklists have
demonstrated that they protect against failure, they establish a higher standard of
baseline performance, and they are only an aid if they are done right to begin with
(Gawande, 2011).

Standardized communication tools such as the SBAR (Situation, Background,
Assessment, Recommendation) technique (www.ihi.org/resources/Pages/Tools/
SBARTechniqueforCommunicationASituationalBriefingModel.aspx), and using stan-
dardized order sets, protocols, and other best practices can be used by nurses and other
members of the healthcare team to prevent errors, ensure quality care, and reduce vari-
ability in patient care and the potential for error.

It is important for nurses to work in organizations dedicated to a culture of
safety and communication when an error does occur. Organizations that have a
culture of safety are nonjudgmental, acknowledge the risk and error-prone nature
associated with healthcare, and focus on improving healthcare systems and pro-
cesses. In that quality and patient safety errors are often systems related and are
not always attributable to individual negligence or misconduct, organizations that
foster a culture of safety continuously strive to intercept errors before they happen,
measure the quality of care processes and outcomes, and mitigate (or take action
to minimize) harm involving patients. Organizations with a true culture of safety
maintain an environment where nurses are not afraid to speak up and report errors
or potential errors.

When something goes wrong and patients are harmed, it is difficult for clinicians,
leadership, and patients. The first thing to remember is that when an adverse event
occurs, it is important to respond in a timely manner, and as the Leapfrog Group rec-
ommends, do the following:

1. “Apologize to the patient and family
2. Waive all costs related to the event and follow-up care
3. Report the event to an external agency
4. Conduct a root-cause analysis of how and why the event occurred
5. Interview patients and families, who are willing and able, to gather evidence for

the root cause analysis

CRITICAL THINKING 1.2 (continued)

1. What specific ways do you see the QSEN competencies being used in your
nursing courses?

2. What specific ways do you see quality and safety being practiced in your
clinical experiences?

18 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

6. Inform the patient and family of the action(s) that the hospital will take to pre-
vent future recurrences of similar events based on the findings from the root cause
analysis

7. Have a protocol in place to provide support for caregivers involved in Never
Events, and make that protocol known to all caregivers and affiliated clinicians

8. Perform an annual review to ensure compliance with each element of Leapfrog’s
Never Events Policy for each never event that occurred

9. Make a copy of this policy available to patients upon request” (Leapfrog Group,
2017)

One tool that health care organizations and providers can consider using to learn
more about being successful after an adverse event occurs is the Communication and
Optimal Resolution (CANDOR) kit. CANDOR is a communication and resolution pro-
cess designed to open lines of communication between clinicians, patients, and their
families after patient harm occurs. The free program (available at www.ahrq.gov/
professionals/quality-patient-safety/patient-safety-resources/resources/candor/
introduction.html), includes eight training modules and also encourages clinicians to
report near misses and errors to better inform patients (AHRQ, 2016).

WHY IS IT WRONG TO BLAME AND POINT FINGERS?

When errors occur, we seem to traditionally blame the nurse as causing the error since
many of the roles of nurses in patient care often put the nurse in direct contact with
patients. In the past, we have even gone so far as to blame nursing leadership for
“allowing” nurses to cause errors. By being in direct contact with patients, nurses are
in a unique position to most likely be the only person in the room with the patient or
the last person able to stop a chain of events that may result in an error. If a nurse is
unable to stop an error from happening, the nurse is seen as literally at the sharp end
of the arrow of blame. The term “sharp end” has been used to identify the important
and significant direct contact role that nurses at the bedside, closest to clinical activi-
ties, play in recognizing the need for and potential impact of practice changes. Nurses
may see the sharp end effects on patients and others first when the right care is not
provided. Front line clinical nurses (as well as nurses in formal leadership positions)
often assume leadership at the “sharp end” of care in direct contact with patients to
assure safety and quality.

Nurses are qualified to offer invaluable insights and perspectives about what is
preventing effective and efficient care as well as how the quality and safety of care can
be improved based on their skills and experience. Other contributing factors, whether
individual or health system related (e.g., such as the physician who may have ordered

CRITICAL THINKING 1.3

During your shift, you discover that the wrong medication was given to the wrong
patient. Hospitals have policies and procedures that should be followed when a patient
is given the wrong medication.

1. What are the policies and procedures at your clinical agency?
2. What do those policies state?

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 19

the wrong medication, or the design flaw in the infusion pump that malfunctioned),
while maybe not in direct contact with the patient when the error occurred, also con-
tribute to errors.

CAN HEALTHCARE BE PERFECT?

The quality and safety of care does not just spontaneously improve, and in many
respects, it may not be possible to have error-free care that is of the highest quality
at all times and in all places. Generally speaking, something needs to be done or
someone needs to take action to either make improvements or ensure that a quality
standard is maintained. A key goal of healthcare is to reduce unwarranted variation
in healthcare safety and quality to ensure optimal patient outcomes. Yet even with
the understanding that the quality of healthcare in the United States and throughout
the world needs to improve, there is no consensus on how to best achieve consistent,
high-quality care.

One of the challenges we have in improving healthcare is that nurses tend to be
resilient—meaning that if something does not work well while they are providing care
to a patient, they work around the “normal” way of doing things. These workarounds
increase the opportunities for inconsistent care and inconsistent outcomes. Related to
this, patients can also at times be resilient. For example, some patients can take the
wrong medication at the wrong time and have no effects. Unfortunately, the resiliency
of nurses coupled with the resiliency of patients does not guarantee the best possible
outcomes nor does it ensure safe quality care.

Over the years, healthcare has become very complex. It involves multiple health-
care professionals and information from many sources. This complexity is closed
linked with increased opportunities or increased risk for something going wrong and
patients being harmed or the quality of care being compromised. Patients in hospitals
and those that receive care from multiple healthcare providers at multiple sites of care
are particularly vulnerable to safety and quality errors.

In an effort to ensure that safety is fundamental for every healthcare system, the
IOM asserted that “Patients should not be harmed by the care that is intended to help
them, nor should harm come to those who work in health care” (IOM, 1999).

IOM stated in its Crossing the Quality Chasm: A New Health System for the 21st Century
(IOM, 2001) report that the healthcare system should focus on six aims (Table 1.4).

TABLE 1.4 SIX “STEEEP” AIMS OF THE HEALTHCARE SYSTEM

Safe No one should ever be harmed by or as a consequence of receiving
healthcare services.

Timely Care should be obtained when needed with minimal delays.
Effective The best available evidence should guide how healthcare is delivered

to achieve the best possible outcomes.
Efficient The quality of care should be maximized at the lowest, possible cost.
Equitable Everyone should have equal quality of care even if patients may differ

in personal characteristics other than their clinical condition or
preferences for care.

Patient
centered

A patient’s culture, social context, and specific needs deserve
respect, and each patient should have an active role in making
decisions about their own care.

Source: Institute of Medicine (IOM). (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.
Retrieved from https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the

20 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

I live in the state of Georgia and up to this year, I have purchased individual
coverage through Blue Cross and Blue Shield (BCBS) of Georgia. The cost has
increased substantially in the last few years, but at least I was able to sign up
for a preferred provider organization (PPO) plan. BCBS has notified me that
they pulled out of the individual market for 2018. Thus, today I spent sev-
eral hours looking for health insurance. None of the large companies (BCBS,
United Healthcare, AETNA, Humana, etc.) offer individual health insurance
coverage in Georgia. It looks like the best I can do is to sign up for a Health
Maintenance Organization (HMO) with Kaiser Permanente HMO, which
costs just under $900 per month. They do not offer PPOs for individuals in
Georgia and only their Signature HMOs are available to me at all three HMO
levels (bronze, silver, and gold). This offers a very limited number of doc-
tors and hospitals near me. It is crazy, but it is the best I can do. The Kaiser
Signature HMOs require me to find a general practitioner within their net-
work of doctors that accept my plan. If I need a specialist, they will refer me
to one in their network. However, for each HMO level, there are only a few
doctors within 10 miles of my home and only one major hospital that accepts
my HMO. This will be the first time in my life that I have an HMO. It is also
the most I have ever paid for health insurance. The plan I am signing up for
now will only cover 70% of expenses. I will have to pay 30% of expenses out
of pocket. Going to an HMO means that I will not be able to go outside a pre-
scribed network of HMO doctors in Georgia.

At present, the healthcare situation in the United States for middle class
individuals like me that have to pay for our own health insurance is sub-
optimal. I have lived in several countries in Europe and Latin America and
never found myself in this predicament. Usually, the healthcare is covered
by some sort of national insurance. If you are middle class, you can afford to
either purchase a private health insurance plan or simply pay out of pocket,
since the cost of medical procedures and prescriptions is a lot more reason-
able. In the United States, the costs of medical treatment and prescriptions
are prohibitive without medical insurance. For example, if I were to get seri-
ously sick and need treatment in a place like Spain or Panama, I could make
an appointment with any specialist in a private clinic or hospital and pay out
of pocket a lesser amount than the cost of my 30% insurance charges in the
United States For instance, a doctor’s visit in Spain or Panama costs less than
$100. A specialist costs slightly more. You can get a full checkup including full
blood and urine tests, Pap test, mammogram, and dermatologist check up
from $500 to $700. Most common surgeries cost a few thousand dollars, not
tens of thousands of dollars like in the United States. If you are a middle-class
person there, you may not even need to have insurance. Medical tourism to
other countries is growing fast in the United States, as you can obtain treat-
ment in a foreign country, pay out of pocket, and it will cost you less than the
out of pocket healthcare expenses in the United States, even with the travel
expenses involved.

O. H.
Atlanta, GA

REAL-WORLD INTERVIEW

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 21

The 2001 IOM report further noted that by focusing on these six aims, a transfor-
mation will begin to occur in the healthcare system. In another report, the IOM stated
that healthcare systems needed to be redesigned to improve quality of care and patient
safety, but to do so, organizations needed to meet these six challenges:

1. Redesign care processes
2. Make effective use of information technologies
3. Manage clinical knowledge and skills
4. Develop effective teams
5. Coordinate care across patient conditions, services, and settings over time
6. Incorporate performance and outcome measurements for improvement and

accountability (IOM, 2001)

INTERNATIONAL ADVANCES IN QUALITY AND SAFETY

Researchers and healthcare providers throughout the world have been actively
involved in improving patient safety and quality of care. Significant research and
practice innovations have been developed primarily in the United Kingdom, Canada,
Australia, and the United States. Research across the world on strategies to under-
stand and improve healthcare quality and patient safety can be found throughout
peer-reviewed healthcare journals.

Even though some may consider the United States as the leader in healthcare
or in efforts to improve healthcare quality and patient safety, comparative stud-
ies by the Organization for Economic Cooperation and Development (OECD), the
United Kingdom, and The Commonwealth Fund, among others, have consistently
found that the United States does not have better healthcare outcomes than other
industrialized nations, including countries in Europe, Australia, Canada, and New
Zealand (The Commonwealth Fund, 2014; The Commonwealth Fund, 2015; The
Health Foundation, 2015; OECD, 2017). Poor U.S. healthcare outcomes do not make
sense when you consider the fact that year after year, the United States continues to
spend more on healthcare (per capita), than any other country in the world (OECD,
2017). Higher spending appears to be largely driven by greater use and cost of
medical technology (Table 1.5) and higher drug and healthcare prices, rather than
by more frequent doctor visits or hospital admissions (Table 1.6). Despite spending
more on healthcare, Americans have poor health outcomes, including shorter life
expectancy, greater prevalence of chronic conditions, and higher infant mortality
rates (The Commonwealth Fund, 2017; Table 1.7).

TABLE 1.5 SELECTED COSTS OF MEDICAL TECHNOLOGY

MRI machine $1,541,788
OR table $65,263
Electric bed $15,981
Stretchers $7,618
Implantable pacemaker $3,820
Knee implant—femoral $1,970
Drug-eluting stent $1,189
Hip implant—acetabular shell $1,073

Source: Modern Healthcare. Technology price index. Retrieved from
http://www.modernhealthcare.com/section/technology-price-index

22 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

While organizations focused on improving the quality and safety of care have
been previously mentioned in this chapter, there are similar organization outside
the United States and even organizations within the United States that are focusing
on either country-specific goals or global initiatives. For example, the European
Medicines Agency and Health Canada have similar functions as the FDA in the
United States The U.S.-based Joint Commission, has an international component
that has established the International Patient Safety Goals that are used worldwide,
including:

1. “Identify patients correctly
2. Improve effective communication
3. Improve the safety of high-alert medications
4. Ensure safe surgery
5. Reduce the risk of healthcare-associated infections
6. Reduce the risk of patient harm resulting from falls” (Joint Commission International

[JCI], 2017)

Each of these international goals can be related to the U.S.-based Joint Commissions
patient safety goals. The World Health Organization (WHO) also continues to lead
worldwide efforts to improve patient safety (see www.who.int/patientsafety/en as an
example). And since 1998, the Australian Patient Safety Foundation has also led key
initiatives to improve patient safety (see apsf.net.au).

As these and other countries became involved in focusing on improving quality
and safety of healthcare, inconsistency continued in how patient safety terms were
used across nations, which hampered global advances to improve patient safety. The
World Alliance for Patient Safety, a part of the WHO, developed the International
Patient Safety Classification framework to facilitate a common understanding and use
of definitions and preferred terms for patient safety (WHO, 2009; see www.who.int/
patientsafety/taxonomy/icps_statement_of_purpose.pdf). Also, there has been incon-
sistency in how quality and safety of care is measured. The OECD developed a set of
indicators for comparing the quality of health across OECD member countries through
its Health Care Quality Indicator Project (see www.oecd.org/els/health-systems/
health-care-quality-indicators.htm).

TABLE 1.6 MEDICATION COSTS

UNITED STATES CANADA

100 mg of sitagliptin (Januvia) $382 $105.03
1 inhaler of Advair Diskus 250

mcg/50 mcg
$386.97 $131.87

dimethyl fumarate (Tecfidera) 60-capsule package of 120
mg costs $6,805.76 or
$113 per capsule

42 capsule supply
of 120 mg costs
$1,177.80, or
$28.04 per
capsule

Source: The Motley Fool. (2017). 5 drugs that are way cheaper in Canada. Retrieved from https://www.fool.com/
investing/2017/01/21/5-drugs-that-are-way-cheaper-in-canada.aspx

TABLE 1.7 U.S. HEALTHCARE FROM A GLOBAL PERSPECTIVE

Total
Healthcare
Spending
per Capitaa

Infant
Mortality
per 1000
Live Births,
2013

CT Scanners
per 1 Million
Population

Price Comparisons
for In-patient
Pharmaceuticals,
2010 United
States set to 100b

Life
Expectancy
at Birth

Percent of
Population
With Two
or More
Chronic
Diseases,
2014

United
Kingdom

$3,364 3.8 7.9 46 81.1 33

New Zealand $3,855 5.2c 16.6 81.4 37
Australia $4,115a 3.6 53.7 49 82.2c 54
France $4,361 3.6 14.5 61 82.3 43
Canada $4,569 4.8c 14.7 50 81.5c 56
Germany $4,920 3.3 – 95 80.9 49
Netherlands $5,131d 3.8 11.5 – 81.4 46
United States $9,086e 6.1c 43.5 100 78.8 68

a 2012.
b Price for basket of in-patient pharmaceuticals; lower number is lower price.
c Source, OECD Data, 2015.
d Current spending only; excludes spending on capital formation of healthcare providers.
e Adjusted for differences in cost of living.
Source: The Commonwealth Fund. (2017). U.S. health care from a global perspective. Retrieved from http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-
health-care-from-a-global-perspective

24 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

WHAT IS THE COST OF ACHIEVING QUALITY AND SAFETY

From a systems perspective, the cost of providing safety and quality care comes at a cost
(Table 1.8). Across types of healthcare organizations, there are many categories of costs,
primarily including the costs of healthcare salaries (Table 1.9), costs associated with the
technology used to provide healthcare services, and the cost of the physical space where
healthcare is delivered. Hospitals also have significant costs when it comes to ensuring
quality of care and patient safety. While some of these costs can be seen as high, the
cost of poor quality of care far exceeds these amounts. The majority of hospitals in the
United States (American Hospital Association [AHA], 2017) are required by the CMS
to meet TJC accreditation requirements to be reimbursed for care received by Medicare
and Medicaid beneficiaries, who represent the majority of hospitalized patients. There
are over 4,000 hospitals and approximately 77% of them are currently accredited by TJC
(2017). The accreditation process, which includes an expensive onsite survey, recurs every
3 years (JCI, 2017).

EVIDENCE FROM THE LITERATURE

Citation

Marsa, L. (2017, September). Take charge of your health care: Surgeries and side effects.
(p. 20).

Discussion

These are among the most common surgeries for Americans over 50 and the
most common complications. In 2% to 4% of all cases, complications happen, and
the patient needs to be readmitted to the hospital within 30 days.

SURGERY COMPLICATION OCCURRENCE

Cataract removal Posterior capsule opacity 20%
Pacemaker implant Hematoma 2.2% in patients over 70
Colectomy Infection 12.4%
Coronary artery bypass Atrial Fibrillation 24%
Hip replacement Dislocation 2%
Knee replacement Blood Clot 1%
Prostate removal Bleeding 5.3%
Inguinal Hernia Infection 0.3% Open surgery

0.2% Laparoscopic surgery
Cholecystectomy Infection 7.6% Open surgery

1% Laparoscopic surgery
Appendectomy Infection 4.3% Open surgery

1.9% Laparoscopic surgery

Implications for Nursing: Nurses must be aware of the higher incidence of
complications in patients over 50 and, when possible, implement nursing care
strategies to prevent complications.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 25

TABLE 1.8 SELECTED COSTS OF ACHIEVING QUALITY OF CARE AND PATIENT SAFETY

ORGANIZATION REQUIREMENT WHAT IS INVOLVED
AVERAGE ANNUAL
COST

Hospital Joint
Commission
Accreditation

• Meeting each of the
standards

• Planning for the survey
• Staff time in record

keeping and treatment
planning

• Conducting a mock
survey

• Actual survey

Approximately
0.03% to 1%
of a hospital’s
operating budget.
Annual fees are
based on type of
hospital, volume,
and types of
services provided
(TJC, 2017c)

Home care
agency

Joint
Commission
Accreditation

• Meeting each of the
standards

• Planning for the survey
• Staff time in record keeping

and treatment planning
• Conducting a mock survey
• Actual survey

Average of $1,500
for single-service
home care
providers, and
onsite survey fee
of $3,240 (TJC,
2015)

Healthcare
organization

Director of QI • Lead and direct process
improvement activities
to provide efficient and
effective care

Average salary =
$109,293 (range
$95,713-$127,272)
(Salary.com)

Healthcare
organization

Nursing
informatics
specialist

• Manage information and
communications (including
documentation) for nursing

Average salary =
over $100,000
(HIMSS, 2017)

Hospital Magnet®
Accreditation

• Performing a gap analysis
to identify problems

• Meeting each of the
Magnet® requirements

• Preparing and submitting
an application and required
documentation

• Actual site visit survey

Average annual
cost of $500,000
(total average
investment of
$2,125,000
over several
years) (Robert
Wood Johnson
Foundation
[RWJF], 2014)

Healthcare
organization

Baldrige
Award

• Meeting each of the
criteria

• Preparing and submitting
an application and
required documentation

Eligibility certification
= $400 (initial cost)
then the

application fee
= $10,560
to $19,800,
supplemental
section = $1,100
to $2,200, and site
visit = $33,000
to $66,000
(National Institute
of Standards and
Technology [NIST],
2016)

Source: Glassdoor. (2017). Salary.com Salaries. Retrieved from https://www.glassdoor.com/Salary/Salary-com-Salaries-
E35301.htm

26 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

There are also costs and savings for outpatient organizations when it comes to
improving quality of care. For example, improving a patient’s glucose management
would increase the average cost per individual with diabetes by $327 per year, but
would save between $555 to $1,021 annually (Nuckols et al., 2011).

Preventing hospital-acquired conditions (HACs), such as adverse drug events, falls,
pressure ulcers and healthcare associated infections, can avert death. For example, about
44% of HACs are considered preventable. Recent decreases in the number of HACs has
resulted in billions of dollars of savings for national healthcare expenses (AHRQ, 2015).

RECOGNIZING HOSPITAL EXCELLENCE

The most recognized award for excellence within a hospital is the Baldrige Award. The
Baldrige Health Care Criteria for Performance Excellence have been used by many
healthcare organizations to improve quality. Recipients of the Baldrige Award are
selected based on the following Criteria for Performance Excellence:

1. Leadership: How upper management leads the organization and how the organiza-
tion leads within the community.

2. Strategy: How the organization establishes and plans to implement strategic
directions.

TABLE 1.9 SELECTED HEALTHCARE SALARIES

ROLE SALARY SOURCE

CEO, Merck
Pharmaceuticals

$24.2 million www.usatoday.com/story/money/
markets/2016/08/26/drug-
money-pharma-ceos-paid-71-
more/89369152/, Retrieved September
10, 2017

Anesthesiologist Mean annual
wage $269,600

www.bls.gov/oes/current/oes291061.
htm, Retrieved September 10, 2017

General practitioner Mean annual wage
$200,810

www.bls.gov/oes/current/oes291062.
htm, Retrieved September 10, 2017

Nurse practitioner Mean annual
wage $104,610

www.bls.gov/oes/current/oes291171.
htm, Retrieved September 10, 2017

Pharmacist Median annual
wage $122,230

www.bls.gov/ooh/healthcare/
pharmacists.htm, Retrieved September
10, 2017.

Dietitian Median annual
wage $58,920

www.bls.gov/ooh/healthcare/dietitians-
and-nutritionists.htm, Retrieved
September 10, 2017.

Registered nurse Median annual
wage, $68,450

www.bls.gov/ooh/healthcare/registered-
nurses.htm, Retrieved September 10,
2017

Licensed practical
nurse

Median annual
wage$44,090

www.bls.gov/ooh/healthcare/licensed-
practical-and-licensed-vocational-
nurses.htm, Retrieved September 10,
2017.

Nursing assistant Median annual
wage $26,590

www.bls.gov/ooh/healthcare/nursing-
assistants.htm, Retrieved September
10, 2017.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 27

3. Customers: How the organization builds and maintains strong, lasting relationships
with customers.

4. Measurement, analysis, and knowledge management: How the organization uses
data to support key processes and manage performance.

5. Workforce: How the organization empowers and involves its workforce.
6. Operations: How the organization designs, manages, and improves key processes.
7. Results: How the organization performs in terms of customer satisfaction, finances,

human resources, supplier and partner performance, operations, governance
and social responsibility, and how the organization compares to its competitors”
(ASQ, 2017).

The Criteria for Performance Excellence is based on a set of core values. Award recipi-
ent organizations are considered to have a role-model organizational management
system that continuously makes improvements in delivering products and/or ser-
vices, demonstrates efficient and effective operations, and provides a way of engaging
and responding to customers and other stakeholders.

RECOGNIZING NURSING EXCELLENCE

The American Nurses Credentialing Center’s (ANCC, 2017) Magnet Recognition
Program awards healthcare organizations that have achieved superior performance
and is often referred to as the ultimate credential for high-quality nursing. The
Magnet Recognition Program evaluates sources of evidence that create the
foundational infrastructure for excellence, while its focus on results fosters a
culture of quality and innovation. To achieve Magnet Recognition, organizations
participate in a rigorous review process where organizations must demonstrate
support of professional clinical practice, promote excellence in the delivery of
nursing services to patients, and have processes to promote best nursing practices
(ANCC, 2017).

Similar to the Magnet Recognition Program, but not as expensive and not requir-
ing as extensive a process, is the Pathway to Excellence Program. To be nationally
recognized and designated for the Pathway to Excellence Program, a healthcare orga-
nization must meet specific practice standards, including:

1. Shared decision making
2. Leadership
3. Safety
4. Quality
5. Well-being
6. Professional development (ANCC, 2017).

Organizations earn the award by demonstrating that their practices and policies help
create a safe, positive work environment for nurses and high-quality, safe care for patients.

There are also numerous opportunities for individual credentialing, where licensed
nurses complete a specific number of education hours and/or hours of experience and
take a test to demonstrate mastery of a body of knowledge and acquired skills in a
particular specialty (McHugh et al., 2014). The ANCC, among many other organizations,
offers numerous certification for the various types of nursing care (see http://www.
nursecredentialing.org/Certification).

28 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

ROLE OF NURSE LEADERS IN ENSURING QUALITY AND
SAFETY

In 2010, the IOM released the report, The Future of Nursing: Leading Change, Advancing Health
(IOM, 2010). The key message of the report was for nurses to take a greater leadership role
across care settings in the increasingly complex U.S. healthcare system. As the population
ages and becomes increasingly diverse and to effectively respond to the changes and
complexity of healthcare, the report examines how the roles, responsibilities and education

TABLE 1.10 IOM RECOMMENDATIONS FOR THE FUTURE OF NURSING, 2010, AND 2015

IOM RECOMMENDATIONS—2010

• Remove scope of practice barriers
• Implement nurse residency programs
• Expand opportunities for nurses to lead and diffuse collaborative improvement efforts
• Double the number of nurse with a doctorate by 2020
• Build an infrastructure for collection and analysis of interprofessional healthcare

workforce data
• Increase the proportion of nurses with a baccalaureate degree to 80% by 2010
• Ensure that nurses engage in lifelong learning
• Prepare and enable nurses to lead change to advance health

IOM RECOMMENDATIONS—2015

• Build common ground with other health professions groups around scope of practice
and other issues in policy and practice

• Create and fund transition-to-practice residency programs
• Expand efforts and opportunities for interprofessional collaboration and leadership

development for nurses
• Make diversity in the nursing workforce a priority.
• Promote nurses’ pursuit of doctoral degrees
• Continue pathways toward increasing the percentage of nurses with a baccalaureate degree
• Promote nurses’ interprofessional and lifelong learning
• Promote the involvement of nurses in the redesign of care delivery and payment systems
• Improve workforce data collection
• Communicate with a wider and more diverse audience to gain broad support for

campaign objectives

Source: Institute of Medicine (IOM). (2010). The future of nursing: Leading, changing, advancing health. Retrieved from
http://nationalacademies.org/HMD/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

NURSE LEADER AND MANAGER

RADM Jessie M. Scott, DSc, RN, FAAN, was Assistant Surgeon General in the
U.S. Public Health Service and led the Division of Nursing for 15 years. She was
instrumental in the passage and implementation of the Nurse Training Act. Her
career led her to address nursing shortages from Arkansas to Connecticut and
later to work with nursing education programs in India, Egypt, Liberia, and
Kenya. Read more about her at www.nursingworld.org/halloffame

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 29

of nursing should change to improve healthcare for everyone. In that nurses represent the
largest segment of the healthcare workforce, the IOM recommended that nursing:

1. Be able to practice “to the full extent of their education and training
2. Improve nursing education
3. Assume leadership positions and serve as full partners in healthcare redesign and

improvement efforts
4. Improve data collection for workforce planning and policy making” (IOM, 2010)

A few years later, the IOM released a report on the progress achieved on
the IOM 2010 report recommendations (see Table 1.10), focusing on the areas of
removing barriers to practice and care; transforming education; collaborating and
leading; promoting diversity; and improving data. In this report, the IOM com-
mittee concluded that “no single profession, working alone, can meet the complex
needs of patients and communities. Nurses should continue to develop skills and
competencies in leadership and innovation and collaborate with other profession-
als in healthcare delivery and health system redesign. To continue progress on the
implementation of The Future of Nursing recommendations and to effect change in
an evolving healthcare landscape, the nursing community must build and strengthen
coalitions with stakeholders both within and outside of nursing” (IOM, 2015).

KEY CONCEPTS

1. Healthcare quality is defined as “the degree to which healthcare services for indi-
viduals and populations increase the likelihood of desired health outcomes and
are consistent with current professional knowledge” (IOM, 2001).

2. Several organizations have significant roles in influencing the quality of care and
patient safety;, for example, The ISMP, The NAM, The NQF, IHI, TJC, The Leapfrog
Group, HFMA.

3. Data from CMS Hospital Compare provide information on the quality of care
provided to patients in hospitals and includes information about patients’ experi-
ences (HCAHPS), timely & effective care, complications, readmissions and deaths,
use of medical imaging, payment and value of care.

4. There are several examples of quality care and patient safety measures that are
used primarily in healthcare organizations, such as hospitals, nursing homes, and
outpatient clinics; for example, the CMS Core Measures, AHRQ Quality Indicators,
AHRQ Patient Safety Indicators, NQF and ANA Nurse Sensitive Indicators, and
the NCQA HEDIS Measures.

5. Unwanted variation is variation in the use of medical care that cannot be explained
on the basis of illness, medical evidence, or patient preferences.

6. Transparency is considered to include reporting not only the real cost of care, but
also clearly reporting information about performance failures as well as successes
(Austin et al., 2016).

7. It has been estimated that, while hospitalized, about one in four patients experi-
ence one or more adverse events that result in a longer hospital stay, permanent
harm, the need for a life-sustaining intervention, or death. Of these adverse events
that resulted in injury, almost half were preventable (OIG, 2010).

30 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

8. Nurses are key to ensuring and improving quality of care and safety for patients
and families, as well as for the organizations in which they work.

9. Strategies to reduce unwarranted variation and ensure predictable and favorable
patient-care outcomes have proven successful in improving healthcare quality and
patient safety; for example, developing checklists and other standardized tools,
using best practices, working in an organization with a culture of safety, and com-
munication when an error does occur.

10. Standardized communication tools such as the SBAR technique and using stan-
dardized order sets, protocols, and other best practices can be used by nurses and
other members of the healthcare team to prevent errors, ensure quality care, and
reduce variability in patient care and the potential for error.

11. The term “sharp end” has been used to identify the important and significant direct
contact role that nurses at the bedside, closest to clinical activities, play in recognizing
the need for and potential impact of practice changes. Nurses may see the sharp end
effects on patients and others first when the right care is not provided. Front line clini-
cal nurses (as well as nurses in formal leadership positions) often assume leadership
at the “sharp end” of care in direct contact with patients to ensure safety and quality.

12. Workarounds may occur when something doesn’t work well while nurses are
providing care to a patient and they work around the “normal” way of doing
things. These workarounds increase the opportunities for inconsistent care and
inconsistent outcomes.

13. Even though some may consider the United States as the leader in healthcare or
in efforts to improve healthcare quality and patient safety, comparative studies
by the OECD, the United Kingdom, and The Commonwealth Fund, among oth-
ers, have consistently found that the United States does not have better health-
care outcomes than other industrialized nations, including countries in Europe,
Australia, Canada, and New Zealand (The Commonwealth Fund, 2014; The
Health Foundation, 2015; OECD, 2017).

14. Poor U.S. healthcare outcomes do not make sense when you consider the fact that
year after year, the United States continues to spend more on healthcare (per cap-
ita), than any other country in the world (OECD, 2017).

15. Higher U.S. spending appears to be largely driven by greater use and cost of medi-
cal technology and higher drug and healthcare prices, rather than by more fre-
quent doctor visits or hospital admissions.

16. Despite spending more on healthcare, Americans have poor health outcomes,
including shorter life expectancy, greater prevalence of chronic conditions, and
higher infant mortality rates (The Commonwealth Fund, 2017).

17. The U.S.-based Joint Commission has an international component that has estab-
lished the International Patient Safety Goals that are used worldwide.

18. The majority of hospitals in the United States (AHA, 2017) are required by the CMS to
meet TJC accreditation requirements to be reimbursed for care received by Medicare
and Medicaid beneficiaries, who represent the majority of hospitalized patients.

19. There are over 4,000 hospitals and approximately 77% of them are currently
accredited by TJC (TJC, 2017).

20. The CEO of Merck Pharmaceuticals has an annual salary of $24.2 million.
21. The Baldrige Health Care Criteria for Performance Excellence has been used by

many healthcare organizations to improve quality.
22. ANCC Magnet Recognition Program awards healthcare organizations that have

achieved superior performance and is often referred to as the ultimate credential
for high-quality nursing.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 31

KEY TERMS

Adverse event
Errors
Healthcare quality
High-quality care

Sentinel events
Sharp end
Transparency

REVIEW QUESTIONS

1. A group of emergency department nurses are asked to develop an action plan to
improve the time before patients who present with chest pain receive an ECG. Which
of the following would not be helpful when working on a QI effort like this?

A. Identify an interprofessional group of individuals to help review current
performance.

B. Compare current hospital emergency department data results to benchmark
comparison information reported on a national website.

C. Post current hospital performance data results openly to staff in the nursing
lounge.

D. Identify whose fault it is that results are not very good.

2. As a staff nurse you are interested in making QIs in the overall care of patients
with heart failure. Where would be most helpful to look for data and information
to help you get started with these improvements?

A. Explore the IHI website (www.IHI.org), which includes white papers,
evidence-based protocols, blogs, and improvement stories that can be applied
to patients with heart failure.

B. Review the National Cancer Institute’s website, which includes facts
and statistics related to cancer care, resources, and latest research
developments.

C. Review drug companies’ websites to see if there are any new medications
available to treat heart failure.

D. Google “heart failure” to see if you can get access to the latest treatment
options for this patient population.

3. An 87-year-old patient was admitted to an acute care hospital. The patient was
in a severe automobile vehicle accident. He is unconscious in intensive care and
on a ventilator. On Day 3 of the patient’s hospitalization, the patient experiences
a cardiac arrest and a code blue is called. The code blue lasts for an hour. The
patient’s heart rhythm is restored. When the family is notified of the event, the
wife is very upset. She states she had provided the hospital with the patient’s
advance directive, which clearly stated the patient should not be resuscitated. You
are the nurse talking to the wife. What do you do?

A. Apologize, but state that the patient was a full code, which means he must be
resuscitated.

B. Apologize, and assure the wife that you will be contacting the attending
physician and your nurse manager that the problem occurred. The risk
management department will probably review this case.

32 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

C. Notify the wife that the advance directive is not legal or binding and that
the wife needed to tell them specifically that the patient did not want to be
resuscitated.

D. Tell the wife to try to focus on the positive, that her 87-year-old husband is
still alive.

4. A patient asks a nurse what it means to have a hospital accredited by TJC. Which
one of the following is not a Joint Commission quality compliance requirement?

A. Billing models
B. Core measures
C. Safe practice measures
D. Process improvement efforts

5. A patient read that hospitals are not getting reimbursed by the CMS for certain
never events and asks a nurse to explain. Which one of the following is an example
of a never event?

A. Absence of a hospice unit within the hospital
B. Emergency department admissions of over 1,000 per month
C. Nursing stations located at the end of the hall versus in the middle of the

patient-care unit
D. Stage IV hospital-acquired pressure ulcer

6. What is a common cause of errors within healthcare settings?

A. Uncaring professionals
B. Incompetent caregivers
C. Communication problems between caregivers
D. Phones not connecting to the nurse’s station

7. QSEN has developed multiple quality and safety competencies to guide
nursing practice. Identify which of these are considered a part of the six key
competencies.

A. QI, teamwork and collaboration, and EBP
B. Fact finding, mission statements, and strategic planning
C. Stakeholder feedback, budget reconciliation, and strategic planning
D. Financial reporting, wait time measurements, and time delays in getting

treatments

8. You are the nurse caring for a patient who was recently told he has heart failure.
The patient will be relocating next week to a different state. The patient has a pri-
mary care provider in his new state and intends to follow up as instructed upon
discharge. However, he would like to identify an acute care hospital in his new
state that is adept in caring for heart failure patients, in the event that he needs
to be admitted. The patient asks for your recommendation. All of the suggestions
below may give him good information. What would be your best suggestion to the
patient so that he may make a well-informed, objective decision?

A. Tell the patient that hospitals publicly report their quality data associated
with caring for heart failure patients on a website and instruct him where he
can retrieve this information.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 33

B. Tell him to ask members in the community or family and friends where they
have had good experiences.

C. Tell him to ask his primary care provider for a recommendation.
D. Tell him to visit the websites of hospitals in the community where he is moving.

9. You are an administrator working in an urban health system. You have been
charged to lead the efforts of redesigning the patient-care delivery model. This
model is intended to best represent patient expectations. As such, in developing
the model, you recognize the importance of taking into account the patient’s qual-
ity concerns. Which answer best represents the top patient quality concerns as
described by the HFMA Value Project (2011)?

A. Access: Make care available and affordable. Safety: Do not hurt me.
Outcomes: Make me better. Respect: Respect me as a person, not a case.

B. Access: Make care available and affordable. Safety: Do not hurt me.
Quality: Provide high-quality care. Respect: Respect me as a person,
not a case.

C. Safety: Do not hurt me. Outcomes: Make me better. Value: Deliver care at a
reasonable price. Inclusion: Include my loved ones in any care plans.

D. Safety: Do not hurt me. Quality: Provide high-quality care. Value: Deliver
care at a reasonable price. Respect: Respect me as a person, not a case.

QSEN ACTIVITIES

1. Go to the QSEN website (www.qsen.org) and search for Quality. Click on
Quality Improvement (www.homehealthquality.org/Education/Best-Practices.
aspx). Work on Cardiovascular Health Part 1 (www.homehealthquality.org/
Education/Best-Practices/BPIPs/Cardiovascular-Health-Part-1-BPIP.aspx). Can
this information help improve patient safety?

2. Go to the QSEN website (www.qsen.org) and search for Quality. Click on Quality
Improvement (www.homehealthquality.org/Education/Best-Practices.aspx). Work
on Cardiovascular Health Part 2. Can this information help improve patient safety?

REVIEW ACTIVITIES

1. Go to the QSEN Institute website, qsen.org. Click on Competencies, Pre-Licensure.
Also, click on Teaching Strategies. What did you find at these sites that apply to you
as a student?

2. What patient safety challenges do you see in hospitals or in outpatient care sites?
3. Read through the summary of recommendations for two reports in the Quality

Chasm series (go to www.nap.edu/catalog/21895/quality-chasm-series-health-
care-quality-reports), and look at the list of recommendations. Of these recommen-
dations, what surprised you?

CRITICAL DISCUSSION POINTS

1. Are all adverse events inevitable?
2. How is the FDA involved in improving patient safety?

34 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

3. Do sentinel events have to be reported to TJC?
4. Are there similarities in the measures of patient safety and the measures of quality

of care (Table 1.3)?
5. Should only events that harm patients be reported to external quality and safety

organizations?
6. Are patients safer if they stay in the hospital longer?
7. Name three of the QSEN competencies.
8. Does blaming a nurse for an error improve patient safety?
9. Name the six aims of the healthcare system from the IOM Crossing the Quality

Chasm 2001 report.
10. Is improving quality and patient safety expensive?

EXPLORING THE WEB

1. AHRQ—www.ahrq.gov
2. ANCC—www.nurscredentialing.org
3. Baldrige Foundation—www.baldrigefoundation.org
4. CMS—www.cms.gov
5. FDA—www.fda.gov
6. IHI—www.ihi.org
7. NQF—www.qualityforum.org
8. QSEN Institute—qsen.org
9. Quality Chasm Series—www.nap.edu/catalog/21895/quality-chasm-series-health-

care-quality-reports?gclid=EAIaIQobChMIjIeh35-31QIVBoNpCh2y0ASvEAAYASA
AEgIhY_D_BwE

10. TJC—www.jointcommission.org
11. U.S. News and World Report ratings of hospitals—health.usnews.com/best-

hospitals/rankings

EVIDENCE FROM THE LITERATURE

Citation: The Economist. (2018). Land of the free-for-all: America is a health-care
outlier in the developed world. Retrieved from www.economist.com/news/
special-report/21740871-only-large-rich-country-without-universal-health-
care-america-health-care-outlier

DISCUSSION

America has some of the best hospitals in the world but it is also the only large
rich country without universal healthcare coverage. About half of Americans
have their health insurance provided by their employers. Healthcare costs can
be financially ruinous for others. In 2016, America spent $10,348 per person on
healthcare, roughly twice as much as the average for comparably rich countries.
On average, both hospital cost and drug prices can be 60% higher than in Europe.
The American Affordable Care Act expanded the health insurance system and
cut the number of uninsured people from 44 million to 28 million but still left a
gap among people not poor enough to qualify for Medicaid but not rich enough
to buy private insurance.

1 OVERVIEW OF PATIENT SAFETY AND QUALITY OF CARE • 35

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SUGGESTED READINGS

Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: CRC Press.
Gawande, A. (2011). The checklist manifesto: How to get things right. New York, NY: Picador.
Haviley, C., Anderson, A., & Currier, A. (2014). Overview of patient safety and quality of care.

In Kelly, P., Vottero, B., & McAuliffe, C. (2014). Introduction to quality and safety education for
nurses: Core competencies. New York, NY: Springer.

Hughes, R. G. (Ed.) (2008). Patient safety and quality. An evidence-based handbook for nurses. Rock-
ville, MD: U.S. Agency for Healthcare Research and Quality (US).

Institute of Medicine (IOM). (2001). In Kohn L. T., Corrigan J. M., & Donaldson M. S. (Eds.),
To err Is Human: Building a safer health system. Washington, DC: National Academy Press.
Retrieved from https://www.nap.edu/read/9728/chapter/1

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century.
Retrieved from https://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-
health-system-for-the

Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environment of
nurses. Washington, DC: National Academy Press. Retrieved from https://www.nap.edu/
catalog/10851/keeping-patients-safe-transforming-the-work-environment-of-nurses

Institute of Medicine (IOM). (2010). The future of nursing: Leading, changing, advancing health.
Retrieved from http://iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-
Advancing-Health.aspx

The Commonwealth Fund. (2015). 2015 international profiles of health care systems: Australia,
Canada, China, Denmark, England, France, Germany, India, Israel, Italy, Japan, The Netherlands,
New Zealand, Norway, Singapore, Sweden, Switzerland, and the United States. Mossialos E.,
Wenzl M., Osborn R., & Sarnak D., D (Eds.), The Commonwealth Fund, Pub No. 1857.

The Joint Commission (TJC). (2017). Initiatives. 5 million lives campaign. Retrieved from http://
www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspx

The Joint Commission (TJC). (2017). Initiatives. The IHI triple aim initiative. Retrieved from http://
www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

The Joint Commission (TJC). (2017). Sentinel event policy and procedures. Retrieved from https://
www.jointcommission.org/sentinel_event_policy_and_procedures/

Lee, D. S., & Mir, H. R. (2014, October). Global systems of health care and trauma. Journal of
Orthopedic Trauma, 28(Suppl. 10), S8–S10, doi:10.1097/BOT.0000000000000213.

Wachter, R. M. (2012). Understanding patient safety (2nd ed.). New York, NY: McGraw-Hill.

Upon completion of this chapter, the reader should be able to

1. Review a brief history of the Quality and Safety Education for Nurses (QSEN)
initiative in the United States.

2. Discuss the various phases of development of the QSEN initiative.

3. Identify the six QSEN competencies, which are patient-centered care (PCC),
quality improvement (QI), safety, teamwork and collaboration, evidence-
based practice (EBP), and informatics.

4. Identify the knowledge, skills, and attitudes (KSAs) associated with each of
the six QSEN competencies.

5. Identify QSEN competencies related to accreditation standards for nursing
programs.

6. Recognize resources available for further learning about QSEN competencies.

7. Discuss special issues of nursing journals that have focused on QSEN.

2
QUALITY AND SAFETY EDUCATION
FOR NURSES

Catherine C. Alexander, Gail Armstrong, and Amy J. Barton

One goal of QSEN is to alter nursing’s professional identity so that when we think of what it means to be
a respected nurse, we think not only of caring, knowledge, honesty, and integrity. But also, that it means
that we value, possess, and collectively support the development of quality and safety competencies.
(Cronenwett, 2007)

40 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

A
n 86-year-old woman fell at home and suffered an intertrochanteric hip fracture. She
will have a plate and screws surgically placed to stabilize the fracture. This patient has
a past medical history of osteoporosis and atrial fibrillation. The patient takes Fosamax
(alendronate sodium) 70 mg by mouth once a week and Coumadin (warfarin) 3 mg by

mouth once a day. She proceeds to surgery without any member of the healthcare team checking
her last dose of Coumadin or her international normalized ratio (INR) level. During surgery, the
patient begins to bleed profusely and requires a transfusion of 5 units of packed red blood cells.
The patient is transferred to the ICU for further monitoring. After this transfer, the interprofessional
healthcare team gathers to review elements of this case (see Figure 2.1).

1. Which members of the interprofessional healthcare team should be present to review this
case?

2. How was patient safety and quality compromised in this case?
3. Which processes of patient care might be reviewed to ensure that this type of error does

not occur again?

The national nursing initiative, Quality and Safety Education for Nurses (QSEN), funded by the Robert
Wood Johnson Foundation, has trained over 1,000 nursing faculty throughout the United States in
how to build quality and safety content in prelicensure nursing curricula through education workshops
sponsored by the American Association of Colleges of Nursing (AACN). In 2016, QSEN sponsored
an international task force to guide the integration of the QSEN competencies in several countries
across the globe (Canada, South Korea, Taiwan, Germany, and Sweden). The QSEN competencies
are now translated into Spanish and can be found on the QSEN website (www.qsen.org). Plans are
in place to translate the competencies into Chinese, Korean, and Swedish. Both faculty and students

will find that the QSEN website (www.qsen.org) is a rich resource
for ongoing education related to quality and safety.

This chapter outlines a brief history of QSEN, discusses the
four phases of development of the QSEN initiative, and reviews
the six QSEN competencies, that is, safety, informatics, patient-
centered care (PCC), quality improvement (QI), teamwork
and collaboration, and evidence-based practice (EBP). Built
into each QSEN competency are the knowledge, skills and
attitudes (KSAs) associated with each QSEN competency. The
chapter then identifies how the QSEN KSAs are integrated
into various phases of a nursing curriculum. The chapter also
connects the QSEN competencies to accreditation standards
for nursing programs. Finally, the chapter discusses nursing
journals that have published QSEN-specific supplements
and resources available for further learning about the QSEN
competencies.

HISTORY OF QSEN INITIATIVES IN THE UNITED STATES

Educating the next generation of nurses in quality and safety is the overarching goal of
the QSEN organization. To understand QSEN’s history, one must go back to 1999. Since
the Institute of Medicine (IOM, 1999) report, To Err Is Human: Building a Safer Health Care
System, which estimated 98,000 lives were lost yearly in hospitals due to preventable

FIGURE 2.1 Interprofessional
activities at the University of
Colorado.

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 41

medical error, a new era of consciousness about quality and safety in the U.S. healthcare
system took root. Since the IOM report was published, healthcare leaders in both aca-
demia and practice have worked diligently to repair our fragmented healthcare system.
However, progress has been slow since the report was issued. In 2015, The National
Patient Safety Foundation (NPSF) convened an expert panel that concluded that despite
advances in patient safety over the last 15 years, patients continue to experience harm
that could be prevented (NPSF, 2015). In a report issued by Makary and Michael (2016),
it was noted that medical errors are now the third leading cause of death, estimating
252,454 people lose their lives annually because of medical error.

Why are so many lives being lost to medical errors and what steps must be taken
to fix the problem? Preventable deaths are linked to human factors including poor
communication among providers, fatigue, time pressure, and systems breakdowns
(Wachter, 2010). The NPSF acknowledges that our current healthcare system is far
more complex than was previously understood and recommends that we rethink
safety based on “systems thinking.”

Dolansky and Moore (2013) define systems thinking as “the ability to recognize,
understand and synthesize the interactions and interdependencies in a set of compo-
nents designed for a specific purpose and understand how the components of a com-
plex healthcare system influence the care of an individual patient” (p. 2). Healthcare
leaders have a large role to play in providing safe, high-quality care. The NPSF report
states “leaders must shift from a reactive approach to patient safety to one that consis-
tently prioritizes a safety culture that includes the well-being and safety of the work-
force” (NPSF executive summary, 2015). To accomplish this, leaders must be focused
on patient safety at every level of an organization and, in particular, at the frontline
of care. The American Organization of Nurse Executives (AONE) Guiding Principles docu-
ment (2007) supports the following four patient safety goals: change from a culture of
blame to one that is focused on teamwork, develop a leadership model that embraces
shared decision making rather than the top down leadership style found in many
hierarchical organizational structures, enhance collaboration within and external to
the organization, and develop leadership competencies that are patient-centered and
focused on patient safety.

Since the 1999 report, To Err Is Human, several subsequent reports have been pub-
lished by the Institute of Health that address the causes of the startling number of
preventable deaths in the acute care setting. The 2001 IOM report, Crossing the Quality
Chasm, identified the need for safe, timely, efficient, equitable, effective, and patient-
centered healthcare goals. The acronym STEEEP is often used as a mnemonic for these
goals (IOM, 2001; Table 2.1).

In 2003, the IOM published Health Professions Education: A Bridge to Quality focused
on the importance of all health professions students being educated in how to deliver
care that exhibits qualities of patient-centeredness, QI, teamwork and collaboration,
evidence-based practice (EBP), and informatics. The 2010 IOM report, The Future of
Nursing, Leading Change, Advancing Health, called on nursing to lead the quality and
safety movement. The report cited that nurses are in a unique position to impact the
safety movement in the United States. However, there is a critical need to reassess
nursing educational models that thread quality and safety throughout nursing curri-
cula at the undergraduate, graduate, and doctoral levels. This reassessment is needed
for nurses to lead QI initiatives at all levels of a healthcare organization. In 2015, a
follow-up report by the IOM, Assessing Progress on the Institute of Medicine Report—The
Future of Nursing, acknowledged that nursing had made significant strides in meeting
many of the 2010 recommendations, but there is more work to do if nursing is going
to lead collaborative improvement efforts through interprofessional teams. A pressing

42 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

question is how to engage healthcare professionals and frontline staff in QI “at the
sharp end of the healthcare delivery system” where a patient’s healthcare needs are
met (Nelson, Batalden, & Godfry, 2007, p. 6).

The term “sharp end” has been used to identify the point in a healthcare system
where providers, for example, nurses, physicians, aides, and so on, work and give
care to patients. This point or sharp end of patient care is where errors may occur
(Reason, 1990). Errors on the sharp end of patient care have often been considered to
be the result of provider deficiencies such as careless behavior or lack of knowledge or
skill. In fact, these sharp end errors have now been recognized to often be the result of
organizational and extra-organizational issues, referred to as latent issues in a health-
care system. These latent issues can be caused by healthcare system organization and
management factors (Vincent, 2006), as well as by healthcare regulators, payers, insur-
ance administrators, economic policymakers, and technology suppliers. All of these
latent end issues affect the behavior of providers at the sharp end point of service with
patients and may lead to patient-care errors.

PHASES OF DEVELOPMENT OF THE QSEN INITIATIVE

A group of nurse leaders, who had collaborated yearly since 1993 at an interprofessional
conference with physicians and healthcare administrators, met to explore the impact of
the 2003 IOM report, Health Profession Education: A Bridge to Quality, on health profes-
sions education. Engaging with other national thought leaders in nursing, this influential
group asked the question: “What teaching strategies will prepare graduates in the health
professions with the necessary skills to continuously improve the quality and safety of
the healthcare system in which they work?” This question challenged this interprofes-
sional group to outline a new curriculum that incorporates the principles of patient-
centeredness, QI, teamwork and collaboration, EBP, and informatics outlined in the 2003
IOM report Health Professions Education: A Bridge to Quality. During the same period of
time, the first phase of the Quality and Safety for Nurses (QSEN) initiative began with
funding by the RWJF. The overall goal was to prepare nurses with the KSAs required to

TABLE 2.1 INSTITUTE OF MEDICINE’S (IOM) DEFINITIONS OF STEEEP

IOM TERM DEFINITION

S Safe Avoiding injuries to patients from the care that is intended to help
them

T Timely Reducing waits and sometimes harmful delays for both those who
receive and those who give care

E Efficient Avoiding waste, including waste of equipment, supplies, ideas,
and energy

E Equitable Providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location,
and socioeconomic status

E Effective Providing services based on scientific knowledge to all who could
benefit, and refraining from providing services to those not likely
to benefit

P Patient-
centered

Providing care that is respectful of and responsive to individual
patient preferences, needs, and values, and ensuring that
patient values guide all clinical decisions

Source: STEEEP Healthcare Goals. Compiled with information from the report, IOM. (2001). Crossing the quality chasm:
A new health care system for the 21st century. Washington, DC: National Academies Press.

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 43

improve quality and safety in healthcare systems (Cronenwett et al., 2007). At the time,
safety and high reliability consciousness were rising as critical components for the
delivery of safe patient care. The QSEN Advisory Board decided to add safety apart
from QI as the sixth competency. Cronenwett (2007) explains the QSEN Advisory
Board’s decision to add safety as a sixth competency this way: “The culture of nurs-
ing education was about preparing a competent, safe nurse and safety was viewed as
a component of the individual professional rather than the system and we needed to
make clear that preparation for future nurses needed to include that aspect of prepar-
ing for safety as well.”

From 2005 to 2012 three phases of the QSEN initiatives were written that defined
the quality and safety competencies that would be integrated into nursing programs
throughout the United States. In Phase I, QSEN faculty outlined the KSAs appropriate
for prelicensure education for each of the six competencies (Cronenwett et al., 2007).
KSAs are defined as knowledge: the mental skills required to complete a task and the
theoretical understanding of a subject; skill: the “hands on” or physical skills that one
applies to his or her work, the proficiency or observable competence that is acquired
or developed through education, and experience; and attitude: a behavior or point of
view and the way a person views or responds to people or an experience. The KSAs
for the six competencies can be found on the QSEN website (www.qsen.org). Phases
II and III focused on faculty education and development and Phase IV, which began
in 2012, expanded the competencies at the graduate level. Today, QSEN is a vibrant
national initiative for nurses and nursing educators that offers resources for integrat-
ing the IOM’s recommendations into models of nursing education both in prelicensure
and graduate nursing education.

Phase I

Early QSEN data indicated that no nursing graduates were entering practice with
updated knowledge about safe systems or knowledge from safety science. Safety
science uses scientific methods and theoretical frameworks to achieve a trustworthy
system of healthcare delivery. Safety science helps to describe how safety errors and
near misses are recognized and reported, ways to manage human factors that impact
safe healthcare delivery, and the competencies required for health professionals to
provide safe care. Safety science has its roots in high-performance industries such as
aviation and nuclear power and has now been adapted for use in healthcare. Safety
science uses processes such as checklists and web-based reporting systems to improve
care. Safety science has two important goals: It is the personal responsibility of all
healthcare workers to both prevent errors and to continuously improve the delivery of
healthcare services for both patients and staff.

Phase II

QSEN’s Phase II work, also funded by the RWJF, occurred between 2007 and 2009 and
focused on developing a QSEN Pilot School Learning Collaborative for faculty devel-
opment. Fifteen nursing programs were selected to experiment with various peda-
gogical teaching strategies. The goal of this pilot program was to integrate the KASs,
using the five competencies cited in the IOM 2003 report (i.e., PCC, QI, teamwork and
collaboration, EBP, and informatics). Safety was added as the sixth competency given
nursing’s impact on patient outcomes at the frontline of care.

44 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Phase III

QSEN’s Phase III work occurred between 2009 and 2012, again funded by the RWJF.
Phase III had three goals:

• Promote the ongoing development and evaluation of methods to assess student
learning of KSAs of the six QSEN competencies and disseminate the new knowledge.

• Develop the faculty expertise necessary to assist the learning and assessment of
achievement of quality and safety competencies in all types of nursing programs.

• Create a mechanism to sustain the will to change among all nursing education
programs.

The focus of the Phase III work was to begin to change the content in nursing text-
books, accreditation certification standards, licensure exams, and continued competence
requirements. Through the QSEN Phase III work, faculty from across the country were
trained in how to integrate updated quality and safety concepts into their nursing edu-
cation programs.

Phase IV

In 2012, the Tri-Council for Nursing, an alliance of four nursing organizations (i.e., the
American Association of Colleges of Nursing [AACN], National League for Nursing
[NLN], American Nurses Association [ANA], and American Association of Nurse
Executives [AONE]) expanded the QSEN competencies at the graduate level. With sup-
port from the RWJF, the four nursing organizations led the $4.3 million effort to advance
state and regional strategies to create a more highly educated workforce.

Integration of the KSAs Into Nursing Curricula

For practicing nurses, it is helpful to understand how nursing education is changing
and to consider how QSEN KSAs are integrated into nursing curricula. Incorporating
QSEN into a nursing curriculum requires an understanding of the six QSEN compe-
tency definitions of PCC, QI, teamwork and collaboration, EBP, informatics, and safety
that are available on the QSEN website. Incorporating QSEN into a curriculum also
requires a clear sense of how to effectively place the 162 KSA elements that operational-
ize those six QSEN competencies into a nursing curriculum. To provide guidance to fac-
ulty, a modified Delphi research strategy was used. The Delphi research strategy is an
interactive forecasting method that allowed a panel of experts to gain consensus about
where individual KSAs should be introduced in the nursing curriculum and where
they should be emphasized (Barton, Armstrong, Preheim, Gelmon, & Andrus, 2009).

Each of the KSAs were identified as appropriate for introduction and emphasis
either in a beginning-level nursing course, an intermediate-level nursing course, or an
advanced-level nursing course. A beginning-level nursing course is one of a student’s
first nursing education courses. An intermediate-level nursing course is taken in the mid-
dle of a student’s nursing education program. And an advanced-level nursing course is
taken by a student just before graduation. The KSAs of the six QSEN competencies pro-
vide a strong foundation for quality and safety practices at the undergraduate level. The
work of QSEN has only evolved over the last decade and many current nursing students
will likely work with nurse preceptors who are not aware of the six competencies.

Table 2.2 provides a summary table of the Delphi results, indicating where KSAs
from five of the six QSEN competencies should be introduced and where they should

TABLE 2.2 OVERVIEW OF DELPHI STUDY FINDINGS

QSEN
COMPETENCY

BEGINNING
INTRODUCTION

INTERMEDIATE
INTRODUCTION

ADVANCED
INTRODUCTION

BEGINNING
EMPHASIS

INTERMEDIATE
EMPHASIS

ADVANCED
EMPHASIS

PCC KSA
competencies

KSA
competencies

Teamwork and
collaboration

Skill and attitude
competencies

Knowledge
and skill
competencies

Attitude
competencies

Knowledge
and skill
competencies

EBP Knowledge
and attitude
competencies

Skill
competencies

Knowledge
and attitude
competencies

Skill and
attitude
competencies

Safety KSA
competencies

Attitude
competencies

KSA
competencies

Knowledge
competencies

Informatics Skill and attitude
competencies

Knowledge
competencies

Skills
competencies

Knowledge
and attitude
competencies

QI Attitude
competencies

Skill and attitude
competencies

Knowledge
competencies

Attitude
competencies

KSA
competencies

EBP, evidence-based practice; KSA, knowledge, skill, and attitude; PCC, patient-centered care; QI, quality improvement; QSEN, Quality and Safety Education for Nurses.

Source: Compiled with information from Barton, A. J., Armstrong, G., Preheim, G., Gelmon, S. B., & Andrus, L. C. (2009). A national Delphi to determine developmental progression of quality
and safety competencies in nursing education. Nursing Outlook, 57(6), 313–322.

45

46 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

be emphasized in a prelicensure nursing curriculum. Most interesting of these Delphi
results is the clear message that all six quality and safety competencies need to be
introduced and emphasized throughout a prelicensure nursing student’s education
program.

THE SIX QSEN COMPETENCIES

PCC

PCC emphasizes recognition of the patient or designee as the source of control and
full partner in providing compassionate and coordinated care based on respect for the
patient’s preferences, values, and needs. For example, KSAs for this PCC competency
are the following:

• K—Integrate understanding of the multiple dimensions of PCC: Patient/family/
community preferences and values; coordination and integration of care; infor-
mation, communication, and education; physical comfort and emotional support;
involvement of family and friends; transition; and continuity.

• S—Elicit patient values, preferences, and expressed needs as part of clinical inter-
view; implementation of the care plan; and evaluation of care.

• A—Value seeing healthcare situations through the patient’s eyes (Cronenwett
et al., 2007).

The KSAs for PCC allow for not only the basic needs of the patient to be met (bath-
ing, feeding, toileting) but they also allow for the basic needs to be met in a way that
considers patient preferences and values in the delivery of care. For example, when
would the patient like to be bathed? How does he or she like to be fed? What aspects
of the care is the patient able to carry out that they would prefer to do independently
of the nurse? Do family members want to be active participants in their loved one’s

You are the charge nurse on a medical–surgical unit. A new graduate nurse is car-
ing for a complex patient who has been hospitalized for over 2 weeks. The patient
and the family have expressed frustration and mistrust in the healthcare team
because of poor communication among members of the team. An individualized
care plan was developed based on the unique needs of the patient. After report,
you ask the new graduate nurse to read the plan of care for specific instructions
related to the physical and psychosocial needs of the patient. The nurse states
“I don’t have time to read the plan of care, I have to pass my medications. I will
read it later.” Reading the plan of care later in the shift does not allow the nurse
to consider the patient’s preferences, values, or needs and may compromise the
delivery of patient-centered care.

1. Which (QSEN) competency would help you in expanding the nurse’s practice?
2. Which resources for this QSEN competency might help you in working with this

nurse?
3. Describe leadership attributes that would have helped this nurse provide PCC.

CASE STUDY 2.1

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 47

care? Physical comfort and emotional support are one knowledge aspect of the larger
PCC competency. A report by the Picker Institute and the Commonwealth Fund titled
Patient-Centered Care: What Does It Take? provides the contemporary context for PCC
(Shaller, 2009). Table 2.3 offers learning activities for PCC at the beginning, intermedi-
ate, and advanced levels of nursing education.

Teamwork and Collaboration

The QSEN competency of teamwork and collaboration emphasizes healthcare pro-
viders functioning effectively within nursing and interprofessional teams, fostering
open communication, mutual respect, and shared decision making to achieve quality
patient care. Examples of KSAs in this competency include the following:

• K—Describe scope of practice and roles of healthcare team members.
• S—Engage in appropriate handoff communication during shift report, patient-

care rounds, discharge, or interfacility transfer.
• A—Value the personal contribution that team members make to achieve effective

team functioning.

TABLE 2.3 PATIENT-CENTERED CARE LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning
level

Interview a patient about his or her diagnosis. What does the diagnosis
mean to the patient? How does the patient’s perspective of the
diagnosis differ from that of the healthcare team? Write up your
understanding of the patient’s perspective and share it with the patient.
Ask the patient for feedback about accuracy and interpretation.

Intermediate
level

Are there barriers in your practice environment to actively involve families in
patients’ healthcare processes? Examine system barriers like limited visiting
hours in the ICU or inability of family to be present in the perioperative
setting. Are there policies that interfere with family involvement? What is the
history of these policies? Do they still make sense?

Advanced
level

Sometimes the nurse must initiate a conversation about patient-centered
care. Use the following resource to identify effective strategies for
such conversations: Toolkit: Conversations on Patient-Centered Care
(https://www.orpca.org/files/Toolkit_Conversations_about_Pt_Ctrd_
Care.pdf)

CRITICAL THINKING 2.1

The video in which Donald Berwick shares his view of PCC: www.youtube.com/
watch?v=SSauhroFTpk

1. Why is “indignity” promulgated and tolerated within healthcare
institutions?

2. How can families be more authentically included in a patient-care
experience?

3. Identify three concrete actions you can take to honor the concept of patient
centeredness.

48 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

TABLE 2.4 TEAMWORK AND COLLABORATION LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning
level

Explore the tools recommended for healthcare teams in
the TeamSTEPPS program. These tools can be found at
www.teamstepps.ahrq.gov. Which TeamSTEPPS communication
strategies would be helpful for patient care on your unit?

Intermediate
level

Teamwork and collaboration are core elements of surgical care
processes. The IHI launched a national campaign to standardize
aspects of perioperative teamwork and collaboration. Go to IHI’s
home page at www.ihi.org. Use the search box and type in SCIP.
Look at the elements of the SCIP Project. What components of the
SCIP Project are present in your perioperative services?

Advanced
level

Review the article by Neily et al. (2010) and examine the implications of
these authors’ findings on training healthcare teams. Note the impact
of teamwork training on patient outcomes. The first author on this
research article is a nurse.

IHI, Institute for Healthcare Improvement; SCIP, Surgical Care Improvement Project.

Emma, a new graduate, just completed her 3-month orientation. She is given a com-
plex patient assignment without the assistance of a preceptor. After receiving a quick
bedside report from the night nurse, Emma notices that her patient is restless and has
an elevated respiratory rate. She is concerned, but realizes her patient is not wearing
his oxygen. She puts the nasal cannula on the patient and tells him she will be back
to check on him. Emma is starting to get behind in her work, but she wants to make a
good impression with her colleagues and decides not to ask for help. One hour later,
the nursing assistant tells Emma that her patient is in respiratory distress. Emma
checks on her patient and decides to ask the charge nurse for help. After assessing
the patient, the charge nurse calls the interprofessional rapid response team and tells
Emma to bring the crash cart into the room. When the team arrives, they decide the
patient is unstable and must be transferred to the ICU for close monitoring.

1. What critical steps should Emma have taken to engage the interprofessional team
sooner?

2. Describe the places where teamwork and communication could have been strength-
ened in this case.

3. Identify the quality and safety issues that emerged around teamwork and collabora-
tion. What actions could have been taken to prevent a patient transfer to the ICU.

4. Describe one leadership concept that would have been beneficial for Emma to use to
speak up and ask for help?

CASE STUDY 2.2

Students begin to value the nurse’s role in planning care and the nurse’s impact on
patient outcomes when the nursing scope of practice is learned within the context
of interprofessional teams. Teamwork is one of the core competencies, along with
communication, roles and responsibilities, and ethics, that all health professions
students should achieve. The nurse is often at the center of communication for the
healthcare team and frequently facilitates important patient-care transitions. For

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 49

example, communication of the patient’s changing status is vital to successful use
of rapid response teams. Rapid response teams are a group of individuals from a
variety of disciplines such as nursing, medicine, and respiratory therapy that use
evidence-based interventions in the acute care setting to provide timely, focused
care for patients experiencing rapid deterioration. The Institute for Healthcare
Improvement’s (IHI) 5 Million Lives Campaign (2006) facilitated widespread adop-
tion of this team-based intervention. Details about rapid response teams can
be explored at IHI’s website (go to www.ihi.org and search for rapid response
teams). Table 2.4 offers learning activities that focus on the teamwork and collabo-
ration competency at the beginning, intermediate, and advanced levels of nursing
education.

Evidence-Based Practice

Nurses play a key role in protecting patients from harm by providing high-quality
healthcare (Balakas & Smith, 2016). Research indicates that the implementation of EBP
leads to higher quality of care, improved patient outcomes, and decreased healthcare
costs (Melnyk, Fineout-Overholt, Gallagher, & Kaplan, 2012). The QSEN competency

TABLE 2.5 EVIDENCE-BASED PRACTICE LEARNING ACTIVITIES

CURRICULUM LEVEL LEARNING ACTIVITIES

Beginning level There is a body of research around barriers to
utilizing EBP in nursing practice. Read the article
titled “Evidence-Based Practice Barriers and
Facilitators From a Continuous Quality Improvement
Perspective: An Integrative Review,” by Solomons
and Spross (2011).

Does the article resonate with what you are seeing
in practice regarding the barriers for utilization of
EBP? What did the authors identify as the barriers
for continuous quality improvement in the clinical
setting?

Intermediate level Go to QSEN.org. On the search bar click the education
tab. Both faculty and students will find competencies
and teaching strategies related to evidence-
based practice. Choose one to explore. Under the
evidence-based practice tab there is a selection of
articles for both students and faculty to read.

Advanced level Nurses still struggle to get evidence into practice.
The article, “Barriers and Facilitators to the Use of
Evidence-Based Practice,” by Scott and McSherry
(2009) explains that, for evidence-based nursing to
occur, nurses need to be aware of what evidence-
based nursing means and what the process of
EBP is to apply the evidence. This article examines
the concept of evidence-based nursing and its
application to clinical practice. Use the article as a
basis for your discussion of nursing’s struggle to get
evidence into practice (Scott & McSherry, 2009).

EBP, evidence-based practice.

50 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

of evidence-based practice integrates the best current evidence with clinical expertise
and patient/family preferences and values for the delivery of optimal patient care.
Examples of this competency include the following:

• K—Describe EBP to include components of research evidence, clinical expertise,
and patient/family values.

• S—Base individualized care plans on patient values, clinical expertise, and
evidence.

• A—Value the concept of EBP as integral to determining best clinical practice
(Cronenwett et al., 2007).

Traditional medical–surgical nursing skills are now often taught along with their
bases in EBP. For example, nursing research highlights emerging best clinical practices
related to fluid balance, peripheral intravenous insertion and maintenance, urinary
catheter care, care of central lines, and nasogastric tube insertion. As confirmation of
the core role of EBP in developing clinical practice, most nursing texts now include
evidence-based support to explain rationales for clinical practice. Table 2.5 offers learn-
ing activities for this competency.

Quality Improvement

The QSEN competency of quality improvement (QI) is defined as the use of data to
monitor the outcomes of care processes and using improvement methods to design
and use changes to continuously improve the quality and safety of healthcare systems.
Nursing programs have integrated QI methods and tools to help students engage in
frontline improvement (IOM, 2003). Examples of KSAs for this competency include
the following:

• K—Recognize that nursing and other health professions students are parts of sys-
tems of care and care processes that affect outcomes for patients and families.

• S—Use tools (such as control charts and run charts) that are helpful for under-
standing variation.

• A—Appreciate that continuous QI is an essential part of the daily work of all
health professionals (Cronenwett et al., 2007).

Formal, systems-focused QI processes that engage a healthcare team, such as
adverse events reporting, should be part of the early components of the nursing
curriculum. Root cause analyses and resulting system changes are relevant to study
in a clinical nursing course. As students progress through clinical courses, they
will see many examples of nurses contributing to QI processes in the acute care
setting. Nurses are well positioned to offer insights into how to improve patient-
care processes to improve patient outcomes. Table 2.6 offers learning activities at
the beginning, intermediate, and advanced levels of nursing education for this
competency.

In addition to learning about QI from a nursing perspective, engaging with other
health professional students is an effective learning strategy. Students can learn about
QI together in classroom, simulation, and clinical settings (Headrick et al., 2012). In
fact, the IHI has established an “open school” to distribute free online courses, provide
experiential learning opportunities, as well as build community (available at www.ihi
.org/offerings/ihiopenschool).

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 51

EVIDENCE FROM THE LITERATURE

Citation

Hermann, C., Head, B., Black, K., & Singleton, K. (2016, January–February). Preparing
nursing students for interprofessional practice: The interdisciplinary curriculum for
oncology palliative care education. Journal of Professional Nursing, 32(1), 60–71.

Discussion

The Interprofessional Education Collaborative, a collaboration of key educational
associations, including the American Association of Colleges of Nursing (AACN),
established core competencies for interprofessional collaborative practice that apply
to all students of the health professions. Evidence supports the collaboration of
health professionals to improve patient outcomes, especially those related to quality
and safety. This study identifies the development of an interprofessional Curriculum
for Oncology Palliative Care Education (iCOPE) using team-based palliative oncol-
ogy education as a framework for teaching students interprofessional practice skills.

Implications for Practice

The study concludes that health education can no longer be taught in separate silos,
but must take an interprofessional approach to curriculum design. Nurse educators are
ideally suited to lead these initiatives. The project serves as a model for ongoing efforts
to develop and implement interprofessional education initiatives going forward.

TABLE 2.6 QUALITY IMPROVEMENT LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning
level

Nurses are involved in QI work at every level of healthcare. A checklist,
developed by Peter Pronovost, around central line insertion has
standardized the practice of central line insertion and reduced central
line-associated bloodstream infections. Read Atul Gawande’s article on the
development of this checklist, paying attention to the role of nurses in the
checklist’s implementation (Gawande, 2007)

Intermediate
level

The article “Adverse Event Reporting and Quality Improvement in the
Intensive Care Unit,” by Heavner and Siner (2015) illustrates the
process of QI and adverse event reporting. Form student teams to
review an adverse event and propose system solutions.

Advanced
level

Partner with someone who works in the QI department of your hospital.
Shadow that person for 2 full days. Notice the focus of their work. Which
patient outcomes is this department tracking? How are data gathered
for these patient outcomes? What elements of nursing care are tracked
for these patient outcomes? What insight can nurses provide about the
patient-care processes to achieve these patient outcomes?

QI, quality improvement.

52 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Safety

The safety QSEN competency minimizes risk of harm to patients and providers
through both system effectiveness and individual performance. Examples of KSAs for
this competency include the following:

• K—Examine human factors and other basic safety design principles as well as com-
monly used unsafe practices, such as work-arounds and dangerous abbreviations.

• S—Demonstrate effective use of strategies to reduce the risk of harm to self or
others.

• A—Value the contributions of standardization/reliability to safety (Cronenwett
et al., 2007).

QSEN’s definition of safety emphasizes team strategies to promote safe care in a
healthcare system rather than focusing on blaming individuals for safety issues. For
example, maintaining asepsis is a component of an individual nurse’s practice and
has multiple associated safety skills. Maintaining asepsis and reducing infections in

REAL-WORLD INTERVIEW

Quality and safety improvement is more than just a supplemental activity
complementing core clinical education in the health professions. It directly
impacts the health and lives of the people that healthcare professionals have
pledged to help and directly affects the outcomes that we need to achieve
in healthcare. Quality and safety, therefore, must be a personal commitment
and part of the core professional role identity of every healthcare profes-
sional. To achieve this, health professions education must strive to integrate
quality and safety into the core curriculum and prepare “clinician-leader-
improvers” who are ready to lead and continuously improve the work they
are doing in healthcare. QSEN is a key voice for quality and safety educa-
tion in the nursing profession. QSEN also provides guidance and resources,
which are essential in developing competence in quality and safety for
health professions. It is critical that all health professions education pro-
grams integrate the QSEN competencies into their curricula and engage stu-
dents in meaningful applied quality and safety education experiences at the
beginning of their educational development and then onward into profes-
sional practice. To a great degree, the future of our health is in the hands of
our students and in their efforts to improve healthcare quality and safety. As
such, health profession educators have a critical obligation to help them to
develop not only as clinicians, but as leaders and improvers

Brant J. Oliver, PhD, MS, MPH, APRN-BC
Assistant Professor, The Dartmouth Institute &

Geisel School of Medicine at Dartmouth
Adjunct Associate Professor, School of Nursing

MGH Institute of Health Professions
Faculty Senior Scholar

Veteran’s Affairs National Quality Fellowship
in Healthcare Quality and Safety

REAL-WORLD INTERVIEW

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 53

one’s practice also has direct implications for supporting patient outcomes related to
various national safety goals in a healthcare system. The National Patient Safety Goals
(The Joint Commission, 2012), 5 Million Lives Campaign (IHI, 2012), and Safe Practices
for Better Healthcare (National Quality Forum, 2009) all state common goals around
decreasing nosocomial infection rates in the acute care setting. Table 2.7 offers learning
activities at the beginning, intermediate, and advanced level of nursing education for
the competency.

At the heart of our social identity as professionals is the ability to continually
learn and improve our own work. No longer soloists, most of today’s healthcare
work is done with others. Interdependently, patients, families and people from
multiple health professional disciplines work in complex, complicated and
simple systems to cocreate and coproduce healthcare services. Changing and
improving the coproductive work of relationships and actions requires diverse
knowledge and skills (Batalden et al., 2016).

The European safety scholars, Charles Vincent and Rene Amalberti,
remind us that, “we need to see safety through the patient’s eyes, to consider
how safety is managed in different contexts and to develop a wider strategic
and practical vision in which patient safety is recast as the management of
risk over time” (Vincent & Amalberti, 2016). This will involve moving from a
focus on unusual events of failure and harm in hospital settings to a focus on
the patient’s journey over time. Attention to the coproduction and the coor-
dination of services over time in diverse settings will open a new chapter in
traditional safety efforts.

Paul Batalden, MD
Active Emeritus Professor

The Dartmouth Institute for Health Policy & Clinical Practice

Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-
Arrigan, L., & Hartung, H. (2016). Coproduction of healthcare service. BMJ
Quality & Safety, 25, 509–517.

Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world.
Switzerland: Springer Open.

REAL-WORLD INTERVIEW

You are a new nurse working in a busy operating room. You notice that in the
past month, three patients being transferred from the same adult patient-care
unit in the hospital have not been given their preoperative antibiotics prior to
transfer to the operating room.

1. What patient-care processes might you address to attend to this recurring issue?
2. What data might you need?
3. Who would you invite to a meeting to address this patient-care issue?

CASE STUDY 2.3

54 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Informatics

The QSEN competency of informatics calls for the use of information and technology
to communicate, manage knowledge, mitigate (prevent) error, and support decision
making. KSAs from this competency include the following:

• K—Explain why information and technology skills are essential for safe patient
care.

• S—Apply technology and information management tools to support safe pro-
cesses of care.

• A—Value technologies supporting decision making, error prevention, and care
coordination (Cronenwett et al., 2007).

Documentation is an important skill in healthcare informatics. All members of a
healthcare team contribute to an electronic health record that is used extensively
to document shifting patient-care priorities. A broader view of informatics empha-
sizes not only documenting the patient care provided but also encourages the use
of informatics in computerized clinical alerts and decision management. For exam-
ple, a clinical alert signals to the provider that the patient is eligible to receive the
pneumonia or flu vaccine. Decision management in healthcare focuses on having
the appropriate data available at points in the decision making process to be able to
make the best decision in a timely fashion. Data used in decision management may
come from patient records, diagnostic results, providers’ documentation, or EBPs.
Table 2.8 offers learning activities at the beginning, intermediate, and advanced lev-
els of nursing education regarding this competency.

QSEN COMPETENCIES RELATED TO NURSING EDUCATION
ACCREDITATION STANDARDS

Nursing education accreditation standards are driven by rapid changes occur-
ring in nursing practice. Several national reports have focused on the need for
updated quality and safety content in nursing education. A 2010 report by the

TABLE 2.7 SAFETY LEARNING ACTIVITIES

CURRICULUM LEVEL LEARNING ACTIVITIES

Beginning level Read and discuss the National Patient Safety Goals with
colleagues. Describe how they apply in clinical practice.
Go to www.jointcommission.org/2018_national_patient_
safety_goals_presentation/ for a free 2018 National Patient
Safety Goals slide presentation.

Intermediate level The article “Lesson From Colorado: Beyond Blaming
Individuals,” by Smetzer (1998) summarizes the system
failures that led to a sentinel event with a newborn.

Advanced level Note the Nine Patient Safety Solutions identified by The Joint
Commission and the World Health Organization: The purpose
of the Nine Patient Safety Solutions is to guide the redesign
of patient-care processes to prevent inevitable human errors
from actually reaching patients. See www.who.int/mediacentre/
news/releases/2007/pr22/en

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 55

Carnegie Foundation for the Advancement of Teaching titled Educating Nurses:
A Call for Radical Transformation, recommended several initiatives to address the
practice–education gap (Benner, Sutphen, Leonard, & Day, 2010). The report’s
authors emphasize that both didactic academic classroom teaching and clinical
practice teaching models need to more fully reflect the current healthcare empha-
sis on QI and patient safety. An interprofessional report published by the IOM
in 2011, The Future of Nursing: Leading Change, Advancing Health, includes the key
message that nurses need to be full partners with other healthcare team members
to redesign healthcare in the United States. Quality and safety are two significant
areas where interprofessional, collaborative efforts are needed to redesign U.S.
healthcare systems. Accreditation standards for nursing programs have begun to
clearly articulate the need for quality and safety content in prelicensure curricula.
Standards from accrediting bodies for nursing programs, that is, the Accreditation
Commission for Education in Nursing (ACEN), formerly the National League for
Nursing Accrediting Commission (NLNAC), and the AACN are explicit about the
necessity for the QSEN competencies in all nursing prelicensure curricula.

Table 2.9 connects each of the AACN Essentials of Baccalaureate Education to
QSEN competencies. Many of the AACN Essentials of Baccalaureate Education con-
tain several guidelines for prelicensure curricula, thus the connection to more than one
QSEN competency in Table 2.9.

ACEN’s accreditation standards similarly encourage the integration of QSEN
competencies into prelicensure curricula. Table 2.10 connects several of the ACEN
standards to QSEN competencies.

TABLE 2.8 INFORMATICS LEARNING ACTIVITIES

CURRICULUM
LEVEL LEARNING ACTIVITIES

Beginning level Many patients use Internet resources to become educated
about their diagnosis. Use this QSEN learning activity to
evaluate a health-related website that one of your patients
may use. There is an evaluation form provided at qsen.org/
website-evaluation-exercise.

Intermediate
level

The Commission on Systematic Interoperability has been
charged with developing a strategy to make healthcare
information increasingly accessible at various care points in
the healthcare process. Access the following website: www.
endingthedocumentgame.gov. Click on the personal stories
link and read the narratives provided by patients, healthcare
professionals, and nurses about the importance of timely
access to patient data.

Advanced level Consider the number of electronic health records (EHRs) you have
experienced during your nursing rotations. Answer the following
questions:

1. How many EHR systems have you seen in your various clinical
rotations?

2. What similarities have you seen among EHR systems?
3. Which EHR system seemed most “nurse friendly”? Identify what

you mean by “nurse friendly.”
4. What improvements do you think need to be made to existing

EHR systems in the acute care setting to better support nursing
care needs?

56 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

QSEN RESOURCES

The QSEN website (www.qsen.org) has many resources for nurses, nursing stu-
dents, and nursing faculty. Available on the website under the education tab are
the competencies and KSAs for prelicensure nurses and graduate nurses. Here,
students and faculty can read peer-reviewed articles on relevant teaching strat-
egies and EBPs related to the QSEN competencies. Under the resource tab, fac-
ulty can access 18 learning modules that will assist them in integrating quality
and safety competencies into their programs. The learning modules address top-
ics such as appreciating and managing the complexity of nursing work, cognitive
stacking (a process that assists students to more effectively manage the complexity
of their work to promote safe, quality care), informatics, and other topics relevant
for practicing nurses. Books, reports, toolkits, articles, and presentations can also
be accessed under this tab. Under the publications tab, there are books and videos
that highlight exemplar cases such as the Lewis Blackman story and the Josie King
case. Both exemplar cases are potent tools that highlight the vital importance of
quality and safety in nursing practice. Teaching strategies can be found in peer-
reviewed articles at the site.

TABLE 2.10 SELECTED ACEN STANDARDS AND QSEN COMPETENCIES

ACEN STANDARD QSEN COMPETENCY

4.5. The curriculum includes cultural, ethnic, and socially
diverse concepts and may also include experiences
from regional, national, or global perspectives.

PCC

4.6. The curriculum and instructional processes reflect
educational theory, interprofessional collaboration,
research, and current standards of practice.

Teamwork and collaboration
Evidence-based practice
QI

4.10. Students participate in clinical experiences
that are evidence-based and reflect contemporary
practice and nationally established patient health
and safety goals.

Safety
QI

ACEN, Accreditation Commission for Education in Nursing; PCC, patient-centered care; QI, quality improvement.

Source: Developed with information from the ACEN (2013).

TABLE 2.9 SELECTED ACEN ESSENTIALS OF BACCALAUREATE EDUCATION AND QSEN
COMPETENCIES

AACN ESSENTIALS OF BACCALAUREATE EDUCATION QSEN COMPETENCY

II: Basic Organizational and Systems Leadership for
Quality Care and Patient Safety

QI
Safety

III: Scholarship for Evidence-Based Practice Evidence-based practice
IV: Information Management and Application of Patient

Care Technology
Informatics

V: Interprofessional Communication and Collaboration
for Improving Patient Health Outcomes

Teamwork and collaboration
QI

AACN, American Association of Colleges of Nursing.

Source: Developed with information from the American Association of Colleges of Nursing (AACN). (2008). The
essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacnnursing.org/
Portals/42/Publications/BaccEssentials08.pdf

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 57

All of the relevant professional organizations that are making great strides
in improving quality and safety in healthcare (e.g., IHI, www.ihi.org; Agency for
Healthcare Research and Quality Patient Safety Network, psnet.ahrq.gov; National
Association for Healthcare Quality, nahq.org/ and the NPSF, www.npsf.org) as well as
many others can be found on the QSEN website. QSEN’s well-designed website is an
invaluable, updated resource for all nurses and nurse educators.

SPECIAL ISSUES OF NURSING JOURNALS THAT HAVE
FOCUSED ON QSEN

Nurse Educator (2017) published a QSEN-dedicated issue in the September/October
edition and included articles focused on QSEN’S impact on curriculum develop-
ment in schools of nursing to date, as well as advancements in the integration of the
QSEN competencies in the clinical setting. Earlier work in both Nursing Outlook (2009),
November/December, 57 (6), and Journal of Nursing Education (2009), December, 48
(12) published QSEN-dedicated issues that are valuable resources and provide a sub-
stantive contribution to the literature about the importance and logistics of implement-
ing QSEN competencies in nursing curricula.

CRITICAL THINKING 2.2

Go to this link at the IHI website: www.ihi.org/knowledge/Pages/HowtoImprove/
ScienceofImprovementHowtoImprove.aspx

Read about the Model for Improvement. Consider a unit-based project on an adult
patient-care unit where a nurse wants to address decreasing the decubitus ulcer rate
on her unit. Using the Model for Improvement with its three fundamental questions
and its Plan-Do-Study-Act (PDSA) cycle as a model for such a project, answer the
following questions:

1. What team members would have important input on this team?
2. Imagine yourself on the QI team. What change are you trying to accomplish?
3. What might be your goal?
4. What data will you collect that will show that your changes made a

difference?

KEY CONCEPTS

• Historically, a major push for the six competencies of the QSEN initiative came from
the 2003 IOM report, Health Professions Education: A Bridge to Quality, where competen-
cies in quality and safety were recommended for all health professions students.

• All six of the QSEN competencies, that is, PCC, QI, safety, teamwork and collabora-
tion, EBP, and informatics, are integral aspects of nursing clinical practice.

58 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

• Each of the six QSEN competencies has KSA elements that help operationalize each
competency for practice.

• The QSEN competencies are fundamental components of accreditation standards for
nursing programs and are integrated into beginning, intermediate, and advanced
level nursing courses.

• There are a wide variety of quality and safety resources available for nurses at the
QSEN website (www.qsen.org).

• There are several special issues of nursing journals that have focused on QSEN.

KEY TERMS

Attitudes
Evidence-based practice
Informatics
Knowledge
Patient-centered care
Quality improvement

Rapid response teams
Safety
Safety science
Skills
Teamwork and collaboration

REVIEW QUESTIONS

1. The nurse is caring for a newly admitted patient. She introduces herself using her
first and last names and asks the patient what his values, needs, and preferences
are for this hospital stay. The nurse is practicing which of the QSEN competencies?

A. Evidence-based practice
B. Safety
C. Patient-centered care
D. Teamwork and collaboration

2. The primary nurse is caring for a patient admitted to the unit from a nursing home
with a Stage III decubitus ulcer. In looking at the electronic nursing notes, she
notes a discrepancy in the patient’s wound care procedures. The primary nurse
calls the wound care nurse to consult and ensure a consistent plan of care. The
wound care nurse assesses the patient and provides the necessary information
reflecting the standard of care. The primary nurse is practicing which of the QSEN
competencies? Select all that apply.

A. QI
B. Safety
C. Teamwork and collaboration
D. PCC
E. Informatics

3. The nurse is transferring his patient to the Post Anesthesia Care Unit (PACU) from
the surgical unit. He is calling the receiving nurse with a patient handoff report.
Ensuring patient safety by using the handoff report, he is careful to describe the
situation, background, assessment, and recommendation for the patient’s con-
tinued care. Giving an accurate handoff report is an example of ensuring patient
safety by using which QSEN competency?

A. Teamwork and collaboration
B. QI

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 59

C. PCC
D. Informatics

4. The nurse notices that there was an earlier medication error that resulted in an
adverse patient outcome. She asks for assistance from her manager in analyzing
the error. This is an example of using which QSEN competency?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration

5. A medical resident walks into a patient’s room to complete a physical assess-
ment. The nurse notices that the resident did not wash her hands before entering
the room. The nurse gently reminds the resident to use the hand sanitizer before
touching the patient. This reminder is an example of using which of the following
QSEN competencies?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration
E. Informatics

6. The nurse is using barcode administration technology to facilitate the administra-
tion of medications to her patients. This is an example of how barcode medication
administration technology facilitates which of the following QSEN competencies?

A. Teamwork and collaboration
B. Safety
C. Informatics
D. EBP
E. QI

7. The nurse is participating in a team meeting with her patient, the dietician, phy-
sician, and social worker. The nurse recalls that the patient had expressed that
spirituality was important to her. A pastoral care representative is not present in
the meeting. The nurse notices this and contacts pastoral care to be included in the
meeting. This inclusion is an example of using which QSEN competency?

A. Teamwork and collaboration
B. Safety
C. PCC
D. Informatics

8. The nurse realizes that her patient’s pain management is not effective. She has
noticed this with other patients in the past and decides to analyze the unit-based
pain control chart posted in the break room. She decides to explore additional pain
management options for patients whose pain is not controlled with the usual pain
management. Which QSEN competencies best describes her approach?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration

60 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

9. In administering medication to her patient, the nurse saw that the medication
administration record indicated the dose amount to be 5 mg. She immediately
double checked the order and confirmed that the dose was supposed to be 0.5 mg.
The nurse remembered to always use a zero before a decimal when the dose is less
than a whole unit and she updated the medication administration record accord-
ingly. Which QSEN competency applies?

A. Safety
B. QI
C. PCC
D. Teamwork and collaboration

10. The nurse is concerned about his patient’s lab values and medication regimen.
The nurse uses the electronic health record to obtain information about medica-
tion doses, lab results, and notes that the patient’s lab results are within normal
limits. This use of the electronic health record is an example of using which QSEN
competency?

A. Teamwork and collaboration
B. Safety
C. PCC
D. Informatics

REVIEW ACTIVITIES

1. Select one of the six QSEN competencies from the QSEN website (www.qsen.org)
and create a 60-second video explaining the competency that was chosen and why
it matters to professional nursing practice. Present the video in class and lead a
discussion on the video’s application to practice.

2. Interview three nurses on the unit where you are currently doing a clinical rota-
tion. Ask each nurse, “What is the most pressing patient safety issue on this unit?”
Take notes. Compare the nurses’ answers. Discuss the results with your classmates
and instructor in post conference. What did you find?

CRITICAL DISCUSSION POINTS

1. Discuss the importance of what QSEN has accomplished to date.
• Defined quality and safety competencies for nursing and proposed targets for the

KSAs to be developed in nursing prelicensure programs for each competency:
patient-centered care, teamwork and collaboration, EBP, QI, safety, and informatics.

• Completed a national survey of baccalaureate nursing program leaders and a
state survey of associate degree nursing educators to assess beliefs about the
extent to which the competencies are included in current curricula, the level
of satisfaction with student competency achievement, and the level of faculty
expertise in teaching the competencies.

• Partnered with representatives of organizations that represent advanced prac-
tice nurses and drafted proposed KSA targets for graduate education.

• Funded work with 15 pilot schools committed to active engagement in curricu-
lar change to incorporate quality and safety competencies

• Discussed the goals of the QSEN competencies at the prelicensure level.

2 QUALITY AND SAFETY EDUCATION FOR NURSES • 61

• Set the overall goal for QSEN to meet the challenge of preparing future nurses
who will have the KSAs necessary to continuously improve the quality and
safety of the healthcare systems in which they work.

2. Discuss one potential barrier for incorporating the QSEN competencies in a
patient’s plan of care. Are any of the following an issue in your clinical setting?
• Lack of teamwork and collaboration among the interprofessional team members.
• Developing a plan of care without consideration of the preferences/values of

the patient/family.
• Poor handoffs when a patient is being transferred from one unit to another.

3. Using the QSEN competency of teamwork and collaboration, discuss how you would
apply those KSAs to a complex clinical situation.

4. Why it is essential that the QSEN competencies align with accreditation standards?
5. Select one article from The Journal of Nursing Education, September/October 2017,

QSEN Supplement, and reflect on how the article is related to your practice.
Discuss with colleagues what you have learned.

6. Discuss in class some of the most useful resources on the QSEN website.
• Competencies
• Teaching strategies
• QSEN integration modules
• Learning modules
• Books, reports, toolkits
• Evaluation tools
• Videos
• Conferences

7. What does the word “systems thinking” mean to you related to the QSEN
competencies?

QSEN ACTIVITIES

1. Explore the teaching strategies published on the QSEN Website (www.qsen.org).
These are peer-reviewed teaching strategies published on the site. Ask students to
choose one of the strategies and apply it to a clinical situation. Discuss an imple-
mentation plan for the strategy chosen. Discuss which QSEN competencies apply.

2. Select one of the six QSEN competencies from the QSEN website (www.qsen.org)
and create a 60-second video explaining the competency they chose and why it
matters to professional nursing practice. Have students present the video in class
and lead a discussion on the video’s application to practice.

EXPLORING THE WEB

1. National Patient Safety Foundation—www.npsf.org
2. QSEN Institute—www.qsen.org
3. Institute for Healthcare Improvement—www.ihi.org
4. TeamSTEPPS—www.teamstepps.ahrq.gov
5. IHI Open School—www.ihi.org/offerings/ihiopenschool
6. Agency for Healthcare Research and Quality Patient Safety Network—psnet.ahrq

.gov
7. National Association for Healthcare Quality. Q Essentials Info Session February

2016—www.youtube.com/watch?v=kP9-8V93s30

62 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

REFERENCES

Accreditation Commission for Education in Nursing (ACEN). Retrieved from www.acenursing
.org/resources-acen-accreditation-manual/

American Association of Colleges of Nursing (AACN). (2008). The essentials of baccalaure-
ate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/
education-resources/BaccEssentials08.pdf

American Organization of Nurse Executives (AONE). (2007). Guiding principles for nurse lead-
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nursing

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SUGGESTED READING

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Clinical nursing education: Current reflections (pp. 207–227). Washington, DC: National
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nurses: Looking forward. Nurse Educator, QSEN Supplement, 42(5), S1–S2.

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safety and quality in pediatric pain management. Pediatrics, 131, e921–e927. doi:10.1542/
peds.2012-1378

Cohen, N. L. (2013). Using the ABCs of situational awareness for patient safety. Nursing, 43,
64–65. doi:10.1097/01.NURSE.0000428332.23978.82

64 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: CRC Press.
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St. Martin’s Press.
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nurses. Washington, DC: National Academies Press.
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by medical care teams in acute hospital settings—limited evidence of effectiveness. BMC
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learning of nursing quality and safety competencies. Nurse Educator, 38, 71–75. doi:10.1097/
NNE.0b013e3182829c7d

Triola, N. (2006). Dialogue and discourse: Are we having the right conversation. Critical Care
Nurse, 26, 60–66. AACN

Wachter, R. M. (2008). Understanding patient safety. New York, NY: McGraw-Hill.

Upon completion of this chapter, the reader should be able to

1. Explain major leadership theories in relation to the Quality and Safety
Education for Nurses (QSEN).

2. Describe roles and responsibilities of leadership.

3. Define management as distinguished from leadership.

4. Discuss the importance of followership in relation to an organization’s
mission and vision.

5. Explain how the hospital’s finances influence safety and quality of patient
care.

6. Describe how a budget influences staffing.

7. Discuss the importance of the Code of Ethics for Nurses.

8. Discuss the importance of Emancipatory Knowing in relation to the call for
every nurse to function as a leader.

9. Discuss the four key elements of the Future of Nursing (FON): Campaign for
Action in the context of functioning as a leader at all levels of care.

NURSES AS LEADERS AND MANAGERS
FOR SAFE, HIGH-QUALITY PATIENT CARE

Carolyn A. Christie-McAuliffe

All truth passes through three stages: first it is ridiculed; second it is violently opposed; third it is accepted
as being self-evident.

—Arthur Schopenhauer

3

66 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

S
ally graduated from nursing school a year ago and is now working full time on a medical–
surgical floor. Several novice nurses with no prior nursing experience have joined the
staff and expressed feeling overwhelmed with all there is to know and be done. Sally
is happy to have the additional help; however, she has noticed many patients are not

being assisted out of bed or ambulated. She clearly remembers her first few months out of school
and empathizes with the new nurses’ feelings. However, she is also worried about the risk of
pneumonia, bedsores, and other health complications in patients who remain in bed for extended
periods of time.

• What can Sally do to support her new colleagues?
• What are some things Sally can do to support her colleagues’ patients?
• What could Sally do to prevent a similar situation the next time the floor hires new graduates?

Leadership is frequently described in terms of personal attributes such as having
confidence and being strong. Often, these leadership attributes have been assumed to
be a quality one has been born with or cultivated by how the person has been raised.
However, many experts now argue leadership can be taught, fostered, and refined.
Many nurse leaders agree with this more contemporary viewpoint. Specifically, they
are calling for nursing education that incorporates leadership content which encour-
ages nurses to demonstrate leadership at all levels of nursing practice. The leader-
ship they advocate would directly and indirectly impact the safety and quality of
patient care.

This chapter provides the foundation for understanding leadership and this new
call to action. Theories are presented as context for discussion as leadership is dis-
cussed in relation to management and followership. Similarities and differences of
the qualities, roles, and responsibilities of leadership, managers, and followers are
described within the framework of economic and financial constraints. The impact of
economics and finance will be discussed in relation to the ability to deliver safe, qual-
ity care. However, the emphasis of this chapter is substantiating the need to shift the
focus of care from individual patients to now include care of the healthcare system
as well. This substantiation comes from many influences, including Nursing’s Social
Contract as well as the Code of Ethics for Nurses, the Quality and Safety Education
for Nurses (QSEN), the Future of Nursing (FON) Campaign for Action, and the under-
standing of Emancipatory Knowing.

Nursing has a rich history of leading change. Florence Nightingale, Clara Barton,
Margaret Sanger, and Hazel Johnson-Brown are but a few nurses who have advanced
nursing and healthcare through their efforts to facilitate change. More recently, lead-
ership has been demonstrated by nursing in response to the Institute of Medicine’s
(IOM) reports, To Err Is Human: Building a Safer Health System (2000) and Crossing the
Quality Chasm (2001), which documented the need to restructure the healthcare sys-
tem. These reports revealed issues of both safety and quality of care, specifically in
the context of increased complexity within the healthcare system. The IOM reports
identified many causes of this complexity, including the health status of patients,
technology, as well as economics, politics, and social factors. National organizations
such as The Joint Commission (TJC) and the Institute for Healthcare Improvement
(IHI) launched programs in response to the IOM findings. Similarly, nurse leaders
responded to the same IOM findings at local, state, and national levels with many
initiatives; however, two of these initiatives stand out: The QSEN Initiative and the
FON: Campaign for Action.

In 2005, QSEN was formed to develop competencies of knowledge, attitude, and
skill related to safety of patient care and as a means to ensure continuous quality

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 67

improvement in healthcare organizations and institutions. Six core competencies
were developed with measures differentiated at prelicensure and graduate levels
as follows:

1. Patient-Centered Care
2. Teamwork and Collaboration
3. Evidence-Based Practice (EBP)
4. Quality Improvement (QI)
5. Safety
6. Informatics (QSEN, 2017)

The aim of the QSEN competencies was and is to provide relevant materials and
resources to nurse educators that can be incorporated into existing curricula.
In addition, QSEN wanted to provide objective measures of knowledge, attitude, and
skill that nurse faculty could use to determine if students understood and could apply
interventions aimed at increasing safety and quality of care. Since its formation, QSEN
has funded and/or supported innovative programs in specific schools, the Veterans
Administration, the American Association of Colleges of Nursing, and more.

The FON: Campaign for Action is another powerful initiative within nursing.
In 2008, the Robert Wood Johnson Foundation (RWJF) partnered with the IOM to
launch a specific study investigating the role of nursing in transforming health-
care. Their research discovered much diversity of educational preparation, unde-
rutilization of nursing knowledge and skill, and fragmentation of purpose within
the nursing profession. However, they also found great potential. In 2011, the IOM
published The Future of Nursing: Leading Change, Advancing Health. In this report,
eight recommendations were offered to policymakers, educators, healthcare organi-
zations, and businesses, as follows:

1. Remove scope-of-practice barriers.
2. Expand opportunities for nurses to lead and diffuse collaborative improvement

efforts.
3. Implement nurse residency programs.
4. Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.
5. Double the number of nurses with a doctorate by 2020.
6. Ensure that nurses engage in lifelong learning.
7. Prepare and enable nurses to lead change to advance health.
8. Build an infrastructure for the collection and analysis of interprofessional health-

care workforce data (IOM, 2011, pp. 9–15).

As a result of this report, the RWJF joined forces with AARP (formerly known as the
American Association of Retired Persons) to create the FON: Campaign for Action. All
50 states now have an Action Coalition Committee aimed at meeting the eight recom-
mendations of the IOM report.

Despite these initiatives, little improvement in safety and quality of care has been
demonstrated. The call to action has never been more ardent or urgent. Nurses at all
levels, from the patient bedside to the boardroom, are now asked to step into their
authentic power with moral courage to be leaders for change. No longer can responsi-
bility for leading change sit solely with nurse administrators or academicians; nurses at
every level of educational preparation and position are now called to improve patient
safety and quality of care within the healthcare system in which they work, as well as
with individual patients. As a profession, nursing now realizes all nurses should func-
tion as leaders to heal patients as well as the healthcare system.

68 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Cultivating leadership in nursing has not been stud-
ied extensively. However, residency programs for new
graduate nurses have provided some valuable insight.
Curtis, de Vries, and Sheerin (2011) discuss factors that
contribute to leadership in nursing including the offer-
ing of educational activities and role modeling as well
as the opportunity to practice leadership skills. They dis-
cuss being open to new ideas and being extroverted as
traits likely to foster leadership. Likewise, the role of age
and experiences are positive influences. Interestingly,
they found the most important skill necessary for lead-
ership involved fostering effective relationships. They
describe this specific skill as more important than
knowledge surrounding management skill or technical
abilities (Figure 3.1). They found that the most impor-
tant qualities of effective relationships include effective
communication, approachability, and emotional intelli-
gence. Wagner, Cummings, Smith, Olson, Anderson, and
Warren (2010), as cited in Curtis et al. (2011), discovered
the organizations that promoted nurse empowerment
resulted in increased “positive work behaviors and atti-
tudes, including leadership behavior” (p. 308).

LEADERSHIP THEORY

Historical review of how leadership has been perceived provides insight into how and
why nursing gravitates to some leadership theories over others. During the Industrial
Revolution, leadership was focused almost exclusively on how to manage productiv-
ity. Success was measured by precise, scientific measurements and standards, which
was appropriate and beneficial for institutions primarily focused on manufacturing.
During the mid-20th century, organizations identified the need for clearer structure
and standardization. Max Weber (1864–1920) offered a theoretical framework based
on establishing a hierarchy of authority and power that clearly delineated policies
and procedures as a way of standardizing work. As institutions grew focused mainly
on efficiency and growth, a dehumanizing quality to administration and leadership
developed. In response, government organizations enacted regulations to protect
workers. With this national shift, unions formed to further ensure safe and fair work-
ing conditions. The focus of leadership then evolved further to the individual within
an organization, specifically looking at maximizing their efforts and strengths. With
this new focus, a movement toward “human relations” emerged that continues today.
Many, if not most, contemporary leadership theories are based on the behavioral sci-
ences, which aim to explain human behavior. This perspective of leadership provides
organizations with a better understanding of what influences behavior. Having a clear
understanding of what an organization wants allows its leaders improved ability to
manage those influences.

Dinh et al. (2014) conducted a comprehensive literature review of established
and emerging leadership theories that revealed 23 thematic categories and 66
domains or areas of foci. Nursing does not espouse a single theory of leadership
but, rather, most often views leadership through the lens of nursing theory, incor-
porating and applying relevant leadership theory as appropriate. Three commonly

FIGURE 3.1 Leadership as
mentor.

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 69

referred to theories of leadership that nursing utilizes include Chaos, Quantum,
and Systems Theories. Each of these theories relates and interrelates to each other.

Chaos Theory

Chaos theory is based on the belief that underneath the seemingly unpredictable
nature of life and/or business, a pattern or order exists. While many leadership styles
and strategies are based on the belief that events are predictable and can be controlled,
Chaos Theory calls for leaders to be vigilant to the dynamic changing nature of eco-
nomic, political, and social cues. This awareness allows leaders to guide their orga-
nization through disorder. By seeking insight from these cues, the leader finds a new
pattern of understanding. Through this pattern of understanding, leaders accept the
reality of complexity as well as unpredictability in order to learn to anticipate needed
change and flexibility (Porter-O’Grady & Malloch, 2011). The leader then translates
this understanding for the need for change and flexibility to the organization in a way
that provides relevance, importance, and direction.

Quantum Theory

Quantum Theory acknowledges the complexity and chaotic nature of life. This theory
is based on quantum physics, which states particles or matter can exist simultaneously
in two different states of being. Quantum Theory asks leaders to simultaneously con-
sider the reality of a situation and the potential or ideal. Porter-O’Grady and Malloch
(2011) explain that in order to achieve this requirement, leaders must adopt a whole
systems approach versus an approach of individual parts. They explain that every
part of a system is part of one comprehensive system and smaller systems are linked
to form larger, more complex systems. This explanation provides the need and benefit
of interdependence (Box 3.1). They continue their explanation that Quantum Theory
requires leaders to focus on outcomes, not the process; in other words, what a job or

In nature, everything is interdependent. There is an ebb and flow among all elements of
life. Leaders must see their role from this perspective. Most of the work of leadership will
be managing the interactions and connections between people and processes. Leaders
must keep aware of the following truths:
• Action in one place has an effect in other places.
• Fluctuation of mutuality means authority moves between people (followers can be

leaders and leaders can be followers in a dynamic relationship).
• Interacting properties in systems make outcomes mobile and fluid (function in the

present but work toward the future).
• Relationship building is the primary work of leadership.
• Trusting feeling is as important as valuing thinking.
• Acknowledging in others what is unique in their contribution is vital.
• Supporting, stretching, challenging, pushing, and helping are part of being present to

the process, to the players, and to the outcome (Porter-O’Grady & Malloch, 2011, p. 22).

BOX 3.1 INTERDEPENDENCE

70 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

work results in rather than just that someone preformed the work for work’s sake. It
asks leaders to emerge from all levels of nursing, independent of educational prepara-
tion or position, learning to adapt to dynamic, unpredictable change in order to see
what is alongside what could be. In this way, the leader functions for the present but
works toward the future.

Systems Theory

Systems Theory espouses the same belief as Quantum Theory that all parts of a system are
vital and interdependent of the whole. Based on General Systems Theory developed by
biologist von Bertalanffy, Systems Theory addresses seven fundamental elements: input
(resources), output (product or service), throughput (planning), feedback (data on ser-
vice or product that allow for self-correction), control (evaluation), environment (milieu),
and goals (vision, mission). Ultimately, to be viable or sustainable, an organization as a
system, must have a clear vision and mission that is substantiated by feedback and able
to adapt to changing economic, political, and social conditions. Dolansky and Moore
(2013) argue Systems Theory or thinking allows nurses to move from a specific focus on
individual patient care to a perspective that sees patient care in the context of the care
of the “system.” In this broadened and more global view, the nurse is able to appreciate
and impact safety and quality of care on multiple levels. With this viewpoint, nurses are
able to see how various actions benefit the patient directly and indirectly. Their example
(Figure 3.2) of how this occurs on a continuum is poignantly illustrative.

Leadership Defined

Leadership can be explained or described in many ways; however, simply put, leader-
ship is the ability to lead or command a person or group of people (Figure 3.3). In this
simplistic perspective, anyone who leads and facilitates change by speaking up, pro-
viding education, role modeling, and/or coaching resulting in changed behavior of an
individual or group is a leader. As mentioned earlier, historically, leadership has been
viewed as something a person is born with that demonstrates a list of specific charac-
teristics. That viewpoint is no longer considered accurate. More contemporary views of
leadership consider the possibility of success to be a cocreation of a group that allows
for creativity and innovation. Grossman and Valiga (2016) explain this cocreation and
shared responsibility for success occurs when a group can appreciate and foster one
another’s strengths and attributes and commit to inspiring each other, as well as to be
self-aware, insightful, and accountable. The qualities of responsibility and accountabil-
ity share a sense of fidelity or dependability to others. Both of these qualities are com-
ponents of being a leader; however, each quality is slightly different from the another.

Personal Effort/
Individual Care

Systems Thinking/
System Care

I will turn my
patient

I will post a note
above the bed to
remind others

I will ask other nurses
about products to
prevent ulcers

I will compare our
unit ulcer rate with
benchmarks

FIGURE 3.2 Example of continuum of systems thinking for quality
and safety in healthcare.
Source: From Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses
(QSEN): The key is systems thinking. The Online Journal of Issues in Nursing, 18(3), Manuscript 1.
Retrieved from https://www.nursingworld.org/Quality-and-Safety-Education-for-Nurses.html

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 71

Responsibility is typically a requirement
of assigned tasks, roles, and/or a position
(i.e., a staff nurse on a medical surgical
floor is responsible for monitoring vital
signs of her assigned patients), whereas
accountability speaks to one’s willingness
to accept responsibility for an assignment
(i.e., the nurse accepts accountability for
all assignments related to her job).

Nursing leaders such as Porter-
O’Grady and Malloch (2011) distinguish
leadership that simply facilitates change
from that which transforms, explaining,
“A transformational leader creates a new
and improved system that allows individ-
uals to contribute to their fullest potential
to deliver the most effective healthcare possible” (p. 375). As described earlier, this
model of leadership abdicates sole “control” by the individual or individuals holding
formal, authorized power in exchange for shared ownership. In this new model, every-
one involved owns responsibility to identify strengths, weaknesses, and opportunities.

ROLES AND RESPONSIBILITIES OF LEADERS

Distinct roles and responsibilities are associated with the various positions within an
organization. These are typically outlined in a job description. A role is a position or
the part the position fulfills within an organization, such as a CEO or Vice President
(VP) of Nursing. Depending on the formal position, appropriate responsibilities will
be delegated or assigned. For a leader, these roles typically involve developing a vision
and facilitating change on a large scale, such as for a department or institution. John
Gardner (1993), considered one of the experts in the field of leadership, distinguishes
leaders from managers in six respects. Leaders:

1. Think long term.
2. Influence the organization/unit they lead.
3. Reach out to those impacted by, as well as those impacting their organization.
4. Focus on facilitating a vision by actualizing values through motivation and guidance.
5. Exhibit political skill in managing conflict related to multiple and potentially differ-

ing and/or competing priorities.
6. Include measures to always improve how an organization or institution functions

to meet their stated mission and vision.

Gardner (1993) further distinguishes the tasks or responsibility of the leader to include,
first and foremost, that of creating a vision for the group. This vision includes a detailed
plan as well as directions for managing conflict that might arise from competing goals.
The second task of the leader involves affirming the organization or group’s values,
vision, and mission, which might include facilitating agreement between people or
groups with opposing thoughts. The third task of the leader is to motivate the group
by fostering ownership, positivity, and excitement for what has been committed to by
the group. Managing priorities and work in order to actualize the group’s vision and
mission is the fourth task of the leader, whereas the fifth task is to facilitate cohesion
of mind and purpose. This fifth task is accomplished by establishing trust and loyalty
among the members of the group. Gardner further states, the sixth task is to accept

FIGURE 3.3 Direct patient care; leadership
at the front line.

72 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

responsibility for ensuring understanding of the vision and mission, specifically as it
relates to individual roles and responsibilities of group members. The seventh task of
the leader is to serve as a role model. Gardner explains, the leader serves as the risk
taker, the group’s voice as well as the force that brings the group together and provides
positivity that they can accomplish their goal. The eighth task of the leader involves
serving as the advocate for the group and their vision; the leader speaks as well as
acts on behalf of the group. The last task of leadership that Gardner speaks to is the
responsibility for ensuring the renewing or sustainability of the group’s mission; this
task is accomplished by balancing continuity with change so that group members do
not become complacent or satisfied with the status quo. The leader helps to maintain
momentum and movement toward accomplishing their goal.

Many changes have occurred in nursing and across healthcare environments
over the past few decades. The landscape and culture of healthcare has emerged
with a new awareness of nurses as leaders in their own right. Nurses are no lon-
ger viewed as being in a dependent role or relationship with the medical disci-
pline but rather collaborative partners to influence policy, practice, and patient
outcomes. Today, nurses lead as patient advocates as they support and provide
patient-centered care practices regardless of nursing education background.
Nurses play a pivotal role in quality to improve the effectiveness of their care.
They are mindful of the technological advances in healthcare and assume lead-
ership roles as informatic super users, managing information to communicate
patient progress and propose care decisions that guide the actions of the health-
care team based on its evaluation.

Nurses lead in promoting a culture of best practices for their patients
and mutually share in organizational goals to justify their services through
empirical, ethical, theoretical, and seminal works across disciplines. Nurses are
influencers as they collaborate with peers in best evidence and care practices,
promote professional practice environments, and adhere to national parameters
that ensure safety and quality outcomes. Today’s nurses at every level are lead-
ers as they assume their role and responsibility to influence others and continue
to transform the landscape of healthcare for future generations.

Esther Bankert, PhD, RN
Board Member, St. Elizabeth’s Hospital, Utica, NY

REAL-WORLD INTERVIEW

A new graduate nurse is eager to be a valuable member of the Dialysis Unit he
has just been hired to work on. He quickly realizes patient safety is a concern
because of short staffing.

1. What is the most pressing concern related to short staffing?
2. What course of action could the nurse pursue to help this situation?
3. What aspects of leadership could he employ to facilitate change?

CASE STUDY 3.1

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 73

Formal and Informal Leadership

Leadership within an organization can occur both formally and informally. Formal
leadership involves specific role responsibility and authority related to the position
one holds. This type of leadership is typically based on certain skill, knowledge, and
experience. A variety of formal leadership positions exist within healthcare organi-
zations including nurse executives that might hold positions such as Chief Nursing
Officer or VP of Nursing. Other positions of leadership include a head nurse or charge
leader. Effective leadership exemplifies the qualities of trustworthiness, courage, com-
mitment, and perseverance.

In contrast, informal leadership is not explicit or official. It is based on personal
power or credibility in the eyes of others. This credibility can come from many
sources but typically evolves from education and/or experience as well as from
personal characteristics such as charisma, certainty, and/or courage to speak up or
take action. Nurses at all levels, even newly graduated nurses have the potential
for informal leadership and facilitating positive change by asking question, speak-
ing up when something doesn’t appear right, and engaging in continuous quality
improvement.

MANAGEMENT

Clearly, managers can also be leaders, inspiring and motivating their subordinates.
However, the roles and responsibilities of a manager are distinct and different from
that of formal leaders within an organization. A manager is someone who is respon-
sible for controlling all or parts of an organization. The focus of a manager is getting
the work of the designated group or unit done effectively. As a nurse manager of a
patient care unit, the role and tasks or responsibilities associated with this position
involve the running of a floor or unit and usually include responsibilities such as the
following:

1. The hiring of nursing staff.
2. Creating, reviewing, and amending policies and procedures.
3. Coordinating orientation of new nurses.
4. Creating staffing schedules.
5. Developing and maintaining a budget.
6. Conducting employee evaluations.
7. Providing for professional development.

Roles and Responsibilities of Managers

While the ultimate goal of nurse managers is safe and high-quality patient care, most
often they do not provide direct patient care themselves. Rather, they manage nurses
giving the care, coordinate quality improvement of that care, and help resolve any
patient care concerns. In this role, nurse managers work closely with nursing and
other inter-professional team members including ancillary staff and managers from
other units, departments and disciplines. This list could include individuals from any
department or discipline within the organization, such as pharmacy, physicians and
other providers, as well as administration. Meetings, emails, safety huddles, and other
forms of interaction help the nurse manager to coordinate communication and efforts
of the interprofessional team.

74 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

The list of tasks a nurse manager is responsible for directly and indirectly help
ensure that patient care is both safe and of high quality. They aim to hire qualified staff,
provide adequate staffing to meet their unit’s needs, allow for sufficient resources,
and foster continuous quality improvement. Policies and procedures help to provide
clear expectations to relevant staff. Policies and procedures also provide measures
of performance, knowledge, and skill. As a working document, periodic review and
modifications of policies should occur. This review provides additional opportunity
for continuous improvement.

FOLLOWERSHIP

Not everyone in an organization can be a leader at the same time. And good followers
are just as important as good leaders. Neither exists without each other. A follower is
an individual who supports and is guided by another person who usually functions as
a leader. However, a good follower is not blindly led but rather exhibits traits of dis-
cernment, commitment, and trustworthiness; that is, exhibits similar traits of a leader.
A relationship must exist between the leader and the follower that, to be effective,
must be based on mutual trust and shared goals. As with effective leadership, effective
followership approaches this relationship as equally responsible partners in accom-
plishing the vision and mission at hand. Ideally, followers know their own strengths
and weaknesses as they critically appraise the leader and group’s ideas, thus provid-
ing support and intelligent advocacy.

Shared Responsibility

To be effective leaders, managers, and followers, effective communication is required.
QSEN emphasizes this importance throughout its competencies with specific inter-
ventions/tools such as SBAR and TeamSTEPPS, which are topics discussed in depth
in subsequent chapters.

Chain of Command

Considering the importance of communication to the effective running of any orga-
nization, understanding chain of command is important. Chain of command is the
order or hierarchy of authority within an organization typically delineates flow of
communication and delegation. For example, using a chain of command, a staff nurse
reports to a charge nurse who reports to the head nurse, who in turn might report to
a Department Supervisor. That person might then report to a senior manager who
reports to the VP of Nursing. That VP then typically reports to the CEO who heads the
organization. The chain of command is important for communication and direction of
power. In most institutions and organizations, to initiate or suggest change, follow-
ing the chain of command is a well-established process. For staff nurses, typically the
chain of command starts with their head nurse.

Strategic Planning

Strategic planning and goal setting are based on an organization’s vision and mission.
Many resources exist to aid organizations in developing a strategic plan. One such
resource is the Society for Human Resource Management (SHRM). These resources or
associations help organizations distinguish between similar but different terms. Access

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 75

to resources sometimes requires a membership to an organization. SHRM is one of
those associations; however, membership is free and comes with many advantages.
According to SHRM, the vision of an organization is a statement that describes its
ideal or future state, whereas the mission describes why an organization or institution
exists. Based on the vision and mission of an organization, goals are set. Based on the
set goals, the organization will then develop a strategic plan to accomplish them. This
strategic plan typically includes very specific steps, clearly stating who will do what
with exact timelines. Specific units within a hospital will set goals and a strategic plan
that flows from the executive level to them. That is, the unit’s strategic plan helps them
to meet the unit’s goals which support the institution’s goals and strategic plan. QSEN
as well as the FON call nurses to participate in this strategic planning on all levels of an
organization to affect change. This includes sitting on relevant committees and boards
within the healthcare organization as well as within the community in order to partici-
pate equally alongside other interprofessional team members.

FINANCIAL AND ECONOMIC INFLUENCES

Though nursing is in the business of caring, healthcare is clearly a business that must
be financially solvent to exist. As a business, revenue is generated by the care given to
patients. This revenue pays for the expenditures incurred. A budget is an estimate of
anticipated earnings and expenses that allows organizations to plan and function with
forethought. A budget stems from the organization’s mission and goals. While a variety
of budgets exist, most hospitals employ both a capital and an operating budget. A capital
budget focuses on fixed costs such as land and buildings, whereas an operating budget
focuses on day-to-day expenses such as linen and clerical items. An operating budget
typically involves the allocation of resources including those resources involving staff
and needed supplies. Nursing units normally function with an operating budget that
focuses on salaries and supplies required for the care the unit provides (Sherman, 2012).

Incoming Revenue

The revenue of an organization comes from reimbursement paid for patient care.
Reimbursements come from insurance companies, governmental agencies, and out-
of-pocket payments made by the patient. If a hospital is fortunate to conduct research
and/or allow for auxiliary boards, unique and separate sources of funding or money
can augment what is received in reimbursements.

Up until more recently, healthcare reimbursement has been tied to patient care
provided in a fee-for-service model. A fee-for-service model of reimbursement pays a

Samantha is a nurse manager of a busy neuro floor. She has noticed a steady
decline in patient satisfaction rates.

1. Should she ignore this situation?
2. How should Samantha approach this matter with her staff?
3. How could Samantha’s supervisor help her with this matter?

CASE STUDY 3.2

76 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

provider or institution for each individual or separate component of care, independent
of quality or patient satisfaction. However, healthcare reimbursement is now based on
additional factors such as patient outcomes (how well did the patient respond to the
care provided?) as well as patient satisfaction measures. These additional performance
measures alongside decreased reimbursements from many private and public insurers
have tightened hospital’s and organization’s budgets significantly.

Staffing

Misuse of finances within the healthcare setting can have dramatic consequences on indi-
vidual patients as well as on the institution. As professionals responsible for patient care,
nurses have a moral obligation to understand how finances impact their ability to do their
jobs safely, including how budgets affect staffing, which in turn affects patient care. In fact,
studies show that patient mortality and morbidity is directly affected by the number of
patients assigned to a nurse in a given shift. The number of patients assigned to a nurse
depends on staffing of the unit. Staffing can be centralized where one unit or department is
responsible for determining the needs for all units. Staffing can also be decentralized where
the individual unit or department determines its specific staffing needs. Typically, staffing
needs are expressed in a ratio of nurses to patients, which can be determined by one or
more factors including budget allocation, beds filled, and patient acuity (Mensik, 2014).
An example of this ratio on a medical–surgical floor might be one nurse to 24 patients or a
1:3 ratio. Adequate staffing helps to ensure nurses are able to provide safe and high-qual-
ity care. Organizations like the Agency for Healthcare Research and Quality: Advancing
Excellence in Healthcare and Planetree.org provide valuable tools to nurses and healthcare
organizations to use for many aspects of healthcare, including safe staffing.

In 2004, California became the first state to mandate minimum nurse–patient
ratios. The legal mandate was limited to the following ratios:

• 6:1 patient-to-nurse workload in psychiatrics
• 5:1 patient-to-nurse in medical–surgical units, telemetry, and oncology
• 4:1 in pediatrics
• 3:1 in labor and delivery
• 2:1 in ICUs

Aiken et al. (2010) studied the impact of this mandate on patient outcomes and found
it significantly improved patient outcomes and nurse retention.

Ensuring that the competencies of QSEN are implemented has been shown to save
hospitals money. For example, cost savings have been demonstrated with the provi-
sion of patient-centered care. See the Evidence From the Literature for one such study.

CRITICAL THINKING 3.1

A nurse has been working on an oncology floor for 1 year. At times she feels frustrated
that concerns regarding patient safety are not being taken seriously. She cares deeply for
her patients as well as the floor itself and believes she could make a difference as a more
formal leader. When an opening for a nurse manager position opens up, she applies for
and gets the position.

(continued)

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 77

EVIDENCE FROM THE LITERATURE

Citation

Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between
nursing leadership and patient outcomes: A systematic review update. Journal of
Nursing Management, 21(5), 709–724.

Discussion

A systematic review of existing studies was undertaken to examine the rela-
tionship between the practice of nursing leadership and patient outcomes. The
authors identified 20 articles documenting the study of this relationship. They
found a distinct correlation between positive, effective leadership and bet-
ter patient outcomes. The specific leadership qualities found to most effective
were positive, relationship based, and transformational, and reflected organiza-
tional goals and missions. Patient outcomes of this positive leadership included
improved patient satisfaction and decreased mortality, medication errors, noso-
comial infections, and use of patient restraints.

Implications for Nursing: Patient safety and quality of care is affected by
leadership. Therefore, efforts to encourage leadership of nurses at all levels of
practice are warranted.

CRITICAL THINKING 3.1 (continued)

1. How could her understanding of Quantum Leadership Theory guide her in
her new role?

2. How might she ensure staff feel heard?
3. In what other ways can she help staff be effective leaders?
4. In what ways can she help staff be effective followers?

Maria works as a staff nurse on a medical–surgical floor. She is asked to join
a new committee focused on improving communication between the various
departments providing care on her floor. The committee is led by a dynamic and
inspiring pharmacist.

1. How is Maria a leader in this scenario?
2. How is she a follower?
3. How could her understanding of Chaos Theory helps her in this scenario?

CASE STUDY 3.3

78 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

NURSING’S SOCIAL CONTRACT AND CODE OF ETHICS

Nurses’ right and authority to practice as nurses are based on an ethical social contract
with society that explicates specific rights and responsibilities based on education and
licensure. Within this contract, nursing describes and agrees to the essence of the profes-
sion with clear guidelines for behavior and intention. Documented as Nursing’s Social
Policy Statement, the relationship between nursing (and individual nurses within the
profession) and society is explained and spelled out. The behaviors expected of nurses
are based on autonomy to function and perform within the scope of nursing practice.
The autonomy of nurses is in turn based on nursing’s acknowledgment of public trust as
well as nursing’s agreement to self-regulate and accept legal parameters and regulations.

Within the social contract is a Code of Ethics for Nurses that lists nine provi-
sions. These provisions allow nurses to fulfill the commitment made to their patients.
However, it also guides nurses to effectively serve as leaders in any and all positions.
The nine provisions are the following:

• The nurse practices with compassion and respect for the inherent dignity, worth,
and unique attributes of every person.

• The nurse’s primary commitment is to the patient, whether an individual, family
group, community, or population.

• The nurse promotes, advocates for, and protects the rights, health, and safety of
the patient.

• The nurse has authority, accountability, and responsibility for nursing practice;
the nurse makes decisions and takes action consistent with the obligation to pro-
mote health and to provide optimal care.

• The nurse owes the same duties to self as to others, including the responsibility to
promote health and safety, preserve wholeness of character and integrity, maintain
competence, and continue personal and professional growth.

• The nurse, through individual and collective effort, establishes, maintains, and
improves the ethical environment of the work settings and conditions of employ-
ment that are conducive to safe, quality healthcare.

• The nurse, in all roles and settings, advances the profession through research and
scholarly inquiry, professional standards development, and the generation of both
nursing and health policy.

• The nurse collaborates with other health professionals and the public to protect
human rights, promote health diplomacy, and reduce health disparities.

• The profession of nursing collectively through its professional organizations
must articulate nursing values, maintain the integrity of the profession, and inte-
grate principles of social justice into nursing and health policy (American Nurses
Association, 2015).

CRITICAL THINKING 3.2

Your hospital is hosting the next FON: Campaign for Action in your area. You express
interest in attending the meeting; however, your nurse manager denies your request
because the floor will be short staffed.

1. What options do you have in response to this decision?
2. In this scenario, how can you be an effective informal leader?
3. In this scenario, how can you be an effective follower?

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 79

To Be a Profession

In the mid-1980s, reimbursement for patient care moved from a retrospective reim-
bursement system or fee-for-service to one of prospective payment. Reimbursing for
care prospectively meant providers and hospitals were paid based on standardized
care related to a patient diagnosis. Diagnostic-related group formulas (DRGs) were
created as a way to control hospital costs, which represented a way to “capitate” or
control costs. At the time, some nurse leaders believed it provided an opportunity for
nursing to become more visible. Because patients are admitted to the hospital for nurs-
ing care, it was hoped DRGs would emphasize the centrality of nursing. Along with
this realization, it was thought nursing would also move into a position of more author-
ity. At the time, a revered nurse leader Donna Diers (1986) addressed District Four of
the New York State Nurses Association. The title of her speech was “To Profess—To Be
a Professional.” She began by explaining the meaning of “to profess,” which infers a
dishonesty or insincerity of beliefs. She argued nurses were and are professional; how-
ever, she also stated nurses had not yet obtained the authority for the responsibility
they had been delegated. Like others, she spoke of the social contract nurses have with
their patients and society. She also spoke of nursing’s primacy of caring. Diers believed
the DRGs were the start of a revolution that offered nurses the opportunity to step into
a place of authentic and deserved authority. Nurse’s moral imperative is to care. But
simply providing care or exerting compassion and concern are not enough. Diers and
many others throughout nursing’s history have argued caring must be intelligent and
intentional. She states:

Nursing is not just comfort, care, coordination, collaboration, or just applied psy-
chology, physiology, sociology, anthropology or diluted medical science. Nursing
is all of those things and more. It requires an effort of considerable intellectual
acuity—which looks to an outsider like intuition—to thread one’s way through
all the knowledge, technique, and tenderness one has and to come out with the
right action to serve the patient’s particular need. (Diers, 1986, p. 27)

Like many of her contemporary counterparts, Diers acknowledged that the applica-
tion of caring must extend from individual patient care to the creation of budgets,
committees, curricula, community efforts, and legislative work. However, what she
argued most ardently was nurses’ legitimacy as professionals would not come from
advanced degrees or credentialing. Rather, Dier’s proposed, nursing’s professionalism
and authority would be established when nursing’s practice was professional. She
argued this would only happen if and when nurses took ownership of the work per-
formed once education occurred.

This argument has been made by many others over time, both within as well as
outside the nursing profession. Suzanne Gordon is another powerful and ardent cham-
pion of nursing and nurses’ need to “own the knowledge of their work.” Ms. Gordon is
a journalist who has become a nationally recognized expert in healthcare systems but
specifically on teamwork, nursing, and patient safety. She is a prolific author, speaker,
and advocate/activist. Like Diers, Gordon argues nurses are solely responsible for
how they are viewed in her 2006 landmark book authored with Bernice Buresch, From
Silence to Voice:

If nurses aren’t willing to talk about their work, the results will be catastrophic
for nursing. Nursing, like every other profession in today’s work, must justify its
existence and compete for resources. If nursing is misunderstood by the public
and those with influence, it will continue to be disproportionately vulnerable to

80 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

the budget ax, and new resources for nursing education and practice will not be
forthcoming at sufficient levels.

If nursing’s script continues to emphasize the virtues of the nurse as a person
to the detriment of the knowledge work that nurses do, then nurses themselves
offer a rationale for limiting resources for nursing. Focusing on who the nurse is
rather than what the nurses does can be an invitation to seek not the best and the
brightest recruits, but the most virtuous, meekest and self-sacrificing who will
try to do more and more with less and less. (p. 4)

EMANCIPATORY KNOWING

Acknowledging and accepting responsibility for the knowledge required to do the work
of nursing is an important start. But knowledge is based on knowing, which speaks
to subjective perception and a dynamic ontology or way of being. When knowing is
expressed in a way that can be shared, it is considered to be knowledge. Knowledge
of a discipline, such as nursing, encompasses the body of shared knowledge. This pro-
cess of sharing knowledge within a discipline is vital to the creation of a community.
According to Chinn and Kramer (2013), once knowledge moves beyond the individual
to the discipline as a group, “social purposes form, and knowledge development and
shared purposes form a cyclical interrelationship that moves us toward perspective,
value-grounded change or praxis” (p. 4). For Chinn and Kramer, praxis is the outcome of
critical thought and reflection of the art and science of nursing. Change occurs with the
inclusion of ethics and the therapeutic use of self that ultimately results in some type of
action. This process of thinking and reflection that leads to action is called Emancipatory
Knowing.

As with Chaos and Quantum Theories, Emancipatory Knowing stems from criti-
cal evaluation of economic, social, and political influences of a reality or status quo
simultaneously looking at its potential for positive change. For Chinn and Kramer, this
positive change must involve alleviating injustice in order to ensure equitable condi-
tions for individual and groups. In doing so, individuals and groups are provided the
opportunity to fulfill their potential.

FON: CAMPAIGN FOR ACTION

As discussed earlier, the IOM reports of 2000 and 2001 have led to many initiatives,
including the formation of the FON: Campaign for Action. Within this initiative, sev-
eral organizations joined forces to support nurses in a unique way. The RWJF, AARP,
and the AARP Foundation pledged their support and resources to aid the nursing

CRITICAL THINKING 3.3

You work on a busy pediatric floor. During casual conversation with colleagues, you
realize medication errors are increasing significantly.

1. How could you proactively respond to this realization?
2. With whom should you first begin discussing this realization?
3. Who else should be involved in assessing and addressing this situation?

REAL-WORLD INTERVIEW

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 81

profession in addressing the eight recommendations listed earlier. While the FON
acknowledges the importance of all recommendations, they identified four specific
or key elements to ensuring all nurses will be prepared to assume a leadership role
within institutions and healthcare as a whole (Box 3.2).

Nurses entering the profession often voice their reason for choosing nursing as a
desire to “make a difference” by impacting or facilitating another’s physical and
mental well-being. Through helping others, a challenge develops that offers the
nurse an opportunity to grow morally, ethically, and spiritually. The challenge is
the quest for “doing the right thing” for the patient. This implies that the nurse
must be responsible for developing therapeutic alliances, monitoring and evalu-
ating patient needs, as well as ensuring interventions have produced the intended
results and outcomes. This further implies that nurses must be successful in criti-
cally questioning and then identifying necessary changes, within their own nurs-
ing practice, as well as using their leadership skills in the development of teams
that promote evidence-based practice with patient-focused care and goals.

Nurses’ growth and experience in providing quality care happens over
time. Quality is achievement, refinement, and satisfaction in and of practice,
but the quest to become “REAL” requires a continuous commitment to the
very process that is often infused with the challenges that we ethically, morally,
and spiritually need to address in order to “become.” Rising to the challenge
requires developing leadership skills in defining and critically analyzing what
is inherent in quality nursing practice; for example, doing a nursing interven-
tion because it is the “right thing to do” and not because that “is how it has
always been done.” Essential to achieving best outcomes requires that:

• Quality, the quest for best practice, becomes the way we do business.
• Mentors for quality who are respected clinicians and knowledgeable role

models with moral courage will step forward when necessary to serve as
patient advocates and to promote quality care endeavors, such as critically
questioning, investigating, and promoting nursing practice in the ever-
changing healthcare arena.

• Academic nursing programs support clinical experiences with practicing
nurses that routinely incorporate quality behaviors on the front line and
embrace quality endeavors as the main approach to promoting best outcomes.

• Reinforcement of quality and change theory principles in continuing edu-
cation for all healthcare professionals and the expectation that these prin-
ciples be used by all in the patient-centered setting.

If we choose to make a committed difference individually, what follows is
the collective commitment to quality and safe nursing practice that offers the
nurse, patient, team, and health administrative staff the best care.

Judy Kilpatrick, RN, MS, CCNS, ANP
Syracuse, NY

Denise A. Karsten RN, MS, DC, Adult/Gero Nurse Practitioner
Primary Spine Practitioner

Upstate Brain and Spine Center
Syracuse, NY

REAL-WORLD INTERVIEW

82 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

The call to action by multiple nurse leaders and organizations is clear: Nurses must
step into leadership positions at all levels of practice. From advocating for the primary
prevention of nosocomial infections to safer staffing to working on committees to refine
policies ensuring safer and higher quality patient care on units, in institutions, and on
more global levels, nursing can have a powerful and important role to play. Nursing’s
social contract requires nursing to engage in a more global systems thinking that
embraces moral courage and the knowing of its profession. By doing so, nursing will
step into leadership that influences the safety and quality of care of patients individually
and as a whole.

KEY CONCEPTS

1. Nursing education must prepare nurses to demonstrate leadership at all levels of
nursing practice, directly and indirectly impacting the safety and quality of patient
care.

2. Three theories of leadership that guide nursing practice are Chaos Theory,
Quantum Theory, and Systems Theory.

3. Leadership is the ability to lead or command a person or a group of people.
4. The roles of a leader typically involve developing a vision and facilitating change

on a large scale, such as for a department or institution.
5. A manager is someone responsible for controlling all or part(s) of an organization,

and for getting a designated group or unit’s work done effectively.
6. A follower is an individual who supports and is guided by a leader, who shares

mutual trust and goals with the leader, and who is an equally responsible partner
in accomplishing the vision and mission at hand.

7. Nursing care must be provided within the context of the business of healthcare. It
must generate revenue and operate within the constraints of the budget.

8. Nursing practice is based on an ethical social contract with society that expli-
cates specific rights and responsibilities of nurses, such as those embodied in the
Nursing Code of Ethics.

9. Nursing practice should be guided by emancipatory knowing, which is a process
of thinking and reflection that leads to action.

1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved

education system that promotes seamless academic progression.
3. Nurses should be full partners with physicians and other health professionals in

redesigning healthcare in the United States.
4. Effective workforce planning and policy making require better data collection and an

improved information infrastructure (IOM, 2011, p. 58).

BOX 3.2 KEY ELEMENTS

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 83

10. The FON: Campaign for Action is an initiative in which several organizations have
joined forces to support nurses and prepare them to assume leadership roles with
institutions and healthcare as a whole.

KEY TERMS

Accountability
Follower
Leadership

Manager
Responsibility
Roles

REVIEW QUESTIONS

1. The nurse is working on a busy medical–surgical floor caring for oncology
patients. One of the patients with a poor prognosis is asking for a glass of wine
with dinner. The floor policy states that patients are not allowed to consume alco-
hol while admitted to their floor. The nurse believes the policy as stated does not
take into consideration the circumstances this patient is experiencing. The nurse
approaches the manager with a request to review and potentially modify the cur-
rent policy. The manager agrees a review of the policy is warranted but would like
the nurse to invite several other interdisciplinary team members to the meeting in
order to consider their perspective. The manager specifically invites them to this
discussion because they understand the impact allowing alcohol could have on
departments such as Dietary, Pharmacy, and Physical Therapy. What leadership
theory explains the manager’s perspective most accurately:

A. Chaos
B. Quantum
C. Change
D. Systems

2. A nurse decides to apply for a hospital leadership position after receiving a glow-
ing performance review at her fifth year anniversary as a floor manager. The nurse
is aware that a formal leadership position will include unique roles and responsi-
bilities. Which of the following apply to leadership (distinguished from manage-
ment)? Select all that apply.

___ Improve on ways an organization functions to meet its goals and objectives.
___ Conducts periodic review of unit policies and procedures.
___ Develop skills in managing conflicts of different groups with differing

priorities.
___ Enforce policies such as continuing education requirements for nursing staff.
___ Focus on the long term.
___ Identify areas for marketing campaigns to increase income, thus increasing

staffing.
___ Create the staffing schedule for the medical–surgical unit.
___ Actualize and demonstrate the organization’s mission by motivating others.
___ Lead by displaying your education and professional certifications to inspire

others.

84 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

3. A nurse applies for a position as a unit manager. In the interview process, the
nurse is asked to list responsibilities they assume will come with the position. List
three tasks that could be included in this list:

A. _______________________
B. _______________________
C. ________________________

4. A nurse has just taken a new position on an orthopedic floor as a staff nurse. Before
this new position, the nurse had been a Team Leader on the Telemetry Unit for almost
5 years. In this new position and role, the nurse is aware that being a follower is a
vital piece of demonstrating an organization’s mission and values. The nurse also
understands that all nurses are followers and leaders, often at the same time. How
can the nurse best demonstrate followership in this new role? Select all that apply:

___ Demonstrate the organization’s missions and values in patient care.
___ Know the strengths and weaknesses that you bring to both roles.
___ Challenge every suggestion the group leader makes.
___ Build relationships with those you follow.
___ Only accept tasks that are of personal interest.
___ Recognize that followers always support their leaders.

5. The nurse works for a hospital that is experiencing budget cuts and layoffs due
to decreased reimbursements. The nurse is concerned about how this might affect
patient care. What potential ramifications should the nurse be concerned about?
Select all that apply.

___ Poor staffing ratios
___ Use of unqualified staff
___ Increased patient satisfaction
___ Fewer supplies on the unit
___ Hiring freezes
___ Poor patient outcomes

6. The nurse is asked to work overtime because replacements have not been hired yet
to fill recent vacancies. The nurse is very concerned about agreeing to this over-
time, because the shift is already down two nurses. The nurse is also concerned
because the hospital is freezing budgets and most likely will not fill these vacant
positions for a while. What outcome is the nurse concerned about relative to safety
and quality of care? What factor in a hospital budget has the most direct effect on
patient morbidity and mortality?

________________________________________

7. The nurse is attending general orientation with a group of new graduates. A clini-
cal nurse specialist (CNS) presents a 1-hour talk on professionalism and respon-
sibility to function as leaders in the new positions the nurses will assume. Within
this presentation, the CNS states all nurses practice within a Code of Ethics and
agree to a social contract with society. What are the components of Nursing’s Code
of Ethics? Select all that apply.

___ Compassion
___ Patient dignity
___ Commitment to the patient

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 85

___ Protecting patient rights
___ Health and safety
___ Promotion of health
___ Participating in improving ethical environment in care setting and/or larger

community
___ Collaborating with others to establish/maintain standards, articulate values,

and generate policy

8. Jim, a nurse, has volunteered to sit on a professional development committee as a
representative from the floor he works on. In one of the first committee meetings,
Jim is asked what he would be interested in knowing more about. Jim explains he
is confused about the meaning of autonomy. Which of the following is false?

A. Autonomy refers to delegating responsibility to others.
B. Autonomy refers to the right to self-regulate or govern.
C. Autonomy in nursing has been earned by society’s trust.
D. Autonomy in nursing includes legal parameters delineating scope of practice.

9. Mary works as a nurse in an NICU with a few unhappy colleagues. Unfortunately,
the demeanor of these few nurses affects many people, including the parents of
the neonates. Mary knows the impact of stress on these vulnerable families and
infants so she begins to explore how to change the situation. In researching ideas,
Mary discovers an intervention that might help and reflects on the interpersonal
dynamics of the unit alongside the complexity of the health of its patients. Mary
considers each person’s right to self-determination and autonomy and also con-
siders how best to approach proposing change. Ultimately, the thought, reflection,
and therapeutic use of self leads to deliberate action by Mary, facilitating effective
change. What is this process called?

________________________________________

10. A nurse is orienting to a new position on a transplant floor. Part of the job expec-
tations includes serving on committees. The nurse is interested in promoting the
nursing profession, particularly as it relates directly and indirectly to ensuring
safe and high-quality patient care. As such, the nurse is interested in joining the
local Action Coalition of the FON: Campaign for Action. Because this activity will
require quite a bit of time off the unit, the nurse will need to provide a brief expla-
nation of this initiative. As a foundation, the nurse lists the four key elements of
the FON. Please list two of the four elements:

A. ____________________
B. ____________________

REVIEW ACTIVITIES

1. Consider how the Key Elements of the FON, Campaign for Action could help you
as a nurse leader in your first position as a staff nurse.

2. How does the Nursing Code of Ethics impact how you will practice as a new nurse?
3. What characteristics of leadership do you bring to the frontline of patient care?

86 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

CRITICAL DISCUSSION POINTS

1. Leadership theories provide effective guidance in understanding how best to facili-
tate change.

2. The roles and responsibilities of leaders directly and indirectly affect the safety as
well as the quality of patient care.

3. Management incorporates aspects of leadership but is primarily focused on getting
the work of an assigned group accomplished.

4. Being an effective follower includes critical thinking, commitment to the group’s
goals, and mutual trust.

5. The FON: Campaign for Action is a national initiative that provides a forum for
collaborative effort aimed at empowering the nursing profession.

6. Staffing directly affects patient satisfaction surveys but more importantly, patient
outcomes.

7. Staffing adequacy is based on a sufficient budget.
8. Nursing’s Code of Ethics provides guidance for practice and action.
9. Emancipatory Knowing requires one to integrate critical thought, reflection, ethics,

and therapeutic use of self within a community created by shared knowledge. This
integration leads nurses to take action and facilitate change at all levels of practice.

EXPLORING THE WEB

1. Visit QSEN.org and review the various Graduate QSEN Competencies, specifically
noting the knowledge, attitude, and skill for each of them. Reflect on which of these
competencies you feel comfortable with at this time. Consider which you feel are
essential to have acquired before you start as a graduate nurse.

2. Visit the following websites to compare and contrast resources: Agency for Healthcare
Research and Quality: Advancing Excellence in Healthcare and Planetree.org.

3. Search the Internet for how the FON is referenced and incorporated into action
plans within nursing and as an interprofessional approach to change.

4. Conduct an Internet search for the terms “leadership” and “nursing.” Describe
what your search reveals.

REFERENCES

Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A., … Smith, H. L.
(2010). Implications of the California nurse staffing mandate for other states. Health Services
Research, 45(4), 905.

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver
Spring, MD: American Nurses Association.

Buresh, B., & Gordon, S. (2006). From silence to voice: What nurses know and must communi-
cate to the public (2nd ed). Ithaca, NY: ILR Press/Cornell University Press.

Chinn, P. L., & Kramer, M. K. (2013). Integrated theory and knowledge development in nursing (7th
ed.). St. Louis, MO: Mosby Elsevier.

Curtis, E. A., de Vries, J., & Sheerin, F. K. (2011). Developing leadership in nursing: Exploring
core factors. British Journal of Nursing, 20(5), 306–309.

Diers, D. (1986). To profess—To be a professional. Journal of Nurse Administration, 16(3), 25–30.
Dinh, J., Lord, R. G., Gardner, W. L., Meuser, J. D., Liden, R. C., & Hu, J. (2014). Leadership theory

and research in the new millennium: Current theoretical trends and changing perspectives.
The Leadership Quarterly, 25(1), 36–62.

3 NURSES AS LEADERS AND MANAGERS FOR SAFE, HIGH-QUALITY PATIENT CARE • 87

Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The
key is systems thinking. The Online Journal of Issues in Nursing, 18(3), 1–10. Retrieved from
www.nursingworld.org/Quality-and-Safety-Education-for-Nurses.html

Gardner, J. (1993). On leadership. New York, NY: The Free Press.
Grossman, S. C., & Valiga, T. M. (2016). The new leadership challenge: Creating the future of nursing

(5th ed.). Philadelphia, PA: F.A. Davis.
Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health.

Washington, DC: The National Academies Press.
Mensik, J. (2014). What every nurse should know about staffing. American Nurse Today. Retrieved

from www.americannursetoday.com/what-every-nurse-should-know-about-staffing
Oxford Dictionary. (2017). Integrity. Retrieved from https://en.oxforddictionaries.com/

definition/integrity
Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming

health care (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.
QSEN. (2017). QSEN institute: Quality and safety education for nurses. Retrieved from www.

qsen.org
Sherman, R. (2012). The business of caring: What every nurse should know about cutting costs.

American Nurse Today. Retrieved from www.americannursetoday.com.
Society for Human Resource Management (SHRM). (2017). Mission & vision statements: What

is the difference between mission, vision and values statements? Retrieved from https://
www.shrm.org/

SUGGESTED READINGS

AHRQ. (2016). AHRQ patient safety tools and resources. Retrieved from http://www.ahrq.gov/pro-
fessionals/quality-patient-safety/patient-safety-resources/resources/pstools/index.html

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession.
Silver Spring, MD: American Nurses Association.

Anderson, C. L., & Agarwal, R. (2011). The digitalization of health care: Boundary risk, emotion,
and consumer willingness to disclose personal health information. Information Systems Research,

22(3), 469–490.
Bertakis, K. A., & Azari, R. (2011). Patient-centered care is associated with decreased health care

utilization. Journal of the American Board of Family Medicine, 24, 229–239.
Chinn, P. L. (2013). Peace and power: New directions for building community. Burlington, MA: Jones

and Bartlett Learning.
Fischer, S. A. (2016). Transformational leadership in nursing: A concept analysis. Journal of

Advanced Nursing, 72(11), 2644–2653.
Hughes, R. G. (2008). Patient safety and quality. Rockville, MD: Agency for Health Care Research

and Quality.
Kreidler, M. L. (2015). Quality improvement in health care. Research Starters: Business (Online

Edition).
Nadeem, E., Olin, S., Hill, L., Hoagwood, K., & Horwitz, S. (2013). Understanding the compo-

nents of quality improvement collaboratives: A systematic literature review. Milbank Quar-
terly, 91, 354–394.

National Committee for Quality Assurance. (2007). About NCQA. Retrieved from http://www.
ncqa.org/AboutNCQA.aspx

The National Academies of Press. (2011). The future of nursing: Leading change, advancing
health. Retrieved from http://www.nap.edu/read/12956/chapter/10#235

Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between nursing Lead-
ership and patient outcomes: A systematic review update. Journal of Nursing Management,
21(5), 709–724.

Wong, C. A., Lashchinger, H. K., & Cummings, G. G. (2010). Authentic leadership and Nurses’
voice, behavior, and perceptions of care quality. Journal of Nursing Management, 18, 889–900.

Upon completion of this chapter, the reader should be able to

1. Define high-reliability organizations (HROs).

2. Evaluate the characteristics of HROs.

3. Describe how high reliability affects all aspects of an organization.

4. Identify how healthcare can learn about high reliability from other industries.

5. Analyze healthcare system changes essential for HRO.

6. Discuss nursing responsibilities and interprofessional team functions required
for achieving high reliability.

7. Compare and contrast methods for assessing a culture of high reliability.

8. Discuss barriers to achieving high reliability.

9. Identify internal and external resources helpful in an organization’s journey to
high reliability.

4
QUALITY AND SAFETY IN
HIGH-RELIABILITY ORGANIZATIONS

Patti Ludwig-Beymer

Every system is perfectly designed to get the results it gets. (Attribution disputed)

90 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

A
patient who was discharged postabdominal surgery at General Hospital returned
a week later with sepsis from a surgical site infection. During her rehospitalization,
x-rays revealed that a sponge was retained in her abdomen during the initial surgical
procedure. By definition, this is a sentinel event, and it is thoroughly investigated by a

team that includes nurses, physicians, surgical technicians, anesthesiologists, and staff from risk
management and quality. The team conducts a root cause analysis to determine the underlying
cause of the retained sponge and to create a corrective action plan. The sentinel event is reviewed
and the corrective action plan is approved by hospital leadership and governance. Everyone at
the hospital expresses confidence that the processes put into place will prevent this event from
happening again. Unfortunately, within a few months, a sponge is retained in another patient’s
abdomen after a gynecological surgical procedure.

• How could this sentinel event error happen again?
• What unit or organizational characteristics may have contributed to this sentinel event?
• What can the interprofessional healthcare team do to prevent future errors?

In To Err Is Human, the Institute of Medicine (IOM;1999) described the safety of
healthcare in the United States and suggested that up to 98,000 people die in hos-
pitals each year as a result of medical errors that could have been prevented. To Err
Is Human provided a roadmap to safety, including strategies to enhance knowledge
about safety; identifying and learning from errors; raising expectations for improv-
ing safety; and implementing safety systems in healthcare organizations to ensure
safe practices at the patient care delivery level. Unfortunately, errors that cause harm
to patients continue to occur.

More recently, Makary and Daniel (2016) estimated medical errors cause 251,000
deaths each year, making it the third leading cause of death in the United States, after
heart disease and cancer. Yet medical error is not even recorded on U.S. death certifi-
cates. Most medical errors do not result from individual recklessness or the actions of
a particular group but are instead caused by faulty healthcare systems, processes, and
conditions that lead people to make mistakes or fail to prevent them. As a result, mis-
takes can best be prevented by designing the health system to make it easier to do the
right thing and harder to do the wrong thing.

Makary and Daniel propose a three-part model for reducing harm from individual
and system errors: (a) transparency to make errors more visible, (b) rapid response
to errors, and (c) decrease the frequency of errors. Transparency is defined as openly
sharing and making errors and other aspects of performance visible so that everyone
can learn from the errors and improve quality. Within the model, the responsibility for
reducing harm lies with both the organization and the individual.

The Joint Commission (TJC, 2017), an independent, not-for-profit group in the
United States that administers voluntary accreditation programs for hospitals and
other healthcare organizations, adopted a formal Sentinel Event Policy in 1996 to
help hospitals that experience serious adverse sentinel events improve safety and
learn from those sentinel events. A sentinel event is a healthcare error that reaches
a patient and results in death, permanent harm, or severe temporary harm and
requires healthcare interventions to sustain life. A sentinel event requires immediate
investigation and response by the interprofessional healthcare team to prevent it
from happening again.

Each year, TJC publishes a list of the most frequent sentinel events that occurred
nationally (Box 4.1). TJC recommends, but does not require reporting of sentinel
events. As a result, this published sentinel events list represents only a fraction of the

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 91

actual number of sentinel events. Careful investigation and analysis of sentinel events
and other patient safety events and creation of corrective actions are essential to reduc-
ing risk and preventing patient harm.

This chapter focuses on building a high-reliability organization (HRO), a cultural
transformation designed to ensure safe practices and reduce errors and sentinel events
in healthcare. The chapter begins by defining HROs and presenting the characteristics
of HROs. The effect of high reliability on all aspects of an organization is described.
Healthcare changes essential for creating HROs are discussed, and the nurse’s responsi-
bilities required for achieving high reliability are described. The importance of interpro-
fessional team function is addressed. Finally, barriers to achieving high-reliability and
internal and external resources helpful in a journey to high reliability are summarized.

HIGH-RELIABILITY ORGANIZATIONS

HROs, such as commercial aviation and nuclear power plants, operate under very
trying conditions all the time and yet manage to have fewer than their fair share of
accidents. HROs in healthcare establish and maintain high quality and safety expec-
tations for patient care and keep quality and safety error rates near zero (Weick &
Sutcliffe, 2007). HROs have the ability to provide consistent healthcare at a high
level of excellence over a long period of time. Reliability is defined as the prob-
ability of failure-free performance over a specified timeframe. It is also called quality
over time (www.businessdictionary.com/definition/reliability.html). Morrow (2016)
describes reliability as “getting the expected outcome throughout the expected time”
(p. 9). The risk of healthcare error is a function of both probability and consequence.

Healthcare can be dangerous and errors can have devastating consequences. For
example, administering IV fluids safely is an important aspect of treating a dehydrated
patient who has heart failure. Administering fluids too slowly can result in prolonged
hypotension. Administering fluids too rapidly can result in worsening of the heart
failure. An IV pump is used to assist the nurse in providing accurate amounts of
fluid. The IV pump decreases the probability of error. However, if the pump fails, the

1. Unintended retention of a foreign body—116 reported
2. Wrong patient, wrong site, wrong procedure—95 reported
3. Falls—114 reported
4. Suicide—89 reported
5. Unassigned (category unassigned at time of report)—54 reported
6. Delay in treatment—66 reported
7. Other unanticipated event (including asphyxiation, burn, choked on food, drowned,

or found unresponsive)—60 reported
8. Operative/postoperative complication—19 reported
9. Medication error—32 reported

10. Criminal event—37 reported

BOX 4.1 TOP 10 SENTINEL EVENTS IN THE UNITED STATES, 2017

Source: The Joint Commission (TJC). (2018). Summary data of sentinel events reviewed by The Joint Commission. https://www.
jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

92 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

consequences can still be catastrophic. By decreasing the probability of an error, HROs
operate to make healthcare systems safer. In an HRO, a culture of safety permeates the
organization, and everyone is expected to ensure safety.

To improve safety, HROs maintain a focus on reducing errors. An error is a devia-
tion from generally acceptable performance standards. Generally acceptable perfor-
mance standards are found internally within a healthcare organization and externally
outside of an organization. Internal standards include policies, procedures, proto-
cols, and order sets. External standards include healthcare industry and accreditation
imposed practice requirements and professional practice standards. For example, a
hospital may establish a protocol that requires a nurse to assess an IV infusion site
in pediatric patients every 2 hours. This is an internal standard. On the other hand,
the American Association of Critical-Care Nurses (2015, p. 14) requires that the nurse
“intervenes to prevent and minimize complications and alleviate suffering.” If the
nurse fails to assess a patient on a ventilator and provide sedation and pain medica-
tion as needed, the nurse has deviated from generally acceptable external performance
standards.

A deviation from performance standards may cause varying levels of harm to a
patient. A near miss safety event occurs when the safety event does not reach the
patient because it is caught by chance or because the process was engineered with a
detection barrier. For example, the medication reconciliation process in hospitals is
often designed with purposeful redundancies. On admission, a nurse or pharmacist
meets with a patient to obtain an accurate list of current medications. The physician
then reviews the list, verifies it with the patient, and places the medication orders.
A pharmacist reviews the medications, and the nurse administers the medications.
Despite these steps, sometimes an incorrect medication is ordered. If this is discov-
ered before the medication is administered, it is considered a near miss event. Nurses
and other clinicians may fail to report near misses, rationalizing that no one was hurt.
However, near miss safety events serve as an early warning system of something that
could go wrong. By reporting near miss safety events, healthcare organizations can
work on improving processes so that no one else makes the same error.

Precursor safety events occur when the healthcare error reaches the patient and
results in no harm or minimal detectable harm. Adverse events or serious safety
events occur when the error reaches the patient and results in moderate-to-severe
harm or even death. They are an undesired or unintended consequence of the care
provided, such as a significant decrease in blood pressure after a wrong dose of medi-
cation is given.

To differentiate a precursor safety event from a serious safety event, consider this
example. A nurse assesses Mr. Z and determines that he is a high fall risk. The nurse
puts fall prevention precautions in place, including placing the bed in its lowest posi-
tion, activating the bed alarm, and using floor mats to cushion the floor around the
bed. However, Mr. Z gets out of bed and falls before anyone can respond to his bed
alarm. If Mr. Z suffers no harm, the event is considered a precursor safety event. Like
near miss safety events, the nurse should report this precursor event and the care team
should investigate what could have been done differently to keep Mr. Z safe from falls.
After all, Mr. Z’s lack of injury was due to luck rather than healthcare system design.
On the other hand, if Mr. Z suffers a fall and fractures his hip, the injury is a serious
safety event. In addition to providing immediate patient care and reporting the serious
safety event, the nurse should participate in an in-depth analysis called a root cause
analysis (RCA). An RCA allows a healthcare team to determine the primary cause of
the safety event and put together an action plan to prevent it from happening again.
See Chapter 10 for further discussion of RCAs.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 93

The healthcare team often becomes aware of errors at the point of care, where
nurses and other clinicians interact with patients. According to Cook and Woods
(1994), this is the “sharp end” of a triangle, where clinicians interface with patients.
Clinicians experience remorse and blame themselves when errors happen. However,
their work with patients is influenced by many factors and decisions made by indi-
viduals prior to an actual error event. These factors and decisions are the “blunt end”
of the triangle. For example, policies and procedures put in place to ensure consistent
healthcare processes may be inaccurate, difficult to interpret, or hard to access. Work
processes might be convoluted and patient handoffs can be inadequate. The environ-
ment may be cramped and noisy, making it difficult to concentrate. Technology can be
cumbersome or may fail completely. The culture of the hospital might hinder a nurse’s
ability to speak up about safety concerns. Groups and individuals may blame others
rather than taking responsibility for their actions. All of these “blunt end” factors can
contribute to an error at the “sharp end,” where the consequences of all healthcare
activities reach the patient.

James Reason (1997) proposed the Swiss cheese model to illustrate how errors
occur. The model suggests that every step in a process has the potential for error. The
holes in the Swiss cheese represent opportunities for a process to fail, and each slice is
a defensive layer to prevent an error in the process. An error may pass through a hole
in one layer but in the next layer, the hole is in a different spot and catches the error
before it reaches the patient. More layers of cheese and smaller holes allow more errors
to be stopped or caught. When the holes in the Swiss cheese line up, the defenses are
defeated and an error occurs.

For example, a nurse may be caring for a female patient who requires the insertion
of an indwelling urinary catheter. The intent is to place the catheter into the correct
patient using aseptic technique. A variety of protective layers are in place to prevent
errors as the nurse performs this procedure. The nurse is educated on the policy, pro-
cedure, and equipment. The nurse verifies the order and checks the patient’s identi-
fication using two patient identifiers. The nurse explains the procedure to the patient
and obtains an assistant to help with proper patient positioning. The nurse ensures
the environment is appropriate, with privacy and sufficient lighting. If one or more
of these protective layers are circumvented, an insertion error may occur, resulting in
patient harm.

CHARACTERISTICS OF HIGH-RELIABILITY
ORGANIZATIONS

Weick and Sutcliffe (2007) identified five key principles of high reliability organiza-
tions: preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise (Table 4.1). These characteristics,
when present, help an organization to achieve high reliability.

Preoccupation With Failure

Preoccupation with failure requires the nurse and other healthcare providers to be
aware that the risk of error is always present. An HRO acknowledges that failures can
occur and puts healthcare processes in place to diminish harm. An HRO proactively
identifies high-risk activities and analyzes all the potential error points in the process.
Conducting a failure modes and effect analysis (FMEA) is one way of accomplishing

94 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

this analysis. FMEA is a rigorous process in which a team of clinicians identify and
eliminate known and potential failures, errors, or problems before they actually occur
(Hughes, 2008). “Failure modes” refer to the ways in which something might fail and
cause potential or actual harm. “Effect analysis” examines the consequences of those
failures. Failures are prioritized according to the seriousness of the consequences,
how frequently they occur, and how easily they can be detected. The purpose of an
FMEA is to take actions to eliminate or reduce failures, starting with the highest prior-
ity ones.

For example, during an acute bleeding episode, a nurse may need to adminis-
ter multiple units of blood during a very short time period. This requires coopera-
tion among physicians, nurses, the blood bank staff, transportation staff, and many
others. A hospital might examine the process used for massive blood transfusion by
convening an interprofessional team. The team identifies each step in the process,
from ordering of the blood to administration and determines where failures might
occur. Through the FMEA, the hospital might learn that the greatest risk of error
occurs in small units with a limited number of nurses. As a result, they may create
a code transfusion team to bring additional resources to the bedside during acute
bleeding episodes.

Preoccupation with failure also requires that critical information is communi-
cated across time, across the healthcare team, and across sites of care. For example,
the day shift nurse communicates her concerns about the patient and what should
be monitored with the oncoming night shift nurse. Last, preoccupation with failure
requires the nurse to pay attention to near miss safety events and precursor safety
events as an early warning that something is wrong. This requires that nurses and
others report questionable or unsafe practices. Nurses need to recognize when an
error can or has occurred, feel confident in stopping unsafe practices, and assume
the responsibility for reporting errors or near misses. HROs then use those reports
to correct unsafe processes through rigorous process improvement activities.

TABLE 4.1 HIGH-RELIABILITY ORGANIZATION CHARACTERISTICS

CHARACTERISTIC ELEMENTS

Preoccupation with failure • Be alert to near-miss events
• Recognize weaknesses in healthcare systems early

Reluctance to simplify • Recognize the complexity of work
• Do not focus on superficial causes of failure

Sensitivity to operations • Acknowledge the complexity of healthcare processes
• Have situational awareness of the environment,

distractions, availability of resources and supplies
• Be aware of relationships

Resilience • Anticipate and mitigate failure
• Determine how to diminish risk of harm to patients
• Identify strategies to recover when an adverse event

occurs
Deference to expertise • Use teamwork that recognizes each member’s

knowledge, skill, and expertise
• Facilitate active participation from healthcare

professionals
• Be comfortable in sharing information
• De-emphasize hierarchy

Source: Adapted from Weick K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age
of uncertainty (2nd ed.). San Francisco, CA: Jossey-Bass.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 95

Reluctance to Simplify

Reluctance to simplify drives an organization’s search to understand the cause of
errors. Staff members in HRO healthcare facilities focus on drilling down to determine
the true cause of error. They take nothing for granted and challenge the status quo
to make healthcare processes and structures safer. For example, a nurse may fail to
change a dressing. Upon questioning to determine why this event occurred, the easy
answer is “I forgot.” However, probing further for contributing factors to this failure
encourages the organization to find real, sustainable solutions. In the case of the dress-
ing change, the information may not have been shared at change of shift, or a prompt
in the electronic health record (EHR) may have been missing, or the necessary supplies
may not have been available at the time the nurse had planned to change the dressing.
An examination of each of these factors allows an HRO to determine ways to improve
the healthcare process.

Reluctance to simplify also addresses work arounds, a common phenomenon in
healthcare. Work arounds occur when nurses and other clinicians use shortcuts in an
effort to streamline care without realizing the potential impact on safety. For example,
healthcare organizations require dual (two person) verification for high-risk medica-
tions. Letty, a nurse in critical care, generally abides by this policy. However, she has
been administering a propofol infusion to her patient for several days and has begun
to adjust the dose without seeking an independent double check. Letty uses this work
around to save time. Unfortunately, it also increases risk to her patient. Leaders in
HROs identify and extinguish these types of workarounds.

Sensitivity to Operations

Sensitivity to operations creates an awareness of the many factors that influence the
care environment. Healthcare workflows are complex and factors such as fatigue, dis-
tractions, and workload can contribute to unsafe conditions. Sensitivity to operations
requires healthcare leaders to make rounds and talk to staff to look for weaknesses in
the care delivery system that allow errors to occur. Once weaknesses are identified,
leaders provide guidance and feedback and allocate resources to prevent harm. For
example, in an attempt to create an open-floor plan on a medical–surgical unit, the
automated medication dispensing system was placed in an alcove in the hallway. With
no barrier in place, the nurse was frequently interrupted by physicians, patients, visi-
tors, and other staff while obtaining medications from the dispensing system. Nurses
expressed concern about this process, which interfered with their ability to concen-
trate on the task at hand. Nursing leaders observed this when making rounds and
resolved the problem by creating a small medication room to house the automated
medication dispensing system and minimize distractions for the nurse while prepar-
ing medications.

Commitment to Resilience

Commitment to resilience addresses the need to talk about and learn from mistakes.
Rather than blaming others, clinicians in HRO healthcare settings discuss how the
error occurred and what can be done to prevent such an error in the future. Because
we are human, mistakes will happen. Resilience describes the ability to recover
when something bad happens. For an HRO, resilience is the ability to overcome

96 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

problems, learn from mistakes, and move forward. Transparency is paramount. An
HRO openly discusses errors and uses them to improve healthcare processes. Nurses
and other clinicians in an HRO are taught to perform quick situation assessments
when an error occurs, work as a team to contain or manage the error, and then take
steps to reduce the harm.

HROs ensure that clinicians are offered support when they are involved in a safety
event. When a nurse or other clinician makes an error that harms a patient, she or he
feels guilty. The term “second victim” has been coined to label the pain and anguish

experienced by the clinician (Wu, 2000). Programs have
been developed to assist clinicians to build resilience and
recover from these safety events. The forYOU program
(Scott, 2015) is an evidence-based second victim interven-
tion that provides immediate emotional and social sup-
port. Members of the forYOU team provide emotional
support using a three-tiered methodology. In tier one, local
support is provided by colleagues. In tier two, specially
trained peers provide support. In tier three, support is pro-
vided by a referral network of chaplains, social workers,
and employee assistance programs.

Last, simulation learning is a tool used in HROs to
practice responses to errors or safety events. Drills for
rapid responses, cardiopulmonary resuscitation, active
threats, and environmental disasters help nurses and other

clinicians to work as an interprofessional team and build
resilience for emergency situations (Figure 4.1).

Deference to Expertise

Deference to expertise acknowledges that collective expertise is better than any individ-
ual’s expertise. This deference allows an HRO to take advantage of the unique skills of
everyone involved. In an HRO, teams recognize that each member has knowledge and
skills unique to his or her profession and role. HROs minimize the authority gradient and
hierarchy so that everyone feels comfortable to speak up. Authority gradient refers to
positions within a group or profession, such as a direct care nurse and the nurse manager
or a medical resident and the attending physician. The term was defined first in avia-
tion when it was noted that pilots and copilots did not always communicate effectively in
stressful situations if there was a significant difference in their perceived authority. A num-
ber of unintentional aviation, aerospace, and industrial incidents have been attributed to
authority gradients. The concept of authority gradient was introduced to medicine in the
IOM’s(1999) report To Err Is Human. Hierarchy refers to perceived level of power across
groups, such as a housekeeper and a direct care nurse, or a direct care nurse and a physi-
cian. Healthcare has been and remains hierarchical. Physicians are viewed as the “captain
of the ship,” with nurses and other clinicians viewed as less powerful.

Regardless of authority gradient or hierarchy, deference to expertise specifies that
team members with the most expertise about the issue have the authority to make
decisions. For example, in an HRO, decisions about nursing practice are informed by
and driven by practicing nurses rather than by the chief nursing officer (CNO) or by
physicians. Ignoring a team member’s expertise can generate anger, indifference, or a
failure to respond, which create opportunities for error to occur. Open communication
with information flowing in all directions among all team members is essential for the
delivery of consistently safe care.

FIGURE 4.1 An interprofessional
team responds to a code in a
simulation center.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 97

THE EFFECT OF HIGH RELIABILITY

A culture of reliability affects all aspects of an organization. HRO improves safety,
which was identified as one of the six elements of quality healthcare in the IOM’s
(2001) report Crossing the Quality Chasm. Patient safety is recognized as an important
element of an effective, efficient healthcare system. Safety has to do with lack of
harm and focuses on avoiding bad events. Safety makes it less likely that mistakes
and errors will happen. When care processes are performed as intended over long
periods of time, the result is no harm. For example, an interprofessional team may
focus on reducing harm to patients caused by catheter-associated urinary tract infec-
tions (CAUTIs). Using evidence from the literature and standards from professional
organizations, the team constructs a CAUTI bundle, a standard set of procedures to
be used consistently to prevent CAUTIs. If the procedures are consistently applied
by every clinician providing care to the patient, the likelihood of harming the patient
with a hospital-acquired CAUTIs usually drops exponentially. Functioning in a cul-
ture of reliability prevents harm and enhances safety.

Similarly, a culture of high reliability enhances quality. Quality has to do with
efficient, effective, and purposeful care that gets the job done at the right time for the
right cost. It focuses on doing things well and employs quality improvement tech-
niques so that the overall care continues to improve. CAUTI rates are widely measured
and reported as a quality measure for healthcare systems. At the individual level,
preventing CAUTI simproves quality for that patient.

In addition, a culture of reliability enhances the patient experience. The patient
experience is more than patient satisfaction. It is “the sum of all interaction, shaped by
an organization’s culture, that influences patient perceptions, across the continuum of
care” (The Beryl Institute, 2017). Most clinicians strive to provide patient-centered care
in a kind and compassionate manner. Yet all too often, patients receive mixed messages
and inconsistent information. This occurs because care is provided by humans, and
humans are fallible and variable in their approaches. However, in a culture of high reli-
ability, enhanced communication among staff results in more consistent communication
with patients. Clinicians are educated to be competent, compassionate, and consistent.
Patient satisfaction scores, one measure of the patient experience, tend to rise in such an
environment. Patients and their family members are unhappy when their care is unsafe
or of poor quality. Returning to the earlier CAUTI example, no patient wants to develop
a urinary tract infection, with the corresponding symptoms and required treatment.
Patients who have this experience often evaluate their overall care less positively when
they complete patient satisfaction surveys. They may also express their dissatisfaction
when talking with friends and families, thus eroding the reputation of the hospital.

Last, a culture of reliability also improves financial performance, which reflects
the income and the expenses of a healthcare organization. A culture of reliability helps
to increase income and decrease expense. Hospitals and ambulatory care settings are
increasingly being reimbursed based on safety, quality, and patient experience out-
comes. The Centers for Medicare and Medicaid Services (CMS) oversees three hospital-
based pay-for-performance programs that tie reimbursement to reliability: Value-Based
Purchasing (VBP) Program, Readmission Reduction Penalty Program, and Hospital-
Acquired Conditions (HAC) Reduction Program. In VBP, hospitals earn scores based
on achievement or improvement of their safety, quality, patient experience, and finan-
cial scores. VBP scores a hospital on five domains as follows:

• Patient- and caregiver-centered experience of care/care coordination (contribut-
ing 25% of the score)

• Clinical care outcomes (contributing 25% of the score)

98 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

• Efficiency and cost reductions (contributing 25% of the score)
• Safety (contributing 20% of the score)
• Clinical care processes (contributing 5% of the score)

The Readmission Reduction Penalty Program focuses on patients being readmitted
to hospitals for specific conditions, including acute myocardial infarction, coronary
artery bypass graft surgery, chronic obstructive pulmonary disease, heart failure,
pneumonia, and total hip and knee arthroplasty. The hospital’s actual readmission
rate is compared to the expected rate of readmissions given the patient’s comor-
bidities. Comorbidities are two or more coexisting medical conditions or disease
processes that are additional to an initial diagnosis. For example, a patient may be
admitted for a total knee arthroplasty. If the patient has diabetes and heart failure,
these coexisting conditions must be documented because they make patient care
more complex.

The HAC Reduction Program examines the hospital’s performance on coded data
derived from the documentation of physicians and advanced practice clinicians. The
coded data are then analyzed as part of the Agency for Healthcare Research and Quality
(AHRQ, 2013a) Patient Safety Indicators (PSI-90) and the Centers for Disease Control
and Prevention (CDC) National Healthcare Safety Network (NHSN) databases. In 2017,
6% of Medicare reimbursement to hospitals was tied to these three pay-for-performance
programs, representing billions of dollars. Hospitals with better than expected out-
comes received higher reimbursement for patients insured under Medicare, whereas
those with worse than expected outcomes received lower reimbursements.

Additionally, healthcare organizations may experience less waste and lower
cost when care is provided in a consistent manner. Returning to CAUTI preven-
tion as an example, an important first step in preventing the infection is to clearly
identify which patients truly require the insertion of an indwelling urinary cath-
eter. By providing evidence-based care and inserting indwelling urinary catheters
only when needed for care, the number of indwelling catheters can be reduced,
with a corresponding decrease in the CAUTI rate and the cost of urinary catheter
supplies. According to the Association for Professionals in Infection Control and
Epidemiology (2017), each urinary tract infection adds on average $5,904 to the cost
of the hospital stay. Simply put, hospitals and patients can save money by prevent-
ing CAUTIs.

LEARNING FROM OTHER INDUSTRIES

Commercial Aviation

Commercial aviation has worked diligently to change the culture in airplane cock-
pits to advance airline safety. Their work began after research conducted by the
National Aeronautics and Space Administration in the 1970s suggested that the
majority of commercial airplane crashes were caused by failure of communica-
tion among pilots and crew, not by mechanical failures. As a result, crew resource
management (CRM) training programs were developed and implemented. Teams
make fewer errors than individuals, especially when each team member knows
his or her own responsibilities along with those of other team members. The CRM
program is widely credited with the dramatic safety improvements in the airline
industry (Helmreich, Merritt, & Wilhelm, 1999) and has tremendous applicability
in healthcare.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 99

Nuclear Power

Similarly, the nuclear power industry has worked for many years to improve safety.
The Institute of Nuclear Power Operations defines seven safety culture characteristics
that are adaptable to the healthcare environment as follows:

1. Leaders demonstrate commitment to safety in their decisions and behaviors.
2. Decisions that support or affect safety are systematic, rigorous, and thorough.
3. Trust and respect permeate the organization.
4. Opportunities to learn about ways to ensure safety are sought out and implemented.
5. Issues potentially impacting safety are promptly identified, fully evaluated, and

promptly addressed and corrected, commensurate with their significance.
6. A safety-conscious work environment is maintained where personnel feel free to

raise safety concerns without intimidation, harassment, discrimination, or fear of
retaliation.

7. The process of planning and controlling work activities is implemented so that
safety is maintained.

Science of Human Error: How Humans Function

Humans function primarily in three modes: skill-based performance, rule-based per-
formance, and knowledge-based performance. Each mode is described in the follow-
ing along with the errors that can occur when functioning in that mode.

When individuals are using skill-based performance, they are essentially on auto-
pilot. Skill-based performance is used for routine, familiar tasks that can be done with-
out thinking about them. For example, the drive to work or school may be so familiar that
the driver arrives without knowing how he or she got there. Nurses often function in this
mode because of the repetitive nature of some nursing tasks. Consider, for example, Jim,
a nurse completing his documentation in the EHR. Jim logs onto the EHR many times
each day. He does not need to think about his user identification or his password. He
is on auto-pilot. He pulls up his assigned patients in the EHR and begins to document.

In general, skill-based performance is accurate. But even though these repetitive
tasks may be simple, there is still a risk for error. Slips occur when, without intending to,
the individual does the wrong thing. Jim could pull up the wrong patient and document
care that was delivered to a different patient. Lapses occur when, without intending to,

CRITICAL THINKING 4.1 APPLYING NUCLEAR POWER
SAFETY CHARACTERISTICS TO HEALTHCARE

Review the seven nuclear power safety characteristics outlined in the chapter.

1. Which characteristics can be applied to healthcare?
2. How might a nurse leader demonstrate commitment to safety in decisions

and behaviors?
3. How have you seen nurses demonstrate trust and respect in your clinical

setting?
4. What experiences have you had at school to learn about ways to ensure

safety? What experience have you had in your clinical setting?
5. How might you raise safety concerns during your clinical rotations?

100 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

the individual fails to do what he meant to do. Jim could document on his patient but
forget to save or file his work before closing the record. Fumbles occur when, without
intending to, an individual mishandles a word or action. Jim may be documenting using
a hand-held device. If he drops the device, he has experienced a fumble.

Skill-based errors may be prevented by stopping and thinking before acting. Double
checking one’s own work helps to prevent these errors. This is why nurses learn to check,
recheck, and recheck again before administering medications. Determining that the right
drug in the right dose is being given by the right route, at the right time, and to the right
patient involves checking the medication label against the medication order or medica-
tion administration record three times. In addition, two unique patient identifies need
to be used prior to administering the medication. Healthcare facilities typically define
which two patient identifiers are to be used, most often full name and date of birth.
High-risk medications, such as insulin, require independent verification by another
nurse. The independence of this double check helps to prevent skill-based errors.

In rule-based performance, the clinician has learned a rule and applies it in appro-
priate situations. The delivery of healthcare is largely based on rules, often called proto-
cols. Rules may be learned in nursing school or through continuing education, clinical
experience, or life experiences. Errors may also occur when functioning in a rule-based
performance mode. Sometimes, clinicians use the wrong rule. They may have been
taught or somehow learned the wrong response for a situation. For example, Susan
learned many years ago in nursing school to treat patients with hypoglycemia if glu-
cose was 60 mg/dL or less. If Susan has not kept current with more recent diabetes
and hypoglycemia guidelines, she will fail to treat a patient with glucose of 70. The
solution to this type of error is to educate clinicians with the right rule.

A rule-based error may also occur if the clinician misapplies the rule. The nurse
may know the right response but select another response instead. For example, Susan
may know that a blood sugar of 68 should be treated with 15 g of glucose. However,
she may misapply the rule, and give 30 g of carbohydrates instead. This could over-
correct the low blood sugar, causing the blood sugar to spike and creating another
patient safety event. This can be prevented by pausing and thinking a second time.

Noncompliance can also cause a rule-based performance error. The clinician may
know the rule but choose not to follow it. For example, Susan knows that she should
recheck her patient’s glucose level 15 to 30 minutes after treating hypoglycemia. Susan’s
patient has a hypoglycemic event and she treats it appropriately. Susan sees that the patient
looks fine, is alert, and oriented. She assumes the patient will put on her call light if she
runs into any problems, so Susan decides not to recheck the blood sugar. Noncompliance
with rules can be prevented in several ways. First, Susan needs to understand the risks
involved in not following the rules. In addition, organizations need to reduce the burden
or difficulty of following the rules. For example, are there an adequate number of bedside
glucose monitors so that a glucose recheck is easy? Is staffing sufficient to allow time for
the glucose recheck? Susan also may need to be coached by her supervisor to make better
decisions. If this is a repeated behavior, Susan needs to be counseled.

In knowledge-based performance, a clinician is solving problems in a new and
unfamiliar situation. The clinician tries to figure out how to perform based on what they
already know. They may use trial and error or even guess at a solution. This is very dan-
gerous. Up to 60% of all knowledge-based decisions may be made in error. For example,
consider Cathy, an experienced nurse who has been working in critical care for 15 years.
When she arrives on her shift, her patient is receiving continuous renal replacement ther-
apy. Cathy has not previously managed this therapy and is not familiar with the supplies
and fluids used. Rather than proceeding independently, Cathy needs to stop and consult
an expert. The expert may be a colleague or another member of the healthcare team. Or
the expert may be a written resource, such as an evidence-based protocol.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 101

The concepts of skill-, rule-, and knowledge-based performance are essential when
investigating errors. Clinicians involved in the error should focus on how they made the
decision they did. Did they develop a shortcut or work-around to save time? Did they fail
to do a double check of their own work? Did they proceed even though they were not
familiar with the procedure? Each type of error requires a different solution. The three per-
formance modes are critical to keep in mind when designing error prevention strategies.

THE ROLE OF LEADERSHIP IN CREATING A
HIGH-RELIABILITY ORGANIZATION

For the purposes of this chapter, leadership is defined as the governing body of an
organization, typically the board of directors or trustees, senior health system man-
agement, and nursing, physician, and other clinical leadership. To build an HRO,
all of these leaders must share the vision of eliminating harm to patients (Chassin &
Loeb, 2013). The governing body plays a critical role in setting goals and priorities for
healthcare organizations and in overseeing patient safety. Ganghi and Yates (2017)
identify the following eight questions board members should ask to ensure that the
healthcare organization is focused on safety:

• Is safety positioned as an uncompromising core value?
• Is there a comprehensive plan for improving patient and workforce safety and for

monitoring progress?
• Is transparency embraced for sharing adverse patient safety events and lessons

learned across the system?
• Do we have a healthy reporting environment and a fair and just culture?
• Do we expect respect for patients, coworkers, and physicians within the organization?
• Are patient stories heard regularly?
• Are quality and safety implications considered for every major organizational

decision?
• Does the board devote sufficient time to safety, quality, and the patient experience

of care?

Creating a Culture of Safety

Leadership is accountable for the provision of effective and efficient care while pro-
tecting the safety of patients, employees, and visitors. Competent leaders understand
that every step of the care process has the potential for failure simply because humans

What is the role of the board of directors in our journey toward high reliability?
We begin with the philosophy that “good isn’t good enough.” We need to be
sensitive to our systems and processes to identify where things may not work or
can be improved upon. And we must build a culture of open communication and
reporting by all, for the good of all, to inspire and achieve greater results.

Joseph DePaulo
Board Member, Edward-Elmhurst Health; and Chair, Edward Hospital Quality

Committee of the Board

REAL-WORLD INTERVIEW

102 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

make mistakes. TJC’s Sentinel Event Database suggests that leadership’s failure to cre-
ate an effective safety culture is a contributing factor for many types of adverse events
(TJC, 2017, February 17). Understanding and shaping an organization’s culture is essential
for enhancing safety.

A culture of safety is what an organization is and does in the pursuit of safety (TJC,
2017). Leaders in HRO healthcare facilities realize their role in creating a culture of safety.
As such, leaders need to show their commitment to safety and eliminate fear of reporting.
Leaders must make their commitment to safety clear. This is accomplished in a variety of
ways: telling safety stories at each meeting; expecting, encouraging, and rewarding the
reporting of safety events; and expecting and supporting staff to speak up for safety. The
focus of a safety story can be on an event of harm, an explanation of why safety is impor-
tant, a review of an error prevention tool, a thank you for being committed to patient or
employee safety, or an example of using a safety tool at home or at work. Many hospitals
use these techniques to keep safety at the top of everyone’s mind.

Leaders in HRO organizations know they must eliminate the fear of reporting in
order to encourage and reward the reporting of safety events. This may be accomplished
by thanking staff for reporting errors, mistakes, events, and near misses. The Good Catch
award is one way to recognize staff who report near misses or close calls (Figure 4.2).
Many hospitals across the nation have implemented the Good Catch award program.
Edward Hospital in Naperville, Illinois, implemented the Good Catch award in 2008.
Each month, risk managers identify safety events that have been identified by staff and
have not reached the patient to cause harm. They summarize the top safety events and
ask members of the senior leadership team to vote on the most important event. The
person or team responsible for submitting the top safety event is recognized at a man-
agement team meeting and receives a certificate, a lapel pin, and a Good Catch traveling
trophy, which rotates monthly. The Good Catch program recognizes those who speak up
about near miss safety events, and fosters a culture of transparency and safety.

During handoff report from the emergency department, Colleen Erhardt, RN,
learned that her patient had become increasingly confused. Upon arrival to the
floor, her patient remained disoriented, had garbled speech, and was lethargic.
No family was present and the patient’s spouse could not be reached. Physician’s
orders included a neurology consult, stat head CT scan, and NPO status. While the
patient was receiving his CT scan, Colleen reviewed the patient’s morning lab work
and noted his blood sugar was 70 mg/dL. Realizing there had not been a repeat
blood sugar obtained since that time, Colleen proceeded to the radiology depart-
ment to check the patient’s blood sugar and found it had decreased to 31 mg/dL.
Colleen administered 50 mL of D50. The patient immediately responded and was
able to answer all orientation questions appropriately. The neurologist was notified
of the blood sugar and CT results, which revealed no acute neurological problem.
The neurologist noted the source of the patient’s confusion appeared to be hypogly-
cemia and after this was resolved, the patient returned to normal.

1. What type of error is a Good Catch?
2. What factors allowed Colleen to make this Good Catch?
3. What are the typical signs and symptoms of hypoglycemia?
4. Why might this patient have experienced this episode of hypoglycemia?
5. Why is it important to identify and discuss Good Catches?

CASE STUDY 4.1

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 103

HRO leaders support investigations
into how errors occur. This encourages
reporting and learning. HRO leaders
make errors visible in a way that has
meaning to the audience. For example,
hospitals tend to report injuries as percent-
ages, rates, or raw numbers. However,
putting a face to that number is essential
for understanding the impact of the
error. For example, consider this commu-
nication, which demonstrates transparency
and paints a vivid picture of the event:
“We had one fall with injury reported this
week. The patient was a grandmother who
required surgery to repair her fractured
hip and experienced a prolonged separa-
tion from her family because of her stay in
a skilled nursing facility.”

Correcting System Problems

Consistent with sensitivity toward opera-
tions, leaders must identify and correct sys-
tem problems. HRO leaders are always on
the lookout for system problems and work diligently to fix those problems. A helpful tool
to accomplish this is a daily safety huddle. This brief huddle includes senior and opera-
tional leaders who meet at the start of each day to discuss safety concerns and resolve
problems. Operational leaders prepare for the daily safety huddle by reviewing the past
24 hours and anticipating the next 24 hours. They summarize safety issues that have
already occurred and identify if those safety issues impact other departments. They dis-
cuss any barriers to providing safe care, such as inadequate supplies, staffing, or technol-
ogy. They describe any high-risk or nonroutine situations, such as two patients with the
same first and last names on the same unit. At the daily safety huddle, issues critical to the
safety of patients or staff can be addressed quickly and efficiently. Appropriate experts are
mobilized and empowered to solve the problem. For example, safety huddles may reveal
an increase in work place injuries inflicted by patients. This information may be used to
launch a system-wide task force designed to decrease violence in the workplace, including
early identification of potential problems, environmental modifications, and employee
training. Workplace injuries will begin to decrease if the interventions are effective.

FIGURE 4.2 Colleen Erhardt, RN (right),
receiving the Good Catch Award with her
manager, Deb Kocsis, RN.

“The single best thing we’ve implemented here as part of our ‘Road to Zero
Harm’ is the daily Safety Huddle. While it only lasts 10 to 15 minutes, we all
attend or call in to hear 49 operational leaders report on the safety issues in their
areas. The Safety Huddle allows us to quickly identify and act on safety trends.
It’s helping to make our care safer.”

Bill Kottmann
President and CEO, Edward Hospital

REAL-WORLD INTERVIEW

104 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Building and Reinforcing Accountability

HRO leaders are also responsible for building and reinforcing accountability. They
reinforce sound safety habits, console those who make honest mistakes, and counsel
those who make risky choices. To build a culture of accountability, leaders must set
clear expectations, educate and build skills within the staff, and build and reinforce
accountability. The behavioral expectations should be consistent with the organiza-
tion’s mission, vision, goals, and standards for performance. Edward Hospital uses
the phrase “Road to Zero Harm” to connote their journey toward high reliability.
Individuals at all levels of the organization must be educated on these expectations.
In addition, leaders need to create a system that allows nurses and other staff members
to convert all their behaviors into safe work habits.

Individuals experience three sources of accountability: vertical, horizontal, and
intrinsic. Vertical accountability is applied by leaders, that is, the sense that managers
are watching. Peers account for horizontal accountability, the sense of teamwork and the
desire to function as effectively as others. Intrinsic accountability exists within the indi-
vidual. All three types of accountability are important in creating a culture of safety and
accountability. Leaders need to expect accountability and build the intrinsic motivation of
the individual to meet performance expectations. HRO leaders take every opportunity to
build and reinforce accountability by making regular rounds and creating a just culture.

Leaders who visit and make rounds to clinical practice areas are essential for build-
ing a culture of high reliability. “Management by walking around” allows leaders to see
firsthand the conditions that exist at the front line, where care is being delivered. Making
rounds demonstrate leadership’s commitment to safety and allow leaders to talk with
staff about safety concerns for themselves and their patients. It also provides an oppor-
tunity for leaders to provide quick feedback and reinforcement to staff. The science of
human performance suggests that providing both positive and constructive feedback is
needed to decrease human errors, and that the overwhelming majority of feedback should
be positive. Instant feedback helps to reinforce positive behaviors and should be immedi-
ate and based on facts. A verbal thank you for practicing safely is very effective in rein-
forcing safe behaviors. During rounds, leaders may observe unsafe behaviors and should
immediately correct the behavior and offer a practice tip to extinguish the unsafe behavior.

For example, nurses and clinicians in many hospitals and healthcare settings are
inconsistent in performing hand hygiene before and after patient contact (see Figure 4.3).
Edward Hospital is no exception. As a result, leaders decided to focus on hand hygiene
during rounds. To prepare leaders, a rounding tool was created by Mary Anderson, an
infection preventionist at Edward Hospital. The rounding tool allowed leaders to relate
hand hygiene to the core value of safety. Clinicians were then asked how they perform
hand hygiene and expectations were clarified if necessary. Clinicians were asked what
barriers exist for performing hand hygiene and how hand hygiene can be better met in
the future. Last, clinicians were asked to commit to performing hand hygiene and help-
ing others to do the same. This effective rounding tool provided actionable feedback to
leaders (for more information, go to www.eehealth.org). For example, leaders received
input on the need for structural modifications, and they are working to increase the num-
ber of sinks and hand gel stations.

Creating a Fair and Just Culture

Leaders are also responsible for creating a fair and just culture. A fair and just culture min-
imizes blame and punishment and creates an environment that encourages individuals
to report errors so that the system problems can be corrected. Traditionally, healthcare’s

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 105

culture has held individuals accountable for all errors that occur with patients under their
care. This punitive approach toward errors views those who make errors as “bad apples”
(IOM, 1999). This approach has served as a disincentive to reporting errors and mistakes.
After all, who would report an error if it meant they would get in trouble? As a result,
organizations missed opportunities to uncover and correct problems that impacted
performance and outcomes. The pendulum then swung to the opposite extreme, to a
nonpunitive culture. This was interpreted by some to mean the individual was always
blameless when an error occurred, which allowed intentional disregard for work rules.
Most recently, the concept of a just culture has been embraced within healthcare.

James Reason (1997) wrote that a just culture creates an atmosphere of trust, encour-
aging and rewarding people for providing essential safety-related information. A just
culture also clearly identifies what constitutes acceptable and unacceptable behavior.
Marx David (2001) wrote that individual practitioners should not be held accountable
for system failings over which they have no control. He held that discipline should be
tied to the behavior of individuals and the potential risks of their behavior rather than
only to the actual outcome of their actions. A just culture recognizes that many errors
represent predictable interactions between human operators and the systems in which
they work. In a 2010 position paper, the American Nurses Association (2010) endorsed
the just culture model, noting its wide use in the aviation industry.

Ultimately, the just culture model is about creating a learning culture that is open
and fair; managing behavioral choices; and designing safe healthcare systems. The
model acknowledges that humans make mistakes and because of this no system can
be designed to produce perfect results. A just culture views errors as opportunities

FIGURE 4.3 Clean Hands Count for Healthcare Providers.
Source: Centers for Disease Control and Prevention. Retrieved from http://cdc.gov/handhygiene

106 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

to improve the understanding of both healthcare system risk and individual behav-
ioral risk. It changes staff expectations and behaviors so that everyone looks for
risks in the environment; reports errors; helps to design safe healthcare systems;
and makes safe choices, such as following procedures, policies, and protocols.

The just culture model requires leadership competencies that appropriately hold
individuals accountable for their behaviors and investigates the behavior that led to the
error. James Reason (1997) developed a Performance Management Decision Guide that
is used across the world to guide management decisions when human error occurs. It
starts with a deliberate act test. If the individual acted with malicious intent, disciplinary
action and a report to a professional group, regulatory body, and/or law enforcement
is warranted. If there is confirmed ill health and the individual was unaware, a leave of
absence and physician referral are appropriate. If substance abuse is suspected, testing
and disciplinary action are warranted. If the individual chose to take an unacceptable
risk based on policies, procedures, and protocols commonly used within the organiza-
tion, disciplinary action may be warranted. However, if the individual adhered to gen-
erally accepted performance expectations and simply made an unintended error, the
individual needs to be consoled and coached. In every case, leadership is also respon-
sible for correcting all safety problems that contributed to the error.

Fostering a Learning Environment

The learning organization was first described by Peter Senge (1990) as an organization
where people continuously learn and enhance their capabilities to create. An HRO
cannot exist in the absence of learning. A learning organization views each failure as
an opportunity to learn from mistakes. An HRO readily admits its weaknesses and
commits to learning from its mistakes (Hughes, 2008). Key tenets of improving patient
safety at the organizational level include taking a systems approach to safety and
improving the culture of safety. Healthcare systems that embody this approach are
considered learning organizations. Leaders in these organizations support learning
and create a supportive learning environment. They put specific processes in place to
facilitate learning and encourage creativity among employees. Such a learning envi-
ronment requires a level of transparency related to safety, so that everyone is aware
of opportunities for improvement. Reporting errors and near miss safety events can
assist in understanding a problem rather than hiding that a problem exists.

Enhancing Process Improvements

An HRO has a strong commitment to healthcare process improvement. Becoming an
HRO requires a systematic look at the complexity of the healthcare process, identifica-
tion of the root causes of failures in the healthcare process, implementation of solutions,
measuring and monitoring outcomes from the implemented solutions, and then build-
ing ways to sustain the improvement. In some cases, an entirely new process may be
required to enhance safety. Increasingly, patients and their families are being engaged
to assist in healthcare process improvements. The use of systematic process improve-
ment methodologies and tools such as Six Sigma and Lean are discussed in Chapter 13.

Identifying and Reporting Events

In an HRO, all healthcare providers are responsible for reporting safety events, includ-
ing near misses, adverse events, and sentinel events. This type of reporting has its limi-
tations, as it depends on both the recognition of the safety event and the completion of

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 107

a safety event report. When using voluntary reporting and error tracking, only around
10% to 20% of all errors are reported in healthcare organizations (Classen, Lloyd,
Provost, Griffin, & Resar, 2008). Hospitals need a more effective way to identify events
that cause harm to patients in order to select and test changes to reduce harm.

In an HRO, a multifaceted reporting approach is needed that is comprehensive
and provides accurate measurements of errors and near misses. The Institute for
Healthcare Improvement (IHI) Global Trigger Tool (GTT; IHI, 2017c) helps health-
care organizations get a clearer understanding of the safety of care by measuring
risk and harm at the hospital level. The GTT uses specific patient care triggers as
indicators that an adverse event (AE) may have occurred. Using GGT to identify
AEs is an effective method for measuring the overall level of harm from patient care
in a healthcare organization. The GTT provides an easy-to-use method for accu-
rately identifying AEs (harm) and measuring the rate of AEs over time. Tracking
AEs over time is a useful way to tell if changes being made are improving the safety
of the patient care processes.

For example, transfer to a higher level of care is one of the Global Triggers. A patient is
transferred to the ICU from a medical–surgical unit due to a rapid drop in blood pressure
and decreased level of consciousness. This would cause activation of the trigger and a
review of the patient’s EHR to determine what happened to the patient, when it happened,
and if it could have been avoided. There are more than 50 triggers that are consolidated
into categories on the GTT related to the provision of surgical, ICU, perinatal, medication,
and emergency department care. The categories and triggers can be viewed at the IHI
website (www.ihi.org/resources/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.
aspx). In an HRO, investigation results and the GTT results are shared with healthcare
providers and process improvement changes are put into protocols, policies, and proce-
dures to reduce the chance of future safety problems occurring.

Deploying Technology

In an HRO, health technologies help facilitate and sustain quality improvement
efforts to improve patient safety. For example, the use of IV pumps with built in
limits for high and low medication doses helps to reduce medication errors. Elaine
is caring for a patient with a pulmonary emboli. She reviews the medication orders
to administer 80 units of heparin per kilogram by IV bolus, followed by 18 units per
kilogram as an hourly infusion. Elaine knows her patient weighs 150 pounds, or 68
kg. She correctly calculates and administers the initial dose of 5,540 units. Elaine
calculates the continuous infusion rate at 1,224 units per hour. When programming
the pump, however, her finger slips and she enters 12,244. Because that dose is
beyond the normal range for heparin, the pump does not administer the drug, and
Elaine receives an error message. She quickly identifies and corrects the program-
ming. A double check from a peer for this high-risk medication would also catch
this programming error before it reaches the patient.

All too often, however, hospital leaders apply technology to faulty healthcare pro-
cesses and hope to prevent errors with technology. Technology can only help improve
healthcare processes when applied appropriately. A focus on a safe and efficient health-
care process design using technology to support and sustain any improvement is critical.

Committed leaders are needed to implement system changes that are essential
for becoming an HRO. However, leadership is not sufficient. Every individual within
an organization needs to be committed to high reliability. The next section addresses
the individual responsibilities for nurses and other members of the interprofessional
healthcare team on a journey toward high reliability.

108 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

INDIVIDUAL RESPONSIBILITIES: SAFETY BEHAVIORS
FOR NURSES

While many contributing factors lead to errors, an actual error occurs when the clini-
cian interacts with the patient, at the “sharp end” of care. The nurse is often the last
line of defense against healthcare errors. As such, the nurse must be cognizant of both
internal behaviors to enhance safety and communication techniques that can be help-
ful in preventing errors and patient harm.

Internal Behaviors to Enhance Safety and High Reliability

Nurses and other members of the interprofessional healthcare team must always strive to
focus their attention and to think before they act. This is effective in preventing many task-
based errors, especially in stressful, noisy, and pressured situations. A tool used to focus
and think in these situations is Pause-Act-Review (PAR). Nurses and other clinicians are
asked to pause for 1 or 2 seconds to focus their attention on the task; act by concentrating
and performing the task; and review their actions to check for the desired result. This self-
checking takes only a few seconds but greatly reduces the probability of making an error.

For example, Karly, a nurse on the telemetry unit, uses the PAR technique when
pulling medications from the automated medication dispensing system (Figure 4.4). She

pauses, acts, and reviews her action. The automated
medication dispensing system is located in the supply
room; the area gets considerable traffic and can become
noisy. Karly recognizes that noise and congestion can
increase the risk of errors. She takes her concern to the
Practice Council, and a decision is made to post a sign
by the automated medication dispensing system. The
sign serves two purposes. It reminds other staff to be
quiet and avoid interrupting the nurse who is prepar-
ing medications, and it reminds the nurse to use PAR.

Another internal behavior helpful in enhancing
safety is maintaining a questioning attitude when
providing patient care. The nurse must carefully
consider the patient care situation and ask questions
of herself. Is this what I expected to see? Does this fit
with what I know? Does this make sense to me? If a
question or concern remains, the nurse confirms by
checking with independent, expert sources, either
competent people or written materials that can help
in resolving the question.

As an example of a questioning attitude, Chris is
caring for a 3-month-old with a history of supraven-
tricular tachycardia who is admitted to the pediatric
ICU with a cough and congestion. Chris reviews the
medication orders and finds orders for propranolol
20 mg TID. As an experienced pediatric nurse, Chris
realizes that this dose is high. He knows pediatric
doses are weight-based and consults a drug refer-
ence book (an external expert) to determine the
appropriate dose. Chris also talks with the mother

FIGURE 4.4 Karly Blaschak, RN, focuses
on retrieving medications from an auto-
mated medication dispensing system.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 109

(an expert in her child’s care) and finds that the infant was taking 2 mg of propranolol
TID at home. Chris questioned what he saw and investigated appropriately. He then
spoke to the physician, who changed the medication order and thanked Chris for his
diligence.

Communication Techniques

In the fast-paced healthcare arena, clear communication is essential, both within nurs-
ing and with other members of the interprofessional team. Communication ensures
that messages are heard correctly and accurately and prevents incorrect assumptions
and misunderstandings that could lead to wrong decisions. One of the National Patient
Safety Goals (NPSGs) is to improve the effectiveness of communication among care-
givers (TJC, 2016). TeamSTEPPS® (AHRQ, 2013b) provides a variety of tools that can
be helpful in improving communication, including callout and closed loop (or three-
way) communication. Callout is a tool used to communicate important information.
It informs all team members simultaneously during an emergency and helps team
members anticipate next steps. For example, during a code, the nurse uses a callout to
report “I’ve administered 1 mg epinephrine IV.”

Closed-loop communication ensures that the message received is the same as the
message sent. The sender initiates communication with a receiver by providing an
order, request, or information. The receiver acknowledges the communication with a
repeat-back of the order, request, or information. The sender then confirms the accu-
racy of the acknowledgment by saying “that’s correct.” If communication is not clear,
the nurse must clear up the confusion. “Let me ask a clarifying question” is a helpful
and nonthreatening phrase to use when attempting to clarify communication. As an
example, Pam is a nurse on a medical–surgical unit. When she receives a telephone
order from a physician, she enters it into the EHR and reads it back to the physician.
Pam waits for the physician to verify the order before terminating the conversation.
Pam also uses closed-loop communication when communicating with or delegating to
a patient care tech (PCT).

Communication also includes the transfer of information during transitions of
care, for example, during shift changes, transfer to another unit, or discharge from
the hospital. These communication handoffs provide an opportunity to ask questions,
clarify information, and confirm understanding. The tools I PASS the BATON and
SBAR can be used effectively in handoffs. The I PASS the BATON acronym for remem-
bering the key components of the handoff is presented in Box 4.2.

The acronym, SBAR, stands for Situation, Background, Assessment, and Recom-
mendation. It was originally adapted by Kaiser Permanente from a U.S. Navy tool
to enhance collaboration between nurses and physicians (IHI, 2017b). In the struc-
tured SBAR communication, Situation refers to a concise statement of the immediate
problem. Background includes brief and pertinent information related to the situation.
Assessment refers to analysis and consideration of action options. Recommendation
addresses the actions requested.

Jean uses SBAR as a nurse in labor and delivery. When caring for Mrs. Jones, she
calls the obstetrician to report, “Here’s the situation. I’m concerned about the decelera-
tions that Mrs. Jones is experiencing. Mrs. Jones is 34 years old, gravida 2, para 1. My
assessment finds baseline fetal heart tones are 120 with minimal variability and repeti-
tive late decelerations. I’ve initiated all intrauterine resuscitation measures without
improvement. I need you to come assess Mrs. Jones as quickly as possible. When can
I expect to see you?”

110 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Initially, it appears that speaking up for safety is an easy behavior. After all, health-
care providers come into healthcare to do the right thing, help patients, and cause no
harm. However, speaking up for safety requires a change in culture. Leadership must
clearly communicate that everyone has the authority to stop for a safety concern at any
time. Nurses are expected to voice their concern and “stop the line” if they sense or dis-
cover a safety issue. The acronym CUS may be used, representing “I am Concerned”;
“I am Uncomfortable”; and “This is a Safety Issue.” A phrase like “I have a safety con-
cern” is useful to help staff feel comfortable with speaking up.

Consider this example of a culture where nurses feel empowered to speak up for
safety, regardless of authority gradient. Mary Ann was caring for an infant in the NICU.
At the request of the infant’s parents, the hospital’s CEO, COO, and CNO arrived in the
private NICU room. Mary Ann calmly and professionally asked, “Did you scrub in?” All
three retreated to the sink, scrubbed in, and thanked Mary Ann for speaking up. In fact,
Mary Ann received recognition for her actions at a management team meeting. Mary
Ann’s action ensured safety for a vulnerable infant. The story of the positive response of
the CEO, COO, and CNO spread widely throughout the hospital, helping to promulgate
the understanding that everyone is rewarded for speaking up for safety.

The Interprofessional Team

The delivery of healthcare requires strong and supportive healthcare teams. Team mem-
bers monitor team function, share the workload, and support each other. TeamSTEPPS
(AHRQ, 2013) provides team strategies and tools to enhance performance and patient
safety. CRM, described earlier in this chapter, has been adopted from aviation into
healthcare to promote and reinforce team behaviors such as cooperation, coordination,
and sharing regardless of formal position. It has been used to improve patient care in
obstetrics, the operating room, emergency department, and other settings (Kreiser, 2012).

Providing feedback to team members is important for fostering high performance.
HROs foster a culture where nurses and other staff members are expected to provide
and are comfortable providing both positive and constructive feedback to team members.
Positive feedback is essential for reinforcing safe behavior. Clinicians perform many safe

I—Introduction—Introduce self and role
P—Patient—Name, identifiers, and basic demographic information
A—Assessment—Present chief complaint, vital signs, and diagnoses
S—Situation—Current status, including code status, recent changes, and response to
therapy
S—Safety Concerns—Critical lab values, allergies, alerts such as high fall risk and isolation
B—Background—Comorbidities, previous issues, current medications, family history
A—Actions—Actions taken or provided with rationale
T—Timing—Level of urgency and prioritization
O—Ownership—Identify who is responsible, including patient and family members
N—Next—Plan of care, anticipated changes, contingency plan

BOX 4.2 I PASS THE BATON

Source: Adapted from Agency for Healthcare Research and Quality (AHRQ). (2013). TeamSTEPPS® pocket guide. Retrieved from
https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/
pocketguide.pdf

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 111

actions every day and should be recog-
nized for that. Constructive feedback
is needed to discourage and change
unsafe behaviors. People tend to avoid
constructive feedback because they are
uncomfortable providing it. However,
as in the speaking up example earlier in
this chapter, Mary Ann reminded oth-
ers to wash their hands before enter-
ing the patient’s room. This simple
reminder is often all that is needed to
correct behavior. Constructive feedback
should always be met with a thank you
and a change in behavior.

Cross-monitoring is tool to assist
in error reduction during team func-
tioning. Cross-monitoring allows team
members to take advantage of working
together and monitor unusual situa-
tions or hazards, identify safety slips
or lapses, and provide impromptu consultation and feedback. For example, TJC (2017,
March 1) has set an NPSG to improve the accuracy of patient identification. Because of
the negative outcomes that could occur if incorrect blood were administered to a patient,
the NPSG requires a two-person identification process if automated identification
technology is not available. The two-person process with a peer is an essential safety step
and reinforces teamwork when providing care. Some hospitals adopt a phrase such as
“I’ve got your back” to connote a supportive team environment (Figure 4.5). In this way,
staff support each other and feel comfortable asking each other for help.

Providing mutual support to team members builds a strong team and helps mem-
bers avoid work overload situations. Mutual support is the ability to anticipate team
members’ needs and provide assistance as needed through accurate knowledge about
their workloads and responsibilities. By providing mutual support and feedback to
a team member, team function is enhanced. Feedback should be timely, respectful,
specific, considerate, and directed toward quality improvement. Team members are
expected to advocate for the patient, particularly when a team member’s view doesn’t
coincide with that of the main decision maker on the team. If conflict erupts on the
team, the DESC tool can be used to manage and resolve the conflict: First, describe the
specific situation or behavior you are concerned about and provide concrete data about
it. Next, express how the situation makes you feel and what your concerns are. Third,
suggest alternative actions and seek agreement. Last, state possible consequences in
terms of impact on established team goals and strive for team consensus. Try using this
tool the next time you have a safety concern.

ASSESSING THE CULTURE OF A HIGH-RELIABILITY
ORGANIZATION

Organizational culture is the shared values and beliefs of individuals in a group or organi-
zation. Schein (2004) describes organizational culture at three levels: observable artifacts,
values, and basic underlying assumptions. Observable artifacts are visible manifestations
of values and may include signage, décor, dress code, traffic flow, medical equipment,

FIGURE 4.5 Three Edward Hospital
emergency department nurses have each
other’s backs.

112 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

and visible interactions. Values are explicitly stated norms and social principles and are
manifestations of an organization’s assumptions. Basic underlying assumptions are the
shared beliefs and expectations that influence perceptions, thoughts, and feelings about
an organization. They are the core of an organization’s culture. These assumptions define
the culture of the organization, but because they are invisible, they may not be recog-
nized. At times, the assumptions of an organization are unclear and self-contradictory,
especially when an organizational merger or acquisition has occurred.

Essentially, culture is how we act when no one is looking. Take for example,
Elizabeth, a patient care technician caring for a patient in isolation. Elizabeth entered
the patient’s room without donning appropriate personal protective equipment. She
deviated from policy and may have put herself, her family, patients, staff, and every-
one she encountered at risk of infection. When asked about her behavior, she admit-
ted that she knew the patient was in isolation and that she should put on a gown and
gloves. Elizabeth stated, however, that she did not think anyone was watching. This
illustrates an employee who has not yet internalized a culture of safety.

On the other hand, consider Tom, a housekeeper who informed his supervisor that
he found a piece of metal that came off the door handle in a restroom on the Adolescent
Behavioral Health Unit. Tom was concerned that there were sharp edges and that some-
one could get hurt. The supervisor asked facilities to fix the handle as quickly as possi-
ble. The facilities manager noted that two screws were missing and asked Tom if he had
found them. When Tom said no, the manager of the Adolescent Unit was notified of the
situation and staff members searched each patient’s room. After a long and exhaustive
search, the missing screws were located in a patient’s orthodontic retainer case. Because
of Tom’s attention to detail and willingness to speak up, the patient was kept safe from
harming himself. This scenario exemplifies an employee who is living a culture of safety.

Many organizations use a culture of safety survey tool to capture the perspectives
of healthcare providers. Two commonly used tools are the survey on patient safety
culture (AHRQ, 2017) and the safety attitudes questionnaire (Sexton et al., 2006).
Organizations may also choose to assess their stage of organizational maturity toward
becoming an HRO using a model proposed by Chassin and Loeb (2013).

To support a culture of patient safety and quality improvement, AHRQ spon-
sored the development of separate patient safety culture surveys for hospitals, nurs-
ing homes, medical offices, community pharmacies, and ambulatory surgery centers.
Each survey measures various dimensions of the safety culture. For example, the
hospital survey measures teamwork within units; supervisor/manager expectations
and actions promoting patient safety; organizational learning; management support
for patient safety; overall perceptions of patient safety; feedback and communication
about error; communication openness; frequency of event reporting; teamwork across
units; staffing; handoffs and transitions; nonpunitive response to errors; and number
of events reported; and asks the participant to assign a patient safety grade to the orga-
nization. The patient safety culture surveys are available in English and Spanish and
are publicly available at no cost on the AHRQ website (https://www.ahrq.gov/sops/
quality-patient-safety/patientsafetyculture/index.html).

AHRQ has established comparative databases for patient safety culture survey
data from organizations that administer the surveys. The databases allow healthcare
organizations to compare their patient safety culture survey results to similar sites in
support of patient safety culture improvement. AHRQ provides an action-planning
tool to assist an organization in analyzing and improving its patient safety culture.
Survey results are used by organizations to:

• Raise staff awareness about patient safety
• Diagnose and assess the current status of the patient safety culture

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 113

• Identify strengths and areas of opportunity for patient safety culture improvement
• Examine trends in patient safety culture changes over time
• Evaluate the cultural impact of patient safety initiatives and interventions
• Conduct internal and external evaluations of the culture of safety

The safety attitudes questionnaire was developed with funding from the Robert
Wood Johnson Foundation and AHRQ (med.uth.edu/chqs/surveys/safety-attitudes-
and-safety-climate-questionnaire/). The 36-item survey is designed to obtain frontline
staff perspectives about specific patient care areas. The key factors that are measured
on the survey are teamwork climate, safety climate, perceptions of management, job
satisfaction, working conditions, and stress recognition. The survey is known to be
accurate in measuring these factors and is used by healthcare organizations to com-
pare themselves to other organizations, identify interventions needed to improve
safety attitudes, and measure the effectiveness of the interventions.

Chassin and Loeb (2013) developed a grid to allow healthcare organizations to assess
their stage of organizational maturity toward becoming an HRO: beginning, develop-
ing, advancing, and approaching. Chassin and Loeb identified performance based on
position in the organization (board member, CEO/management, physicians); initia-
tives (quality strategy, quality measures, information technology); safety culture (trust,
accountability, identifying unsafe conditions, strengthening systems, and assessment);
and robust process improvement (methods, training, and spread). Their grid may be
used by leaders to assess their journey toward becoming an HRO.

IDENTIFYING AND OVERCOMING BARRIERS TO
HIGH RELIABILITY

Achieving high reliability in an organization is an ongoing journey, with many barri-
ers along the way. The culture, history, and traditions of a healthcare organization can
pose a barrier to becoming an HRO. Workplace intimidation and disruptive behaviors
can oppose the creation of an HRO. Blending various professional healthcare subcul-
tures into a common professional culture creates challenges for leaders. In addition,
the lack of robust health technology and information systems can undermine the abil-
ity to achieve high reliability and safety. Regardless of the challenges, organizations
can overcome each barrier.

Culture, History, and Traditions

The overall culture of an organization is a reflection of past learning experiences.
Revising the cultural patterns of basic assumptions and beliefs is difficult, time con-
suming, and anxiety provoking. If a past experience with reporting an error resulted
in punishment, it may deter future reporting of errors. The fear of punishment can be a
significant barrier to error reporting. Changing the culture requires a significant lead-
ership commitment to focus on healthcare processes and systems that lead to errors
rather than on individual blame. Considerable effort is required to change a long-
standing tradition of blame and punishment.

The history and traditions of a healthcare organization set the stage for becoming
an HRO. Some healthcare organizations assume that high reliability is not achievable in
healthcare. The amount of change needed to address the complexity of the work needed
to achieve HRO status may overwhelm the organization. The past history of how quality
improvements were made in the healthcare organization can limit future improvements.

114 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

For instance, a nurse is preparing an insulin injection at the medication station. When
reaching for an insulin syringe, the nurse discovers that insulin and tuberculin syringes
are mixed together in the same container. Using the wrong syringe would result in a
medication error. The last time a medication error was made on the unit, the nurse was
suspended for 3 days. Due to the punishment associated with the last medication error,
the nurse decides to separate the insulin and tuberculin syringes into two containers
rather than reporting the near miss. In this example, the organization does not have the
opportunity to examine why the two syringes were mixed together in the same container
since the nurse fixed the problem. Without knowledge of the near miss, no actions can be
taken to prevent the problem from occurring again.

Workplace Intimidation and Disruptive Behavior

Workplace intimidation and making others feel fearful, timid, orinferior destroys the
trust environment that is essential for a culture of high reliability. Workplace intimi-
dation is created by disruptive behaviors or behaviors that do not support a culture
that makes safety a priority. A culture of safety is a necessary element of an HRO.
Workplace intimidation behaviors such as refusing to answer a question, not answer-
ing a page, using nonverbal gestures of disapproval, and raising one’s voice need to be
eliminated in an HRO to build the critical component of trust. Accepting disrespectful
or disruptive behavior from any interprofessional team member is a potential threat to
quality and safety for an organization. Committed leaders must recognize and manage
this unwanted behavior to create a culture or safety.

Interprofessional Complexity

The complexity of the healthcare environment creates challenges for the HRO. The
safety of patient care relies on effective coordination and communication among the
diverse interprofessional staff who provide healthcare. Different members of the inter-
professional team come from very diverse educational preparation and may use dif-
ferent terminology. This diversity creates a challenge in making decisions required for
safe care. The complex dependency of healthcare processes requires coordination of
efforts across the healthcare continuum. For example, the coordination of interprofes-
sional healthcare processes is essential for a safe patient transition when preparing a
patient to be discharged from the acute care setting to the home environment. Extensive
coordination and clear communication among the entire healthcare team facilitates the
provision of posthospital services the patient may require, the prescriptions needed,
follow-up appointments, patient and family understanding of care instructions, and
appropriate transportation.

Hierarchies

Challenges inherent in healthcare hierarchies was discussed earlier in this chapter.
Traditionally, the physician was the leader in the provision of healthcare, and the hier-
archical roles of physicians, nurses, and organizational leadership create a challenge
to implementing the HRO principles. In contrast, the HRO values the perspective of
all healthcare team members. In doing so, the HRO works toward eliminating power
hierarchies and allowing for open communication among the interprofessional health-
care team to ensure safety.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 115

Information Systems

The use of health information systems for the documentation of care and the gather-
ing of quality and safety information is essential. Additionally, healthcare informa-
tion systems provide a means for reporting errors and near misses. The lack of health
information systems can impede progress to an HRO. Healthcare organizations may
be challenged with devoting scarce resources to implement information systems that
require significant capital expense and ongoing maintenance costs.

INTERNAL STRUCTURES AND ROLES TO SUPPORT
AN HRO

A strong infrastructure is needed to support the goals and strategies of the organi-
zation’s quest toward becoming an HRO. The governing body, typically the board
of directors, must set the priority for quality and safety. Implementing quality and
safety initiatives requires an executive team that is committed to leading an orga-
nization on the journey to high reliability. Nurses, physicians, and all members of
the interprofessional team must be engaged at all levels of the quality and safety
infrastructure.

The CEO sets the tone when creating an HRO. The CEO oversees safety and qual-
ity efforts within the organization. Often, the CEO chairs an interprofessional safety
and quality committee. Committee membership includes a patient safety officer; phy-
sicians; nurses; pharmacists; staff from risk management, quality, patient experience,
and infection control; and a community member. Multiple committees, defined in
Table 4.2, exist to support the overall work of the board of directors and the safety and
quality committee.

In addition to the committees discussed, certain departments and key positions
in an organization support the infrastructure of an HRO. Supporting departments can
perform multiple functions. They may ensure public reporting of quality and safety
data, identify external benchmarks, facilitate process improvements, participate in
external learning collaboratives, improve clinical documentation, detect and prevent
infections, expedite peer review, oversee regulatory and accreditation compliance,
provide risk management, and improve the customer experience.

Key positions in an organization also support the journey to high reliability. Not
all healthcare organizations will have every position described in the following, but
most will have a majority of the positions. A patient safety officer is the quality and
safety leader at the executive level. The patient safety officer provides leadership for
error prevention, error identification and reporting, and reduction of the severity of
harm. The role of the patient safety officer closely aligns to the role of risk manager.
The risk manager is responsible for protecting the assets of the organization by under-
taking activities to identify, evaluate, and reduce the likelihood of patient injury and
the risk of loss to the organization.

In the journey to high reliability, several new roles have emerged or expanded
in healthcare organizations. A human factors engineer (HFE) may be engaged in
an HRO as a support professional. Human factor engineering is an interprofes-
sional approach that looks at the safety and efficiency of work systems. The HFE
examines how people, policies, technology, and work structures interact to improve
quality, safety, efficiency, and reliability of healthcare provision. The HFE can also
function as educator and project consultant for clinical effectiveness and quality
improvement teams. A quality analyst can also function as an expert in the process

116 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

improvement methodologies and tools. A clinical documentation expert assesses
and supports documentation processes to ensure that they accurately reflect the
patient’s condition and the level of service required to meet the patient’s care need.

TABLE 4.2 COMMITTEES THAT SUPPORT A JOURNEY TOWARD HIGH RELIABILITY

Board Quality Committee Provides oversight for patient safety and quality of
care, including physicians and other professional
credentialing and privileging. In some hospitals, the
board of trustees may perform these functions.

Medical Staff Executive
Committee

Supports medical staff processes and clinical quality
improvement.

Credentials Committee Ensures that qualified, competent providers practice
in the organization.

Hospital Safety and Quality
Committee

Provides leadership to implement the safety and
quality plan.

Infection Control Committee Provides leadership for the infection prevention and
control program.

Utilization Review Committee Oversees appropriate utilization of care and services
provided by the hospital; ensures the management
of the appropriate admission status of the patient
(inpatient, outpatient, or observation) based on the
severity of the patient’s illness.

Medical Staff Quality
Committee

Conducts retrospective reviews of patient care (peer
review), focused professional practice evaluation,
and ongoing professional practice evaluation to
identify opportunities for improvement and to share
what was learned with other physicians, licensed
independent practitioners, and advanced practice
clinicians.

Safety Event Review
Committee

Reviews and classifies safety events and
commissions root cause analyses.

Nursing Quality Committee Fosters nursing and interprofessional performance
improvement activities.

Nursing Peer Review
Committee

Conducts retrospective reviews of nursing patient
care, focused professional practice evaluation, and
ongoing professional practice evaluation to identify
opportunities for improvement and to share what
was learned with other clinicians.

Pharmacy and Therapeutics
Committee

Provides leadership for safe medication processes.
May include a subcommittee focused on antibiotic
stewardship.

Environment of Care
Committee

Provides leadership for the ongoing evaluation and
improvement of the environment of care safety
management program.

Ethics Committee Provides support for ethical dilemmas that present
themselves in clinical care.

Institutional Review Board
Committee

Responsible for ensuring that all research practices
are safe and follow standard guidelines for the
conduct of research.

Workplace Safety Committee Reviews workplace injuries and sets goals and
strategies for improving workplace safety.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 117

A patient experience expert provides leadership to ensure that the patient receives
respectful and coordinated care and to facilitate a process to address complaints
that may arise when failure to meet patient’s healthcare expectations occur.

As healthcare increases its focus on coordinated healthcare across multiple
providers and settings, many organizations are expanding care management and
social services to encompass transitional care for patients. This community case
management role focuses on ensuring safe patient transitions to home or to another
healthcare service. An initial primary focus is on the transition from hospital to
home for patients with chronic disease and end-of-life issues to ensure that health-
care is provided seamlessly. Transitional care nurses help coordinate care between
transitions to different care settings such as hospital to home healthcare and assist
patients to navigate the complex healthcare system. A well-defined organization
infrastructure that promotes teamwork and communication supports the transi-
tion to an HRO.

EXTERNAL INFLUENCES FOR CHANGE AND HRO
RESOURCES

Increasingly, the government is mandating that hospitals publicly report safety, qual-
ity, and financial indicators. This transparency is designed to help the consumer make
informed choices about selecting healthcare providers. Transparency holds healthcare
providers and organizations accountable for quality care. In other purchase transac-
tions, consumers can easily obtain information about cost and value to make informed
purchases. Healthcare is now being asked to follow the same practice of transparency.
Public awareness of medical errors, poor quality outcomes, and perceived low value
are driving changes in healthcare.

Centers for Medicare and Medicaid Services

Healthcare costs have escalated along with poor quality of care and patient outcomes,
healthcare errors, and waste. Historically, organizations were rewarded for the vol-
ume of healthcare services delivered instead of for their achievement of high-quality
and safety outcomes. For example, a hospital used to be reimbursed for the number
of appendectomies performed regardless of the outcome. As previously described,
safety, quality, and experience outcomes now affect hospital reimbursement. In addi-
tion, safety, quality, and patient experience data are posted on the CMS website (www.
medicare.gov/hospitalcompare/search.html). Last, the Centers for Medicare and
Medicaid Innovation was created as part of the Affordable Care Act to enhance the
quality of healthcare and reduce costs through innovative approaches to healthcare
delivery.

Leapfrog

Leapfrog, a business consortium, is a voluntary reporting agency that collects and
publishes quality information. The Leapfrog website allows insurance companies
and the public to access hospital ratings and use the information to make informed
healthcare decisions. The Leapfrog consortium works on behalf of the public and

118 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

employers to inform Americans about the performance of hospitals on quality
measures. The Leapfrog group promotes full disclosure of hospital performance
information and helps provide employers with information to provide the best health-
care benefits to employees.

Accreditation Agencies

Several accrediting agencies for hospitals address patient safety. These agencies
include TJC, Healthcare Facilities Accreditation Program (HFAP), and Det Norske
Veritas Healthcare, Inc. (DNV, n.d.; Meldi, Rhoades, & Gippe, 2009).

The mission of TJC is to continuously improve healthcare for the public, in col-
laboration with other stakeholders, by evaluating healthcare organizations and inspir-
ing them to excel in providing safe and effective care of the highest quality and value
(TJC, 2017). TJC uses the Donabedian conceptual framework of structure, process, and
outcomes to assess an organization. Using this framework, TJC (2017, March 1) set 11
expectations for leadership in developing a safety culture as follows:

1. Create a transparent, nonpunitive approach to reporting and learning from
adverse events, close calls, and unsafe conditions.

2. Establish clear, just, and transparent risk-based processes for recognizing and sep-
arating human error and error arising from poorly designed systems from unsafe
or reckless actions that are blameworthy.

3. Adopt and model appropriate behaviors and champion efforts to eradicate intimi-
dating behaviors.

4. Establish, enforce, and communicate to all team members the policies that support
safety culture and the reporting of adverse events, close calls, and unsafe conditions.

5. Recognize team members who report adverse events and close calls, who identify
unsafe conditions, or have good suggestions for safety improvements.

6. Establish an organizational baseline measure on safety culture performance using
the AHRQ hospital survey on patient safety culture or another tool, such as the
safety attitudes questionnaire.

7. Analyze safety culture survey results from across the organization to find oppor-
tunities for quality and safety improvement.

8. Develop and implement unit-based quality and safety improvement initiatives
designed to improve the culture of safety.

9. Embed safety culture team training into quality improvement projects and orga-
nizational processes to strengthen safety systems.

10. Proactively assess system strength and vulnerabilities and prioritize them for
enhancement or improvement.

11. Repeat organizational assessment of safety culture every 18 to 24 months to
review progress and sustain improvement.

HFAP was originally created in 1945 to conduct an objective review of services
provided by osteopathic hospitals. In 1965, HFAP received authority from the CMS to
provide accreditation to hospitals, ambulatory care/surgical facilities, mental health
facilities, physical rehabilitation facilities, clinical laboratories, and critical access hos-
pitals. HFAP has adopted the 34 Safe Practices set forth by the National Quality Forum
(NQF) in 2009 (HFAP, 2017).

DNV is dedicated to empowering quality and patient safety through an efficient
and outcomes-based accreditation program. DNV received authority from the CMS to

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 119

provide accreditation to hospitals in 2008, and has accredited nearly 500 hospitals of
all sizes and in every region of the United States. They integrate the CMS Conditions
of Participation with the ISO 9001 Quality Management Program. The ISO 9001 qual-
ity system is a structured way of delivering a better service or product, supported
by detailed procedures such as work instructions, quality manuals, and written qual-
ity policies to provide all employees with detailed, understandable, and workable
instructions that define both expectations and actions to achieve the stated quality
goals. DNV’s goal is to enable a broader culture change toward high performance and
continual improvement by combining the mandatory CMS evaluation with a quality
management system into one seamless program.

State Requirements

Along with the quality and safety measures publicly reported by the CMS, many states
are now requiring some form of mandatory reporting of safety and quality indicators
and specific adverse events.

Public Recognition of Quality Achievements

In the race to achieve competitive advantages for patient safety and quality, health-
care organizations are seeking recognitions that set them apart from other healthcare
organizations. The Baldrige Award recognizes organizations that have improved
and sustained quality results. The purpose of the Baldrige Award in healthcare is
to challenge organizations to improve their effectiveness of care and healthcare out-
comes to pursue excellence, which moves organizations toward becoming an HRO.
The Baldrige framework embraces integration among leadership, strategy, custom-
ers, workforce, operations, and results. The Baldrige framework is built on core val-
ues and concepts and requires measurement, analysis, and knowledge management
(NIST, 2016).

Designation by the American Nurse’s Credentialing Center (ANCC) as a Magnet®
organization denotes nursing excellence and is factored into payer reimbursement and
recognition (ANCC, 2013). The components of the Magnet Recognition Program®,
discussed in Chapter 1, are congruent with the HRO concepts. The Magnet® com-
ponents include Transformational Leadership; Structural Empowerment; Exemplary
Professional Practice; New Knowledge, Innovations, and Improvements; and Empirical
Outcomes. The original forces of Magnetism emphasized structure and process. The
current Magnet Model recognizes that an excellent infrastructure must result in posi-
tive outcomes in order to create a culture of excellence and innovation. Safety is a main
component of a culture of excellence.

The Transformational Leadership component of the Magnet Model requires
strong advocacy and support for staff and patients by all nursing leaders. In a Magnet-
designated hospital, the CNO is an active leader in creating an HRO by establish-
ing strategic goals for quality and safety in conjunction with the hospital’s executive
team. These strategic goals support the organization’s commitment to zero major
quality failures. For example, one source of evidence related to Transformational
Leadership calls for nurse leaders and clinical nurses to advocate for resources to
support nursing unit and organizational goals. The Structural Empowerment com-
ponent of Magnet addresses the need to create structures and processes that allow

120 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

nurses to practice safely and effectively. For example, one source of evidence related
to Structural Empowerment calls for clinical nurse involvement in interprofessional
decision-making groups at the organizational level. In total, five of the 11 Structural
Empowerment sources of evidence address the culture of safety for patients and
nurses. Both the Transformational Leadership and Structural Empowerment compo-
nents of Magnet require the active engagement of nurses.

The Exemplary Professional Practice component of Magnet indicates that “achieve-
ment of exemplary professional practice is grounded in a culture of safety, quality
monitoring, and quality improvement” (ANCC, 2013, p. 42). Many of the Exemplary
Professional Practice sources of evidence require documentation of safe nursing prac-
tices. For example, Magnet acute care organizations with ambulatory services are
required to report on these six nurse-sensitive clinical indicators: patient falls with
injury, hospital-acquired pressure ulcers, central line-associated bloodstream infection,
CAUTI, one indicator from the Core Measures Set, and one indicator from primary or
specialty outpatient services. The performance on each of these indicators must exceed
the mean or median value on the majority of units the majority of the time to meet
Magnet standards. The New Knowledge, Innovations, and Improvements component
of Magnet requires nurses to use evidence and innovation for safe, high quality care.
Last, the Empirical Outcomes component of Magnet requires the organization to con-
tinually assess and monitor a variety of indicators for nursing leadership and clinical
practice. Sustained quality performance on empirical outcomes will move an organi-
zation on the journey to becoming an HRO.

Additional Resources for Organizations Striving for High Reliability

A patient safety organization (PSO) is a group, institution or association that improves
patient care by reducing errors. PSOs exist to allow organizations to learn from their
own safety events and the safety events of others. The Patient Safety and Quality
Improvement Act of 2005 (Public Law 109–41), signed into law on July 29, 2005, was
enacted in response to growing concern about patient safety in the United States and
the IOM’s (1999) report To Err Is Human. A healthcare provider can obtain the confi-
dentiality and privilege protections of the act by working with a federally listed PSO.

A nurse works for an organization that has achieved Magnet designation. The
nurse is a member of the Quality and Safety Unit Practice Council. As a member
of the Council, the nurse is assigned the task of educating nursing and other peers
on how the Magnet designation supports and helps the organization become an
HRO. Complete a web literature search on the Magnet components and correlate
the key Magnet principles to the HRO concepts.

1. How do the Magnet components support the organizational requirements for high
reliability?

2. How do the Magnet components align with the HRO process concepts?
3. How do the Magnet components support a culture of safety?

CASE STUDY 4.2

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 121

The law provides confidentiality protections and privilege protections, which means
the information cannot be included in a law suit. A complete list of federally approved
PSOs may be found on the AHRQ website (www.pso.ahrq.gov/listed).

The AHRQ’s mission is to produce evidence to make healthcare safer, higher
in quality, more accessible, equitable, and affordable, and to work with the U.S.
Department of Health and Human Services and with other partners to make sure that
research findings are understood and used. AHRQ creates materials to teach and train
healthcare systems and professionals to put the results of research into practice and
funds a variety of initiatives. In addition to the AHRQ initiatives already discussed in
this chapter, successful initiatives include the following:

• Re-Engineered Discharge (RED)—a structured protocol and suite of implementa-
tion tools that help hospitals rework their discharge processes to reduce readmis-
sions by determining patients’ needs and carefully designing and communicating
discharge plans.

• The Comprehensive Unit-based Safety Program (CUSP)—a highly effective
method of preventing healthcare-associated infections (HAIs) by combining
improvement in safety culture, teamwork, and communication.

• EvidenceNOW, an initiative aligned with Million Hearts®—provides clinical
practice support to over 5,000 primary care physicians with the goal of improving
the heart health of millions of patients and improving the capacity of the practices
to incorporate new research findings and information into practice.

• AHRQ’s Healthcare Cost and Utilization Project—helps highlight the opioid over-
dose epidemic and contributed to the Department of Health and Human Services’
launch of a major multipronged initiative to reduce opioid abuse.

The work of the IHI began in the late 1980s as part of the National Demonstration
Project on Quality Improvement in Health Care to redesign healthcare into a sys-
tem without errors, waste, delay, and unsustainable costs. IHI uses the science of
improvement approach to work with health systems, countries, and other orga-
nizations on improving quality, safety, and value in healthcare. The approach is
characterized by the combination of expert subject knowledge with improvement
methods and tools. It is interprofessional, drawing on clinical science, systems the-
ory, psychology, statistics, and other fields.

IHI’s methodology traces back to W. Edwards Deming (1900–1993), who taught
that by adhering to certain principles of management, organizations can increase
quality and simultaneously reduce costs. Based on Deming’s work, the IHI Model for
Improvement asks three questions as follows:

1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in improvement?

The Model then employs Plan-Do-Study-Act (PDSA) cycles for small, rapid-cycle tests of
change. IHI uses the Model for Improvement in all of its improvement efforts (IHI, 2017a).

The vision of the National Patient Safety Foundation (NPSF, 2017) is to create a
world where patients and those who care for them are free from harm. A central voice
for patient safety since 1997, NPSF partners with patients and families, the health-
care community, and key stakeholders to advance patient safety and healthcare work-
force safety and disseminate strategies to prevent harm. Committed to a collaborative
approach in all that it does, the NPSF offers a portfolio of programs targeted to diverse
stakeholders across the healthcare industry. The American Society of Professionals in

122 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Patient Safety (ASPPS) is part of NPSF. It provides education and oversees profes-
sional certification (ASPPS, 2017).

The Institute for Safe Medication Practices (ISMP) is the nation’s only nonprofit
organization devoted entirely to medication error prevention and safe medication use.
It is respected worldwide as a resource for impartial, timely, and accurate medication
safety information. ISMP’s medication error prevention efforts began in 1975. ISMP
began a voluntary practitioner error-reporting program to learn about errors happen-
ing across the nation, understand their causes, and share “lessons learned” with the
healthcare community. Today, ISMP’s initiatives, which are built upon a nonpunitive
approach and system-based solutions, fall into five key areas: knowledge, analysis,
education, cooperation, and communication (ISMP, 2017).

ISMP is also responsible for reviewing all medication error reports submitted by
healthcare facilities to the Commonwealth of Pennsylvania Patient Safety Authority.
Each year, ISMP’s national Medication Errors Reporting Program (MERP) receives hun-
dreds of error reports from healthcare professionals. In addition, ISMP’s wholly owned
corporate subsidiary, Med-ERRS (Medical Error Recognition and Revision Strategies),
works directly and confidentially with the pharmaceutical industry to prevent errors
that stem from confusing or misleading naming, labeling, packaging, and device design.

The mission of NQF is to improve the quality of healthcare. Patient safety
is central to achieving this mission. Of the over 600 NQF-endorsed quality mea-
sures, approximately 100 are patient-safety focused. NQF has also endorsed 34
Safe Practices for Better Healthcare and 28 Serious Reportable Events (NQF, 2017).
Despite these achievements, there are still significant gaps in the measurement of
patient safety. By convening panels and other educational forums, NQF works with
quality measure developers and others in healthcare to help understand measure-
ment gaps and encourage strategies to fill them. A list of 28 adverse events, also
called never events because they should never occur in healthcare, is grouped into
six categories: surgical, product or device related, patient protection, care manage-
ment, environmental, radiologic, and potential criminal events (www.qualityfo-
rum.org/topics/sres/serious_reportable_events.aspx).

Medical Product Safety Network (MedSun)

The Medical Product Safety Network (MedSun) is an adverse event reporting program
launched in 2002 by the U.S. Food and Drug Administration’s Center for Devices and
Radiological Health (FDA, 2017). The primary goal for MedSun is to work collaboratively
with the clinical community to identify, understand, and solve problems with the use of
medical devices. Once a problem is identified, MedSun clarifies the problem and shares
lessons learned with the clinical community and the public, without facility and patient
identification, so that clinicians nationwide may take necessary preventive actions.

The Safe Medical Devices Act defines device user facilities as hospitals, nursing
homes, and outpatient treatment and diagnostic centers, and requires them to report
medical device problems that result in serious illness, injury, or death. MedSun par-
ticipants are also highly encouraged to voluntarily report problems with devices, such
as “close-calls,” potential for harm, and other safety concerns. By monitoring reports
about problems and concerns before a more serious event occurs, the FDA, manufac-
turers, and clinicians work together proactively to prevent serious injuries and death.
Human Factor Engineers can play a key role here, as they examine how clinicians,
products, policies, and the work environment interact to affect safety.

Healthcare organizations are recognized for reporting events that result in
manufacturing changes. For example, Nancy is a nurse in the ICU. She received

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 123

a patient from surgery who was wearing a purple armband, which designates a
Do Not Resuscitate (DNR) status in Nancy’s hospital. There was no indication of
a DNR order for this patient, so Nancy asked the patient about the purple band.
The patient explained that she received the purple band at an outpatient surgical
center when her port was implanted. It was part of the port kit provided by the
manufacturer, and staff suggested that the patient wear the band to remind health-
care providers of her port. Nancy then explained the meaning of the band at most
hospitals. When the patient heard this, she stated her desire to be resuscitated,
Nancy asked permission to remove the band. The patient granted this permission
and Nancy reported the event as a near miss. Nancy received a Good Catch award
for averting harm. In addition, the organization reported the event to MedSun.
MedSun worked with the manufacturing company to change their practices and
the company stopped including the purple band in their port kits. This is an exam-
ple of high reliability at its finest—focusing on improving patient safety internally
and nationally.

The journey toward high reliability is complex and involves every aspect of an
organization. Errors in healthcare cause harm to patients. Healthcare organizations
can apply what has been learned in other safety-focused industries to improve patient
safety. Nurses are in a strong position to advocate for patient safety and lead interpro-
fessional efforts to achieve high reliability. While barriers to HRO exist, they can be
overcome with the use of internal and external resources.

KEY CONCEPTS

• An HRO targets near-zero rates of failure.
• Characteristics that differentiate healthcare HROs from other healthcare organiza-

tions are preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise.

• Being a HRO affects a healthcare organization’s safety, quality, patient experience,
and financial performance.

• Healthcare has learned a great deal about high reliability from other industries, such
as commercial aviation and nuclear power.

• To achieve high reliability, an organization must have strong leadership commit-
ment, an established culture of safety, and a well-developed quality improvement
program.

• A fair and just culture minimizes blame and punishment and creates a learning envi-
ronment where errors are reported so that system problems can be corrected.

• The nurse is responsible for implementing internal behaviors and communication
techniques and working effectively in an interprofessional team in a healthcare HRO.

• Organizational culture can be assessed with valid and reliable tools to support a
journey toward becoming an HRO.

• Barriers to achieving high reliability may include culture, history and traditions,
workplace intimidation and disruptive behavior, interprofessional complexity, hier-
archies, and information systems.

• A healthcare organization’s infrastructure must provide support to achieve high
reliability.

124 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

• Many organizations influence a healthcare organization’s decision to become an
HRO and provide support for the journey toward high reliability.

• The components of the Magnet Recognition Program are congruent with HRO concepts.

KEY TERMS

Adverse event or serious safety event
AHRQ
Authority gradient
Baldrige Award
Comorbidities
Cross-monitoring
Culture of safety
Daily safety huddle
Error
Fair and just culture
Financial performance
FMEA
Hierarchy
HRO
IHI
ISMP
Knowledge-based performance

Magnet
Mutual support
Near miss safety event
NQF
Organizational culture
Patient experience
Precursor safety event
PSO
Quality
RCA
Reliability
Rule-based performance
Safety
Sentinel event
Skill-based performance
Transparency
Work arounds

REVIEW QUESTIONS

1. Which of the following recommendations was not made by the Institute of
Medicine’s publication To Err Is Human?

A. Identify and learn from errors.
B. Avoid talking about errors.
C. Improve safety.
D. Ensure safe practices at the delivery level.

2. Which statements about an HRO are false? Select all that apply.

A. HROs avoid discussing failures.
B. HROs explore a variety of reasons for errors and are reluctant to simplify

explanations.
C. HROs are aware of the many factors that influence the care environment.
D. HROs understand that decisions should be made by the highest ranking

official.
E. HROs know that when small things go wrong it is often a sign of a larger

problem.

3. Errors occur when there is a deviation from generally acceptable performance
standards. Which of the following is not an example of a generally acceptable per-
formance standard?

A. Professional practice standard.
B. Article published in the Wall Street Journal.

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 125

C. Evidence-based policy.
D. Evidence-based order set.

4. High reliability affects the entire organization. Which of the following statements
is false?

A. Quality often improves in HRO organizations.
B. An HRO improves patient and staff safety.
C. Enhanced communication and reliability helps to increase patient satisfaction

in HROs.
D. Financial performance is negatively impacted in HROs.

5. Healthcare can learn about high reliability from a variety of other industries.
Which of the following statements is false?

A. Commercial aviation found that the most common cause of error was mechani-
cal failures.

B. The Institute of Nuclear Power Operations believes that trust and respect are
needed in an HRO.

C. Human beings can make skill-based, rule-based, and knowledge-based errors.
D. Commercial Aviation embraced CRM training programs in an effort to enhance

communication in the cockpit.

6. Leadership plays an important role in creating an HRO. Which of the following
statements demonstrates the best understanding of the role of leadership?

A. Leaders are accountable for the provision of effective and efficient care while
protecting the safety of patients, employees, and visitors.

B. Leaders must identify system problems and ask employees to fix them.
C. While fostering a learning environment, leaders must never discipline employ-

ees for their behaviors.
D. Leaders may rely solely on technology to build and reinforce accountability.

7. A nurse is asked how quality, safety, and performance improvement are addressed
in an HRO. Which response demonstrates the best understanding?

A. “We have an interprofessional committee on our unit that looks at patient
outcomes, practice issues, and most recently, the number of falls on our unit.
Together, we figure out the best way to fix the problem and suggest changes.”

B. “A couple of nurses got together last night to look at the number of falls on our
unit. We are concerned about the problem and think there is a better way to do it.”

C. “I saw an article about falls on a unit like ours. I took the article to work to
show my unit director but she said the solution isn’t feasible on our unit.”

D. “Our fall rates are so high that the physical therapist formed a committee to
address the issue and came back to the nursing staff with some recommenda-
tions for changes in our care delivery.”

8. Which of the following methods are helpful for assessing the culture of an HRO?
Select all that apply.

A. Observe the behaviors of employees when they think no one is watch-
ing to determine if they are adhering to the policies and expectations of the
organization.

B. Review safety event reports, including near miss, precursor, and serious safety
events.

126 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

C. Use a standard tool to assess the patient safety of the organization.
D. Assume the culture exists if process improvement activities are underway.

9. Many barriers keep healthcare organizations from becoming HROs. Which of the
following statements is false?

A. Culture, history, and tradition may be a barrier to becoming an HRO.
B. Information systems always serve as a barrier to creating an HRO.
C. Workplace intimidation and disruptive behavior cannot be tolerated in an HRO.
D. The hierarchical roles of physicians, nurses, and organizational leadership cre-

ate a challenge to implementing HRO principles.

10. Which of the following external organizations strongly influence hospitals to
change to become HROs? Select all that apply.

A. CMS
B. Magnet recognition by the American Nurses Credentialing Center
C. The National Labor Relations Board and Office of Human Subjects Protection
D. Accreditation agencies, such as TJC and DNV
E. Consumer groups, such as Leapfrog
F. Vendors of EHRs

REVIEW ACTIVITIES

1. During one of your clinical days, ask nurses to describe the process in place to
report an error in their hospital and what happens when an error is reported. Ask
the nurses if they have ever reported an error. Based on what you have learned, is
the reporting method focused on blame or learning?

2. Leaders are responsible for creating a culture of high reliability. Review the roles of
the leader as outlined in this chapter. During your next clinical rotation, assess the
culture of the healthcare organization. Is it obvious that the leaders are commit-
ted to safety? Are the leaders visible? Does the healthcare organization provide a
learning environment? Are process improvements underway? Is technology used
to enhance safety?

3. Review the chapter content related to Safety Stories. Why is it important to share
Safety Stories? How does it strengthen the HRO culture and a healthcare organiza-
tion? During your next clinical day, identify a Safety Story and share it with your
classmates.

4. Review the chapter content related to the Science of Human Error. Why is it impor-
tant to know if the error is skill-based, rule-based, or knowledge-based? What
types of errors have you made in your personal or professional life? What types of
tools would be helpful in preventing these errors?

5. Review the chapter content related to the SBAR and I PASS the BATON commu-
nication tools. The next time you are providing care, try using one of these tools
in your handoff to another provider. How effective was the tool? Did the tool help
you to organize your thoughts more concisely? Did it prompt you to share the
most pertinent information?

6. Review the external forces that influence the need for change in quality and safety.
How does transparency influence quality and safety? What resources are available
to assist a healthcare organization on the road to high reliability?

4 QUALITY AND SAFETY IN HIGH-RELIABILITY ORGANIZATIONS • 127

CRITICAL DISCUSSION POINTS

1. Consider a recent clinical experience. What characteristics of an HRO were vis-
ible? Describe what you felt met the explanation in the text of characteristics
of HROs.

2. Interview a nurse about the error reporting process in his or her current practice
setting. Is it anonymous? Does it include reporting near misses or just errors? Ask
if the nurse feels comfortable reporting his or her own or other’s errors. Why or
why not?

3. What would you consider a priority for an organization that is working towards a
culture of safety? Explain why you selected the priority.

EXPLORING THE WEB

1. Go to the website for the AHRQ (www.ahrq.gov). Review one of the patient safety
survey tools. How would you complete the survey for the site of your most recent
clinical rotation?

2. Go to the website for the CMS Hospital Compare at www.medicare.gov/hospital
compare/search.html. Review the ratings for several hospitals close to your zip code.

3. Go to TJC website at www.jointcommission.org. Review their vision for health-
care. Review the most recent NPSGs.

REFERENCES

Agency for Healthcare Research and Quality (AHRQ). (2013a). Agency for Healthcare Research and
Quality (AHRQ). Retrieved from https://www.ahrq.gov

Agency for Healthcare Research and Quality (AHRQ). (2013). TeamSTEPPS pocket guide. Retrieved
from https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html

Agency for Healthcare Research and Quality (AHRQ). (2017). Surveys on patient safety cultureTM.
Retrieved from https://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/
index.html

American Association of Critical-Care Nurses (2015). AACN Scope and Standards for Acute and
Critical Care Nursing Practice. Aliso Viejo, California: AACN.

American Nurses Credentialing Center (ANCC). (2013). 2014 Magnet application manual. Silver
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American Nurses Association. (2010). Position statement: Just culture. Retrieved from http://
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ASPPS. (2017). American Society of Professionals in Patient Safety. Retrieved from http://www.
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Association for Professionals in Infection Control and Epidemiology. (2017). Health care- associated
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The Beryl Institute. (2017). Retrieved from http://www.theberylinstitute.org/
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2017. Retrieved from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_
HAP_Jan2017.pdf

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Makary, M. A., & Daniel, M. (2016, May 3). Medical error—The third leading cause of death in
the U.S. British Medical Journal, 353, i2139.

Marx, David (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives.
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SUGGESTED READINGS

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Creating a fair and just culture: One institution’s path toward organizational change. The
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Francis Group.

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MD: Agency for Healthcare Research and Quality.

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Patient safety and quality: An evidence-based handbook for nurses (chap. 4). AHRQ Publication
No. 08–0043. Rockville, MD: Agency for Healthcare Research and Quality.

Upon completion of this chapter, the reader should be able to

1. Identify the three branches of the U.S. Government.

2. Define the role of Administrative Agencies.

3. Review the role of law in shaping nursing practice.

4. Identify the four elements of negligence.

5. Discuss negligence and malpractice.

6. Review the Health Insurance Portability and Accountability Act of 1996
(HIPAA).

7. Discuss Medicare.

8. Discuss the Anti-Kickback Law.

9. Discuss the Stark Law.

10. Review the International Council of Nurses’ Code of Ethics and the American
Nurses Association’s Code of Ethics.

11. Describe common ethical principles that influence the practice of nursing.

5
LEGAL AND ETHICAL ASPECTS
OF NURSING

Theodore M. McGinn

As a nurse, we have the opportunity to heal the heart, mind, soul and body of our patients, their
families and ourselves. They may not remember your name but they will never forget the way you
made them feel.

—Maya Angelou

132 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Y
ou are a nurse with 15 years of experience and have always been proud of the care
you provide and the rapport you create with your patients and their families. Late one
evening, the ED calls with handoff report for an admission to your unit. During report,
you learn that while in the ED for the past 14 hours, the patient has been uncooperative,

difficult to manage, and lashing out at staff and other patients. The patient was in a motor vehicle
accident and tested positive for both alcohol and drugs. Upon arrival to the ED, the examination
of the patient revealed two broken ribs, bruising on his chest, and multiple facial lacerations. The
ED nurse states that the patient is currently stable and must be moved immediately because
they are expecting multiple patients with critical injuries to arrive in the ED shortly. Currently, your
medical–surgical unit is short-staffed because of nurse call-offs. The patient arrives on the unit
and is quiet and withdrawn. His initial vital signs include a pulse rate of 110 and blood pressure of
90/50. These assessment findings concern you, so you make a note of rechecking the patient’s
vitals after you assess your other patients. Within an hour of admission, before you have an
opportunity to reassess the patient, the patient experiences a cardiac arrest and dies. Three
weeks after the incident you are informed of a lawsuit that has been filed and that you are named
as a defendant.

1. Will you be arrested and have to go to jail?
2. Should you call the patient’s family and apologize?
3. Will you lose your nursing license?
4. Should you hire a lawyer?

The law provides guidance for the way we live our lives and, in many instances, for the
manner in which we conduct our work. The healthcare system is highly regulated with laws
and regulations that guide the way nurses interact with patients and identify the rights that
patients can legally expect during healthcare delivery. These laws and regulations derive from
federal statutes, state statutes, state common law, and administrative rules and codes. Simply
put, nurses are bombarded with laws.

The expanding role of the nurse in direct patient care and the expanding roles that nurses
occupy in our healthcare system make it imperative that nurses understand our current legal
system and nurses’ role in complying with the laws governing nursing practice. Advances in
technology, healthcare, and pharmacology are also constantly changing the care that is reasonably
expected to be provided to the patient. As an integral part of the healthcare system with significant
interaction with patients and families, nurses must not only stay current with emerging risks and
trends, but must also assume leadership and management in designing healthcare systems and
processes to minimize those risks.

This chapter describes the three branches of the U.S. government system and defines
the role of administrative agencies. It reviews the role of law in shaping nursing practice and
discusses negligence and malpractice. The chapter reviews the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and discusses Medicare. It also discusses the Anti-Kickback
Law and the Stark Law. Finally, the chapter reviews the International Council of Nurses’ Code
of Ethics and the American Nurses’ Association Code of Ethics and describes common ethical
principles that influence the practice of nursing.

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 133

THE U.S. GOVERNMENT SYSTEM

Following the American Revolution, the nation floundered under the Articles of
Confederation. The Founding Fathers, Benjamin Franklin, George Washington, Thomas
Jefferson, and Alexander Hamilton, understood that the Articles of Confederation
failed miserably in that too much power was left to the individual states. Without
an effective central government, the United States lacked a cohesive economic and
political structure. As more states became interested in changing the Articles of
Confederation, a meeting was set in Philadelphia on May 25, 1787. This became the
Constitutional Convention. It was quickly realized that changes would not work and
instead the entire Articles needed to be replaced (Kelley, 2017). On March 4, 1789, the
government under the Articles of Confederation was replaced with the federal gov-
ernment under the Constitution (Rodgers, 2011). The new Constitution provided for
a much stronger federal government by establishing a chief executive (the President),
courts, and taxing powers.

In drafting the U.S. Constitution, the Founding Fathers set forth three branches of
federal government, each with specific and occasionally overlapping roles and duties.
They devised this federal government with a separation of powers, a government sys-
tem with checks and balances that allow one branch of government to limit another
and that ensure that no one single branch of government can ever have total control or
power. For example, the U.S. Supreme Court may declare a law passed by Congress and
signed into law by the President as unconstitutional. The three branches of the federal
government are the executive branch, the legislative branch, and the judicial branch.

Branches of Government

The executive branch of the federal government consists of the office of the president
of the United States. The executive branch of the government shapes the agenda for
the country. This agenda is theoretically based on promises made during elections and
is often based on how the president’s party seeks to advance its agenda. The president
has a significant role in making law. Although the president does not write legisla-
tion, the president can approve a bill passed by Congress, thus making it a law. The
president may also veto a bill, preventing it from becoming a law. This veto may be
overturned by Congress. The president is responsible for the execution and implemen-
tation of federal laws, often through the members of the Cabinet and through numer-
ous governmental agencies. The president is also the Commander in Chief, responsible
for defending the country and leading the U.S. Armed Forces. The president can sign
treaties, issue executive orders, declare states of emergency, make appointments to the
judiciary, and grant pardons.

The legislative branch of the federal government has the responsibility under the
U.S. Constitution to make laws. This branch of government is also known as Congress.
It is composed of the House of Representatives and the Senate. The Founding Fathers
were very intentional when they defined the duties of the legislative branch and when
they set the terms for holding office. The members of the House of Representatives
are elected to 2-year terms. Currently, there are 435 members of the House of
Representatives. The number of representatives each state has is based on the respec-
tive state’s population. The members of the Senate are elected to 6-year terms. Each
state has two senators.

134 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

The legislative branch also has the power to tax and spend. It may regulate inter-
state commerce, borrow money, and ratify treaties signed by the president. The legis-
lative branch has the sole power to approve members appointed by the president to
the judiciary. Finally, the legislative branch has the sole power of impeachment of the
president, judges, and members of Congress.

The judicial branch of the federal government has the responsibility of interpreting
federal laws and ensuring that the laws are in compliance with the U.S. Constitution.
The Supreme Court judges who comprise the judicial branch are appointed by the
president and approved by Congress. Justices of the Supreme Court are appointed for
lifetime terms. This is intended to ensure that Supreme Court justices are not subject to
the whims of the electorate who may seek to have a federal or Supreme Court justice
removed from his or her position because he or she rendered a decision in a manner
that might have been contrary to other political beliefs. Judges are expected to base
their decisions only on the facts of the case at hand and their interpretation of the law
relevant to the case.

Administrative Agencies

The legislative branch and the executive branch of the federal government often del-
egate authority to governmental administrative agencies. These governmental admin-
istrative agencies may arise under the cabinets of various presidents. Other agencies
are created by Congress by statute. The 50 states also have a web of state governmental
agencies in existence. Regardless of the source, such agencies permeate the landscape
of America.

One of the most influential agencies in the healthcare industry is the U.S.
Department of Health and Human Services (HHS). This agency consists of 11 operat-
ing units that influence laws surrounding many aspects of our healthcare delivery
system, including payment of healthcare services, regulation of medical drugs and
devices, vaccine programs, healthcare research, and patient safety. HHS agencies can
also write regulations but often run into difficulties with some of the branches of gov-
ernment, for example, when Congress refuses to allocate dollars to enact laws. Table 5.1
lists the agencies under HHS and briefly describes its most important functions. Many
of these HHS agencies are familiar to nurses working both in direct patient care and
in administration.

CRITICAL THINKING 5.1

President Jones was elected in 2022 on a campaign promoting tax code reform.
Unfortunately for President Jones, the other party has control of Congress. After several
months of inaction, President Jones becomes impatient and orders the Internal Revenue
Service to reduce the effective tax rates across the board.

1. Is that constitutional?
2. Will President Jones be able to reduce the tax code?

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 135

TABLE 5.1 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) AGENCIES AND
FUNCTIONS

U.S. DEPARTMENT OF
HEALTH AND HUMAN
SERVICES AGENCY MOST IMPORTANT FUNCTIONS

The Administration
for Children and
Families

Promotes the economic and social well-being of families,
children, individuals, and communities through a range of
educational and supportive programs in partnership with
states, tribes, and community organizations.

The Administration for
Community Living

Increases access to community support and resources for
the unique needs of older Americans and people with
disabilities.

The Agency for
Healthcare Research
and Quality

Produces evidence to make healthcare safer, higher quality,
more accessible, equitable, and affordable, and to work
within the HHS and with other partners to make sure that
the evidence is understood and used.

The Agency for Toxic
Substances and
Disease Registry

Prevents exposure to toxic substances and the adverse
health effects and diminished quality of life associated
with exposure to hazardous substances from waste sites,
unplanned releases, and other sources of environmental
pollution.

The Centers for
Disease Control and
Prevention

Part of the Public Health Service; it protects the public health
of the nation by providing leadership and direction in the
prevention and control of diseases and other preventable
conditions and responding to public health emergencies.

The Centers for
Medicare & Medicaid
Services

Combines the oversight of the Medicare program, the
federal portion of the Medicaid program and State
Children’s Health Insurance Program, the Health Insurance
Marketplace, and related quality assurance activities.

The Food and Drug
Administration

Part of the Public Health Service; it ensures that food is safe,
pure, and wholesome; human and animal drugs, biological
products, and medical devices are safe and effective; and
electronic products that emit radiation are safe.

The Health Resources
and Services
Administration

Part of the Public Health Service; it provides healthcare to
people who are geographically isolated or economically or
medically vulnerable.

The Indian Health
Service

Part of the Public Health Service; it provides American
Indians and Alaska Natives with comprehensive health
services by developing and managing programs to meet
their health needs.

The National Institutes
of Health

Part of the Public Health Service; it supports biomedical and
behavioral research with the United States and abroad,
conducts research in its own laboratories and clinics, trains
promising young researchers, and promotes collecting and
sharing medical knowledge.

Substance Abuse
and Mental
Health Services
Administration
(SAMHSA)

Part of the Public Health Service and improves access and
reduces barriers to high-quality, effective programs and
services for individuals who suffer from or are at risk for
addictive and mental disorders, as well as for their families
and communities.

136 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

THE ROLE OF THE LAW IN SHAPING NURSING PRACTICE

The federal government is generally responsible for carrying out those powers spe-
cifically delegated to it in the U.S. Constitution. All other powers are reserved to
the states. The U.S. Constitution does not directly address the regulation of nursing.
Therefore, the states are the bodies that have created most of the nursing regulations.
Moreover, the law that governs individual practice is dependent upon the particular
state where the practice in question takes place. There are many state and federal laws
that govern the healthcare industry and influence the practice of nursing. Nurses are
regulated by both criminal law and civil law as well as by both common law and
statutory law.

Criminal Law Versus Civil Law

Generally, law is divided into two distinct categories: criminal law and civil law. The
primary distinction between the two categories relates to the particular goal of the law
in question. Is the law designed to punish the wrongdoer? If so, then it is criminal law.
On the other hand, civil law aims to provide for compensation to a victim. Examples
of criminal law would include traffic violations, assault or battery, burglary, and/or
murder. Examples of civil law would include negligence, breach of contract, and/or
infringement of trade secrets. There are many differences in purposes and objectives
for these two law categories.

One of the most significant differences is the burden of proof required in any
legal proceeding. In a criminal law matter, the prosecution must prove its case
beyond a reasonable doubt. For a civil law matter, the plaintiff must prove its case
by a preponderance or greater amount of evidence. Another important distinction is
that in a criminal law matter, the case is initiated by the prosecution who is working
on behalf of the government. Criminal law proceedings are referred to as criminal
prosecutions. In a civil law matter, the legal case is initiated by private individuals
or corporations.

Another difference between criminal law and civil law relates to the resolution
of the case. In a criminal law matter, if the prosecution is successful, the defendant is
required to spend time incarcerated in jail or are assessed a fine. In a civil law matter,
if the plaintiff or the person who brings a case against another in a court of law is suc-
cessful, the defendant, that is, an individual, company, or institution sued or accused
in a court of law, has to reimburse the plaintiff for the amount of damages determined
by the court.

Statutory Law Versus Common Law

Within the category of civil law, law is further divided into two additional categories:
statutory law and common law. Statutory laws are written laws that derive from a
legislative body; for example, written laws from the U.S. Congress, a state legislative
body, or a municipal board of trustees of a city or town. Members of these legislative
bodies are elected by the citizens of their respective communities. An example of statu-
tory law would be the applicable state Nurse Practice Act that is enacted by the various
states that govern the licensure process for nurses.

Common law is the body of law that has been created through the application of
prior court decisions, that is, precedents, to a unique set of facts; it has been developed

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 137

by judges, courts, and other special courts or tribunals appointed to deal with a par-
ticular problem. If a similar matter has been heard by a court in the past, a court will
generally follow the prior court decision and apply the reasoning given in the earlier
precedent case to the matter that is pending before the court at that time. There are
times, however, where the set of facts in the pending case are different from all prior
cases and there are no statutes that are applicable, whereupon the court is required to
render a decision. This is known as a matter of first impression. There are other situa-
tions where a statute may be applicable, but the statute does not expressly address the
facts in question. In that situation, the court is required to interpret the statute using
prior decisions and/or legislative history. Examples of common law would be negli-
gence or malpractice matters.

Nurse Practice Acts

The nursing industry is regulated by nurse practice acts (NPAs), which are laws that
have been enacted by state governments to protect the public’s health, safety, and wel-
fare by overseeing and ensuring the safe practice of nursing. As with state laws, NPAs
also vary by state but generally include a definition of the scope of nursing practice
allowed in the state, the types of licenses and the requirements for each, grounds for
disciplinary action and remediation, education standards for nursing programs, and
the authority and power of the state Board of Nursing.

NPAs generally are designed to protect the public’s health, safety, and welfare.
NPAs are designed to shield the public from nurses who lack the minimum qualifi-
cations to preform competent nursing services. In addition, the NPAs also contain
protections to punish and/or suspend any nurses who fail to follow proper pro-
tocol or otherwise unsafe practices. NPAs also define the minimum requirements
in order to obtain a license within a particular state. NPAs are designed to ensure
that nurses have a minimum level of competency. Finally, NPAs usually set forth
any minimum ongoing continuing education that is required in order to maintain
a license within a state.

In addition to NPAs, state legislatures and agencies also enact certain administra-
tive codes and rules that regulate the nursing industry. Such administrative codes and
rules contain more of the minimum requirements for nurses in practice and define
different disciplinary structures for misconduct. The administrative codes and rules
typically will allow a state governing body the right to suspend or revoke a license for
the following acts:

1. Engaging in conduct likely to defraud or harm the public or demonstrating a will-
ful disregard for the health, welfare, or safety of a patient.

2. Departing from or failing to conform to standards of practice.
3. Engaging in behavior that crosses professional boundaries (such as signing wills or

other legal documents) not related to healthcare.
4. Engaging in sexual conduct with a patient.
5. Demonstrating actual or potential inability to practice nursing with reasonable

skill, safety, or judgement by reason of illness, use of alcohol, drugs, chemicals,
or any other material, or as a result of any mental or physical condition (Illinois
Administrative Code, Title 68, Section 1300.90).

Administrative codes also will set forth the number of hours of continuing educa-
tion required in order to maintain current status of the state licensure. For example,
in the state of Illinois, licensed nurses are required to complete 20 hours of approved

138 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

continuing education per 2-year license cycle (Illinois Administrative Code, Title 68,
Section 1300.130).

All individuals entering into nursing practice must become familiar with their
particular state’s NPA. Failure to understand and comply can jeopardize a nurs-
ing license and the ability to legally practice nursing within a state. Moreover, such
failure may also subject an individual to discipline including fines and license
revocation.

The policies and procedures of an organization that define the manner in which
nurses are to practice in a specific work setting should always be aligned with a state’s
NPA. It is important that these policies and procedures are not only descriptive of the
work nurses are performing in an organization but also are compliant with the state’s
NPA. Because these documents may be used in court to both determine the standard
of care for nurses and to assess whether a nurse was in compliance with the standard
of care, clarity and specificity of these documents are important. Periodic review and
revision of hospital policies and procedures are essential to ensure that they are cur-
rent with the NPAs, as well as evidence based and related to the ever-expanding role
of nurses.

NEGLIGENCE

Negligence is a failure to exercise the care that a reasonably prudent person
would exercise in like circumstances. Malpractice is one form of negligence and
is improper, illegal, or negligent professional activity or treatment by a healthcare
practitioner, lawyer, or public official. In today’s litigious environment, all pro-
fessionals must take care to ensure that they do not make mistakes. Malpractice
claims against nurses are increasing, with more than $90 million paid in nurses’
malpractice claims over a 5-year period (AHC Media LLC, 2016). Table 5.2 identi-
fies common causes of nursing malpractice (McGuire & Mroczek, 2017). All nurses
must understand their responsibilities in order to avoid common causes of nursing
malpractice
A suit for negligence or malpractice is a civil suit brought by a person to recover
damages from the person who caused such damages. A party bringing a mal-
practice suit must prove, by a preponderance or a large amount of evidence, the
following:

• That a duty of care was owed to the patient;
• That there was a breach in that duty;
• That any injury was proximately caused by the breach in duty; and
• That there were damages.

NURSE LEADER AND MANAGER

Imogene King, EdD, MSN, RN, FAAN, is recognized as an international pio-
neering nurse theorist and educator. She is known for her Theory of Goal
Attainment. Read more about her at www.nursingworld.org/halloffame.

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 139

TABLE 5.2 COMMON CAUSES OF NURSING MALPRACTICE

NURSING
MALPRACTICE EXAMPLE

Negligent
infliction of
emotional
distress

In Spangler v. Bechtel (958 N.E.2d 458 [2011]), the Supreme Court
found that the defendants, which included a nurse-midwife, could be
liable for negligent infliction of emotional distress following the death
of the plaintiffs’ stillborn child.

Burns In Pillers v. Finley Hospital (2003 Iowa App. LEXIS 792), the Court
concluded that a nurse was liable along with the physician when
the nurse applied a tourniquet to the plaintiff, as ordered, prior to
surgery. Prep solution leaked around the tourniquet resulting in
chemical burns to the plaintiff’s thigh.

Falls The California Third Circuit Court in Massey v. Mercy Medical Center
Redding (180 Cal. App. 4th 690 [2009]) concluded that expert
testimony was not necessary to prove a nurse’s negligence in
preventing a 65-year old, who had recently had surgery, from falling.

Failure to
properly
diagnose

The Supreme Court of Kansas held that the defendant’s advance
practice nurse and physician failed to diagnose the decedent’s
urinary tract infection, which later caused the decedent’s death
Puckett v. Mt. Carmel Reg’l Med. Ctr., 290 Kan. 406 (2010).

Assault and
battery

The Illinois Fifth Circuit Court of Appeals found a nurse and hospital guilty
of battery, alleging that the nurse attending the plaintiff-patient observed
and touched her without her permission, citing religious stan-
dards and beliefs (Cohen v. Smith, 269 Ill. App. 3d 1087 5th Cir. 1995).

HIPAA
violations

In Guardo v. Univ. Hosps., Geneva Medical Center (2015-Ohio-1492),
Eleventh District Court of Appeals in Ohio upheld the defendant-
hospital’s decision to terminate the plaintiff-nurse due to an
unwarranted disclosure of HIPAA-protected information.

Breach of
privilege

The Fourth District Ohio Court of Appeals found that the defendant-
nurse and physician breached the physician-patient privilege by
revealing the plaintiff’s pregnancy to the plaintiff’s parents. The
liability extended to the nurse as well as to the physician because
she contacted the plaintiff’s parents at the supervising physician’s
direction (Hobbs v. Lopez, 96 Ohio App. 3d 670 [4th Dist. 1994]).

Failure to
observe/
report

Reviewing a decision of the Nevada State Board of Nursing, the Supreme
Court of Nevada upheld the Board’s determination that the plaintiff-
nurse had, among other things, failed to “observe the conditions,
signs and symptoms of a patient, to record the information or to report
significant changes to the appropriate persons” in treating one of
the nurse’s patients. The nurse did not timely deliver medication to a
patient, and the patient subsequently passed away. Additionally, the
nurse back-timed the order for the medication in his report (Nevada
State Bd. of Nursing v. Merkley, 113 Nev. 659 [1997)].

False
imprisonment

The Supreme Court of Mississippi held in Lee v. Alexander (607 So. 2d
30 [1992]) that “all who united in the illegal commitment are equally
liable” in a false imprisonment case. This would extend to nurses
who take part in a patient’s involuntary confinement.

Medication
errors

The Fourth Circuit Court of Appeals in Louisiana affirmed the district
court’s failure to instruct the jury to consider intervening cause.
In that case, the patient suffered an adverse reaction to a drug
administered and not monitored by the attending nurse (Cagnolatti
v. Hightower, 692 So. 2d 1104 [La.App. 4 Cir. 1996]).

HIPAA, Health Insurance Portability and Accountability Act.

140 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Duty of Care

The element of duty of care is generally the easiest of the four elements to prove in
a healthcare negligence or malpractice case. Duty of care is the legal obligation of
professionals to deliver a certain standard of care when performing acts that could
directly or indirectly harm others. A duty of care is often viewed as a social contract
that requires members of a society to behave responsibly toward one another.

Because negligence or malpractice is a state common law, the applicable law
depends on the state where the conduct took place. Each state may have a slightly dif-
ferent legal interpretation. In many states, the test for duty of care is whether the harm
to the patient due to the nurse’s actions was foreseeable. Many states consider the fol-
lowing factors that are weighed to determine if a duty of care exists:

• Foreseeability of harm
• Degree of likelihood of harm
• Relationship of the parties
• Policy of preventing harm
• Available alternative conduct (how could the nurse have handled the situation

differently)

Once a duty of care has been established, a nurse is expected to use the degree of skill,
knowledge, and care that would be offered by a similarly trained nurse in a similar
situation. It is important to note that a nurse is not expected to guarantee a perfect
result or outcome, but a nurse is expected to conform to specific standards of care.

In some unique situations, it may appear that a duty of care may be owed. For exam-
ple, a nurse while exercising at a local health club may encounter someone having a
heart attack. In such a situation, public policy eliminates the duty of care. The nurse is
not obligated to assist the person having the heart attack. Contrast that situation with
a Good Samaritan case, where a nurse or other well-meaning citizen comes to the aid
of a person who has sustained a physical injury or is in physical peril or harm. Courts
want to encourage people to render aid to those in need. If the law of negligence were
not modified in the case of the Good Samaritan, it could discourage people from getting
involved in rendering aid to those in need. Although Good Samaritan laws vary by state,
there are a few principles that are universally accepted. Good Samaritan laws generally
apply when someone renders aid to an individual in an emergency on a voluntary basis
without the expectation of remuneration or compensation. In most states, it is acknowl-
edged that a person, even a person with medical or nursing training, does not need to
come to the aid of someone who has been injured, but if they elect to do so, they must
act in a manner that is reasonable. For example, they cannot come to the scene and offer
assistance and then decide they need to leave and abandon the patient. In many states,
the reasonable person standard is used to judge the conduct of the nurse rather than the
standard of the reasonable nurse professional. This is due to the fact that when render-
ing care or assistance as a Good Samaritan, a nurse would not have access to the tools
and support he or she might have when practicing in a formal healthcare environment.

Breach in Duty

A breach in duty occurs when a nurse or other healthcare professional has a duty
of care toward another person but fails to live up to the accepted standard of care.
Nursing standards of care are established by external and internal sources. Expert

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 141

testimony and scholarly, evidence-based articles and practice guidelines can be used
to establish whether the nurse acted in accordance with best and acceptable standards
of care or whether he or she did not. Hospitals, home health agencies, and physician
and nursing practices adopt policies and procedures on how to treat patients. Such
policies are always evolving based on technology and medication.

A breach in duty can be either an act of commission (doing something but doing
it incorrectly) or an act of omission (not doing what was expected or ordered). Often
hospital policies and procedures are used to determine if a nurse breached a duty of
care. A failure to conform to hospital policies and procedures is evidence of a breach
in duty. The policies and procedures and the nurse’s adherence to them are then sup-
ported or refuted and disproved by a nurse expert, who is credible in light of experi-
ence and background. Determining the applicable standard of care is the crux of the
legal debate on whether a duty in care was breached. Generally, the standard of care is
how a reasonable nurse would treat a patient under the same circumstances. Note that
the standard of care in one community may be different in another community and
may change and evolve based on research and technology.

Injury, Proximately Caused by a Breach in Duty of Care

The third element of negligence or malpractice is Injury, Proximately Caused by a Breach
in Duty of Care. Proximate cause is often very difficult to prove or to get a jury to under-
stand. Proximate cause of injury consists of successfully proving that a patient was
indeed injured and that a breach in the duty of care was the cause of the injury sustained.
Often nurses care for patients who are already very vulnerable and might be subject to
exacerbations of their condition or further injury by the very nature of their condition.
Thus, it can be difficult to prove that an injury was not part of the natural progression of
the patient’s illness or that the injury would not have occurred except for the breach in
duty of care. Lawyers who seek to prove this element of negligence or malpractice again
use experts for this. In addition, many times a patient may have contributed toward the
injury. This is known as contributory negligence. If a lawyer can prove contributory neg-
ligence, the amount of a patient’s monetary award is reduced.

Mary, RN, is busy with four patients. She receives a new intravenous piggyback
medication (IVPB) order from the healthcare provider and orders it from the
pharmacy for her patient. When the unit clerk tells Mary that her patient’s IVPB
has arrived from the pharmacy, Mary quickly grabs the medication and hangs
it. A few minutes later, the patient becomes short of breath. As Mary checks her
patient over, she notes to her horror that she hung another patient’s IVPB for this
patient.

1. What action should Mary take immediately?
2. What should she do next?
3. What should the hospital pharmacy and the nursing unit do to prevent future errors

like this?
4. Is a problem like this the fault of the healthcare system, the fault of the nurse, or both?

CASE STUDY 5.1

142 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Damages

Finally, the fourth element of negligence or malpractice is that the plaintiff’s attor-
ney must present evidence that, as a result of the conduct of the nurse, the plaintiff
(patient) suffered some type of economic or physical damage. The goal of civil litiga-
tion is to award compensation and/or make the patient whole. Typical components of
damages include the following:

1. Actual cost of reversing the injury
2. Future anticipated economic losses because of the injury
3. Pain and suffering
4. Emotional distress that those close to the injured person might have sustained

while witnessing the harm to a loved one
5. Punitive damages, where the plaintiff seeks an amount to punish the nurse or the

organization for particularly egregious bad conduct

The monetary amount of damages that can be awarded varies from state to state
and in rare cases, there may be partial or limited immunity from liability. The dam-
ages award is generally covered under the malpractice insurance program that
has been set up by the organization employing the nurse. That program generally
covers attorney’s fees and any money paid to the plaintiff to compensate for the
injuries. Information about damage caps on a state-by-state basis can be found
at www.alllaw.com/resources/personal-injury/personal-injury-state-law. A table
that lists the limits to punitive damages in each of the 50 states and the District
of Columbia is available at www.legalmatch.com/law-library/article/limits-on-
punitive-damages.html.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT (HIPAA) OF 1996

Advances in technology have impacted the healthcare profession in many ways. One
significant impact is the advent of electronic patient information. On one hand, tech-
nology has made it easier for patient information to be shared among healthcare pro-
fessionals, which in turn has made it easier to diagnose and treat patients. On the other
hand, patient information may fall into the wrong hands or otherwise be misused,
potentially causing damages or harm to the rights of patients. Organizations, indi-
viduals, or other entities could discriminate against patients based upon their medical
condition.

To address this issue, the Health Insurance Portability and Accountability Act
(HIPAA) was passed in 1996 to set national standards for the protection of patient
information. The HHS published final rules implementing HIPAA in 2000 and 2002.
These rules are applicable to health plans, healthcare clearinghouses, and healthcare
providers who electronically transmit health information in connection with transac-
tions for which HHS has adopted standards. Generally, these transactions concern
billing for services or insurance coverage by hospitals, academic medical centers, phy-
sicians, and other healthcare providers who electronically transmit claims to a health
plan. The major goal of HIPAA is to ensure individuals that their patient information
will be protected, while at the same time promoting the free flow of information that
is needed to provide the best care for patients’ health and well-being. HIPAA attempts
to strike a balance that enables professionals to use patient information but it also
protects patient privacy.

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 143

Patient Information

HIPAA regulates the use and maintenance of patient information. Patient information
is information including demographic data that relates to an individual’s past, pres-
ent, or future physical or mental health or condition; the provision of healthcare to that
individual; or the past present, or future payment for the provision of healthcare to
that individual. In order for the information to constitute protected health information,
the information must include identifier information that identifies the individual with
a reasonable basis of belief that it could be used to identify the individual. Identifiable
health information may include the name, address, birthdate, or Social Security num-
ber of the patient. There are ways to deidentify health information where the specified
identifiers have been removed.

Permitted Uses of Patient information

HIPAA defines when patient information may be used and disclosed. HIPPA rules pro-
vide that a healthcare provider may not use or disclose protected patient info except
(a) as the rule permits, for example, for treatment or payment, and so on, and (b) as the
individual who is the subject of the information has authorized in writing. Healthcare
providers must rely on professional ethics and best judgments in deciding which of
the permitted uses and disclosures to make. Providers must also disclose protected
health information to patients when they specifically request access to it or to the HHS
when it is undertaking a compliance investigation.

Authorized Disclosure

A healthcare provider is required to turn over patient information to the patient upon request.
Many times a nurse may be faced with a request for patient information by a family mem-
ber or another person other than the patient in question or another healthcare professional.
HIPAA allows healthcare providers to treat a legally appointed personal representative the
same as the individual with respect to information uses and disclosures. A personal repre-
sentative is a person that is legally authorized to make healthcare decisions on an individu-
al’s behalf or to act for a deceased individual or an estate (such as under a power of attorney
or guardianship). However, a healthcare provider is not permitted to disclose patient infor-
mation to others who are not a patient’s personal representative. In the situations of minors,
the parents are considered to be personal representatives of the patient.

Penalties

The HHS Office for Civil Rights may impose a penalty on a healthcare provider for
a failure to comply with HIPAA. These penalties may vary and it depends on many
factors that are relevant to the violation in question. The penalty ranges from $100
to $50,000 or more per HIPAA violation depending on the severity of the violation.
Moreover, a criminal penalty may be involved and assessed against a person who
knowingly obtains or discloses protected patient information. Such fines could be up
to $50,000 as well as up to 1-year imprisonment. Furthermore, if the violation includes
false pretenses, such as an effort to defraud the patient, the fine cap rises from $200 to
$50,000 and up to 10-years imprisonment.

144 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

MEDICARE COMPLIANCE

The exploding baby boomer population has impacted many facets of American society
including the healthcare industry. In addition, medical technology has contributed to
the longer lifespan of individuals. Within nursing, one area that has gained additional
popularity is the home healthcare arena. Home healthcare is the provision of lim-
ited healthcare services by a nurse or other healthcare professional in the home of the
patient. Although not exclusively, much of the care is funded through the U.S. Centers
for Medicare & Medicaid Services (Medicare), which covers individuals 65 years
of age and older. Many nurses today provide services through a home healthcare
agency. Within that industry, there are certain regulatory requirements that must be
understood.

Certification Compliance

In order for an individual to be eligible for reimbursement for home healthcare ser-
vices, an individual must meet certain requirements. The requirements are summa-
rized as follows:

1. Patient must have medical necessity
2. Patient must be homebound
3. A physician must certify and/or prescribe the need for home healthcare services

If any person, nurse, and/or agency attempts to submit claims to Medicare for
reimbursement for the provision of healthcare services to a patient that does not
meet these three requirements, they may be subject to penalties and/or criminal
prosecution.

Federal Anti-Kickback Statute

The Federal Anti-Kickback Statute is a law that prohibits the payment or receipt of
any gift or remuneration in exchange for federal healthcare referrals to Medicare
patients. Congress has determined that a compensation structure that rewards refer-
ring patients for the receipt of Medicare reimbursement is potentially abusive and
would lead to fraud and waste within the Medicare program. The term, remunera-
tion, is broad and includes anything of value, transferred either directly or indirectly,
in cash or gifts. In other words, remuneration can include trips, meals, and tickets to
sporting events or other shows or concerts. Accordingly, the Anti-Kickback Statute
cannot be avoided merely by using gifts or goods or services in exchange for health-
care referrals.

Although the Federal Anti-Kickback Statute concerns any individual, the
Stark Law relates strictly to a physician. The Stark Law prohibits a physician from
making a Medicare or Medicaid referral to a healthcare provider or organization
with whom the physician or his or her family member has a financial relation-
ship. Similar to the Federal Anti-Kickback Statute, the Stark Law seeks to prevent
potentially abusive circumstances whereby Medicare may be defrauded due to
corrupt physicians.

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 145

Civil Monetary Penalty Law

In addition to the Federal Anti-Kickback Statute and the Stark Law, there are also
other penalties relating to certain misconduct within the Medicare program. A civil
monetary penalty may be assessed against a person if the person provides remunera-
tion to a Medicare or Medicaid beneficiary when the person knows or should know
that such action is likely to influence the beneficiary’s selection of a particular pro-
vider, practitioner, or supplier. When evaluating whether a civil monetary penalty
should be assessed, there is a three-prong test:

• Was there remuneration of an item or service to a Medicare or Medicaid
beneficiary?

• Was it likely that the item or service influenced the beneficiary to select the
providers?

• Did the provider know that the item or service was likely to influence the benefi-
ciary’s selection of the provider?

It is generally held that items of value of $10 or less are considered to be not subject to
the Civil Monetary Penalty Law. Those guilty of a Federal Anti-Kickback Statute viola-
tion may be convicted of a felony, assessed a $25,000 fine, or potentially given a 5-year
prison sentence. For the Civil Monetary Penalty Law violation, there may be a penalty
of up to $10,000 for each violation.

Exclusions

The Office of the Inspector General has the authority to exclude certain indi-
viduals and entities from participation in the Medicare, Medicaid, or other fed-
eral healthcare programs. Excluding an individual or entity is a severe penalty.
Organizations employing or contracting with an excluded individual are not eli-
gible to be paid directly or indirectly by a federal healthcare program for any
items or services such excluded individual provides. Those found guilty of violat-
ing the Federal Anti-Kickback Statute or the Civil Monetary Penalty Law may be
excluded from the Medicare program. In addition, any provider who employs an
excluded individual may be required to return to Medicare any revenue received
that is attributable, directly or indirectly, to the excluded individual.

CRITICAL THINKING 5.2

Dr. Thompson operates a thriving patient practice in Chicago. Many of his patients are
over 65 years of age. Many of them suffer from various healthcare conditions but do not
require hospitalization. Dr. Thompson’s wife is a nurse who started a home healthcare
agency that is eligible to seek reimbursements from Medicare.

1. Can Dr. Thompson refer a patient to his wife’s agency?
2. Does the Stark Law apply to this situation?

146 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

ETHICAL CODES AND PRINCIPLES

In addition to the laws that govern the practice of nursing, there are also ethical
codes and principles that nurses must observe in the performance of their duties. The
International Council of Nurses’ Code of Ethics (2012) groups ethics under four funda-
mental nursing responsibilities:

• Promote health
• Prevent illness
• Restore health
• Alleviate suffering

Ethical codes and principles guide the practice of nursing (Table 5.3). The American Nurses
Association’s (ANA) Code of Ethics (ANA, 2015) has been developed to provide an ethical
framework for nurses. The Code of Ethics make it clear that inherent in nursing is respect
for human rights, including the right to life, to dignity, and to be treated with respect.

The ANA’s Code of Ethics provides a succinct statement of the ethical values,
obligations, and duties of every individual who enters the nursing profession. It is
available at www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-
of-ethics-for-nurses/. A short list of ANA Definitions of Ethical Principles is available at
www.happynclex.com/wp-content/uploads/2016/04/ANA-ethics-definitions-and-
examples.pdf.

TABLE 5.3 ETHICAL PRINCIPLES THAT GUIDE THE PRACTICE OF NURSING

ETHICAL
PRINCIPLES DEFINITION APPLICATION

Benef-
icence

Compassion; taking positive
action to help others; desire
to do good; core principle
of patient advocacy

• Provide all patients, including the
terminally ill, with caring attention
and information

• Become familiar with state laws
regarding organ donations

• Treat every patient with respect and
courtesy

• Give pain medication as quickly as
possible

Non ma-
leficence

Avoidance of harm or hurt;
core of medical oath and
nursing ethics

• Always work within your scope of
practice

• Never give information or perform
duties when you are not qualified to
do so

• Check that patient is oriented when
signing consents

• Keep areas safe from hazards
• Perform procedures according

to facility protocols; never take
shortcuts

• Ask an appropriate person about
anything you are unsure of

• Keep your skills and education up
to date

(continued)

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 147

ETHICAL
PRINCIPLES DEFINITION APPLICATION

Justice This principle refers to an
equal and fair distribution
of resources, based on
analysis of benefits and
burdens of decision.
Justice implies that all
citizens have an equal right
to the goods distributed,
regardless of what they
have contributed or who
they are. For example, in
the United States, we all
have rights to services
from the postal service,
firefighters, police, and
access to public schools,
safe water, and sanitation.

• Treat all patients equally, regardless
of economic or social background

• Learn the laws and your facility’s
policies and procedures for
reporting suspected abuse

Autonomy Agreement to respect
another’s right to self-
determine a course
of action; support of
independent decision
making

• Respect all patient choices and
rights to decision making

• Become familiar with federal and
state laws and facility policies
dealing with autonomy and privacy,
e.g., HIPAA legislation, Patient Self-
Determination Act

• Never release patient information
of any kind unless there is a signed
patient release

• Do not discuss patients with anyone
who is not professionally involved in
their care

Fidelity This principle requires
loyalty, fairness,
truthfulness, advocacy,
and dedication to patients.
It involves an agreement to
keep our promises. Fidelity
refers to the concept of
keeping a commitment and
is based upon the virtue of
caring

• Be sure that contracts have been
completed

• Be careful what you say to patients.
They may only hear the “good
news”

• Keep promises to patients

Respect
for
others

The right of people to
make their own decisions
regarding diagnosis,
therapy, and prognosis.
This principle is heavily
laden as an application
of power over the
patient

• Do not make paternal decisions for
patient based on what you think is
best for them

• Let patients choose what is best for
them

• Provide all persons with information
for decision making

(continued)

TABLE 5.3 ETHICAL PRINCIPLES THAT GUIDE THE PRACTICE OF NURSING (continued)

148 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

KEY CONCEPTS

• The three branches of government are the executive branch, the legislative branch,
and the judicial branch.

• The U.S. Department of Health and Human Services (HHS) has 11 operating units
that influence laws surrounding many aspects of our healthcare delivery system,
including payment of healthcare services, regulation of medical drugs and devices,
vaccine programs, healthcare research, and patient safety.

• There are many state and federal laws that govern the healthcare industry and
influence the practice of nursing. Nurses are affected by both civil and criminal
law.

• Nurse practice acts vary by state but generally include a definition of the scope of
nursing practice allowed in the state.

• A person bringing a malpractice or negligence suit must prove, by a preponder-
ance of the evidence, that a duty of care was owed to the patient; that there was
a breach in that duty; that any injury was proximately caused by the breach; and
that there were damages.

• The Health Insurance Portability and Accountability Act (HIPAA) was passed in
1996 to set national standards for the protection of patient information.

• The International Council of Nurses’ Code of Ethics (2012) identifies four funda-
mental responsibilities for nurses. These responsibilities are promoting health,
preventing illness, restoring health, and alleviating suffering.

ETHICAL
PRINCIPLES DEFINITION APPLICATION

Veracity The obligation to tell the truth • Admit mistakes promptly. Offer to
do whatever is necessary to correct
them

• Refuse to participate in any form of
fraud

Advocacy The obligation to look out or
speak up for the rights of
others

• Provide patients with high-quality,
evidence-based care

• Participate in community actions to
improve patient care

• Participate in professional nursing
actions to improve patient care

Sources: Little, C.B., Dorman, J. Ethical Aspects of Health Care. (2012). In Kelly, P. Nursing Leadership and Management.
Third Edition. Clifton Park, New York: Cengage Learning.

American Nurses Association. Short definitions of ethical principles’ and theories’ familiar words, what do they mean?
Retrieved from https://www.coursehero.com/file/11324675/ANA-defined-ethical-principles/

TABLE 5.3 ETHICAL PRINCIPLES THAT GUIDE THE PRACTICE OF NURSING (continued)

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 149

• The American Nurses Association’s Code of Ethics (2015) identifies distinct
provisions.

• Ethical principles guide the practice of nursing.
• Nurses take action in order to improve the environment of patients, themselves,

other nurses, and members of the interprofessional team.
• Nurses should participate in their professional organizations to assist in the

advancement of quality healthcare policies, civic values, professional standards,
and clinical practice protocols.

• Nurses should also take action to collaborate with the public and promote com-
munity, national, and international efforts to meet the healthcare needs of the
community.

KEY TERMS

Breach in duty
Common law
Duty of care
Executive branch
Federal Anti-Kickback Statute
Health Insurance Portability and

Accountability Act (HIPAA)
Home healthcare
Judicial branch

Legislative branch
Malpractice
Negligence
Nurse practice acts
Personal representative
Separation of powers
Stark Law
Statutory laws

REVIEW QUESTIONS

1. A healthcare provider has ordered you to discharge Mr. Jones from the hospital
despite a new temperature of 102°F (38.8°C). The provider refuses to talk with you
about the patient. In this situation, which of the following is an appropriate nurs-
ing action?

A. Administer an antipyretic medication and discharge the patient.
B. Discharge the patient with instructions to call 911 if he has any problems.
C. Do not discharge the patient until you have discussed the matter with your

nursing manager and are satisfied regarding patient safety.
D. Discharge the patient and tell the patient to take acetaminophen (Tylenol)

when he gets home.

2. A healthcare provider has issued a Do Not Attempt to Resuscitate (DNAR) order
for your patient, a 55-year-old man with cancer. You spoke with the patient this
morning and he clearly wishes to be resuscitated in the event that he stops breath-
ing. What is the most appropriate course of action?

A. Ignore the patient’s wishes because the healthcare provider ordered the DNAR.
B. Consult your hospital’s policies and procedures, speak to the healthcare pro-

vider, and discuss the matter with your nurse manager.
C. Attempt to talk the patient into agreeing to the DNAR.
D. Contact the medical licensing board to complain about the healthcare provider.

150 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

3. The Health Insurance Portability and Accountability Act (HIPAA) protects which
of the following?

A. A patient’s right to be insured regardless of employment status or ability to
pay.

B. The confidentiality of certain protected health information.
C. The nurse’s right to health insurance.
D. The hospital’s right to disclose protected health information.

4. Which of the following elements is not necessary for a nurse to be found negligent
in a court of law?

A. A duty or obligation for the nurse to act in a particular way.
B. A breach of that duty or obligation.
C. The nurse’s intention to be negligent.
D. Physical, emotional, or financial harm to the patient.

5. Inez, RN, did not put the bed-side rails up on a confused patient. The patient
fell and was injured. When there is a connection between the nurse omitting a
duty and the damages occurring to a patient, it is an example of which of the
following?

A. Breach of duty
B. Duty
C. Causation
D. Damages

6. Select the most appropriate documentation example in the following.

A. Patient found covered in stool. The night nurses were too busy to change the
bed.

B. The patient fell because we are short of staff.
C. The patient’s family is difficult and argumentative.
D. Dr. M. Bresley notified through the medical exchange at 0610 of patient’s com-

plaints of difficulty breathing. Orders received for oxygen and arterial blood
gases (ABGs).

7. You call the surgeon for your new postoperative patient who is bleeding exces-
sively. The patient’s blood pressure has decreased 20 mmHg, and his pulse rate
has increased by 20 beats over the past hour. The surgeon’s response to this infor-
mation is “Why did you wake me up at 2 a.m. for this? I am hanging up as I expect
a postoperative patient to be oozing from the operative site and these changes are
not significant. Just watch him.” You are quite concerned about your patient. What
will you do next?

A. Go to the nursing station and complain to the other nurses about how rude the
surgeon was on the phone.

B. Document and quote the surgeon’s response in your nurse’s notes.
C. Inform the surgeon that you do not agree with continuing to just observe this

patient and that you are going to initiate the chain of command.
D. Tell the family what the surgeon said.

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 151

8. An 80-year-old man who lives with his son is brought to your unit because “he
just isn’t acting right.” On physical examination, you note that the patient is mal-
nourished, noncommunicative, and has poor hygiene. When you ask the patient
some questions, he avoids eye contact and does not respond. The son is answering
questions for the patient and refuses to leave the room. You suspect elder abuse.
Choose the most appropriate documentation of the situation.

A. The patient is very thin and does not make eye contact with the nursing or
medical staff. It is obvious that he has been abused and neglected by his family.

B. The patient is a thin elderly male who presents to the unit wearing clothing that
is soiled. He does not make eye contact with the staff or answer our questions.
Social services notified.

C. It appears that the patient’s son manipulates his father by refusing to let his
father answer any questions. We suspect elder abuse.

D. The patient’s son states that the patient “isn’t acting right.” The patient does
not answer questions from the staff due to his abuse.

9. The nurse is given a written order by a healthcare provider to administer an
unusually large dose of pain medicine to a patient. In this situation, which of the
following is an appropriate nursing action?

A. Administer the medication because it was ordered by a healthcare provider.
B. Refuse to administer the medication, and move on to another patient.
C. Speak with the healthcare provider about your concerns, and clarify whether

the medication dose is accurate.
D. Select a dose that you feel comfortable with, and administer that dose.

REVIEW ACTIVITIES

1. Identify the ways in which nurses you observe in your clinical rotations discuss
orders and treatments with healthcare providers. How do nurses address incor-
rect or questionable medication orders? Talk with nurses you see about how they
handle these situations.

2. Go to the website and search for your state’s Nurse Practice Act. Discuss what you
find there.

CRITICAL DISCUSSION POINTS

1. What are the three branches of the American legal system?
2. How does the law play a role in shaping nursing practice?
3. How can nurses protect themselves against a negligence lawsuit?

QSEN ACTIVITIES

1. Go to qsen.org/faculty-resources/patient-centered-care-resources/. Review the
information about the Patient Safety Movement. How can nurses help prevent
the more than 200,000 preventable patient deaths each year?

152 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

2. Review the “Guide to Patient and Family Engagement in Hospital Safety and
Quality” at www.ahrq.gov/professionals/systems/hospital/engagingfamilies/
index.html. Review how this guide helps patients, families, and health profession-
als work together as partners to promote improvements in care.

EXPLORING THE WEB

1. www.nso.com/risk-education/individuals/legal-case-studies
2. www.rmf.harvard.edu/Clinician-Resources/Article/2008/Medical-Mal

practice-Cases-Involving-Nurses
3. listverse.com/2013/05/29/10-horrible-cases-of-medical-malpractice/
4. www.dprnesq.com/pages/news/malpractice-suits-against-nurses-on-the-rise
5. www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-

of-ethics-for-nurses/
6. www.nursingworld.org/practice-policy/nursing-excellence/ethics/

REFERENCES

AHC Media LLC. (2016). More nurses, hospitalists being sued for malpractice, studies say. Retrieved
from https://www.ahcmedia.com/articles/137567-more-nurses-hospitalists-being-sued-
for-malpractice-studies-say

American Nurses Association. (2015). Short definitions of ethical principles and theories familiar words,
what do they mean? Retrieved from http://www.nursingworld.org/MainMenuCategories/
Ethics-Standards/Resources/Ethics-Definitions.pdf

American Nurses Association Code of Ethics (ANA). (2015). The Code of Ethics for Nurses
with Interpretive Statements. Retrieved from http://www.nursingworld.org/Main
MenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html

Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed., pp. 38–39, 152–153).
New York, NY: Oxford University Press.

Butts, J. B., & Rich, K. L. (2008). Nursing ethics across the curriculum and into practice (2nd ed.,
pp. 48, 263). Sunbury, MA: Jones and Bartlett.

Ethics Advisory Board. (2011). Retrieved from http://www.addpriv.eu/uploads/
public%20_deliverables/1.1%2089–ADDPRIV_20110424_WP1_ULANCS_EthicsAB_R2.pdf

Ethics Resource Center. (2009, May 29). Definition of values. Retrieved from http://www.ethics.
org/resources/free-toolkit/definition-values

The International Council of Nurses (ICN) Code of Ethics (2012). Retrieved from http://www.
icn.ch/images/stories/documents/about/icncode_english.pdf

Kelley, M. (2018, March 2). Why did the Articles of Confederation fail? About Education. Retrieved
from https://www.thoughtco.com/why-articles-of-confederation-failed-104674

McGuire, C., & Mroczek, J. (2017). Nurse malpractice. National Center of Continuing Education,
Inc., Retrieved from https://www.nursece.com/courses/99

Rodgers, P. (2011). United States constitutional law: An introduction (p. 109). McFarland.

SUGGESTED READINGS

Andersson, Å., Frank, C., Willman, A. M., Sandman, P. O., & Hansebo, G. (2015). Adverse events
in nursing: A retrospective study of reports of patient and relative experiences. International
Nursing Review, 62(3), 377–385. doi:10.1111/inr.12192

Ferrell, K. (2015). Nurse’s legal handbook (6th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.

5 LEGAL AND ETHICAL ASPECTS OF NURSING • 153

Gostin, L. O. (2017). Five ethical values to guide health system reform: The JAMA forum. JAMA,
318(22), 2171–2172. doi:10.1001/jama.2017.18804

Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). London, England: Pearson.
Hinno, S., Partanen, P., & Vehviläinen-Julkunen, K. (2012). Nursing activities, nurse staffing

and adverse patient outcomes as perceived by hospital nurses. Journal of Clinical Nursing,
21(11–12), 1584–1593. doi:10.1111/j.1365-2702.2011.03956.x

Lucero, R. J., Lake, E. T., & Aiken, L. H. (2009). Variations in nursing care quality across hospitals.
Journal of Advanced Nursing, 65(11), 2299–2310. doi:10.1111/j.1365-2648.2009.05090.x

Lucero, R. J., Lake, E. T., & Aiken, L. H. (2010). Nursing care quality and adverse events in US hos-
pitals. Journal of Clinical Nursing, 19(15–16), 2185–2195. doi:10.1111/j.1365-2702.2010.03250.x

Van Bogaert, P., Timmermans, O., Weeks, S. M., van Heusden, D., Wouters, K., & Franck, E.
(2014). Nursing unit teams matter: Impact of unit-level nurse practice environment, nurse
work characteristics, and burnout on nurse reported job outcomes, and quality of care, and
patient adverse events—A cross-sectional survey. International Journal of Nursing Study,
51(8), 1123–1134. doi:10.1016/j.ijnurstu.2013.12.009

Watts, A. (2017). Limits on punitive damages. LegalMatch. Retrieved from https://www.
legalmatch.com/law-library/article/limits-on-punitive-damages.html

Westrick, S. (2013). Essentials of nursing law and ethics. Burlington, Massachusetts: Jones and
Bartlett.

Upon completion of this chapter, the reader should be able to

1. Define delegation, responsibility, delegated responsibility, assignment,
accountability, authority, and supervision.

2. Discuss the National Guidelines for Nursing Delegation developed by the
National Council of State Boards of Nursing.

3. Describe the Five Rights of Delegation.

4. Discuss delegation related to the healthcare organization and members of
the healthcare team.

5. Review communication factors influencing the delegation process.

6. Utilize the Scope of Nursing Practice Decision-Making Framework.

6
DELEGATION AND SETTING PRIORITIES
FOR SAFE, HIGH-QUALITY NURSING CARE

Maureen T. Marthaler

Embraced for their wisdom and ability to provide outstanding patient-centered care, nurses are now
optimally positioned to influence and help lead our national and global health care systems in the future.

Michele Mittelman, RN MPH. Founder and Editor, Global Advances in Health and Medicine (2014).

M
orning report was given to an RN and one unlicensed assistive personnel (UAP) for
five patients on a busy medical-surgical unit. One of the patients was to receive
one unit of packed red blood cells (PRBC) if the patient’s hemoglobin (Hgb)
was less than 8.0 gm/dL. Later that morning, the patient’s Hgb results came

back as 7.1 gm/dL. The nurse went to the blood bank and picked up the unit of PRBC. The
policy and procedure for administering blood includes two RNs to check the blood at the

156 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

bedside and identify the patient, the patient’s wristband, the unit of blood, the patient’s blood bank
wristband, the blood type and unit number, and the blood expiration date. Prior to the start of the
blood transfusion and during and after the blood transfusion, the patient’s vital signs are to be
obtained and recorded by the nurse.

The policy and procedure was followed by the nurse. Fifteen minutes after the unit of
blood was started, another set of vital signs was obtained by the Unlicensed Assistive
Personnel (UAP). At this time, the patient complained of difficulty breathing and lower
back pain. The UAP rubbed the patient’s back and assured the patient these complaints
were nothing to worry about. The UAP documented the vital signs and went on a break
for lunch. Forty-five minutes later, the nurse was making rounds and found the patient
gasping for air and covered in a raised rash all over the face and arms.

1. How could this patient’s symptoms have been prevented?
2. Was the policy and procedure for blood administration followed? If not, what part

was not followed?
3. Were the Five Rights of Delegation employed or not?

Delegation is a complex nursing skill requiring nursing leadership and management
skills, setting priorities, using good clinical judgment, and assuming accountabil-
ity for patient care. Delegation is guided by one’s state Nurse Practice Act (NPA)

and requires nursing assumption of authority for the deci-
sions and outcomes associated with patient care, sharing
the process of patient care with other responsible members
of the nursing team, and holding all members of the nurs-
ing team accountable for their responsibilities. Delegation
requires nurses to use critical thinking, good communica-
tion skills, and leadership and management to build good
relationships with staff and the interprofessional team to
meet patient needs.

The National Council of State Boards of Nursing
(NCSBN) convened two groups of experts representing
education, research, and practice in 2015. They devel-
oped a set of National Guidelines for Nursing Delegation
that standardized the nursing delegation process in 2016.
The guidelines are meant for licensed nurses. A large
piece of the National Guidelines for Nursing Delegation
addresses UAP advanced roles. Skills that were once
exclusive to licensed practical nurses/licensed voca-
tional nurses (LPNs/LVNs) are now taught in advanced
UAP programs. The NCSBN and other professional nurs-
ing organizations will continue to explore delegation as
healthcare advancements and the roles and responsibili-
ties of providers in a variety of state settings continu-
ously change over time.

The roles of the nurse vary by geographic location and/or institution. The state
NPA and the National Guidelines for Nursing Delegation guide the nurse in nursing
delegation to UAP. The number one priority for nurses is to deliver safe patient care.
The nurse is responsible and accountable for determining the appropriate delegation
of responsibilities to UAP consistent with state NPAs, the policies and procedures of

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 157

the healthcare organization, and the nurse’s obligation to deliver safe, high-quality
patient care. To ensure that this obligation is met, nurses are accountable for patient
care delivered by both themselves and other personnel under their supervision.

This chapter discusses the concept of delegation with an emphasis on quality and
safety. It discusses responsibility, delegated responsibility, assignment, accountabil-
ity, authority, and supervision. NCSBN, National Guidelines for Nursing Delegation,
and the Five Rights of Delegation are discussed. Delegation related to the health-
care organization and members of the healthcare team is discussed and communica-
tion factors influencing the delegation process are reviewed. The Scope of Nursing
Practice Decision-Making Framework is also explored with applications throughout
the chapter.

DELEGATION

Delegation is allowing a delegatee to perform a specific nursing activity, skill, or pro-
cedure that is beyond the delegatee’s traditional role and not routinely performed
(NCSBN, 2016). The National Guidelines for Nursing Delegation were created in 2016
by the NCSBN. The states have different NPAs and rules and regulations. This is infor-
mation all licensed nurses must review prior to delegating. It is the nurses’ responsi-
bility to know what is permitted in their state’s NPA and rules and regulations, along
with the policies of their employer.

Delegation has been a source of significant debate for many years and there
have been many philosophical discussions over the differences between assign-
ment and delegation. Much of the literature surrounding nursing delegation has
focused on the nursing home setting (NCSBN, 2016). Delegation is needed because
of the advent of cost containment, the nursing shortage, increases in patient acu-
ity levels, an elderly chronic patient population, and advances in healthcare
technology.

An armed services member returned home after a 13-month deployment to
Afghanistan. He has come to the clinic where you work with his wife. The nurse
delegates to the UAP to complete the assessment form with him. This is the
first time the UAP has been delegated to complete this task. The UAP opens the
computer and starts asking the patient the questions from the form. Under the
history section on the form, a question reads “Have you ever experienced post-
traumatic stress disorder (PTSD)?” The UAP then asks the patient if he had ever
experienced a sexually transmitted disease. The patient questioned the UAP as
to what was meant by “experienced”? The UAP responded by saying, “I am just
reading the form, sir. I do not write the questions.”

1. What steps should the nurse have taken prior to delegating the completion of the com-
puterized assessment form to the UAP?

2. What guides the process of delegation in an organization?
3. Should completing the assessment form be delegated to an UAP? Why or why not?

CASE STUDY 6.1

158 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

RESPONSIBILITY

Responsibility is the obligation involved when a person accepts an assignment. The
delegation process is not complete until the person who receives the assignment
accepts the responsibility for the assignment. Without this acceptance of responsibility,
assignments cannot be delegated. Further, if a person does not have the knowledge,
skill, experience, or willingness needed to complete an assignment, it is inappropriate
to accept responsibility for the assignment. Once a person accepts responsibility for an
assignment, this responsibility is retained.

NATIONAL GUIDELINES FOR NURSING DELEGATION

All decisions related to delegation are based on the fundamental principles of health,
safety, and welfare of the public. The nursing profession takes responsibility and
accountability for the provision of nursing practice (American Nurses Association
[ANA], 2016). The National Guidelines for Nursing Delegation (NCSBN, 2016;
Figure 6.1) identifies responsibilities of the employer/nurse leader, the licensed
nurse, and the delegatee for public protection. In addition, the National Guidelines
for Nursing Delegation highlight the need to communicate information about the
delegation process and the delegatee competence level; the need for two-way com-
munication; and the need for training and education.

EVIDENCE FROM THE LITERATURE

Citation

Shannon, R. A., & Kubelka, S. (2013). Reducing the risks of delegation use of pro-
cedure skills checklist for unlicensed assistive personnel in schools, Part 1. NASN
School Nurse, 28 (4), 178–181. doi:10.1177/1942602X13489886

Discussion

The school nurse will adhere to the state’s NPA with many state boards of
nursing allowing for some degree of delegation appropriate to the circum-
stance. School administrators are responsible for the assignment of specific
employees to carry out the delegated tasks. Administration of medicines for
asthma, anaphylaxis, diabetes, and seizures can be delegated. The decision to
delegate is based on guidance by the state’s NPA, state board of nursing, an
organization’s administration, policies, and procedures, and the Five Rights
of Delegation.

Implications for Practice

Delegation of tasks in a school setting is no different than in a hospital setting.
The same considerations are employed.

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 159

Each person in the National Guidelines for Nursing Delegation has specific respon-
sibilities that he or she is expected to exercise for public protection. For example, the
employer will identify a nurse leader who will determine nursing responsibilities
that can be delegated, to whom, and under what circumstances; develop delegation
policies and procedures; periodically evaluate the delegation process; and promote a
positive culture and work environment. The nurse leader will also communicate infor-
mation about the delegation process and delegatee competence level to the licensed
nurse and provide training and education.

The Licensed Nurse Responsibilities include to determine patient needs and when to
delegate, ensure availability to delegatee, evaluate outcomes of and maintain accountabil-
ity for delegated responsibility. The Licensed Nurse will communicate information about
the delegation process and delegatee competence level to the Employer/Nurse Leader.
The Licensed Nurse will also maintain two-way communication with the Delegatee. The
Delegatee responsibilities are to accept activities based on his or her own competence
level and to maintain competence and accountability for delegated responsibility.

DELEGATED RESPONSIBILITY

A delegated responsibility is a nursing activity, skill, or procedure that is transferred from a
licensed nurse to a delegatee; according to the National Guidelines for Nursing Delegation
(NCSBN, 2016), “Any decision to delegate a nursing responsibility must be based on the
needs of the patient or population, the stability and predictability of the patient’s condition,
the documented training and competence of the delegatee, and the ability of the licensed
nurse to supervise the delegated responsibility and its outcome, with special consideration
to the available staff mix and patient acuity.” The responsibilities considered for delegation

Employer/Nurse Leader
Responsibilities

Training
and

Education
Public

Protection

Two-way
Communication

Licensed Nurse
Responsibilities

• Determine patient needs
and when to delegate
• Ensure availability to delegatee

Communicate
information about
delegation process
and delegatee
competence
level

• Identify a nursing leader
• Determine nursing responsibilities that can be
delegated, to whom, and what circumstances
• Develop delegation policies and procedures
• Periodically evaluate delegation process
• Promote positive culture/work environment

• Evaluate outcomes of and
maintain accountability for
delegated responsibility

Delegatee
Responsibilities

• Accept activities based on own
competence level

• Maintain competence for
delegated responsibility

• Maintain accountability for
delegated activity

FIGURE 6.1 National Guidelines for Nursing Delegation.
Source: National Council of State Boards of Nursing. (2016). National Guidelines for Nursing
Delegation. Journal of Nursing Regulation, 7(1), 5–12.

160 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

must be in accordance to the state’s/jurisdiction’s laws and rules and organizational poli-
cies and procedures prior to the licensed nurse making a final decision to delegate. If at any
point, the nurse does not feel delegation of a responsibility is appropriate, the nurse must
complete the responsibility himself or herself. The licensed nurse will maintain account-
ability for the patient at all times. The UAP is responsible for the delegated responsibility.

ASSIGNMENT

Assignment is the routine care, activities, and procedures that are within the autho-
rized scope of practice of the RN or LPN/LVN or part of the routine functions of
the UAP (NCSBN, 2016). An example of an assignment is the LPN/LVN caring for a
patient with Crohn’s disease. The nurse expects the LPN/LVN to assess the patient,
monitor intake and output (I and O), administer medications, and take vital signs. As
an assignment, these skills were taught in the LPN/LVN education program and thus
are part of the LPN/LVN scope of practice.

There are exceptions when speaking to the basic educational preparation of a UAP.
The skills once believed to be performed only by a licensed nurse are now taught to
UAPs in certain advanced UAP education programs. Such roles of the UAP include
administering injections and medications. For example, certified medication assistants
(CMAs) are given special training to pass oral medications and give injections. Since
there is a significant level of skill needed when administering medications or injec-
tions, employers and nurses will validate CMA competency. To validate competency,
employers and nurses give skill tests or make observations as needed. Once employ-
ers and nurses are comfortable with a UAP’s competence, procedures can be routinely
delegated to him or her (NCSBN, 2016).

ACCOUNTABILITY

According to the ANA, accountability is defined as “to be answerable to oneself and
others for one’s own choices, decisions and actions as measure against a standard such
as that established by the Code of Ethics for Nurses with Interpretive Statements” (ANA,
2015). The licensed nurse is accountable for the performance of the responsibilities del-
egated to others, for responsibilities the nurse personally performs, and for the act of
delegating responsibilities to others. The nurse is ultimately accountable for the overall
care provided to a patient. The delegatee shares the responsibility for the patient and
is fully responsible for the delegated responsibilities. Licensed nurse accountability
involves compliance with legal requirements as set forth in states/jurisdictions laws
and rules governing nursing. The nurse is also accountable for the quality of nursing
care provided and for recognizing limits, knowledge, competency, and experience of
delegatees (ANA, 2015). Furthermore, the ANA (2015) states, nurses are accountable
even in the event of system and/or technology failure.

UAPs and LPN/LVNs are also accountable to the licensed nurse. Accountability
for the act of delegating involves the appropriate choice of delegatee and responsibil-
ity. For example, a nurse might delegate to the UAP a certain responsibility. If the nurse
has not determined in advance that the UAP understands the delegated responsibil-
ity and has the skills, knowledge, and judgment to complete the responsibility, or the
nurse does not supervise the completion of the responsibility and the UAP does not
carry out the responsibility adequately, the nurse would be accountable for this act of
improper delegation.

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 161

AUTHORITY

Authority is the right to act or to command the action of others. Authority comes with
the job and is required for a nurse to take action. The person with authority must be
free to make decisions regarding the activities involved. Without authority, the nurse
will be unable to provide quality and safe patient-centered care (PCC). Authority is
based on the state’s/jurisdiction’s NPA and guides the development of an organiza-
tion’s job description. If the nurse is in charge of a group of patients, the nurse must
have the authority to act or command the action of others.

SUPERVISION

Supervision is the provision of guidance or direction, evaluation, and follow-up by the
licensed nurse for accomplishment of a nursing task delegated to the UAP (NCSBN, 1995).
Supervision is generally categorized as on site (the licensed nurse being physically present or
immediately available while the activity is performed) or off site (the licensed nurse has the
ability to provide direction through various means of written and verbal communication).

A licensed nurse supervising care will provide clear directions to the interprofes-
sional team. The supervising nurse must identify when and how a task is to be done
and what information must be collected as well as any patient-specific information.

EVIDENCE FROM THE LITERATURE

Citation

Buppert, C. (2016, December 8). Can a patient-care tech perform this task?
Medscape. Retrieved from https://www.medscape.com/viewarticle/873589

Discussion

A nursing educator recently hired at a community hospital in New York observed
a patient-care tech (PCT) removing a peripheral intravenous (IV) line. The nurs-
ing educator looked for a policy and procedure for this task to be completed by
a PCT but was unsuccessful. The nursing educator asks the nursing administra-
tor about it. The nursing administrator stated she wanted a policy to be written
for this particular procedure. The nurse educator contacted the state board of
nursing for New York and was told PCTs are not allowed to perform this task as
stated in the NPA for the state of New York.

Implications for Practice

Some states specify, in the form of a regulation or policy, the tasks UAPs, such as
a PCT, may perform. Some states specify what they may not do and some states
are silent on this issue.

The state NPA trumps the community hospital’s decision to allow PCTs to
remove peripheral IV lines. The hospital’s decisions must refer to their particular
state’s NPA prior to determining a policy and procedure related to nursing care.

162 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

The licensed nurse must identify what outcomes are expected and the time frame for
reporting results. The organization will monitor staff performance to ensure compli-
ance with established standards of practice, policy, and procedure.

FIVE RIGHTS OF DELEGATION

When the needs of the patient coincide with the skills, knowledge, and competency
of UAP and can be performed safely, the licensed nurse will decide that delegation
of a responsibility can occur. This decision is guided by the NCSBN Five Rights of
Delegation (1995, 1996) (Table 6.1).

CRITICAL THINKING 6.1

A nurse working in the emergency department asks a UAP if he wants to try to start an
IV line. The nurse knows the UAP is graduating from nursing school in May. Without
hesitation, the UAP agreed to start the IV.

1. Can this task be delegated to a UAP?
2. Who is responsible in the event the IV insertion site becomes infected?
3. What are the implications for the UAP if he declined the opportunity to start

the IV?

REAL-WORLD INTERVIEW

TABLE 6.1 FIVE RIGHTS OF DELEGATION

Right task • The activity falls within the delegatee’s job description or is
included as part of the established written policies and procedures
of the nursing practice setting. The facility needs to ensure the
policies and procedures describe the expectations and limits of
the activity and provide any necessary competency training.

Right
circumstance

• The health condition of the patient must be stable. If the
patient’s condition changes, the delegatee must communicate
this to the licensed nurse, and the licensed nurse must reassess
the situation and the appropriateness of the delegation.

Right person • The licensed nurse, along with the employer and the delegatee,
is responsible for ensuring that the delegatee possesses the
appropriate skills and knowledge to perform the activity.

Right direction and
communication

• Each delegation situation should be specific to the patient, the
licensed nurse, and the delegatee.

• The licensed nurse is expected to communicate specific
instructions for the delegated activity to the delegatee; the
delegatee, as part of two-way communication, should ask any
clarifying questions. This communication includes any data
that need to be collected, the method for collecting the data,
the time frame for reporting the results to the licensed nurse,
and additional information pertinent to the situation.

• The delegatee must understand the terms of the delegation
and must agree to accept the delegated activity.

• The licensed nurse should ensure that the delegatee understands
that she or he cannot make any decisions or modifications in
carrying out the activity without first consulting the licensed nurse.

(continued)

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 163

The UAP’s knowledge and level of competence impacts effective delegation. This
knowledge and competency can be obtained from a formal educational program or
from on the job training. For example, a licensed nurse in some states can delegate
to UAPs such as secretaries, teachers, or other individuals in a school setting when
certain medications need to be administered. The Five Rights of Delegation must be
followed and the knowledge the UAP has gained from such things as an inservice fol-
lowed by a return demonstration for competency testing is tested.

I am a veteran labor and delivery travel nurse. We had a patient develop
an amniotic fluid embolism in labor on my unit. This is a phenomenon that
occurs in about one in 20,000 births. Therefore, it is not widely recognized
nor easily diagnosed until autopsy. Not only was this patient mine, but I was
in charge of a busy unit and it was 4 o’clock in the morning, when only skel-
eton crews are available. Due to quick thinking, 10 years of experience, and
a lot of divine intervention, we were able to save this mother and her unborn
baby. I remained at the bedside, prepping the patient for an emergency cesar-
ean section. I delegated to another RN to obtain blood that we had on hold
from the laboratory, so the patient could be transfused stat, as we knew dis-
seminated intravascular coagulation (DIC) was looming. I was able to del-
egate to two other RNs at the same time to set the operating room up and call
the house supervisor to alert the main operating room on-call staff. My final
act of delegation was to have another RN call in our own on-call staff and
our management team. This was all done while at the bedside. Granted, I had
an amazing staff that evening, but being able to “hold it together” and think
quickly and clearly to delegate within seconds in a crisis lent a glimmer of
hope to a potentially fatal outcome. That outcome, thanks to skill and prayer,
was a mother and her infant walking out of the hospital 5 days later, going
home alive and well.

Sharon Murphy, RNC, BSN
Silver Spring, Maryland

REAL-WORLD INTERVIEW

Right supervision
and evaluation

• The licensed nurse is responsible for monitoring the delegated
activity, following up with the delegatee at the completion of
the activity, and evaluating patient outcomes. The delegatee
is responsible for communicating patient information to the
licensed nurse during the delegation situation. The licensed
nurse should be ready and available to intervene as necessary.

• The licensed nurse should ensure appropriate documentation
of the activity is completed.

Source: National Council of State Boards of Nursing (NCSBN). (1995). Delegation: Concepts and decision-making
process. National Council of State Boards of Nursing 1995 Annual Meeting Business Book; National Council of State
Boards of Nursing (NCSBN). (1996). Delegation: Concepts and decision-making process. National Council of State
Boards of Nursing.

TABLE 6.1 FIVE RIGHTS OF DELEGATION (continued)

164 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

DELEGATION RELATED TO THE HEALTHCARE
ORGANIZATION AND HEALTHCARE TEAM

The process of delegation begins with the states/jurisdictions NPA. From there, the
healthcare organization selects a nurse leader to oversee the process of nursing delega-
tion. It is imperative this nurse leader is familiar with the NPA, the policies and pro-
cedures of the organization, the National Guidelines for Nursing Delegation, and the
Five Rights of Delegation. Organizational accountability for delegation also includes
the need to provide sufficient staffing, an appropriate staffing mix, and ongoing
education and competency support for all those involved in the delegation process.
Requiring ongoing education and regular competency assessment will keep everyone
involved in the delegation process up to date.

A nursing committee is usually established to create the policies and procedures
for delegation. The nursing committee is often led by the nurse leader. Appropriate
nurse and UAP staffing, the roles of the nurse and UAP, appropriate lines of com-
munication, and the procedure for delegation are developed. The nursing committee
will consider various factors as they write the delegation policy and procedure. These
factors include but are not limited to:

• The nursing responsibilities that can be delegated
• The standards of nursing practice to maintain patient-centered, high quality, safe care

The hospital was preparing to initiate the use of high-flow nasal oxygen therapy
(HFNOT). A committee was charged with writing the policy and procedure for
this new form of oxygen therapy. The policy and procedure for the HFNOT was
not completed prior to the initial use on a patient in the NICU. An anesthesi-
ologist was present during the time of the administration of HFNOT. The nurse
started to feed the neonatal patient a bottle of formula once the oxygen saturation
was over 97%. The anesthesiologist told the nurse to stop feeding the patient, as
it was contraindicated when HFNOT was being administered.

1. How should the nurse respond to the directive by the anesthesiologist?
2. What is the hospital’s responsibility to ensure new equipment such as HFNOT is

implemented correctly?

CASE STUDY 6.2

NURSE LEADER AND MANAGER

In 1854, Florence Nightingale and her staff of 38 female volunteer nurses were sent
to the Crimean War, where they improved the unsanitary conditions at a British base
hospital and reduced the death count by two thirds. In 1859, Nightingale wrote Notes
on Nursing and in 1860, she funded the establishment of St. Thomas’ Hospital and the
Nightingale Training School for Nurses. Notes on Nursing served as the cornerstone
of the curriculum at the Nightingale School and other nursing schools. Read more
about her at www.victorianweb.org/history/crimea/florrie.html.

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 165

• Job descriptions of all healthcare team members that are part of the delegation
process, for example, RN, LPN/LVN, UAP

Licensed nurses throughout the organization are then given the responsibility to
delegate, oversee the delegation process, and evaluate the effectiveness of delegation.
A systematic approach to the delegation process fosters communication and consis-
tency of the process throughout the facility.

The nurse is caring for a patient who is on day 2 post-op gastric bypass surgery.
The patient has been using oxygen periodically. The order is written for oxy-
gen per nasal cannula at 2 L/min whenever necessary. The respiratory therapist
explains to the patient that it is necessary for the oxygen to be worn at all times.
The patient replies that the doctor said to use the oxygen only when needed.
The nurse entered the room just as the patient made the statement and the nurse
concurred. The respiratory therapist then said she had been taking care of gastric
bypass patients longer than the surgeon has performed them. She said to trust
her, it is best to wear the oxygen all the time.

1. How does the nurse know when the patient should wear the oxygen? On what basis
did you determine your answer?

2. Who is responsible for the care of the patient’s respiratory status? Why?

CASE STUDY 6.3

EVIDENCE FROM THE LITERATURE

Citation

Buchwach, D. (2017). Helping new nurses with the fine art of delega-
tion. Adapted from Quick-E! Pro Time Management: A Guide for Nurses.
Retrieved from http://www.strategiesfornursemanagers.com/content.cfm?
content_id=233639&oc_id=602#

Discussion

Delegation is a five-step process. First, as the nurse, determine how, where,
and when assistance can be provided. Next, select an appropriate person. A
discussion occurs wherein authority to complete the task is given from one
person to another. The task is carried out under supervision. Finally, the del-
egation process is evaluated and feedback is given. Some questions to consider
when matching a delegated task with skill level are: Is the person licensed or
unlicensed? Is the person in orientation or off orientation? How long has the
person worked in the role? Has the person been checked off on this particu-
lar skill? Does the person feel confident that he or she can complete the task?
Does the person need additional training or practice prior to completing the

(continued)

166 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

CHAIN OF COMMAND

The licensed staff nurse, including the new graduate nurse, is accountable to the
charge nurse of the unit where they are working. The charge nurse is accountable to
the nurse manager. The nurse manager is accountable to the Chief Nursing Executive.
The Chief Nursing Executive is accountable to the hospital’s Chief Executive Officer.
The hospital’s Chief Executive Officer is accountable to the Board of Directors. The
Board of Directors is accountable to the community it serves and often to another
larger healthcare organization, as well as being accountable to state nursing and medi-
cal licensing boards and accreditation agencies, for example, The Joint Commission
(TJC), Det Norske Veritas Healthcare, Inc. (DNV), Healthcare Facilities Accreditation
Program (HFAP), or American Osteopathic Association. All of the aforementioned are
accountable for their actions to the patients and the communities that they serve. See
the organizational chain of command in Figure 6.2.

COMMUNICATION FACTORS INFLUENCING DELEGATION

Communication is a cornerstone to achieving success when delegating patient care.
The Quality and Safety in Educating Nurses (QSEN) Patient-Centered Care (PCC)
competency is defined as, “Recognize the patient or designee as the source of control
and full partner in providing compassionate and coordinated care based on respect
for patient’s preferences, values, and needs” (www.qsen.org). The knowledge,
skills, and attitudes of PCC include communication; the Five Rights of Delegation
identify the necessity for communication; and the National Guidelines for Nursing
Delegation has communication in the center of the Guidelines.

An excellent guide for communication with coworkers is the golden rule, “Do
unto others as you would have them do unto you.” Communication between nurses
and coworkers often involves nursing delegation. Offering positive feedback to a
UAP such as, “I appreciate the way you spoke with the patient in room 2345 to get
him to ambulate twice this shift,” goes a long way toward team building. “I will
help you as soon as I can,” is a statement that acknowledges that all team members’
responsibilities are important.

The licensed nurse also ensures that all communication is culturally appropri-
ate and respectful. Evidence shows that the better the communication and collab-
orative relationship between the licensed nurse and the delegatee, the better the
chance a positive outcome of the delegation process will ensue (Corazzini et al.,
2013; Damgaard & Young, 2014; Young & Damgaard, 2015). Reviewing the dele-
gated responsibility with the delegatee and allowing for questions for clarification
should be welcomed by the nurse. The licensed nurse should be available to the
UAP for assistance and guidance in an ongoing manner. Under no circumstance is

skill independently? Use the Five Rights of Delegation to reflect on each step
of the delegation process as you do the exercises in the article to examine
how to delegate. Implications for nursing. It is useful to think through vari-
ous scenarios prior to being faced with the decision to delegate as a new nurse.

EVIDENCE FROM THE LITERATURE (continued)

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 167

the nurse permitted to delegate a responsibility that requires any form of clinical
reasoning, nursing judgment, or critical decision making. For example, a licensed
nurse delegates the responsibility of checking a patient’s blood sugar every 2 hours
and reporting the results to the licensed nurse. The delegation cannot include hav-
ing the delegatee make a nursing judgment of what action to take when the patient’s
blood sugar is low.

Communication on a patient-care unit often begins with a handoff report from
one nurse to another to ensure continuity of patient care. The receiving nurse then
completes an assignment sheet (Figure 6.3), a written or computerized plan that
identifies the patient-care assignments on the unit to team members and the pri-
orities for the shift. Assignments should consider several factors (Table 6.2) and
include specific reporting guidelines, times for interventions, and deadlines for
accomplishment of tasks.

SCOPE OF NURSING PRACTICE DECISION-MAKING
FRAMEWORK

In early 2015, the Tri-Council for Nursing, consisting of the American Association
of Colleges of Nursing (AACN), the ANA, the American Organization of Nurse
Executives (AONE), and the National League for Nursing (NLN), in collabora-
tion with NCSBN developed a Scope of Nursing Practice Decision-Making
Framework to assist nurses and their employers in determining the responsibilities
a nurse can safely perform. While decisions to delegate patient-care responsibilities
are unique to different situations, the Scope of Nursing Practice Decision-Making
Framework (Ballard et al., 2016) in Figure 6.4 can be applied to most situations.
This Framework is for all nurses with various types of education and roles in dif-
ferent settings.

State Licensing Boards Community

Board of Directors

Chief Executive Officer

Quality Improvement &
Safety Committee

Chief of Medical Staff

Chief of Medical
Services

MD

Resident

Accreditation Agency

Ethics Committee

Chief Nursing Executive

Nurse Manager

Charge Nurse

Staff RN

Other Staff

FIGURE 6.2 Organizational chain of command.

168 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

Nurse Manager: __________________ House Supervisor: _______________

Charge Nurse: : Day

Census Isolations Discharges Planned Transfers

Patient Care Communication Special Assignments

CODE PAGER: ______________

RNs: UAP:

Room RN UAP Room RN UAP

401 405

402 406

403 407

404 408

__________________SHIFT

FIGURE 6.3 Unit nursing assignment sheet.

TABLE 6.2 FACTORS CONSIDERED IN MAKING ASSIGNMENTS

• Number and acuity of patients
• Priority patient needs
• Number and type of staff
• State laws
• Organizational policies and procedures
• Patient-care standards
• Accreditation regulations
• Unit routines
• Geography of nursing unit
• Complexity of patient needs
• Staff responsibilities
• Attitude and dependability of staff
• Need for continuity of care by same staff

(continued)

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 169

The nurse may perform the activity, intervention or role to acceptable
and prevailing standards of safe nursing care.

Is the activity, intervation or role prohibited
by the Nurse Practice Act and rules/regulations
or any other applicable laws, rules/regulations

or accreditation standards or professional
nursing scope and standards? with evidence
-based nursing and health care literature?

STOP

Is performing the activity, intervation or role
consistent with evidence-based nursing and

health care literature?
STOP

Are there practice setting policies and
procedures in place to support performing

the activity, intervnetion or role?
STOP

Has the nurse completed the necessary
education to safety perform the activity,

intervention or role?
STOP

Is there documented evidence of the nurse’s
current competence (knowledge, skills, abilities,
and judgements) to safety perform the activity,

intervention or role?

STOP

Does the nurse have the appropriate resources
to perform the activity, intervention or role

in the practice setting?
STOP

Would a reasonable and prudent nurse perform
the activity, intervention or role in this setting? STOP

Is the nurse prepared to accept accountability
for the activity, intervention or role and

for the related outcomes?

NO

YES

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO
STOP

FIGURE 6.4 Scope of nursing practice decision-making framework.
Source: Ballard, K., Haagenson, D., Christiansen, L., Damgaard, G., Halstead, J. A, Jason, R. R., … Alexander, M. (2016).
Scope of nursing practice decision-making framework. Journal of Nursing Regulation, 7(3), 19–21.

• Need for fair work distribution among staff
• Need of patient for isolation and/or protection
• Skill, education, and competency of staff, i.e., RN, LPN/LVN, UAP
• Need to protect patient and staff from injury
• Environmental concerns
• Lunch/break times
• All delegation policies

LPN, licensed practical nurses; LVN, licensed vocational nurses, UAP, unlicensed assistive personnel.

TABLE 6.2 FACTORS CONSIDERED IN MAKING ASSIGNMENTS (continued)

170 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

KEY CONCEPTS

• Delegation is allowing a delegatee to perform a specific nursing activity, skill, or
procedure that is beyond the delegatee’s traditional role and not routinely per-
formed (NCSBN, 2016).

• The National Guidelines for Nursing Delegation were created in 2016 by the NCSBN.
• Different states have different NPAs and rules and regulations.
• Responsibility is the obligation involved when a person accepts an assignment. The

delegation process is not complete until the person who receives the assignment
accepts the responsibility for the assignment. Without this acceptance of responsibil-
ity, assignments cannot be delegated.

• If a person does not have the knowledge, skill, experience, or willingness needed to
complete an assignment, it is inappropriate to accept responsibility for the assignment.

• Once a person accepts responsibility for an assignment, this responsibility is retained.
• A delegated responsibility is a nursing activity, skill, or procedure that is trans-

ferred from a licensed nurse to a delegatee. According to the National Guidelines
for Nursing Delegation (NCSBN, 2016), “Any decision to delegate a nursing respon-
sibility must be based on the needs of the patient or population, the stability and
predictability of the patient’s condition, the documented training and competence
of the delegatee, and the ability of the licensed nurse to supervise the delegated
responsibility and its outcome.”

• Assignment is the routine care, activities, and procedures that are within the autho-
rized scope of practice of the RN or LPN/VN or part of the routine functions of the
UAP (NCSBN, 2016).

• Accountability is defined as “to be answerable to oneself and others for one’s own
choices, decisions, and actions as measured against a standard such as that estab-
lished by the Code of Ethics for Nurses with Interpretive Statements” (ANA, 2015).

• Authority is the right to act or to command the action of others. Authority comes
with the job and is required for a nurse to take action. The person with authority
must be free to make decisions regarding the activities involved.

• Authority is based on the states/jurisdiction NPA and guides the development of an
organization’s job description with special consideration to the available staff mix
and patient acuity.

• Supervision is the provision of guidance or direction, evaluation, and follow-up
by the licensed nurse for accomplishment of a nursing task delegated to the UAP
(NCSBN, 1995).

• When the needs of the patient coincide with the skills, knowledge, and competency
of a UAP and can be performed safely, the licensed nurse will decide that delegation
of a responsibility can occur. This decision is guided by the NCSBN Five Rights of
Delegation (1995, 1996).

• The licensed staff nurse, including the new graduate nurse, is accountable to the
charge nurse of the unit where they are working. The charge nurse is account-
able to the nurse manager. The nurse manager is accountable to the Chief Nursing
Executive. The Chief Nursing Executive is accountable to the hospital’s Chief
Executive Officer. The hospital’s Chief Executive Officer is accountable to the Board
of Directors. The Board of Directors is accountable to the community it serves and

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 171

often to another larger healthcare organization, as well as being accountable to state
nursing and medical licensing boards and accreditation agencies, for example, TJC,
DNV, HFAP, or American Osteopathic Association. All of the aforementioned are
accountable for their actions to the patients and the communities that they serve.

• Communication on a patient-care unit often begins with a handoff report from
one nurse to another to ensure continuity of patient care. The receiving nurse then
completes an assignment sheet, a written or computerized plan that identifies the
patient-care assignments on the unit to team members and the priorities for the shift.
Assignments should consider several factors and include specific reporting guide-
lines, times for interventions, and deadlines for accomplishment of tasks.

• The Tri-Council for Nursing, consisting of AACN, ANA, AONE, and NLN, in col-
laboration with the NCSBN developed a Scope of Nursing Practice Decision-Making
Framework to assist nurses and their employers in determining the responsibilities
a nurse can safely perform.

KEY TERMS

Accountability
Assignment
Authority
Delegated responsibility

Delegation
Responsibility
Supervision

REVIEW QUESTIONS

1. The nurse is performing an assessment on a patient who is taking 400 mg of
naproxen for abdominal pain. Which assessment can be delegated to the unli-
censed nursing personnel?

A. Review the results of the patient’s Hgb and hematocrit.
B. Collect and send a stool sample to the laboratory for guaiac testing.
C. Auscultate the abdomen for bowel sounds.
D. Ask the patient what other medications they are taking.

2. Which of the following is a responsibility of the employer and/or nurse leader
when delegating nursing responsibilities to the UAP?

A. Assigning the UAP responsibilities.
B. Establishing licensure guidelines for UAP.
C. Making certain that appropriate policies and procedures for delegation are in

place.
D. Encouraging staff to create a delegation sheet at the beginning of every shift.

3. The licensed nurse delegated to the UAP to ambulate the patient to the bathroom.
The UAP is having difficulties completing this delegated task. What is the proper
action the UAP must take?

A. Delegate the task to another UAP.
B. Notify the employer of the UAP’s inability to complete this particular task.
C. Notify the licensed nurse of the UAP’s difficulties with completing this task.
D. Document that the patient was unable to ambulate to the bathroom.

172 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

4. The patient assigned to a new graduate nurse has an order to have a nasogastric
tube inserted. The nurse has never completed this type of procedure. How should
the new graduate nurse proceed?

A. Request assistance from an experienced nurse.
B. Delegate the procedure to a UAP.
C. Notify the physician of the new graduate nurse’s inexperience.
D. Look-up the policy and procedure, then insert the tube.

5. The nurse delegated to another nurse to disconnect an IV line from a patient once
the infusion is complete. Which factors should the nurse consider prior to delegat-
ing this to another nurse? Select all that apply.

A. Right person
B. Right supervision and evaluation
C. Right direction and communication
D. Right task
E. Right circumstance

6. A new graduate nurse is caring for two patients during the fifth week of new
employee orientation. The new graduate nurse asks one of the unit nurses to see
the policy and procedure for delegation. The unit nurse looks at the new graduate
nurse with a puzzled look and says, “I don’t know if we have one.” What is the
best reason for the unit nurse’s reply?

A. There probably is not a delegation policy or procedure.
B. The new graduate nurse should not be asking this question when caring for

only two patients.
C. The unit nurse is not aware of a policy or procedure for delegation.
D. Delegation is something taught in nursing school, but is not practiced in the

real world.

7. Who is legally responsible for nursing care provided to patients?

A. Physician
B. Nurse manager
C. RN assigned to patient
D. UAP providing care to patient

8. QSEN has developed multiple quality and safety elements to guide nursing prac-
tice. Identify which of these are considered a part of the six key elements.

A. Quality improvement (QI), teamwork and collaboration, and evidence-based
practice

B. Fact finding, mission statements, and strategic planning
C. Stakeholder feedback, budget reconciliation, and strategic planning
D. Financial reporting, wait time measurements, and time delays in getting

treatments.

9. The nurse is preparing to review discharge instructions with a patient. The nurse
instructs the patient regarding medications and wound care for her foot. What
indicates to the nurse the level of understanding the patient has regarding dis-
charge instructions?

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 173

A. The patient signs the discharge instruction sheet.
B. When asked by the nurse, the patient denies any questions or concerns.
C. The patient asks for new prescriptions for the pharmacy.
D. The nurse observes the patient changing the dressing on her foot wound.

10. The nurse is transferring a patient from the ICU to the step-down patient-care unit.
When the ICU nurse calls report to the receiving unit, what is the best way for the
nurse to provide the handoff information?

A. Situation, background, assessment, requirements
B. Situation, background, assessment, recommendations
C. Systems, background, activities, recommendations
D. Systems, background, activities, requirements

REVIEW ACTIVITIES

1. Click on the link from QSEN to watch the Lewis Blackman story: qsen.org/qsen-
videos-lewis-blackman-story-released/. What responsibilities should the nurse
have delegated to allow more time to focus on the patient?

2. Interview three nurses on the unit where you are currently doing a clinical rota-
tion. Ask each nurse, “What responsibility is delegated to Unlicensed Assistive
Personnel (UAP) most often on this unit?” Make a list. Compare their answers.
Review the policy and procedure for the delegated responsibilities to UAPs. What
did you find?

3. Show two nursing instructors the Scope of Nursing Practice Decision-Making
Framework in Figure 6.4. Ask each instructor how they implement the Framework
in their practice. What were their responses?

CRITICAL DISCUSSION POINTS

1. What references should a licensed nurse refer to when considering delegating to a
UAP in a state other than his or her own?

2. During your clinical, what examples of delegation did you observe? Were the
delegated responsibilities in the delegatee’s job description? How was it decided
what could be delegated and what could not?

QSEN ACTIVITY

1. Go to the QSEN website (www.qsen.org) and search for Delegation. Click on
Delegation: A Collaborative, Patient-Centered Approach (qsen.org/delegation-a-
collaborative-patient-centered-approach/). Click on one of the Case Studies and
work through it to improve your Delegation skills.

2. Go to the QSEN website (www.qsen.org) and search for Delegation. Click on Learn-
ing Module 1 (qsen.org/faculty-resources/courses/learning-modules/module-
one/). Use the module to improve your nursing delegation skills.

174 • I INTRODUCTION TO QUALITY AND SAFETY EDUCATION FOR NURSES

EXPLORING THE WEB

1. Visit www.youtube.com and search for “Delegating effectively NCSBN.” Select some
of the Popular Videos on Delegation & Nursing and begin viewing some of them.

2. Visit the Indiana Center for Evidence Based Nursing Practice at www.ebnp.org.
Hover over “About Us” then click on “Evidence into Practice.”

3. Login and register your name at www.nursingcenter.com to receive articles,
continuing education, and information on topics such as quality and safety and
delegation.

REFERENCES

American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive statements.
Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-
Nurses.html

American Nurses Association (ANA). (2016). Code of ethics for nurses. Silver Spring, MD: Author.
American Nurses Association and National Council of State Boards of Nursing. (2006). Joint

statement on delegation. Retrieved from https://www.NCSBN.org/Delegation_joint_state-
ment_NCSBN-ANA.pdf

Ballard, K., Haagenson, D., Christiansen, L., Damgaard, G., Halstead, J. A., Jason, R. R., …
Alexander, M. (2016). Scope of nursing practice decision-making framework. Journal of
Nursing Regulation, 7(3), 19–21.

Buppert, C. (2016, December 28). Can a patient care tech perform this task? Medscape.
Corazzini, K. N., Anderson, R. A., Mueller, C., Hunt-McKinney, S., Day, L., … Porter, K. (2013).

Understanding RN and LPN patterns of practice in nursing homes. Journal of Nursing Regu-
lation, 4(1), 14–18.

Damgaard, G., & Young, L. (2014). Virtual nursing care for school children with diabetes. Journal
of Nursing Regulation, 4(4), 15–24.

National Council of State Boards of Nursing (NCSBN). (1995). Delegation: Concepts and decision-
making process. National Council of State Boards of Nursing 1995 Annual Meeting Business
Book.

National Council of State Boards of Nursing (NCSBN). (1996). Delegation: Concepts and decision-
making process. National Council of State Boards of Nursing 1996 Annual Meeting Business
Book.

National Council of State Boards of Nursing (NCSBN). (2016). Nursing guidelines for nursing
delegation. Journal of Nursing Regulation, 7(1), 5–12.

Shannon, R. A., & Kubelka, S. (2013). Reducing the risks of delegation use of procedure skills
checklist for unlicensed assistive personnel in schools, part 1. NASN School Nurse, 28(4),
178–181. doi:10.1177/1942602X13489886

Young, L., & Damgaard, G. (2015). Transitioning the virtual nursing care for school children with
diabetes study to a sustainable model of nursing care. Journal of Nursing Regulation, 6(2),
4–9. doi:10.1016/S2155-8256(15)30380-X

6 DELEGATION AND SETTING PRIORITIES FOR SAFE, HIGH-QUALITY NURSING CARE • 175

SUGGESTED READINGS

Agency for Healthcare Research and Quality. (2016). Patient safety primer: Handoffs and signouts.
Retrieved from https://psnet.ahrq.gov/primers/primer/9/handoffs-and-signout

Anthony, M. K., & Vidal, K. (2010). Mindful communication: A novel approach to improv-
ing delegation and increasing patient safety. The Online Journal of Issues in Nursing, 15(2).
doi:10.3912/OJIN.Vol15No2Man02

Barra, M. (2011). Nurse delegation of medication pass in assisted living facilities: Not all medica-
tion assistant technicians are equal. Journal of Nursing Law, 14(1), 3–10.

Flicek, C. L. (2012, November/December). Communication: A dynamic between nurses and
physicians. Medsurg Nursing: Pitman, 21(6), 385–387.

Hansen, F., McKenna, H. P., & Keeney, S. (2013). Delegating and supervising unregistered profes-
sionals: The student nurse experience. Nurse Education Today, 33(3), 229–235. doi:10.1016/j.
nedt.2012.02.008.

Kalisch, B. J. (2011). The impact of RN-UAP relationships on quality and safety. Nursing Manage-
ment, 42(9), 16–22.

Kreitzer, M. J., & Koithan, M. (2014). Integrative nursing. Oxford, England: Oxford University
Press.

Lloyd, J. (2014). Still trying to do it all yourself? Tips for effective delegation. Health Care Collec-
tor, 28(7), 8.

McCloskey, R., Donovan, C., Stewart, C., & Donovon, A. (2015). How registered nurses, licensed
practical nurses and resident assistants spend time in nursing homes: An observational
study. (2015). International Journal of Nursing Studies, 52(9), 1475–1483.

McMullen, T. L. Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R.
(2015). Certified nurse aide scope of practice: State-by-state differences in allowable del-
egated activities. Journal of the American Medical Directors Association, 16(1), 20–24.

Mueller, C., & Vogelsmeier, A. (2013). Effective delegation: Understanding responsibility, author-
ity, and accountability. Journal of Nursing Regulation, 4(3), 20–27.

Quality and Safety Education for Nurses. (2017). QSEN. Retrieved from www.qsen.org
Saccomano, S. J., & Pinto-Zipp, G. (2011). Registered nurse leadership style and confidence in

delegation. Journal of Nursing Management, 19, 522–533.
Twigg, D. E., Myers, H., Duffield, C., Pugh, J. D., Gelder, L., & Roche, M. (2016). The impact of

adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient
outcomes: An analysis of administrative health data. International Journal of Nursing Studies,
63, 189–200.

UNIT I I .
THE USE OF QUALITY AND SAFETY
EDUCATION CONCEPTS BY NURSING
LEADERS AND MANAGERS

THE USE OF QUALITY AND SAFETY
EDUCATION CONCEPTS BY NURSING
LEADERS AND MANAGERS

Upon completion of this chapter, the reader should be able to

1. Describe characteristics of patient-centered care (PCC).

2. Identify basic components of empathetic communication and describe its
importance to PCC.

3. Discuss the psychosocial factors associated with the impact of physical
illness and injury.

4. List strategies to support patient-centered healthcare.

5. Describe the impact of legislation such as the Patient Protection and
Affordable Care Act (ACA) in facilitating PCC.

6. Discuss discharge planning as a means of ensuring continuity of care.

7. List information technologies that facilitate PCC.

8. Explain the significance of patient-centered measures and monitors of
quality healthcare.

9. Describe the importance of patient satisfaction relative to measuring the
accomplishment of PCC.

7
PATIENT-CENTERED CARE

Carolyn A. Christie-McAuliffe

Transforming Health Care One Nurse, One Caregiver, One Organization, At a Time.

(Dr. Jean Watson, 2012, World Caring Science Institute, watsoncaringscience.org)

180 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Y
ou are a nurse on a very busy medical–surgical unit. Mrs. Rodriguez is a 76-year-old
patient who suffered a stroke and is being discharged within the next few days. She
is a widow whose children live an hour away and her most frequent visitor is the priest
from her church.

Each day, the interprofessional team completes rounds on the unit. As the contact point for
Mrs. Jones and her family, you have been directed by the charge nurse to communicate the
discharge plan to the patient and family/designee.

• Before you can effectively participate in the interprofessional team rounds, what must you
understand about your patient?

• What are some interventions that will support an effective care transition for this patient?
• Who will be key contact points in the family to ensure patient continuity of care

posthospitalization?

Decades ago a paradigm shift to caring within healthcare settings was introduced that
emphasized moving from a technocratic focus to establishing caring relationships,
identifying the patient as a consumer of care to recognizing the patient as a partner in
care, and providing service from the perspective of the expert provider for healthcare
services to the perspective of the collaborative partnership between patient and pro-
vider for healthcare services. This new paradigm embraces values, relationships, and
preferences, recognizing the patient as a participant in his or her own care. Although
this paradigm shift has taken time to be accepted within a highly technological and
authoritative healthcare system, it has awakened the need for nursing and healthcare
providers to support the patient’s role in control of his or her own healthcare decisions.

Currently, many federal initiatives are being implemented to address the need for
quality care and patient safety and are transforming healthcare settings into account-
able, safe, patient-centered environments that respect the unique needs and values of
the patient. This process of transformation within healthcare has evolved into pro-
viding compassionate care that recognizes the patient as an integral member of the
interprofessional team. With patients central to all services, nurses and healthcare pro-
viders are establishing true, collaborative relationships as partners in healthcare ser-
vice to address healthcare needs through the lens of the patient.

Thus, this chapter focuses on strategies and practices that support patient-centered
care (PCC) that aim to improve patient safety and quality patient care. Characteristics
of PCC are discussed as are the components of communication that help to ensure
it is actualized. Psychosocial factors associated with the realities of disease and ill-
ness are described within the context of how the interprofessional team can implement
strategies that support patient-centered healthcare. Legislation impacting the ability
to deliver PCC is presented. Innovations that foster PCC are discussed including how
continuity of care is augmented with effective discharge planning and use of novel
technologies empowering patients to function as integral members of the interpro-
fessional healthcare team. Finally, patient-centered measures and monitors of quality
healthcare and measurements of patient satisfaction are presented in relation to PCC.

PATIENT-CENTERED CARE

PCC “recognizes the patient or designee as the source of control and full partner in pro-
viding compassionate and coordinated care based on respect for patient’s preferences,
values, and needs” (Quality and Safety Education for Nurses [QSEN], 2012, p. 1). Nurses
and healthcare providers coordinate patient-care services with compassion and respect
through a collaborative partnership between the patient and interprofessional team.

7 PATIENT-CENTERED CARE • 181

Today, with nurse leaders in the forefront of healthcare services, the Institute of Medicine
(IOM) as well as other national campaigns for quality care have drawn attention to the
necessity of maintaining safety, providing quality care, and keeping the patient at the
center and in control of his or her care to meet his or her health needs. This attention is
intended to ensure that all healthcare providers are accountable for quality care through
PCC services, careful monitoring of patient outcomes, and validation of improvement in
the patient’s health. It is paramount that nurses and healthcare providers recognize that
the patient is a full partner within the interprofessional team and that the patient is in con-
trol of his or her care. PCC is a new way of practicing and providing care through the lens
of the patient with respect for his or her values, meaning of health, and preferences. To
achieve true PCC, healthcare practice must include the characteristics of PCC that ensure
patient engagement via effective communication, education, and coordination of ser-
vices. Within this goal, Pettetier and Stickler (2014) address the need for nurse leaders to
accept the responsibility for the achievement of PCC by specifically ensuring patients are
fully engaged in all aspects of their care. They begin this argument by stating the absolute
need and commitment to PCC by healthcare facilities based on respect for patient self-
determination (or right to make decisions for oneself) and autonomy (right to self-govern
based on values). To effectively implement PCC within an organization, they delineate
competencies of the healthcare providers from those of the patient in order to ensure
patient engagement. For providers, Pettetier and Stickler (2014) echo the competencies
outlined by QSEN (2012), which include the need for effective communication that allows
the patient to articulate their values, needs, and desires for care. For nurses, once this
information is obtained, it is expected they will communicate the patient’s preferences to
the rest of the care team. Within this process of integrating the patient’s wishes, the health-
care professional will also assess for any barriers that might impede their actualization,
including the potential need for patient education not to sway the individual’s choice but
rather to ensure full informed decision making. In contrast, the authors explain, patients
need only to be “empowered” through the provision of knowledge as well as know how
to “negotiate” with healthcare providers. While these are important characteristics, it is
important to note that many patients will have difficulty with either or both of these com-
petencies. However, nurses are in a unique and effective position to provide education,
support, and advocacy that facilitate engagement.

It is vital to understand PCC is based on the unique values held by the patient.
These values can be based on many aspects of the person including physical condition,
culture, generation or age, socioeconomic factors, as well as religion and/or spiritu-
ality (see Table 7.1). Soliciting these values becomes a cornerstone of ensuring PCC.
Miles and Mezzich (2011) substantiate the need to consider all aspects of the patient’s
value system within the context of evidence-based medicine in order to allow the cli-
nician and patient the opportunity to establish a relationship based on respect, trust,
equality, and shared responsibility. They contend this ensures the successful intersec-
tion of science, compassion, and quality.

TABLE 7.1 INDIVIDUAL FACTORS THAT
INFLUENCE PATIENTS’ VALUE SYSTEMS

Ethnicity and cultural background
Religion and/or spirituality
Gender identification
Age or generational difference
Educational level
Socioeconomic status
Moral development

182 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Advocacy

Serving as an advocate to patients is another key hallmark of PCC and is an essen-
tial component of nursing and leadership within the interprofessional healthcare

team. Advocacy refers to any activity that ultimately assists a
patient in receiving the “best” care depending on the patient’s
needs and wishes. Florence Nightingale emphasized nurses
must keep the patient central to nursing care, an obligation that
remains embodied in nursing’s application of values such as
beneficence and fidelity (Bradshaw, 1999; Hoyt, 2010). Patient
empowerment reflects a form of self-directed advocacy that
enables and motivates patients to bring about changes and
make decisions to manage and improve their health (Bann,
Sirois, & Walsh, 2010). Through a patient-centered approach
to advocacy and empowerment, a partnership between the
caregiver and the patient can increase the patient’s autonomy
and involvement in his or her own care, especially in chronic
illnesses such as diabetes (Asimakopoulou, Gilbert, Newton, &
Scambler, 2012; Figure 7.1).

PCC is becoming the focus of modern healthcare because people are start-
ing to realize that one size does not actually fit all. As a first responder, in
a mass crisis we are taught to, “Do the most amount of good for the most
amount of people.” If this were healthcare’s approach to giving solely stan-
dardized care, medical/physical/emotional outliers that require specialized
or individualized care would be subject to gross negligence and malprac-
tice. Even EMS calls in the field require unique adaptations to safely stabilize
and transport each patient. Evaluating and treating patients require a two-
way relationship that is both parallel and respectful. By finding out what the
patient needs and wants, both short term and long term, the provider can
treat the patient accordingly. By maintaining a healthy and respectful rela-
tionship, communication and education will drive the individualized care in
a forward direction.

I work in an urban ED with a high daily patient volume. When patients
come into the ED in a tense situation where emotion and stress are high, I
find that it is essential to communicate PCC in short and simple ways. When
moving together, the patient can get the highest quality care and the provider
can ensure no harm is done. The nurse may be the first person to sense what
a patient may need, as nurses are often the first to interact with the patient.
The nurse also knows the medical staff and can anticipate the dynamics of a
patient-care team. This demonstrates how important it is for nurses to identify
the patient’s needs as sometimes the nurse is the only person that the patient
has to advocate for them.

Cara Carpenter, BSN, RN, CEN
St. Joseph’s Hospital and Health Center

Syracuse, New York

REAL-WORLD INTERVIEW

FIGURE 7.1 A patient
waiting for test results.

REAL-WORLD INTERVIEW

7 PATIENT-CENTERED CARE • 183

When I lay in a coma for 47 days in multisystem organ failure I was not cogni-
zant of the 17 specialists, legions of nurses, researchers, technicians, therapists.
I did not know then what I know now—that it is as much a privilege to be a
patient as it is a caregiver. I am alive today because of PCC.

My continuity of care has spanned several decades so much so that my
professional and personal life in the field often feel like one and the same. I take
my responsibility as a patient and caregiver seriously. It is not simply a right
but a privilege to be included in conversation about an individual’s well-being
and safety—be it my own or someone else’s. I hold practitioners to an extremely
high standard, not only for what they already know, but what they want to
know and take the time to learn. In this field, it is time we often seem to be rac-
ing rather than respecting.

We are, in American healthcare, surrounded by resources, research, and
genius. Yet we are all too often lacking in relationship and communication
with patients. The challenges are many: a fractured socioeconomy; a somewhat
unknowable future as it relates to funding and access; and all the nuances of care
for varying populations and needs. Add to that quotas, liability, and privacy
restrictions along with other elements of industry invading the patient experience,
it is a wonder the Hippocratic Oath has not been rewritten to include bylaws with
a daily reminder of the regulations and a mandate of self-care for the provider.

Quality and quantity of service look different with every individual be it in
an office or at the bedside. Triaging patients for myocardial infarctions, GSWs,
and nausea may be your skill set. Triaging mind, body, and spirit is far trickier
and no less important. For every cell in the body of a patient that needs specific

REAL-WORLD INTERVIEW

(continued)

CRITICAL THINKING 7.1

Consider the following situation and identify the nurse’s behaviors associated with
promoting the patient’s sense of control over her care. Mrs. Dawes is in a subacute
rehabilitation facility recovering from a knee replacement. Sue Jones is her primary
nurse. Nurse Jones approaches Mrs. Dawes, introduces herself, and asks Mrs. Dawes
how she would like to be addressed. She also reviews with Mrs. Dawes what she might
expect from the rehabilitation program and how she might deal with the discomfort that
could result from her therapy. Nurse Jones also gives Mrs. Dawes her choices of times
for therapy and menus for meal selection. She answers all her questions and provides
her with the list of her therapies.

1. How has Nurse Jones engaged the patient in a number of behaviors that
would likely increase Mrs. Dawes’s perception of her ability to impact her
own health?

2. What are strategies Nurse Jones could have implemented to include others
on the interprofessional team at the onset of her meeting with Mrs. Dawes to
ensure advocacy and PCC?

184 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

EMPATHETIC COMMUNICATION

As discussed earlier, effective communication is essential for patient engagement and
PCC. To effectively communicate information, consideration for clarity and readiness
to learn must be made. However, to elicit subjective beliefs and values, healthcare
professionals must employ strategies that convey respect and facilitate trust. Strategies
or types of communication that encourage this level of sharing are based on commu-
nication that is based on empathy. Empathetic communication is simply the act of
communicating with someone else from the vantage point of that person’s feelings,
values, and perspective, and is the foundation of establishing relationships that are
consistent with PCC. When using empathetic communication, the nurse and patient
enter into a relationship characterized by both empathy and a genuine sense of respect
for the patient’s opinions and decisions. To better understand the nature of empathetic
communication, the nurse and healthcare provider must first recognize the difference
between empathy and sympathy, be proficient in the basic elements of communica-
tion, and appreciate the major psychosocial factors associated with the role of patient.

While empathy and sympathy are highly related concepts as well as integral to the
provision of PCC, they are distinct and different (Decety & Michalska, 2010). Empathy
involves the ability to understand and share the emotional experience observed in another
person. Sympathy by contrast is defined as emotional concern for another (Kunzmann,
2011). Empathetic communication has three essential components: the ability to take the
perspective of another, the ability to appreciate the emotions of another even when they
are different from your own, and the ability to communicate that understanding to the
patient (Burks & Kobus, 2012). There are a number of behaviors that facilitate empathetic
communication and thus promote PCC. Likewise, there are nonempathetic communica-
tion behaviors that hinder communication and thereby impede PCC. Table 7.2 lists a
representative sample of empathetic and nonempathetic communication behaviors.

treatment there is a unique corresponding memory or experience in those cells
that makes the patient a person, a human being, just like you. And you matter!
The next time you begin your shift, or rounds, or class, remember that everyone
has a story beyond their symptoms that will inform their care. It might be the
one that changes your life. It certainly changed mine.

Kate D. Mahoney
International Speaker, Actorvist, Ambassador to Patients and Caregivers

Author, The Misfit Miracle Girl: Candid Reflections

REAL-WORLD INTERVIEW (continued )

TABLE 7.2 EMPATHETIC AND NONEMPATHETIC COMMUNICATION BEHAVIORS

EMPATHETIC COMMUNICATION NONEMPATHETIC COMMUNICATION

Listens carefully and reflects back a
summary of the patient’s concerns

Interrupts patient with irrelevant
information

Uses terms and vocabulary that are
appropriate for the patient

Uses vocabulary that is either beneath
the level of the patient or not
understandable to the patient

(continued)

7 PATIENT-CENTERED CARE • 185

Elements of Communication

Communication simultaneously takes place verbally and nonverbally. Verbal commu-
nication has a cognitive (what we say) and affective (emotional) component, while
nonverbal communication has a behavioral (what we do) and affective (emotional)
component. To communicate effectively, the listener must attend to all elements of the
communication process. This is not always easy to do although particularly important
to remember in terms of providing PCC.

On morning rounds, a doctor and nurse enter a patient’s room to assess him in
preparation for his cardiac catheterization scheduled later in the day. The nurse
introduces herself to the patient, “Good morning, Mr. Potter, I am Jane Smith,
the nurse, and I will be assisting Dr. Turk with the procedure today.” Mr. Potter
replies, “Okay, I hope you know what you are doing. I am already in pain and
I don’t need you to add to it.” Mr. Potter’s emotional undertones are obviously
hostile and offensive.

1. How do you think Jane Smith, the nurse, felt when listening to hostile tones in the
patient’s voice and remarks toward her competency?

2. How would you respond, maintaining a respectful and open dialogue between you and
the patient?

3. How would you respond if the doctor or another member of the interprofessional team
was criticizing your skills and competency in caring for a patient?

4. How would you respond, maintaining a respectful relationship with the healthcare team?

CASE STUDY 7.1

TABLE 7.2 EMPATHETIC AND NONEMPATHETIC COMMUNICATION BEHAVIORS
(continued )

EMPATHETIC COMMUNICATION NONEMPATHETIC COMMUNICATION

Calls patient by patient’s preferred name Uses language that may be perceived as
cajoling, patronizing, or demeaning, for
example, “honey”

Uses respectful and professional
language

Uses nonprofessional language

Asks patient what they need and
responds promptly to those needs

Chastises patient

Provides helpful and informative
information

Provides patient with inappropriate
information

Solicits feedback from the patient Asks questions at inappropriate times and
gives patient advice inappropriately

Uses self-disclosure appropriately Self-discloses inappropriately
Employs humor as appropriate Preaches to the patient
Provides words of comfort when

appropriate
Scolds the patient

186 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Nonverbal Communication

Sometimes the verbal and nonverbal components of a patient’s communication are
incongruent and provide conflicting messages. For example, a patient might verbally
indicate that nothing is bothering him or her but his or her nonverbal body language
is communicating something quite different (Table 7.3). The empathetic communicator
must discern the real meaning behind the patient’s verbal and nonverbal behavior. It is
the nonverbal aspect of the communication that provides nurses and healthcare provid-
ers with the most important clues about inner feelings. For example, if your patient states
he or she is not afraid to have surgery but looks away from you and/or begins wringing
his or her hands as you discuss the upcoming operation, you would probably think to
yourself that your patient’s words do not match his or her nonverbal communication.

Cultural Influences and Beliefs on Communication

Smiles, warm gestures, and welcoming words are universal signs of caring in many
cultures. Nurses and other interprofessional members of the healthcare team, however,
must also realize that expressions of caring can be perceived differently across cultures.
In addition, there are many factors that can affect the quality and clarity of communica-
tions and healthcare providers must be proactive to address any potential barriers. For

As a senior nursing student, you are under much pressure to follow PowerPoint
slides, listen to the lecture, and take notes, all at the same time! You ask a friend
if you can borrow her notes from class so you can be sure you have everything
you need for the next test. Your friend verbally agrees but places her notes in her
book bag and immediately leaves the room. You try to contact her later that day,
but she does not respond to your calls, texts, or emails.

1. What are major factors underlying the communication process?
2. What conflict in values or beliefs might exist to explain what happened?

CASE STUDY 7.2

TABLE 7.3 EXAMPLES OF NONVERBAL BEHAVIOR

NONVERBAL BEHAVIOR EXAMPLES

Eye movement and features Either steady eye contact or inability to make eye
contact, blinking, teary eyes opened or closed

Body position, movement,
behavior, and stance

Tense, relaxed, jerky, fidgety, legs crossed, arms
crossed, agitated, calm, use of hands, gestures

Facial expression Grimaces, smiles, frowns, no expression or flat
affect, exaggerated expression

Tone of voice Mumbles, whispers, high pitched, quiet; rate of
speech either speedy or slowed

Skin Blushes, sweats, general pallor
General appearance Appropriateness of dress for weather and/or event,

neatness, accessories, stature

7 PATIENT-CENTERED CARE • 187

example, language barriers may be present. The use
of interpreters can provide a safe space where patients
can freely express their concerns and be understood
through the interpreter, calming their fears and appre-
hensions in an unfamiliar situation and setting. While
bilingual family members can be appropriately used
for basic exchanges of information, communication of
complex healthcare information may require the help
of other interpreters. When bilingual family member
interpreters are not available in person, healthcare
providers can access trained interpreters through
various certified telephone services, for example,
CTS Language Link, which can be accessed through
its website at www.ctslanguagelink.com. Certified
healthcare interpreters can help all parties understand
the strengths and needs of the patient and family.
Effective patient-centered communication, even when done through an interpreter, pro-
vides an opportunity for a personal exchange between patient and provider that fosters
clarity and understanding of what is needed to continue the patient’s care and include
the patient as an active partner in the recovery process. Patience and fortitude in under-
standing the patient’s cultural norms and healthcare practices that are unique to the
patient’s culture must be respected (Figure 7.2).

PSYCHOSOCIAL FACTORS ASSOCIATED WITH THE ROLE
OF THE PATIENT

Understanding how a person’s life is affected by illness is essential in understanding
patient reactions and emotions. This level of understanding leads to the ability to take
another’s perspective and is a precursor to empathetic communication, the cornerstone
of PCC (Burks & Kobus, 2012). Being a patient is a role that most people find challeng-
ing. This is because illness can greatly impact a person’s self-concept (Taylor, 2011). For
a better understanding of the impact of illness on the patient, nurses and healthcare

FIGURE 7.2 Nonverbal
communication.

CRITICAL THINKING 7.2

Nurse Johnson is caring for a patient newly diagnosed with diabetes. The patient speaks
English as a second language and is a recent immigrant to the United States. The patient is
able to make her basic needs known but does not ask questions or speak unless prompted to
do so. Nurse Johnson has been unable to determine if this patient can self-inject her insulin.
The patient nods and smiles as Nurse Johnson begins teaching her about insulin and her
diagnosis.

1. What strategies can Nurse Johnson employ to facilitate self-management in
this patient?

2. What resources and/or services can the nurse use to ensure that the patient
has understood the instruction?

188 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

providers need to understand self-concept and the impact illness has on how one per-
ceives oneself. Self-concept is the conception an individual holds about his or her own
particular traits, aptitudes, and unique characteristics; it typically includes physical,
social, and personal components (Taylor, 2011).

Physical self refers to the conception a person has of his or her physical body
and physical capacities. Illness and chronic illness impact a person’s physical self
because it changes how an individual evaluates his or her body. Consider, for exam-
ple, a newly diagnosed breast cancer patient facing a mastectomy. The mastectomy
has the potential of challenging the patient’s perception of herself as a woman. The
mastectomy might also change the patient’s conception of how she sees herself sexu-
ally. Social self involves the roles the individual holds in a social environment. In the
case of the breast cancer patient, the mastectomy might affect the patient’s social self
as a wife and member of the community. A serious illness may change the social self
the patient has in his or her family or work situation. Serious illness and injury may
change the patient’s role from being the family breadwinner to role of the depen-
dent person requiring care and assistance. Personal self embodies all the goals and
dreams we have for ourselves now and in the future. Illness or injury sometimes pro-
hibits the realization of those goals and dreams. For example, the young high school
football star may have had aspirations of becoming a professional football player. A
serious injury on the field may thwart those plans forever.

STRATEGIES TO SUPPORT PATIENT-CENTERED PRACTICE

As discussed earlier, the IOM’s (2001) report identified specific aims to improve
the quality and safety of healthcare. Among these aims, the patient-centered model
of care has become a core component that ensures patient values and guides clini-
cal decisions. Through this patient-centered model of care, the healthcare industry
is called upon to develop innovative strategies to support patients and caregivers in

Mary is a 28-year-old female in the prime of her life. Mary has completed
her master’s degree in education and is employed as a kindergarten teacher,
which she absolutely loves. She has always been independent and enjoyed
being single. Mary developed generalized pain that progressively worsened
over the course of 2 years. Mary also found that her general energy level was
low and she could no longer concentrate for any length of time. Mary sought
medical care and was diagnosed with fibromyalgia. She was forced to give
up her kindergarten job and found herself not only in pain but frustrated
professionally. She believes the fibromyalgia has impacted her physically and
professionally.

1. How can chronic illness impact Mary’s perspective on her personal life?
2. Explore the web for support services that are available to her at home. What might a

few services be?

CASE STUDY 7.3

7 PATIENT-CENTERED CARE • 189

becoming greater participants in their healthcare. Patient-centered outcomes research
emphasizes decision making between the patient and provider that is collaborative,
mutual, and shared. Health literacy is one major factor grounded in informed decision
making. Thus, many innovative strategies exist to enhance PCC including methods for
increasing health literacy.

Alleviating Barriers to Healthcare Literacy

Considering a patient’s health literacy is another crucial aspect to providing PCC.
Ratzan and Parker’s (2000) definition of health literacy is used in the IOM’s (2004)
consensus report on health literacy as “the degree to which individuals have the
capacity to obtain, process, and understand basic health information and services
they need to make appropriate health decisions” (p. 31). A patient’s basic education
and competencies in reading, writing, and mathematics are important components
of his or her health literacy as well as skills such as listening and speaking. Those
patients and families with limited health literacy skills and knowledge do not have
the same resources, ability, or competencies to achieve optimal health services as
those who are health literate. Language barriers and poorly understood cultural prac-
tices may also adversely impact healthcare communication. Populations vulnerable
to low levels of health literacy include ethnic minority groups, recent immigrants,
older adults and elderly populations, individuals living with chronic diseases, and
populations of people at poverty or even lower socioeconomic class (Center for
Health Care Strategies, Inc., 2010).

The issue of health literacy is very complex and requires a multidimensional
approach by the interprofessional healthcare team to understand the impact that it has
on healthy lifestyles, engagement in health promotion activities, self-efficacy, and opti-
mizing one’s potential for well-being. Nurse leaders must recognize that the health-
care system and the educational system, as well as social and cultural factors, all play
a role on the impact of health literacy. Healthy People 2020 (U.S. Department of Health
and Human Services [HHS], 2011c) has identified improving health literacy as one of
its key goals to promoting healthy outcomes and enhancing quality of life. In the past,
health literacy was considered a task of educators and viewed from the perspective of
the patient’s intellectual deficits. Today, health literacy is recognized as a healthcare
system’s issue.

Health literacy is ensured when nurses and the interprofessional healthcare team
reinforce pertinent information with the patient through simple explanations that
avoid medical jargon. Patients must understand their role and what it is they need
to do to safely follow dietary and healthcare treatments. They must understand why
quality of care requires adherence to prescribed medications and the importance of
communicating with their provider when encountering difficulties. Healthcare practi-
tioners must encourage patients to ask questions and take an active role in their edu-
cation to improve care activities. Patients who are well informed and more involved
in their care experience better health outcomes (HHS, 2010). Patient initiatives,
such as Ask Me 3 (National Patient Safety Foundation, 2011) and Questions Are the
Answer (Agency for Healthcare Research and Quality [AHRQ], 2011b) are campaigns
designed to promote communication and encourage patients to seek and understand
the answers to common questions, that is, What is my main problem? What do I need
to do? Why is it important for me to do this? Patient safety can be improved when
patients understand their role in their healthcare.

190 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Patient Decision Making

Soliciting the patient’s values, needs, and preferences is but one part of assisting them
in participatory decision making. Including them in important conversations relative
to health status, treatment choice, and evaluation are crucial but how does a nurse
actually accomplish this? Fortunately, tools exist that systemically and effectively
facilitate this process. One such website is simply called Patient. It offers education
about specific conditions and provides pros and cons of treatments typically suggested
(patient.info/decision-aids) as a starting point for relevant discussions with their
healthcare provider. Additional tools are available through the Mayo Clinic, AHRQ,
and HealthITh.gov.

Nurse scholar, Dawn (2015) has examined how to ensure that decision-making
aids such as the Patient website encourage interprofessional efforts that help all
healthcare providers to hear the needs and wishes of their patients. Her efforts to date
have demonstrated lack of interprofessional application of these aids; however, she
has facilitated important improvements by bringing important attention to why and
how patients make decisions about their healthcare.

EVIDENCE FROM THE LITERATURE

Citation

Stiles, E. (2011). Promoting health literacy in patients with diabetes. Nursing
Standard, 26(8), 35–40.

Discussion

Patients with low health literacy may struggle with obtaining, understanding,
and applying health information. Complex healthcare conditions such as diabe-
tes mellitus are long-term conditions that require good patient understanding
to experience positive outcomes. Strategies to help improve low health literacy
include a patient-centered approach to improve communication between clini-
cians and patients with diabetes, providing information to patients in various
formats, and improving patient access to services.

Implications for Practice

Nurses play a critical role in assessing and improving health literacy, especially
for patients with complex chronic conditions. Culturally appropriate, individual-
ized teaching strategies with tools such as with the use of teach-back methods can
reduce the impact of low health literacy, help improve patient-centered care (PCC),
and help achieve patient self-management. The “teach-back” method has also been
referred to as the “show me” method and is a way for nurses and other members
of the interprofessional healthcare team to verify that what was provided as educa-
tion was received and understood correctly. In the teach-back method, the patient
explains to the person giving the education what was taught, thus confirming or
validating the information was accurately heard and comprehended.

7 PATIENT-CENTERED CARE • 191

LEGISLATION THAT SUPPORTS
PATIENT-CENTERED PRACTICES

In March 2010, Congress passed the Patient Protection and Affordable Care Act (ACA).
This legislation increases access to health insurance coverage, expands federal health
insurance market requirements, and includes measures to improve the delivery and
quality of care (www.innovations.cms.gov). The ACA is being implemented in a
number of ways through new agency programs, grants, demonstration projects, and
regulations. Under the ACA, the Centers for Medicare and Medicaid Innovation has
been established to pilot payment and service delivery models driven by the need for
quality PCC and fiscal responsibility. The Centers for Medicare and Medicaid Services
(CMS, 2012) have established pilot payment and service delivery models driven by the
need for quality PCC and fiscal responsibility.

Patient-Centered Medical Home

As healthcare reformers seek to improve outcomes and reduce costs, the patient-
centered medical home (PCMH) has become a major strategy in the transformation
of primary care and the healthcare system in general (Landon, Gill, Antonelli, & Rich,
2010; Table 7.4). The PCMH concept includes operational characteristics of primary care
that are accessible, continuous, comprehensive, family/patient centered, coordinated,
compassionate, and culturally sensitive (American College of Physicians [ACP], 2006).

TABLE 7.4 PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME

All patients have a personal
provider of primary care

Every patient has a provider trained to deliver continuous,
comprehensive care from the first patient contact
throughout an ongoing patient–provider relationship

The healthcare team is
directed by primary care
provider

Under the leadership of the personal primary care
provider, an interprofessional healthcare team takes
responsibility for the ongoing care of patients

The personal provider is
responsible for all the
patient’s healthcare
needs

A personal primary care provider takes the lead on
providing or coordinating patient care with qualified
professionals to meet all of the patient’s healthcare
needs throughout the stages of life, that is, acute care,
chronic care, preventive services, and end-of-life care

The personal provider
ensures coordinated/
integrated care

Across the continuum of care, the personal primary care
provider implements interventions to ensure that the
patient receives culturally appropriate care at the right
time and place (hospital, subspecialty care, home
health, nursing home) for level of need

The personal provider
pursues quality and
safety of care

The personal primary care provider, along with other
interprofessional healthcare team members, advocates
for the patient in the pursuit of optimal patient-
centered outcomes guided by use of the following:

• Evidence-based medicine and clinical decision-
support tools

• Continuous QI
• Active patient participation in decision making and

use of patient feedback to ensure expectations are
being met

(continued)

192 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Patient-Centered Primary Care Collaborative

In 2006, the Patient-Centered Primary Care Collaborative (PCPCC) emerged after
several large national employers sought the assistance of the American Academy of
Family Physicians (AAFP), and other primary care physician groups to address the
issue of a failing system of comprehensive primary care. Goals of the PCPCC were
to enable improvements in patient–physician relations and develop a more effective
and efficient model of care delivery. The PCPCC has taken a significant interest in the
development and advocacy of the PCMH model as a means to ensure the delivery of
only the highest standards of effective and efficient PCC (PCPCC, 2011).

Health Home Model

The same ACA that supports the Medical Home initiative also provides financial
incentives for the development of Health Homes (CMS, 2012). Health Homes are
designed to be patient-centered systems of care that enable access to and coordination
of care throughout the healthcare continuum, that is, primary, acute, behavioral, and
long-term community-based care. The Health Home model expands on the Medical
Home model by moving beyond primary care to better meet the needs of patients with
multiple chronic conditions. By enhancing coordination and integration of medical
and behavioral healthcare, Health Homes provide comprehensive care for patients.

The Health Home model supports the CMS’s approach to improving health-
care by improving the patient’s care experience, improving the health of popula-
tions, and reducing the costs of healthcare (CMS, 2010). The implementation of
Health Homes is expected to reduce emergency department use, reduce hospital
admissions and readmissions, reduce healthcare costs, and reduce reliance on
long-term care facilities, while improving overall patient satisfaction and quality
outcomes.

TABLE 7.4 PRINCIPLES OF THE PATIENT-CENTERED MEDICAL HOME (continued )

• Information technology to support optimal patient
care, performance measurement, patient education,
and improved communication

• Accreditation/certification of the personal primary
care provider’s practice to demonstrate its ability to
deliver PCC consistent with the Medical Home model

• Patient and family involvement in QI activities
Patients have enhanced

access to care
Open efforts are made to increase availability

of providers as well as other members of the
interprofessional healthcare team through flexible
scheduling, extended office hours, and expanded
communication options

Proper payment to
providers

Payment structure should reflect the added value
provided to patients under the care of a patient-
centered Medical Home model.

PCC, patient-centered care; QI, quality improvement.

Source: American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of
Physicians (ACP), American Osteopathic Association (AOA). (2011). Joint principles of the patient-centered medical
home. Retrieved from https://medicalhomeinfo.aap.org/Pages/default.aspx

7 PATIENT-CENTERED CARE • 193

DISCHARGE PLANNING AND CARE CONTINUITY

As healthcare reforms and payment structures attempt to balance the efficiency and
efficacy of care, acute healthcare systems are facing shorter lengths of stay and rapid
patient turnover. These factors can all too often contribute to fragmented patient care,
for example, patients discharged while still recovering from an illness or disease
exacerbation. The acuity of the patient’s condition may still require continued care
services and careful monitoring by his or her primary care provider and healthcare
team. Patients transitioning between care settings such as hospitals and rehabilita-
tion centers are at risk for potentially avoidable hospitalizations and increased health-
care spending (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). There is a call
for improved patient communication handoffs to avoid common mistakes that can
occur as the patient transitions from one level of care to another (Ventura, Brown,
Archibald, Goroski, & Brock, 2010). Avoiding patient rehospitalization is a key priority
for hospitals with higher than expected readmission rates as they will now be facing
financial penalties enacted by the ACA (Hansen, Young, Hinami, Leung, & Williams,
2011). Hospitals are implementing various initiatives and comprehensive programs
such as Project BOOST (Better Outcomes for Older Adults through Safe Transitions;
Society of Hospital Medicine, 2012) and Project RED (Re-Engineered Discharge;
Boston University School of Medicine, 2012) to facilitate safe patient discharges that
will support patients in their transition from hospital to home and prevent unneces-
sary readmissions to the hospital (AHRQ, 2011a). These programs also provide toolkits
with various interventions and practices that can help healthcare providers be success-
ful, that is, risk assessment tools and how to implement specific discharge strategies.
Despite using these tools, discharge planning is complex and must be individualized
to each patient.

Continuity of care is aided by the effective transition between levels of care, use
of care transition, improved health literacy, and coordination models designed to
improve the quality of care by reducing fragmentation of care and enhancing coordi-
nation and continuity of care for patients with multiple health and social needs as they
receive care across the continuum (Cloonan, Wood, & Riley, 2013). These models often
use a number of patient-centered approaches such as patient navigators, advocates,
and medication reconciliation.

Patient Navigators

Patient navigators are clinical staff members who are paired with a patient to sup-
port, educate, and facilitate the patient’s interactions throughout the experience of
care within a hospital during the outpatient treatment. The concept of patient navi-
gation has developed into a process of advocacy and engagement in the provision
of high-quality PCC (Koh, Nelson, & Cook, 2011). For example, patient navigators
are frequently used in oncology where patients typically need to take in a great deal
of information about their diagnosis and treatment as well as coordinate care among
many providers such as oncologists, their nurses, radiologists, and social workers. A
navigator is assigned to each patient upon admission. This relationship is maintained
until the patient is discharged. Patient navigation is designed to reduce patient-care
barriers and improve patient satisfaction and health outcomes. However, because this
initiative is fairly new, more research and evaluation are needed to demonstrate the
extent to which this initiative has been effective.

194 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Patient Advocates

As discussed earlier, patient advocacy is a hallmark of PCC and healthcare profes-
sionals. In addition, integral to the care provided by the interprofessional team,
healthcare organizations are making every effort to ensure patients are well-informed
and take an active role in their care. As a result, some hospitals have created patient
advocate positions. These patient advocate positions provide a means to increase
the flow of information to patients and staff, address patient concerns, and provide
emotional support to patients and families. Patient advocates serve as a central point
of contact for patients, families, physicians, nurses, and other healthcare staff, and
assist patients by responding to foreseeable or preventable breaks in service. Patient
advocates are an integral part of ensuring that meaningful services are available to
all patients. They enhance patient and staff communication and improve patient-care
services rendered. For example, a patient advocate can help a patient scheduled for
surgery seek all options to anesthesia. They can help the patient formulate the ques-
tions he or she need answers to. The advocate can also help ensure the patient’s wishes
are carried out when the patient cannot speak for himself or herself. The patient can
also request the patient advocate accompany him or her to testing and examinations
when allowed. The patient advocate can be someone supplied by the hospital and
may be a nurse or social worker, however, the position does not require medical or
healthcare training. The patient advocate may also be a friend or family member of
the patient. The key to this person and/or position is that the person be someone the
patient trusts and someone who can effectively communicate for the patient if unable
to speak for himself or herself.

EVIDENCE FROM THE LITERATURE

Citation

Buila, S. M. D., & Swanke, J. R. (2010). Patient-centered mental health care:
Encouraging caregiver participation. Care Management Journal, 11(3), 146–150.

Discussion

Caregivers play a vital role when caring for loved ones suffering from mental ill-
ness. Viewing caregivers as partners within a patient-centered approach to care
can improve the quality of care provided. Five major themes emerged from care-
giver participants in the suicide prevention workshop discussed in this article.
The five themes were that (a) caregivers needed to be included in the mental
healthcare of their family member, (b) expressed concerns related to diagnos-
ing process, (c) stated a need for improved communication with professionals,
(d) articulated a desire for individualized holistic care, and (e) stated a need for
service and resource information.

(continued)

7 PATIENT-CENTERED CARE • 195

INFORMATION TECHNOLOGIES TO SUPPORT PCC

With the growing use of technology, nurses are keenly aware that the landscape for
healthcare providers has challenged the human connection and patient relationship
more than ever before. However, with PCC and collaborative relationships among
the interprofessional healthcare team and the patient, personalized and meaningful
services can be provided with the patient in control of his or her care. The electronic
health record (EHR) creates an opportunity for the interprofessional healthcare team
to ensure the patient remains focal to the healthcare delivered as well as facilitate effec-
tive collaboration between the team and the patients themselves. As patient-care pro-
viders become more adept at electronic data sharing for the provision of continuity of

EVIDENCE FROM THE LITERATURE
(continued)

Implications for Practice

Nurses and other members of the interprofessional team play an integral part in
the treatment of mental illness, particularly in their ability to integrate caregivers
into the plan of care. Supporting the perspective of caregivers and recognizing
their role as partners in care services will enhance the overall care provided to
patients with mental illness.

CRITICAL THINKING 7.3

Teresa is a 10-year-old patient diagnosed with juvenile diabetes. She has been hospitalized
four times in the past year for complications related to diabetic diet noncompliance.
Teresa is an only child who resides with her parents and maternal grandmother of Italian
immigrant descent. She and her family have been in America for 8 years, Teresa and her
parents have mastered the English language, and Teresa has been a very good student. Her
parents both work at the same factory on the assembly line. A number of interprofessional
team members have counseled Teresa and her parents on the risks involved with diabetes
and dietary noncompliance. Teresa and her parents seem to understand the importance of
following her prescribed diabetic diet. As Teresa’s nurse, you notice at this hospitalization
that Teresa’s grandmother spends a great deal of time with her and appears quite agitated
by the fact that her granddaughter is “not getting better.” She expresses concern to you
about Teresa being readmitted to the hospital yet again.

1. Within a patient-centered environment, how would you approach Teresa’s
grandmother?

2. Considering Teresa and her parents seem to understand the importance
of her dietary intervention, how can the interprofessional healthcare team
collaborate in gathering potential missing information about Teresa’s care to
discover the cause for her multiple readmissions?

196 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

care, many providers offer patients access to their healthcare record online and encour-
age them to take responsibility for its accuracy. For example, if a patient accesses his
or her EHR online and discovers the list of allergies is incomplete, the patient will be
expected to update and correct the list. Obviously, inaccurate patient information can
lead to negative patient outcomes and healthcare errors.

Personal Health Record

Several initiatives have emerged to help patients build their own personal health
record (PHR) such as Microsoft Health Vault (Microsoft, 2012). The Josie King
Foundation created a paper and electronic version of a patient journal as a tool to
help patients and their families record details of their care along with the questions
to ask and important things to remember (Josie King Foundation, 2012). Hospitals
can order the journals to provide to patients and their families and/or patients can
request a journal for themselves at the Josie King website located at www.josieking.
org/carejournals. These initiatives are drivers of patient safety and quality care by
empowering patients with specific tools to facilitate active engagement in their own
healthcare.

Online Health Information

Patient-driven research (PDR) is an evolving phenomenon that began in the Internet’s
earliest days. From access to online support groups to access to world-renowned med-
ical centers, patients have access to an incredible amount of online health informa-
tion they can now use to become an active member of their care team. This access to
information gives patients valuable information regarding their conditions, treatment
options, best practices, as well as the healthcare organizations known for their clinical
excellence of care delivery. Patient-driven online healthcare information allows inter-
ested patients to be more informed about their choices and raises their level of expecta-
tions for quality care and safety when seeking healthcare services.

Online Patient Communities

Many online communities exist offering opportunity for patients to share experiences
and learn about diseases and treatments. The term “e-patient” has been coined to
identify this new breed of informed healthcare consumers who are equipped, enabled,
empowered, and engaged in their health and healthcare decisions. Healthcare has
responded to this trend through the development of important resources such as the
Society for Participatory Medicine and Sharecare, thus facilitating a new level of part-
nership between patients and their healthcare teams (Gee et al., 2012).

Participatory medicine is a model of care to support a cooperative approach by all
members of the healthcare team, that is, patients, families, and healthcare profession-
als, across the full continuum of care. Healthcare providers are expected to encourage
and value patients and families as responsible drivers of their health and not as pas-
sengers. Providers who practice participatory medicine promote clinical transparency
through the exchange of information and through support for the e-patient movement
(Society for Participatory Medicine, 2011).

Sharecare (www.sharecare.org) was launched in 2010 by the founder of WebMD,
Jeff Arnold, as an interactive, social question-and-answer platform for consumers of

7 PATIENT-CENTERED CARE • 197

healthcare as well as healthcare professionals. Sharecare has enlisted the nation’s leading
health experts, care providers, organizations, and brands to become part of the health
and wellness dialogue. Sigma Theta Tau, the International Honor Society of Nursing, is
one of the major content contributors for Sharecare. Users of Sharecare have free access to
high-quality, relevant answers to their health questions. These answers are provided by
experts, along with interactive health and wellness tools that allow patients to take action
on what they have learned as an empowered, informed participant of their own care.

PATIENT-CENTERED MEASURES AND MONITORS
OF QUALITY HEALTHCARE

Population-focused healthcare is care based on the health status and needs assess-
ment of a target group of individuals who have one or more personal or environmental
characteristic in common, such as determined by demographics or geography. Public
health core functions of assessment and policy development guide the work of popu-
lation-focused healthcare. The ultimate goal of these policies is improved patient care
that is more effective in treating the underlying causes of disease. By examining trends
in the etiology and intervention of larger groups, population-focused healthcare pro-
vides information to healthcare providers that allow them to deliver care that is com-
prehensive, individualized, and ultimately more effective. The U.S. Department of
Health and Human Services (HHS) is the lead agency responsible for providng essen-
tial human services to Americans, particularly those least able to care for themselves.
Together with 12 operating divisions and over 300 programs, the HHS is charged with
protecting the health of all Americans (HHS, 2011d).

Strategy for Quality Improvement in Healthcare

The secretary of the HHS has established a National Strategy for Quality Improvement
in Health Care to set priorities that guide the nation to increase access to high-quality,
patient-centered, affordable healthcare for all Americans (HHS, 2011b). See Table 7.5
for priorities.

TABLE 7.5 DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL STRATEGIES
FOR QUALITY IMPROVEMENT IN HEALTHCARE PRIORITIES

PRIORITY ACTIONS

1. Give safer care • Exercise relentless effort to reduce risk for injury from care
• Aim for ZERO harm to patients
• Create healthcare systems that reliably provide high-quality care

2. Deliver patient- and
family-centered care

• Give patients and families an active role in their care
• Adapt care to individual and family situations, cultures,

languages, disabilities, and health literacy levels

3. Promote effective
communication and
coordination of care

• Develop processes and use technology to provide
seamless care, that is, electronic health record,
e-prescribing, telemedicine

• Eliminate healthcare gaps and duplication of care
• Use effective care models to facilitate coordination and

communication across the continuum of care

(continued)

198 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

PATIENT SATISFACTION

Patient satisfaction has been an important aspect of feedback used by care providers
for internal quality improvement (QI) efforts. Medicare, Medicaid, and private insur-
ance companies are beginning to place a financial value on patient satisfaction feed-
back. Tangible, measurable patient outcomes, such as infection rates, are an important
indicator of the quality of care patients have received. However, patient satisfaction
with the care that has been provided is now recognized as another quality indicator.
This knowledge is powerful feedback regarding how respected and valued patients
felt as well as how engaged they were relative to their plan of care.

TABLE 7.5 DEPARTMENT OF HEALTH AND HUMAN SERVICES NATIONAL STRATEGIES
FOR QUALITY IMPROVEMENT IN HEALTHCARE PRIORITIES (continued )

PRIORITY ACTIONS

4. Promote effective
prevention and
treatment of
leading causes of
mortality (priority,
cardiovascular
disease)

• Practice key interventions for cardiovascular disease, that
is, ABCS—aspirin, blood pressure control, cholesterol
reduction, and smoking cessation

5. Work with
communities to use
best practices

• Create strong partnerships among local healthcare
providers, public health professionals, and individuals

• Provide clinical preventive services and increase adoption
of evidence-based interventions

6. Provide more
affordable quality
care

• Ensure the right care is provided at the right time for the
right patient

• Reduce healthcare-acquired conditions
• Reform payment structures, reduce waste
• Establish health insurance exchanges to improve cost of

insurance for individuals and small businesses

Source: U.S. Department of Health and Human Services (HHS). (2011b). National strategy for quality improvement
in health care. Washington, DC: Author. Retrieved from http://www.health care.gov/law/resources/reports/
nationalqualitystrategy032011.pdf

REAL-WORLD INTERVIEW (continued)

There are a number of healthcare settings implementing services with the
patient in the center of all care being provided. It is not unique to nursing
services. One acute care hospital where I serve on the Board focuses on foster-
ing relationships with the patient and family as they provide care to meet the
patient’s needs. The patient is an active participant in rounds and most staff
find it very rewarding to work in a caring environment with the patient cen-
tral to all services. The hospital was introduced to a relationship-based model
for care and found there were many success stories from patients and fami-
lies as well as the staff who embraced forming caring relationships with their
patients. The hospital has developed a comprehensive program that helps

REAL-WORLD INTERVIEW

(continued)

7 PATIENT-CENTERED CARE • 199

The QSEN competencies for PCC provide a structured guide for developing and
assessing a nurse’s ability to integrate the patient and/or the patient’s designee as the
primary source for determining care. These competencies include measures of knowl-
edge, skill, and attitudes. Simply listing these measures does not guarantee the accom-
plishment of this complex competency. Clearly, the goal to keep the patient’s preferences,
values, and needs paramount starts with a culture focused on the specific intention of
soliciting a patient’s voice, honoring it, and ensuring it is respected. Resources exist
to assist institutions. An innovative company providing such resources is Planetree
whose mission is to provide education to hospitals and other healthcare organizations
seeking to create and ensure patient-centered, healing environments (Planetree, 2017).
Specifically, they focus on five key areas: cultural transformation, patient activation,
staff engagement, leadership development, and performance improvement. Providing
education to all levels of an organization, Planetree facilitates a cultural shift that hall-
marks the focus on the patient, first and always. A comprehensive program is designed,
implemented, and monitored thatdeliberately seeks and listens to the patient’s wants
and needs. Monitoring the successful implementation of such initiatives is the respon-
sibility of the institution. Many tools are available and used but two surveys are used
most often in hospitals, measuring patient success as a measure within the institution
as well in comparison to other hospitals: Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) and Press Ganey.

Hospital Consumer Assessment of Healthcare Providers and Systems

In 2005, the National Quality Forum, a national organization of healthcare stakehold-
ers, consumer organizations, public and private purchasers, physicians, nurses, hospi-
tals, accreditation/certification bodies, supporting industries, healthcare researchers,
and QI organizations endorsed the HCAHPS (pronounced H-CAPS) survey. The intent
of this survey was to provide a standard instrument to be used by hospitals across the
nation to measure the patients’ satisfaction with their hospital experience. HCAHPS
asks a core set of questions to assess patient satisfaction with their care by nurses,
doctors, and other members of the interprofessional healthcare team; responsiveness
of hospital staff; pain management; communication about medicines; and cleanliness
and quietness of hospital environment. These standardized questions permit valid
comparisons of patient-care experience at hospitals locally, regionally, and nationally.
The HCAHPS survey is focused on three areas:

1. The patients’ perception of care that permits objective and meaningful comparisons
of hospitals on topics important to patients.

ensure each service within the hospital keeps the patient central to what they
do—from housekeepers to surgeons. Besides employee satisfaction, imple-
menting a relationship-based focus on patient-centered care (PCC) has greatly
influenced patient satisfaction.

Esther Bankert, Board Member
Faxton/St. Luke’s Health Care

Utica, New York

REAL-WORLD INTERVIEW (continued)

200 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

2. Public reporting of results, which provides an incentive for hospitals to improve
the quality of care.

3. Public reporting, which also enhances accountability in healthcare by increasing
transparency of the quality of the care provided (CMS, 2011a).

Since 2008, HCAHPS patient satisfaction scores have been available to the public
on the CMS Hospital Compare website that can be found at www.medicare.gov/
HomeHealthCompare/search.aspx.

Press Ganey

Press Ganey is another survey tool used by most hospitals to gauge patient satisfac-
tion (www.pressganey.com). Its survey actually includes the HCAHPS questions to
provide a comprehensive assessment of what the patient experienced and felt while
hospitalized, collecting both objective and subjective data. While the HCAHPS focuses
on measuring “how often a service is provided,” Press Ganey aims to capture how
well that service was delivered and perceived by the patient (www.pressganey.com/
solutions/clinical-quality).

KEY CONCEPTS

• Patient-centered care (PCC) “recognizes the patient or designee as the source of
control and full partner in providing compassionate and coordinated care based
on respect for patient’s preferences, values, and needs” (Quality and Safety
Education for Nurses, 2012, p. 1).

• Pettetier and Stickler (2014) identify the absolute need and commitment to PCC
by healthcare facilities based on respect for patient self-determination (or right
to make decisions for oneself) and autonomy (right to self-govern based on
values).

• PCC is based on the unique values held by the patient, which can be based on
many aspects of the person including their physical condition, culture, gender
identification, generation or age, educational level, socioeconomic status, moral
development, religion, and/or spirituality.

• Advocacy refers to any activity that ultimately assists a patient in receiving the
“best” care depending on the patient’s needs and wishes. Patient empowerment
reflects a form of self-directed advocacy that enables and motivates patients to
bring about changes and make decisions to manage and improve their health
(Bann et al., 2010).

• Empathy involves the ability to understand and share the emotional experience
observed in another person. Sympathy by contrast is defined as emotional concern
for another (Kunzmann, 2011).

• There are a number of behaviors that facilitate empathetic communication and
thus promote PCC. Likewise, there are nonempathetic communication behaviors
that hinder communication and thereby impede PCC (Table 7.2).

7 PATIENT-CENTERED CARE • 201

• Sometimes the verbal and nonverbal components of a patient’s communication
are incongruent and provide conflicting messages (Table 7.3).

• Expressions of caring can be perceived differently across cultures.
• The use of language interpreters can provide a safe space where patients can freely

express their concerns and be understood through the interpreter, calming their
fears and apprehensions in an unfamiliar situation and setting (e.g., CTS Language
Link, www.ctslanguagelink.com).

• Through the patient-centered model of care, the healthcare industry is called upon
to develop innovative strategies to support patients and caregivers in becoming
greater participants in their healthcare.

• Populations vulnerable to low levels of health literacy include ethnic minority
groups, recent immigrants, older adult and elderly populations, individuals living
with chronic diseases, and populations of people at poverty level or an even lower
socioeconomic class (Center for Health Care Strategies, Inc., 2010).

• Healthy People 2020 (HHS, 2011c) has identified improving health literacy as one
of its key goals to promoting healthy outcomes and enhancing quality of life.

• Patients who are well informed and more involved in their care experience better
health outcomes (HHS, 2010).

• Patient initiatives, such as Ask Me 3 (National Patient Safety Foundation, 2011)
and Questions Are the Answer (AHRQ, 2011b) are campaigns designed to pro-
mote communication and encourage patients to seek and understand the answers
to common questions: What is my main problem? What do I need to do? Why is it
important for me to do this?

• One website, called Patient, offers education about specific conditions and provides
pros and cons of treatments typically suggested (patient.info/decision-aids) as a
starting point for relevant discussion with the healthcare provider. Additional tools
are available through the Mayo Clinic, AHRQ, and HealthITh.gov.

• In March 2010, Congress passed the Patient Protection and Affordable Care Act
(ACA). This legislation increases access to health insurance coverage, expands fed-
eral health insurance market requirements, and includes measures to improve the
delivery and quality of care (www.innovations.cms.gov).

• The Patient-Centered Medical Home (PCMH), Patient-Centered Primary Care
Collaborative (PCPCC), and Health Homes (CMS, 2012) are designed to provide
more comprehensive care for patients.

• Hospitals are implementing various initiatives and comprehensive programs such
as Project BOOST (Better Outcomes for Older Adults through Safe Transitions;
Society of Hospital Medicine, 2012) and Project RED (Re-Engineered Discharge;
Boston University School of Medicine, 2012) to facilitate safe patient discharges
that will support patients in their transition from hospital to home and prevent
unnecessary readmissions to the hospital (AHRQ, 2011a).

• Continuity of care is aided by models that often use a number of patient-centered
approaches such as patient navigators, advocates, and medication reconciliation.

• Several initiatives have emerged to help patients, for example, Microsoft Health
Vault (Microsoft, 2012), and the Josie King Foundation patient journal (Josie King
Foundation, 2012, www.josieking.org/carejournals).

• Participatory medicine is a model of care to support a cooperative approach by all
members of the healthcare team, that is, patients, families, and healthcare profession-
als across the full continuum of care, for example, Sharecare (www.sharecare.org).

• Population-focused healthcare is care based on the health status and needs assess-
ment of a target group of individuals who have one or more personal or environmen-
tal characteristics in common, such as determined by demographics or geography.

202 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

• The Secretary of HHS has established a National Strategy for Quality Improvement
in Health Care to set priorities that guide the nation to increase access to high-quality,
patient-centered, affordable health care for all Americans (HHS, 2011b) (Table 7.5).

• Medicare, Medicaid, and private insurance companies are beginning to place a finan-
cial value on patient satisfaction feedback.

• An innovative company providing PCC resources is Planetree, with focus on five
key areas: cultural transformation, patient activation, staff engagement, leadership
development, and performance improvement.

• Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS)
patient satisfaction scores have been available to the public on the CMS Hospital
Compare website (www.medicare.gov/HomeHealthCompare/search.aspx) since
2008.

• Press Ganey is another survey tool used by most hospitals to gauge patient satis-
faction (www.pressganey.com).

KEY TERMS

E-patient
Empathetic communication
Health literacy
Patient advocacy

Participatory medicine
Patient-centered care
Population-focused healthcare
Self-concept

REVIEW QUESTIONS

1. A nurse will attend a seminar discussing patients with family/significant others at
the center for all nursing and interprofessional care services. The nurse knows that
which of the following will most likely be the primary topic?

A. Primary care
B. Medical Homes
C. Interprofessional team approach
D. Patient-centered care (PCC)

2. The nurse wants to use a patient-centered approach to perform patient care. Which
of the following best describes the nurse’s approach?

A. Developing friendships with patients as a means of providing better care
B. Creating an environment of coworkers committed to helping each other
C. Providing care through the eyes of the patient
D. Understanding the nurse’s role and its relation to other care providers

3. The nurse is preparing to review discharge instructions with a patient. The nurse
instructs the patient regarding her medications and wound care for her foot. What
indicates to the nurse the level of understanding the patient has regarding dis-
charge instructions?

A. The patient signs the discharge instruction sheet.
B. When asked by the nurse, the patient denies any questions or concerns.
C. The patient asks for new prescriptions for the pharmacy.
D. The nurse observes the patient changing the dressing on her foot wound.

7 PATIENT-CENTERED CARE • 203

4. When rounding, the nurse discovers that a patient on isolation has soiled the
bed. Upon inquiry, the patient indicated that he did not want to bother the nurse
because she was busy. The nurse tells the patient to use the call bell any time. How
can the nurse most effectively communicate that she is available to the patient?

A. Remind the patient frequently to use the call bell.
B. Ensure that all the patient’s needs have been met before leaving the patient’s room,

avoid appearing rushed, and let the patient know when the nurse will return.
C. Go in and out of patients’ rooms to ensure the patients are aware that the nurse

is available.
D. Make sure the call bell is within the patient’s reach every time the nurse leaves

his room.

5. The nurse is caring for a patient who has multiple chronic conditions and has been
hospitalized twice in the last month. The patient has a complex medication regi-
men, limited family support, and admits to having missed his last two physician
appointments because he did not have a ride. What is the benefit of a referral to a
health home for this patient?

A. Physicians with lower rehospitalization rates operate Health Homes.
B. Complex cases are managed through skilled nursing facilities until patients are

independent again.
C. Home care services are covered for patients regardless of ability to pay.
D. Comprehensive care management enables access to and coordination of care.
E. None of the above

6. A nurse is reviewing discharge instructions with a patient. The patient asks the
nurse about a cardiac medication he forgot to mention to the physician because the
medication is not listed on the discharge instructions. Which action by the nurse is
most appropriate when reconciling discharge medications?

A. Explain to the patient that he should follow up with his primary physician
within 7 days to review the medication regimen.

B. Contact the physician to notify him of the discrepancy and receive direction
regarding the discharge instructions before discharging the patient.

C. Instruct the patient to take only the medications listed on the discharge
instructions.

D. Advise the patient to continue taking the medication until he sees his primary
physician.

7. A patient newly diagnosed with breast cancer is asking in-depth questions about
her diagnosis and sharing what she has found online that has worked for other
patients. The nurse recognizes that this patient represents a growing number of
informed healthcare consumers. Which intervention by the nurse demonstrates
support for the patient’s involvement in her care?

A. Caution the patient about inaccurate information that may be available on the
Internet.

B. Instruct the patient to only follow the advice of her medical provider.
C. Advise the patient to begin building a personal health record (PHR).
D. Explain to the patient the importance of regular checkups to identify any

changes in condition.
E. All of the above

204 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

8. Which of the following actions demonstrates understanding of the role of the
nurse in patient satisfaction? Select all that apply.

A. The nurse discusses the plan of care with the patient and family.
B. The nurse inquires about the patient’s comfort with the room temperature and

desire for a meal because dinner has already been served on the unit prior to
arrival.

C. At the change of shift, the nurse makes rounds with the oncoming nurse and
introduces the new nurse to the patient.

D. The nurse obtains permission for the patient’s pet to visit after the nurse over-
hears the patient express that she misses her dog and is afraid she will not see
it again.

E. The nurse tells the patient to fill out the patient survey she will receive after
discharge and to make sure to rate her experience as excellent if the nurse met
her needs.

F. A, B, C, D
G. None of the above

9. A non-English-speaking patient arrives in the ED and is noted to be crying quietly.
Which of the following is the most important for the nurse to consider in initially
providing care for this patient?

A. Expressions and interpretations of caring may be perceived differently across
cultures.

B. Therapeutic touch is a universal communication of caring.
C. Cultural competence includes looking patients in the eye and communicating

in their language even if through an interpreter.
D. When patients have specific cultural beliefs, nurses should consider them as

part of the patient’s care.

10. The nurse manager in the surgical step-down unit at a large metropolitan hos-
pital would like to evaluate the perceived effectiveness of pain management
for prior patients on the unit. The nurse knows that which of the following
measures would best assist the nurse manager in understanding past patients’
experiences?

A. Home health compare data
B. Value-based performance data
C. Hospital Consumer Assessment of Health Care Providers and Systems

(HCAHPS) data
D. Sentinel events reports

REVIEW ACTIVITIES

Review Activity 7.1

Review the study “The Art of Holding Hand: A Fieldwork Study Outlining the
Significance of Physical Touch in Facilities for Short-Term Stay” by Bundgaard,
Sorensen, and Nielsen (2011).

Explain how the simple act of holding the patient’s hand can instill safety and trust
for the patient undergoing an invasive procedure.

7 PATIENT-CENTERED CARE • 205

What expressions would convey to you the patient is anxious or experiencing
discomfort?

How can the nurse or doctor communicate reassurance to the patient while par-
ticipating in the procedure?

Review Activity 7.2

To practice effective interpersonal skills within a patient-centered environment, one
school tested the effects of pairing students during clinical rotations with the assign-
ment of caring for two patients. Refer to Bartges’s article, “Pairing Students in Clinical
Assignments to Develop Collaboration and Communication Skills” (2012) in Nurse
Educator, 37(1), 17–22.

Role-play a scenario whereby student pairs collaborate on patient assignments and
together review the patient’s records. Each student pair will round with the healthcare
team and, at the completion of the shift, report out to a second pair of students who
will be picking up the same assignment on the next shift.

Reflect upon your experience and describe the collaborative strategies each used
to gather pertinent information about your patient.

Describe communication processes you experienced that were barriers and
enhancers to effectively collaborating with the interdisciplinary team while caring for
your patient.

Discuss one takeaway each student learned from this experience while working
with a peer colleague.

Review Activity 7.3

Refer to the mentor–mentee program described by authors Latham, Ringl, and Hogan
(2011). Professionalization and retention outcomes of a university: Service mentoring
program partnership. Journal of Professional Nursing, 27(6), 344–353.

Nurse mentors in the workplace are often sought to support new nurses or nurs-
ing students in the practice setting. Formal and informal mentoring programs are
developing across academic settings to enhance their partnerships with service.

Discuss the strategies suggested in the study by Latham et al., which formalized
the mentor–mentee relationship between the student nurse and staff member.

What are some of the arguments leaders of acute care organizations express in
opposition to using staff to mentor student nurses in the workplace?

As a champion to mentoring programs for nursing students and new nurses, what
convincing arguments would you present to nurse leaders and the healthcare team in
your healthcare centers?

CRITICAL DISCUSSION POINTS

1. Patient-centered care (PCC) recognizes the unique needs, values, and preferences
of the patient and coordinates care services within a partnership between the
patient and interprofessional team with compassion and respect.

2. Expressions of caring and the interpretation of caring acts are perceived differently
across cultures.

206 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

3. Empathetic communication embodies respect for another person’s feelings, val-
ues, and perspective.

4. Collaboration means to work jointly together and share expertise among members
of the patient’s healthcare team.

5. Physical illness, disease, and injury impact a person’s psychosocial self-concept.
6. Promoting health literacy is one strategy of supporting patient-centered healthcare.
7. The Medical Home is a result of the Patient Protection and Affordable Care Act

(ACA).
8. Continuity of care can be augmented with effective discharge planning.
9. Nurses and healthcare professionals can facilitate PCC by understanding their role

in providing care that supports patient advocacy, continuity, and collaboration
with the patient as a member of the interprofessional team across the continuum
of care.

10. Nursing plays a significant role in patient satisfaction by ensuring the patient’s
values and preferences are incorporated into the care that is meaningful to the
patient.

11. Quality improvement (QI) in healthcare is a major focus in America that requires
an interprofessional approach to support programs and initiatives designed to
develop and guide “e-patients” (equipped, enabled, empowered, and engaged) in
a journey to a healthier nation.

12. Measurement of patient satisfaction can provide valuable feedback to the interpro-
fessional team regarding the delivery of PCC.

13. During your last clinical experience, what patient-centered care (PCC) initiatives
are underway on the nursing unit or within the department of nursing?

14. What PCC resources are available to nurses within the nursing unit or department
of nursing where you have your clinical rotation?

15. How has PCC improved for patients and families in your clinical site?
16. What information from the electronic health record (EHR) helps you give PCC to

patients in your clinical site?
17. Does the health system use PCC initiatives; how do the nurses feel about PCC

initiatives within their work environment?
18. How are nurses involved in decision making affecting PCC at the health system?
19. How are patients included in PCC initiatives in your clinical site? What is the role

of the nurse in PCC initiatives?
20. If a nurse has an idea that will improve PCC initiatives, where would he or she

take that idea within the organization?

EXPLORING THE WEB

1. Explore the Quality and Safety Education for Nurses (QSEN) website specifically
reviewing the Competency of Patient-Centered Care. Find their specific definition
for patient-centered care (PCC) at qsen.org/competencies/pre-licensure-ksas/.
From there, describe the attributes of PCC. Finally, discuss how administration can
support nurses and healthcare providers collaboration to provide PCC in acute
and long-term care facilities.

2. Explore the web for professional sites such as Future of Nursing; Robert Wood
Johnson Foundation, Institute of Medicine (IOM) at campaignforaction.org/ for two
goals of the future of nursing in relation to PCC.

3. Browse the web on any healthcare topic. Access the Internet and complete a
basic search on the healthcare topic of your choice. Be sure to include sites such

7 PATIENT-CENTERED CARE • 207

as WebMD and Sharecare. How can you determine if the information is valid?
Evaluate if the information provided is at an appropriate level for healthcare con-
sumers. Provide rationales for your answers.

4. Explore websites offering patient decision-making tools including www. shared-
decisions.mayoclinic.org, www.ahrq.gov/professionals/education/curricu-
lum-tools/shareddecisionmaking/index.html, and www.healthit.gov/sites/
default/files/nlc_shared_decision_making_fact_sheet.pdf. List pros and cons of
each tool offered.

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8
INTERPROFESSIONAL TEAMWORK
AND COLLABORATION

Gerry Altmiller

It’s less of a thing to do … and more of a way to be. (Unknown Participant, 2007)

Upon completion of this chapter, the reader should be able to

1. Define interprofessional team.

2. Describe how a rapid response team (RRT) contributes to patient safety.

3. Identify the benefit of collaborative interprofessional teams on patient
outcomes.

4. Describe resources interprofessional teams can employ to improve quality
and safety for patients.

5. Identify the characteristics of effective interprofessional teams.

6. List the three steps of the TeamSTEPPS Delivery System.

7. Describe how informatics supports the interprofessional team’s ability to
more efficiently and effectively solve problems.

8. Describe how constructive feedback and reflection contribute to positive
patient outcomes.

9. Discuss strategies the nurse can implement to include the patient as a
partner on the interprofessional team.

10. Discuss strategies and techniques to overcome challenges to teamwork
and maximize effective interprofessional communication.

212 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

A
patient’s family approaches the nurse’s station and verbalizes concerns regarding their
family member’s care. They are worried about the patient’s lack of energy following
surgery to correct a bowel obstruction. They are concerned because the patient is
elderly and has not been out of bed for 2 days. He is not eating well and he has

diabetes. They ask to speak to the people in charge of the patient’s care.

• What do you know about the members of the interprofessional team caring for the
patient?

• How will you bring the patient’s immediate problems to the appropriate team member’s
attention?

• How will you convey the family’s concerns to the interprofessional team?
• How can the interprofessional team work together to address this patient’s needs?

With the increasing complexity of patient care, it is clear that no one person can address a single
patient’s needs. It takes an interprofessional team of people working together, each contributing
their individual expertise for the well-being of the patient. Care for the patient extends beyond the
hands-on care provided by direct caregivers. To be effective, patient care requires the coordinated
services of many people, some not even directly involved with the patient, yet all focused on one
thing, a positive outcome and experience for the patient.

This chapter describes what an interprofessional team is and discusses the charac-
teristics that make a team most effective. It describes how at the very center of the
interprofessional team is the patient and the patient’s family and how their individual
preferences influence the decisions that the team makes as they assist the patient in
achieving optimal patient outcomes. Within this goal of putting the patient front and
center of the interprofessional healthcare team, strategies for how best to include the
patient as a partner are presented. This chapter highlights resources that can be utilized
as well as strategies that individuals and institutions can implement to create an envi-
ronment where effective interprofessional communication supports patient safety and
improves the overall quality of the care provided to patients, including the use of rapid
response teams (RRTs). With the increasing emphasis on quality and safety, techniques
to improve communication between interprofessional healthcare team members con-
tinues to be of great importance. Tools, techniques, and strategies for communication
aimed at facilitating patient safety and quality of care are described, including the use
of reflection by the nurse and other members of the interprofessional healthcare team

as a means of improving patient outcomes.
Likewise, TeamSTEPPS is presented as an effec-
tive way to ensure interprofessional healthcare
teams are able to communicate with each other
to promote situational awareness and patient
safety. Strategies to create and develop effective
team functioning are identified in this chap-
ter. In addition, this chapter discusses how the
World Wide Web has increased the availability
of resources to support improved interprofes-
sional communication and the dissemination
of information. Informatics has contributed
to effective teamwork by making information
available at a moment’s notice so that team
members can exchange ideas to solve problems
(Figure 8.1).

FIGURE 8.1 Interprofessional collaboration
on the patient care unit.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 213

Nursing holds a key position on the healthcare team, contributing to the plan of
care, delivering nursing services, and providing that vital link between the patient, the
patient’s family, and the other members of the healthcare team. Skilled communica-
tion between the nurse and other members of the interprofessional healthcare team
promote the exchange of clear and concise information, which allows the team to react
quickly and appropriately to meet patients’ needs.

WHAT IS AN INTERPROFESSIONAL TEAM?

A team is a group of individuals who work together for a common goal. In healthcare,
the interprofessional team consists of people who have a stake or interest in and con-
tribute to the well-being of the patient. An interprofessional team not only includes
those directly involved in the patient’s physical care such as the physicians, nurses,
and family members, but it also includes those who provide support services such as
pharmacists, social workers, dieticians, and those from departments such as house-
keeping, radiology, the laboratory, transport services, and physical and occupational
therapy. It is important to recognize the valuable contribution that of all these interpro-
fessional team members make to the patient’s care.

RAPID RESPONSE TEAMS

Interprofessional teams in the hospital setting may be brought together to focus on iden-
tified problems and find solutions. This can happen on a patient care unit or in other
areas of the hospital. One common example of an effective team in the hospital is an
RRT. An RRT is a team that includes specific healthcare professionals with specialized
skills, who can mobilize and deliver immediate patient assessment and intervention if
needed at the patient’s bedside any time of day or night, 7 days a week at the beginning
signs of deterioration in the patient’s health status. The RRT is separate from a “code” or
resuscitation team that is also composed of specialized interprofessional team members
who would respond to cardiac and/or respiratory arrest. RRTs were formed based on
recommendations by the Institute for Healthcare Improvement (IHI) to improve safety
and quality, with the intention of preventing deaths outside of the ICU (IHI, 2012). RRTs
may be structured differently within institutions, but most RRTs consist of a physician,
critical care nurse, and respiratory therapist, along with other designated interprofes-
sional members, as needed. Expert communication skills are required by RRT members
because the patient’s safety and well-being depends on the rapid and accurate exchange
of pertinent and clear information between team members coming together in a con-
certed effort to aid the patient. RRTs support an institution’s nurses by providing access
to immediate assistance for any patient with a deteriorating condition. RRTs may be
summoned to a patient’s bedside by anyone, including family members. Providing RRT
support allows for early intervention at the first sign of deterioration in patients, before
they become critically ill or experience a cardiac arrest.

BENEFITS OF COLLABORATIVE INTERPROFESSIONAL
TEAMS

At the center of the interprofessional healthcare team is the patient and the patient’s
family. Patient-centered care ensures that the patient is an integral part of the team
and is central in all interactions and decisions. With patient-centered care, the

214 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

interprofessional team acknowledges patient preferences regarding care and acknowl-
edges individual health values and priorities. Without the patient, there would be no
need for the team.

Like patients, nurses have not always been considered members of the interprofes-
sional healthcare team; traditionally they have taken direction from hospital admin-
istrators and physicians rather than directly contributing to a collaborative plan of
care. Historically, nurses were charged with direct patient care and focused mostly on
providing patient hygiene under the direction of the physician. Differences in educa-
tional requirements prevented even routine tasks such as obtaining a patient’s blood
pressure from being delegated to the nurse. Nurses did not have a role in advocating
for the patient and physicians did not confer with nurses regarding any aspect of the
patient’s care. The interprofessional relationship was strictly one of orders being dic-
tated by the physician team member and orders being carried out by the nursing team
member.

Gender issues have also contributed to the lack of interprofessional collabo-
ration or the ability to effectively work together. In the past, males traditionally
assumed the physician role while nurses have primarily been female. Much has
changed in recent decades with both males and females assuming roles as physi-
cians and nurses, independent of gender. Females still dominate the nursing pro-
fession; however, with the U.S. Department of Labor reporting that in 2011, males
made up only 9% of the nursing workforce (U.S. Department of Labor, 2013). In
comparison, females were reported to make up 36% of the physician workforce
(U.S. Department of Labor).

Economic issues have also contributed to the lack of interprofessional col-
laboration. Nurses represent the largest segment of the hospital-based employee
workforce and have been paid as hourly workers by the hospital. Physicians have
been community based and have managed their practice as a business, directly
billing their patients and the insurance companies. Some of this is changing as the
expanding roles of nurses have created opportunities for hospital-based nurses and
for advanced practice nurses in all areas of healthcare. Both of these groups of RNs
have increased their education and have contributed to bridging the gap between
nurses and physicians. Greater requirements in prelicensure education of nurses
have also resulted in a bedside nurse that is able to assess, plan, implement, and
evaluate care provided to patients, making the nurse a valuable team member.

Nursing knowledge is based on science combined with the art of caring for the
individual needs of patients. Nursing brings a holistic perspective to patient care.
The connection of the nurse to the patient and family through close and continued
interaction allows nurses to understand and advocate for patient concerns and needs
regardless of their practice level. Nurses can build rapport between patients and the
team and facilitate collaboration between the interprofessional healthcare disciplines
involved in the patient’s care. Nurses’ knowledge of the patient experience allows
them to identify subtle changes in the patient’s condition and act quickly to prevent
complications of illness. The ability of the nurse to function proactively helps to
reduce unnecessary costs to hospitals as well as improve patient satisfaction and
outcomes.

Nurses need to recognize the value of this perspective and acknowledge the posi-
tive impact they have on patient outcomes. It is important that nurses articulate the
value of this positive effect on patient satisfaction as well as the financial benefit that
nurses bring to the institutions they serve to enhance their role as contributing team
members and to advance the profession of nursing.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 215

Recognizing the value of nursing, the Institute of Medicine (IOM), now
known as the National Academy of Medicine, in collaboration with the Robert
Wood Johnson Foundation (RWJF), published its report, The Future of Nursing:
Leading Change, Advancing Health (IOM, 2010). This report identified the barriers
that prevent nurses from being able to respond to the rapidly changing healthcare
system. It also validated the important role that nurses play in the delivery of seam-
less, high-quality, affordable healthcare to all. The four key recommendations from
the report were focused on the role that nursing should have in providing care
(Table 8.1).

Advancing Healthcare Through Improved Education

Although educational differences exist among interprofessional team members, it is
important to recognize that each team member brings a perspective to the team that
represents specialized knowledge from his or her discipline. For physicians, the edu-
cational requirements include a baccalaureate degree with an additional 4 years of
medical school, followed by a year of internship in clinical practice, and 2 years of
residency. Medical specialization adds additional years of training and fellowship.
For nurses, there are varied levels of educational requirements for entry into practice.
These include a 3-year diploma school education, a 2-year associate degree education,
and a 4-year baccalaureate degree education as well as master’s completion programs.
Other healthcare disciplines have varied educational degree requirements as well.
No matter the educational requirements, each healthcare discipline needs to be able
to collaborate with others to provide the highest quality care for the patient. While
concepts of interprofessional collaboration are included in the educational process of
each healthcare discipline, Hood et al. (2014) notes that purposeful planning and early
integration of interprofessional learning would foster an enhanced group dynamic as
well as a shared commitment to collaboration with recognition of the value of other
disciplines.

To support the appreciation of each healthcare discipline’s perspective, expertise,
and values, many programs now include an integration of interprofessional educa-
tion as part of their curriculum. Interprofessional education is the opportunity for
multiple healthcare disciplines to learn together in the same learning environment
simultaneously, gaining a greater understanding for each discipline’s role and contri-
butions. A common example of this is medical and nursing students taking an ethics
class together or participating in a communication exercise as part of an orientation
program.

TABLE 8.1 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH

FOUR KEY RECOMMENDATIONS

1. Nurses should practice to the full extent of their education.

2. Nurses should achieve higher levels of education through an improved education
system that promotes seamless academic progression.

3. Nurses should be full partners with physicians and other healthcare professionals in
the redesign of healthcare.

4. Better data collection and information infrastructure are necessary for effective
workforce planning and policy making.

216 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

STRATEGIES FOR MAXIMIZING EFFECTIVE
INTERPROFESSIONAL TEAMS

The changing socialization of physicians and nurses as well as other disciplines has
allowed for the formation of interprofessional teams that not only care for patients but
also tackle some of the toughest problems facing healthcare today. In part, this change
has come from changes in traditional gender roles as well as the attainment of bacca-
laureate and master’s degrees by more and more nurses. Working together, physicians
and nurses have developed work processes to address quality and safety on all levels
of patient care.

Methods such as root cause analysis (RCA) are employed to identify problems
within the healthcare system. With RCA, teams work together to systematically

Healthcare providers have limited educational preparation for complex care
coordination across disciplines that are necessary in today’s increasingly
complex delivery system. Challenging patient health conditions mean no one
discipline can be responsible for the entire spectrum of care, yet, health pro-
fessions’ education remains primarily a professional individual silo experi-
ence where each discipline is educated together and learns separately from
the other healthcare disciplines. To effectively care for and coordinate care
delivery, interprofessional healthcare professionals require repeated blended
educational experiences to achieve the four interprofessional educational
competencies:

• Understand the scope of responsibilities of each team member.
• Maintain ethical conduct and quality of care within the team to develop

respect and trust.
• Communicate effectively with patients, families, and healthcare team

members.
• Utilize teamwork behaviors in executing patient care requirements.

Complex healthcare work environments are driven by little understood
human factors including intricacies of communication and behavior. These
are important for sharing critical information and coordination among the
team. Knowing what each healthcare discipline can contribute during the
stress of a healthcare intervention is a critical factor in delivering safe care. A
well-developed self-awareness allows team members to function alternately
as leader or follower, as appropriate to the situation and individual compe-
tence. Healthcare is a team sport involving multiple individuals in the deliv-
ery of safe care.

Gwen Sherwood
Professor and Associate Dean for Academic Affairs

University of North Carolina at Chapel Hill School of Nursing
Coinvestigator, Quality and Safety Education for Nurses (www.qsen.org)

Chapel Hill, North Carolina

REAL-WORLD INTERVIEW

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 217

investigate serious adverse events and identify the root cause and contributing fac-
tors that lead to error, patient injury, or a negative outcome so that those factors can
be corrected. An RCA can be conducted to identify mechanisms within the healthcare
system that allowed for the error or near miss to occur. A near miss is an event that
could have resulted in an error but was caught in time before it could cause injury. This
reporting process allows for both individual growth and development for the nurse
as well as correction within the healthcare system’s practices to prevent future errors.
RCA discovers the root of a problem by not stopping at the first answer it arrives at for
its cause, but by delving deeper into why the problem occurred, asking questions until
there are no more questions to ask.

Another process used to improve quality and safety is the Six Sigma method. Six
Sigma is a quality assurance strategy developed in corporate America in the mid-
1980s by the Motorola Corporation (Stanton et al., 2014). Six Sigma, used to improve
existing healthcare processes, involves five steps, also referred to as DMAIC: define;
measure; analyze; improve; and control. During the define step of Six Sigma, poten-
tial team members are identified that are knowledgeable about the healthcare process
or service that has been identified as needing improvement. These team members
must have a clear understanding of what the expectation and needs are so they know
where to aim the improvement. During the measure step of Six Sigma, the problem is
investigated and data are gathered to determine how, when, and where the problem
is occurring. The analyze step of Six Sigma allows the team to look for trends and
patterns of the healthcare problem from the data so they can identify a root cause.
During the improve step of Six Sigma, solutions are identified and implemented, and
finally, during the control step of Six Sigma, control mechanisms such as retraining
or monitoring systems that ensure that the problem does not occur again are put in
place.

RESOURCES FOR INTERPROFESSIONAL TEAMWORK
AND COLLABORATION

Nowhere is interprofessional teamwork and collaboration more important than in
providing required healthcare to patients in need. Although all members of the inter-
professional healthcare team possess specific expertise that would benefit the patient,
if they were unable to coordinate those skills and connect vital services together, the
patient would not have the best possible outcome. Team members must work together
to provide coordinated care to achieve the best results.

Patients are at greater risk during transitions between care. Handoff is a term
used to describe the communication method that the interprofessional team uses to
transfer patient care information to one another between shifts or between patient care
units or hospitals. In healthcare, poor outcomes occur when there are breakdowns in
communication, poor teamwork, or inefficient communication “handoffs” that create
situations that can lead to errors. Effective interprofessional teams involved in direct
patient care have common goals of high quality and safety, and ensuring that infor-
mation about the patient is communicated accurately and completely supports those
goals during transitions of care.

Interprofessional teams in healthcare may be focused on more long-term
projects. These interprofessional teams may be assembled to address a number of
concerns which may include anything from quality improvement (QI) processes
to planning for the future of the healthcare institution. Although the work of

218 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

these types of interprofessional teams may seem slower and more deliberate, the
principles that guide them are the same as teams that respond to patient emergen-
cies. For example, a long-term goal of a hospital might be to increase the num-
ber of baccalaureate- prepared RNs to 80% within 10 years. Collaboration between
hospital administration, finance, nursing leadership, and broad representation
from nursing staff, all using effective teamwork and communication strategies,
would be needed to conduct the same steps of assessment, definition of problem,
goal setting, implementation, and evaluation that are part of the nursing process
to achieve goals.

CHARACTERISTICS OF EFFECTIVE INTERPROFESSIONAL
HEALTHCARE TEAMS

Effective interprofessional teams are able to think reflectively about the situation at
hand considering past experiences, contemplate options from all perspectives, and
deliberate the options in an atmosphere of mutual respect. In high- functioning,
successful interprofessional teams, members can voice concerns and opinions,
creating a group dynamic where all members contribute and share in the deci-
sion making. Clear, focused communication and respectful negotiation decrease
the potential for misunderstandings and promote camaraderie among the team
members.

Accountability and Stages of Team Development

Forming, storming, norming, and performing are terms used to describe the stages
experienced by teams as they progress from formation to functioning as high-
performance teams (Tuckman, 1965). The forming stage is generally a short phase
when team members are introduced and objectives are established. As the team
moves into the storming stage, team roles become clarified and processes as well
as structures for the team are established. It is within this process that the details
of the approach being used to accomplish the goals or assignment are decided
upon. The workload of the task becomes clear during this storming phase and can
overwhelm the team members. Conflicts may arise and members build relation-
ships with other team members as they work through conflict resolution. In this
storming stage, teams will fail if work processes and team relationships have not
been well established.

In the norming stage, team members develop a stronger commitment to the
team’s goals and assume responsibility for the team’s progress. Individuals show
leadership in specific areas and team members come to respect each other’s roles.
As members become socialized as a team, they are able to provide construc-
tive feedback to each other. It is important to note that teams can pass back and
forth between the storming and norming stages as new tasks are assigned to the
team. The performing stage is realized through achievement of the team’s shared
vision of the goal. At this point, teamwork feels easier and members can for the
most part join and leave the team without affecting the team’s performance. The
progress achieved from the members’ hard work establishes the team as a high-
performance team.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 219

Delegation

Willingness to assist colleagues is pivotal to interprofessional teamwork and collabo-
ration. Teamwork requires that members can effectively delegate work to each other.
In patient care, it is essential that delegated tasks are within the scope of practice of the
individual to whom the task is being delegated. For example, inserting an indwelling
urinary catheter could be delegated by a nurse to another nurse. It could not be del-
egated to a nursing assistant. When delegating, the nurse employs the following steps:
assess and plan; communicate what needs to be done; ensure availability to assist and
support; and finally, evaluate effectiveness and give feedback (National Council of
State Boards of Nursing, 2016).

With all delegation, clear communication of what needs to be done and confirma-
tion of understanding from the individual being delegated to is essential to ensure
patient safety. The nurse, who is delegating, needs to provide an opportunity for clari-
fication and questions. If an outcome does not meet expectations, the nurse should
lead the discussion with those involved to identify reasons for the unexpected out-
come and determine what could be learned from the experience to improve care and
to ensure a successful outcome in the future.

Crew Resource Management

Crew resource management (CRM) refers to educating individuals that work in high-
stress systems where the human aspect of operations can create an increased potential

The manager of a critical care unit wants to implement self-scheduling among his
large staff. He appoints two staff members from the night shift, two staff members
from the day shift, one assistant manager, and one nurse aide to a committee with
the goal of developing rules to guide the self-scheduling process. The committee
is scheduled to meet weekly until all self-scheduling rules are developed and the
self-scheduling process can be put in place. Immediately, tensions run high in the
committee as there is disagreement about the number of Fridays that must be
worked by each staff member and the number of weekends that must be worked
in a 6-week schedule. Through negotiation, agreement is reached on the committee
regarding these issues. Just when they believe that they have all issues resolved,
there is disagreement among the committee members regarding the number of
schedule changes management can make to accommodate unit needs. This is a
very heated topic and the negotiation for this continues for 3 weeks. Eventually,
it is resolved with agreement by all. It is decided that the scheduling committee
will remain intact, assist with the transition for staff, and manage the scheduling
process. Committee members will work together to cover the unit needs.

1. What team stage is identified as the team begins to work to resolve the number of Fri-
days and weekends that will be required by each staff?

2. What team stage is identified when the committee decides to remain intact to assist
with the transition and manage the scheduling process?

CASE STUDY 8.1

220 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

for error. Originating in the aviation industry for the cockpit crew, CRM develops com-
munication, leadership, and decision-making safety strategies to combat the potential
for human error that is inherent in high-stress systems and its devastating effects. The
healthcare industry shares an interest in interprofessional teamwork and clear com-
munication with the aviation industry to prevent catastrophic events. Healthcare has
applied many CRM strategies to the daily interactions and continuous QI processes of
the interprofessional healthcare team. CRM communication, leadership, and decision-
making safety strategies focus on cognitive and interpersonal skills to promote situ-
ational awareness.

Situational awareness is having the right information at the right time alongside
the ability to analyze that information to appropriately and effectively take action.
Having this awareness, allows for all team members to be conscientious of the facts
in any given situation. The vehicle for this attentiveness is effective communication
between interprofessional healthcare team members.

TEAMSTEPPS

Within healthcare, TeamSTEPPS is a program developed to provide training for effec-
tive communication techniques similar to those promoted by CRM. The program is
designed to teach interprofessional teams how to communicate with each other to pro-
mote situational awareness and patient safety. Specifically TeamSTEPPS is

• A powerful solution to improving patient safety within an organization
• An evidence-based teamwork system to improve communication and teamwork

skills among healthcare professionals
• A source for ready-to-use materials and a training curriculum to successfully inte-

grate teamwork principles into all areas of the healthcare system
• Scientifically rooted in more than 20 years of research and lessons from the appli-

cation of teamwork principles (Agency for Healthcare Research and Quality
[AHRQ], n.d., p. 2)

Developed in collaboration with the Department of Defense, the Agency for
Healthcare Research and Quality (AHRQ) initiated TeamSTEPPS to augment the
effort and abilities of interprofessional teams specially to ensure the highest patient
outcomes within healthcare institutions and systems. By focusing on a three-phased
process of team development, the program optimizes resources within a team, pro-
vides a framework for resolving conflict and enhancing communications, and pro-
vides the basis to effectively address potential barriers to effective patient safety and
quality care.

AHRQ lists the three phases of TeamSTEPPS as (a) assessment; (b) planning, train-
ing, and implementation; and (c) sustainment. Assessment involves pretraining evalu-
ation to determine the willingness and capacity of an organization to change. Within
this phase of the process, an interprofessional team is established that is made up of
a cross-section of healthcare leaders and professionals within the organization itself.
This phase also involves conducting a comprehensive site assessment that identifies
areas of weakness and needs relative to teamwork. From this assessment, the second
phase of TeamSTEPPS is initiated; a training program is developed to effectively over-
come the deficiencies of the team as well as maximize its strengths. Once this educa-
tion has occurred, the third and final phase can be initiated. The long-range goal of
the third phase is to maintain and continually improve teamwork efforts throughout
the organization. Through coaching, feedback, and reinforcement of strategies taught,

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 221

teamwork and communication skills can be continually reinforced and built upon as
opportunities for improvement in clinical and administrative situations throughout
the organization.

Situation, Background, Assessment, and Recommendation

A framework for communication that has been implemented in many healthcare
settings is SBAR, an acronym for the words situation, background, assessment, and rec-
ommendation (AHRQ, n.d.). It was developed by the military and is now applied to
healthcare as a means to relay significant information regarding a patient’s condition
or to be used as patients’ care is communicated and handed off from one caregiver to
another (Table 8.2).

ADDITIONAL TECHNIQUES FOR
EFFECTIVE COMMUNICATION WITHIN
INTERPROFESSIONAL TEAMS

Clear and open communication among team members allows ideas to be shared and
counteracts the potential for human errors of judgment. Techniques such as cross-
monitoring require that team members listen carefully to the details being communi-
cated and provide correction for the team if needed. Cross-monitoring is the process
of monitoring the actions of other team members for the purpose of sharing the
workload and reducing or avoiding errors (AHRQ, n.d.). An example of this tech-
nique can occur during grand rounds where interventions are discussed by a group
of physicians, nurses, pharmacists, and other healthcare providers. Decisions ver-
bally agreed upon can sometimes be missed as orders are articulated for the patient.
A nurse asking for clarification of an order he or she recalls differently is an example
of cross-monitoring.

TABLE 8.2 SITUATION, BACKGROUND, ASSESSMENT, AND RECOMMENDATION

SBAR MEANING EXAMPLE

S Situation: Describe what is
happening with the patient

Doctor, I am calling about Mrs. Smith, your
patient admitted yesterday to room 304
with respiratory distress.

B Background: Explain the
background of the patient’s
circumstances

She was comfortable during the evening
after being placed on 2 L oxygen by
nasal cannula and receiving 20 mg of
furosemide (Lasix) intravenously, but is
now complaining of shortness of breath.

A Assessment: Identify what
data you have regarding
the situation

Her respiratory rate is 28. Pulse is 110/min
and her oximetry measures 91%. She has
crackles in the lower third of her lung fields
bilaterally. She is laboring to breathe.

R Recommendation: Identify
what you think needs to
be done to correct the
situation

I think she may need her furosemide (Lasix)
dose increased.

SBAR, situation, background, assessment, and recommendation.

222 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Other communication techniques can be used to bring attention to patient situ-
ations. A callout is used to communicate important information to the entire team
simultaneously (AHRQ, n.d.). In a callout, the team member would callout to others
for assistance. For example, during a resuscitation effort, also known as a code, a nurse
monitoring the patient’s blood pressure might assertively state the changing status
to the medical resident. Typically, the callout is then followed by a check back, which
verifies receipt of the information and provides feedback and appropriate response.
In this example, the resident might acknowledge the callout by asking for medication
to be given to stabilize the patient’s blood pressure. Check back requires the receiver
verbally acknowledge the message to provide opportunity for correction if needed.

The two-challenge rule states that if an individual does not believe that his or her
first attempt to bring attention to a concerning patient situation has been successful,
the individual is obligated to make a second attempt to make the problem known to
others on the team (AHRQ, n.d.). The two-challenge rule is designed for when team
member’s input is ignored purposely. It is the obligation of the person to bring it for-
ward again to make sure it is not ignored. An example of the two-challenge rule is
when a nurse tells a physician about a concern she has for the patient, like a low urine
output, and the physician does not address it for one reason or another. The nurse is
obligated to bring it forward again.

Another tool that can be used to advocate for a patient is CUS, which is an acronym
for the words concerned, uncomfortable, and safety (AHRQ, n.d.). Frequently, nurses are
expected to advocate for their patients but they may not know how to do so. CUS is a tool
that assists the nurse in taking an assertive stance to do what the nurse believes is needed
for the patient. For example, in the case of a larger than recommended dose of medica-
tion being ordered for a patient, the nurse may approach the ordering provider and state,
“I’m concerned with the dose that has been ordered. I am uncomfortable giving such a
large dose to this patient because of her renal condition. I don’t think it is safe.”

STRATEGIES FOR EFFECTIVE COMMUNICATION WITHIN
INTERPROFESSIONAL TEAMS

Time-outs are mandated in the operating room (OR) and procedure suites by The Joint
Commission to help ensure patient safety (The Joint Commission, n.d.). Time-outs can
also be initiated during any procedure at the bedside. The time-out is an opportunity
for everyone in the room to stop and ensure that the correct patient is having the cor-
rect procedure done to the correct site. The time-out requires that everyone stop his or
her clinical work and devote his or her attention to the patient. Another safety strategy
the team can employ is the use of safety huddles. Safety huddles allow those caring for
the patient to review pertinent information and the plan of care. It is similar to a team
huddle used in sports and ensures everyone is aware and working toward the same
goals for the patient. An example of when a huddle would facilitate effective, coordi-
nated care is when medications need to be altered due to change in a patient’s status.
Responding to an adverse reaction of a patient to a specific medication for instance
would best be handled with a focused, coordinated approach by as many of the inter-
professional team members as possible.

All of the aforementioned communication strategies are developed by the AHRQ
which provides reference videos for clinicians, administrators, and educators demon-
strating TeamSTEPPS tools, strategies, and techniques at its website, www.ahrq.gov/
professionals/education/curriculum-tools/teamstepps/instructor/videos/index.
html (Table 8.3).

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 223

Another way that team members can work to prevent errors is by reporting them
to other members of the healthcare team. Timely reporting of errors and near misses,
also known as close calls where an error could have occurred but was stopped before it
caused harm, provides an opportunity for the team to learn from them. In most cases,
errors and near misses are not the result of a single person’s actions. They are often the
result of a failure within a healthcare system. By reporting all errors or near misses, the
need for an RCA can be evaluated more completely and effectively and actions can be
taken to ensure the same situation does not put patients at risk in the future.

USE OF INFORMATICS FOR EFFECTIVE PROBLEM
SOLVING

Minimizing the potential for errors is the goal of everyone on the healthcare team.
Participating in behaviors that guard against error and protect patients is a fundamen-
tal part of daily healthcare practice. There are many available web resources funded
by government agencies and national healthcare organizations that are designed
to improve teamwork and collaboration, prevent error, promote patient safety, and

TABLE 8.3 AVAILABLE TOPICS FOR REFERENCE AND EDUCATION ON AHRQ TEAMSTEPPS
WEBSITE

SBAR Provides a standardized framework for communication, that is,
situation, background, assessment, and recommendation.

Cross-monitoring Involves listening to other team members to identify correct
and incorrect information. This allows the team to self-correct
healthcare errors before they occur.

Callout Asks for help from other team members.
Two-challenge

rule
Obligates team members to make a second attempt to have a

concern heard when their first attempt to bring attention to a
concern is not acknowledged.

CUS Advocacy strategy using the words concerned, uncomfortable,
safety.

Check back/read
back

Verbally calling out and repeating back information to confirm it is
understood correctly.

Handoff Transferring responsibility for a patient’s care from one unit to
another or from one individual to another.

CUS, concerned, uncomfortable, and safety; SBAR, situation, background, assessment, and recommendation.

CRITICAL THINKING 8.1

The nurse calls the physician to report that a patient has suddenly developed hives
while receiving an IV dose of antibiotic. The hives are covering most of his back. The
physician tells the nurse that he does not think that the antibiotic is the cause and that
she should just continue to monitor the patient. The nurse is concerned that the hives
may be the beginning of a serious allergic reaction.

1. What safety strategy would be most effective for the nurse to use to
advocate for the patient in this situation?

224 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

improve the quality of the care that patients receive. Nurses, as well as other team
members, can access these resources to learn about strategies that address quality and
safety as a way to improve their practice and keep patients safe from errors (Table 8.4).

Communication and Interprofessional Teamwork in QI

All members of the interprofessional healthcare team have an obligation to improve
patient care processes and outcomes by focusing on communication and QI. Debriefing
is the process of reviewing performance effectiveness following challenging patient care
situations. Utilizing strategies such as debriefing allows the interprofessional team to
evaluate the effectiveness of their communication and teamwork and to identify areas
where improvement is possible. It is during debriefing that constructive feedback is
given and received. All team members should feel comfortable to participate in this
process. Individuals may differ in how they provide feedback to peers, but feedback,
whether positive or negative, should always be an unbiased reflection of what occurred,
opening the door to a discussion of evidence-based practice (Clynes & Raftery, 2008).
Constructive feedback should carefully detail events as they occurred and avoid opinion.

Constructive feedback recounts events, offering options for improvement.
Constructive feedback is most effective when focused on a task, a process used, or on
self-regulation, because that focus contributes to learning; feedback focused on the indi-
vidual is less effective because it does not increase learning (Hattie & Timperley, 2007).
For instance, feedback such as “It was wise to gather your supplies before you went
into the patient’s room” focuses on the task. Feedback such as “Your explanation to the
patient before you began allowed the patient to trust you” focuses on the healthcare
process. Feedback such as “It is good that you realized you broke sterile technique and
changed your gloves” focuses on self-monitoring. All of these support knowledge devel-
opment. Feedback such as “You did a good job” focuses on the individual and is least
effective because it does not add to one’s understanding of what aspects of his or her
practice were effective and “a good job.” Although it is difficult to give and receive unflat-
tering feedback, team members must understand that feedback is essential for growth.
Feedback is the mechanism that allows one to make continual adjustments in practice.
Receiving feedback is often the catalyst for change and should be viewed as an oppor-
tunity for growth. Sometimes when receiving feedback that is perceived as negative, it
challenges the team member to consider the validity of the comments made, particularly

TABLE 8.4 WEB RESOURCES FOR TEAMWORK AND COLLABORATION, ERROR
PREVENTION, PATIENT SAFETY, AND QI

RESOURCE WEBSITE ADDRESS

TeamSTEPPS www.ahrq.gov/professionals/education/curriculum-tools/
teamstepps/instructor/videos/index.html

Patient Safety Network psnet.ahrq.gov
The National Database of

Nursing Quality Indicators
nursingandndnqi.weebly.com/ndnqi-indicators.html

ISMP www.ismp.org
The Future of Nursing

Report
www.nationalacademies.org/hmd/Reports/2010/The-Future-

of-Nursing-Leading-Change-Advancing-Health.aspx
QSEN www.qsen.org
The Joint Commission www.jointcommission.org

ISMP, Institute for Safe Medication Practices; QSEN, Quality and Safety Education for Nurses.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 225

considering whether the same feedback has been provided previously by other sources.
If after consideration, feedback is perceived as inaccurate, the team member can ask for
examples of poor performance and focus on improvement, asking the person providing
feedback how he or she feels improvement can be achieved.

Auditing Patient Care and Outcomes

Teams can work together to conduct audits and other organizational studies that
measure quality, safety, and patient outcomes which can have a significant impact on
the process of QI. Collecting and analyzing data regarding patient care practices and
patient outcomes allows the team to document differences between the actual system’s
performance and the goals of the organization. By documenting differences, changes
can be made to narrow the gap between the two and improve team performance for
quality of care and patient safety.

REFLECTION AND FEEDBACK

Communication and interprofessional teamwork skills are a huge part of the protec-
tion from injury and complications that nurses provide for patients. These skills help
not only when interacting with patients and healthcare team members to solve prob-
lems but also when nurses reflect on patient care events and discuss ways to improve
outcomes. Providing feedback to team
members allows the team to iden-
tify strengths and weaknesses, make
changes to the healthcare system, and
adjust practice for individual growth
and development.

Self-evaluation of one’s communi-
cation and decision making is a crucial
element of professional growth and
strengthens one’s ability to contribute
to the team’s decisions by employing
strong clinical judgment. As discussed
earlier in the chapter, reflection supports confidence in decision making and provides
an opportunity for the individual to consider his or her interactions with others and
determine what actions enhanced a positive outcome and what actions worked against
it. Reflecting on clinical situations and their outcomes allows team members to make
positive changes to improve practice (Figure 8.2).

Tanner Model of Thinking Like a Nurse

Tanner’s model of Thinking Like a Nurse (2006) demonstrates how clinical judgment
is developed through reflection, enhancing critical thinking skills. These skills are
essential to develop as one gains expertise in protecting patients through situational
awareness and mindfulness. Mindfulness in this context implies staying focused with
the ability to see the significance of early and weak signals as well as to take strong and
decisive action to prevent harm (Weick & Sutcliff, 2001). Tanner’s model stems from
review of approximately 200 studies focused on the nurses’ development of clinical
judgment. From her review, she concluded that

FIGURE 8.2 Monthly staff meeting.

226 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

• Clinical judgments are more influenced by what nurses bring to the situation than
the objective data about the situation at hand.

• Sound clinical judgment rests to some degree on knowing the patient and his or
her typical pattern of responses, as well as an engagement with the patient and his
or her concerns.

• Clinical judgments are influenced by the context in which the situation occurs and
the culture of the nursing care unit.

EVIDENCE FROM THE LITERATURE

Citation

McBride, A. B. (2010). Toward a roadmap for interdisciplinary academic career
success. Research and Theory for Nursing Practice: An International Journal, 24(1),
74–86.

Discussion

The complexity of today’s health problems requires more than the knowledge
of one provider. This necessitates an interprofessional collaborative approach.
Identified by the Institute of Medicine (IOM) as a core competency of all health-
care professionals, interprofessional collaboration has different meanings to dif-
ferent people. Examples of interprofessional collaboration include understaffed
hospital personnel working together during the night shift to ensure patient
safety or nurses and physicians discussing a patient plan to decrease complica-
tions or multiple disciplines working in partnership for education and research
endeavors to decrease mortality and morbidity within their institution.

One of the barriers to achieving interprofessional collaboration has been the
socialization of the separate healthcare disciplines, which has been focused on
how they differ from one another. Up until recently, each healthcare discipline
was taught without interacting with the other healthcare disciplines; each estab-
lishing its own distinct body of knowledge.

Implications for Nursing

Nursing has built a large body of knowledge based on scientific research.
Nursing’s strengths include its holistic orientation to the patient and its abil-
ity to facilitate the bridging of disciplines and boundaries, thus supporting
interprofessional collaboration. The reward of interprofessional collabora-
tion is an expanded perspective where multiple healthcare disciplines work
together to develop new models of care, new methods of care delivery, and
breakthroughs in disease management, and health promotion. Through inter-
professional collaboration, knowledge obtained from research can be trans-
lated into practice for the benefit of human health. The nursing profession is
in a key position to support collaboration between all healthcare profession-
als from all disciplines as they move forward to meet the core competencies
identified by the IOM.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 227

• Nurses use a variety of reasoning patterns alone or in combination.
• Reflection on practice is often triggered by a breakdown in clinical judgment and

is critical for the development of clinical knowledge and improvement in clinical
reasoning (Tanner, 2006, p. 204).

STRATEGIES TO INCLUDE THE PATIENT AS PARTNER

Communication between the healthcare team, the patient, and the patient’s family
during times of stress and illness can be challenging but it is essential to safety and a
key factor in patient satisfaction. Patients and families look to the nurse to provide a
personal connection with the team. In addition, many patients and families look to the
nurse as a source of information. The nurse should use language that is understand-
able to the patient and provide patient-centered information that allows the patient to
assume a role of partnership rather than dependency. The nurse plays a pivotal role
in including the patient, providing explanations, and providing access for the patient
to communicate with other members of the interprofessional team. To promote the
patient’s partnership with the interprofessional healthcare team, the nurse can create
connections for the patient to other members of the team, such as providing informa-
tion regarding when the physician usually makes rounds. The nurse can encourage the
patient and family to write down their questions for the physician and put the ques-
tions in the chart so that the physician may address them.

Developing Enhanced Communication Skills

The nurse must possess strong communication skills to contribute to effective team
functioning. Communication is the interactive process of exchanging information.
Effective communication is clear, precise, and concise, with no ambiguities. Safety is
enhanced when the communication sender uses the proper terminology and provides
an opportunity for clarification. Ideally, in response, the receiver of the communication
acknowledges the message as heard and understood.

Many barriers can interfere with communication, such as knowledge gaps, educa-
tion levels, culture, language barriers, or stress. It is important for nurses to develop
strategies to identify and overcome these barriers. Nonverbal cues, such as the patient’s
facial expression, eye contact, and body posturing, may signal a message from the
patient, but when safety is a priority such as it is in healthcare, interpreting nonver-
bal cues only is not an acceptable technique for communicating. Any perception one
develops from nonverbal communication must be verified verbally to maintain a safe
environment.

Effective communication is essential to maintaining a safe and protected envi-
ronment for patients. Ineffective communication continues to be identified as the
root cause for many sentinel events reported to The Joint Commission (2016), which
explains why improving communication is a safety priority for the next decade.
Students and nurses who are new to practice may find team interaction intimidat-
ing for several reasons, including that they do not clearly understand the culture of
healthcare communication, they have known knowledge gaps, and they have not
yet gained enough experience in the healthcare setting from which they can draw.
Recognizing what information needs to be communicated to which individuals on
the team and in what time frame is essential to developing effective communication
skills. Regularly scheduled meetings of key team members help to ensure effective

228 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

communications. Quality and safety in patient care are strongly influenced by the
ability of the healthcare team to communicate clearly without uncertainty, in a timely
manner, and to contribute to the healthcare team’s productive, efficient approach to
patient care.

Strategies for Communication in Difficult Situations

Challenging patient care situations such as patient resuscitations, difficult patient pro-
cedures, rapid response efforts, or end-of-life events require extreme attention and
clarity. Unnecessary conversation should cease during these situations and all commu-
nication should focus on the situation at hand without distractions. To ensure patient
safety at these times, communication senders and receivers should continually verify
their communication using read backs or check backs. For example, during a diffi-
cult labor and delivery, the physician might assertively request many urgent medica-
tions and interventions. In this chaotic and unnerving scenario, it is essential that the
nurse and other healthcare professional verify what orders and instructions are being
relayed by repeating them to those giving the orders. In addition, documentation must
be clear and accurate during these times so as to provide a written account of events.
It is during these types of challenging patient care situations that communication with
patients and families can sometimes be overlooked. This can be avoided by includ-
ing the patient in decision making whenever possible and appointing someone on
the team to provide updates to the family. Family presence at patient resuscitations is
becoming more commonplace. Institutions that support this practice designate a mem-
ber of the team, frequently a nurse, to support the family and explain the interventions
and actions of the healthcare team’s efforts. Supporting the family during such a high-
stress, high-stakes event requires skillful communication that is clear, accurate, and
compassionate.

In the operating room (OR), no one can be an individual. Everyone works as a
team. We make it a team effort from the minute we meet the patient. The nurse
anesthetist and the circulating nurse go together to pick up the patient. Even
moving the patient onto the table is a team effort to ensure the patient’s safety.
Everyone has to share information and be able to communicate. The time-out
procedure is a great example of teamwork and communication in the OR.
Everyone must stop what he or she is doing and be attentive to the exchange
of information to ensure the patient’s safety. There is a lot of camaraderie in the
OR because of the high stress associated with the work we do. Each member of
the team contributes. The nurse anesthetist has to be a calming force in the room
to instill confidence in the rest of the team. In the OR, there is a lot of autonomy.
As an advance practice RN, I feel valued as a team member. It motivates me to
communicate with everyone, go above and beyond what is required, and take
pride in what I do.

Daniel Boucot
Rancocas Anesthesia Associates

Kennedy Health System
Sewell, New Jersey

REAL-WORLD INTERVIEW

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 229

Managing Conflict

It is vital to patient safety that the lines of communication remain open among all
those involved in the patient’s care. When there is disruption in the smooth flow of
communication among team members, it is important to address it promptly before
it becomes a more prolonged barrier to communication. Destructive events such as
physicians who will not respond to pages, nurses who are resistant to carrying out
legitimate orders, or pharmacists who do not move quickly to fill STAT or urgent
orders prescriptions, create difficult communications among healthcare providers
that can negatively impact patient care (Table 8.5). It is important to address mis-
understandings and conflicts promptly so that they do not become long-standing
barriers to communication. Team members must be vigilant in fulfilling their ethical
duty to work together for the patient’s well-being.

Negative or difficult communication in the work environment can come from
patients, families, physicians, other nurses, or any person involved in the operations of
the institution. Physicians who yell, do not answer calls, and display disrespect and con-
descension toward colleagues make it uncomfortable to practice. Miscommunications
between the interprofessional team can put patients at risk. Stressed patients, families,
and/or staff can act out frustrations and aggression. It is important that all members
of the interprofessional team respect the expertise of each individual, giving each the
power to speak up and provide input in decision making with the team. Those in
leadership roles should work to equalize the power structure so that all feel safe to
contribute (Rittenmyer, Huffman, Hopp, & Block, 2013).

Horizontal Violence

One of the most troubling conflicts for nurses is nurse-to-nurse aggression, also known
as lateral violence or horizontal violence (Rittenmeyer et al., 2013). Horizontal violence
is uncivil behavior toward colleagues that may manifest as making faces or raising
eyebrows in response to comments, making snide remarks, withholding information
that interferes with a colleague’s ability to perform professionally, refusing to help, or
appearing not available to give help. Scapegoating (blaming one person for all negative
things that have happened), criticizing, breaking confidences, fighting among nurses,
and excluding peers from dialogue and activities are all forms of horizontal violence
and result in injury to the dignity of another (Griffin, 2004). Nurses can experience

CRITICAL THINKING 8.2

During a patient resuscitation, the nurse pulling supplies from the code cart
discovers that supplies are missing. When the code has ended, the nurse reviews the
documentation form to determine who stocked the cart last.

1. What would be the best approach for the nurse to initiate a discussion with
coworkers about the incorrectly stocked cart?

2. What aspects should the nurse focus on during the discussion?
3. How can the nurse create a learning experience for coworkers in this

instance?

230 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

physical consequences (loss of sleep, weight loss, irritable bowel syndrome) and/or
psychological consequences (depression, anxiety, and loss of confidence) as a result
of lateral violence (Becher & Visovsky, 2012). In addition, lateral violence can interfere
with continuity of care and be detrimental to patients and to the institutions that pro-
vide care.

When encountering lateral violence, nurses should respond to it in a manner that
focuses on consensus building rather than respond emotionally with anger. If a commu-
nication becomes angry or difficult, the nurse can refocus the interaction on the patient’s
safety and well-being. Refocusing on the patient’s needs will take the focus off of the
power struggle that occurs when people are angry. In addition to protecting one’s self,
nurses have an obligation to report behaviors that compromise patient safety or the well-
being of coworkers to their supervisor or someone else in authority to adequately address
the problem. Conflicts and negative behaviors place patients at risk because they serve
as a distraction preventing nurse from functioning at their best. In addition, conflicts can
keep nurses from communicating concerns to physicians, from asking questions when
they are unsure, and from asking for help when critical situations arise.

Besides horizontal violence between and among nurses themselves, nurses can expe-
rience hostile work conditions from physicians, patients, or their families. The nurse can
utilize refocusing or de-escalation strategies with physicians, patients, and families as

TABLE 8.5 MANAGING DIFFICULT COMMUNICATIONS

HEALTHCARE
PROVIDER

COMMUNICATION
ISSUE

THE NURSE’S BEST COMMUNICATION
APPROACH

Physician Not answering
page

Call physician’s office or overhead page to
solve immediate problem; later discuss with
physician that the patient’s needs are the
primary concern and give the reason for the
page.

Physician Speaking in
an angry
condescending
manner

Maintain calm and keep focus on the patient;
state your primary concern is to solve the
patient’s immediate need.

Identify the patient’s need clearly and succinctly.
Pharmacist Not filling STAT

orders quickly
Maintain calm and explain patient’s immediate

need.
Unlicensed

assistive
personal

Not following
through with
delegated duties

Explore reasons for why duties were not
completed. If needed, make adjustment
to workload. Develop plan for future
communication regarding delegated duties.

Nurse Rolls eyes and
sighs during
report; indicates
irritation with
you

Respond in civil tone, stating that you sense
there is something the nurse wants to say
and that you learn when people are direct.
Ask nurse to please be direct with his or her
concerns.

Nurse Does not provide
assistance when
needed

Explore reasons for lack of assistance; be quick
to volunteer to help others so they will be
just as quick to return the favor when you
need help.

Nurse Resistant to
carrying out
legitimate orders

Explore concerns related to orders; develop
plan. Offer assistance to peers when able.

STAT.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 231

well. Again, an effective tool to de-escalate difficult or angry communication is to bring
the focus of the conversation back to the patient. Refocusing the discussion back on the
patient’s needs takes the focus off any perceived power struggle and helps everyone to
refocus on the priorities at hand. Nurses can enlist the support of more senior colleagues
when conflicts arise with team members. Other useful neutralizing techniques include
listening attentively to others and demonstrating concern. Nurses can reduce negative
situations by identifying people that are receptive to their questions and are willing to
serve as resources. It is important for nurses to set the example by ending conversations
where coworkers are being discussed in a negative manner.

New-to-practice nurses are more vulnerable to horizontal violence and hos-
tile work conditions in the healthcare environment due to their lack of experience.
Addressing these conditions as soon as possible frequently puts an end to it. However,
it is important not to be confrontational in one’s approach. An effective tactic against
horizontal violence is to develop de-escalation strategies for these encounters, which
can decrease the intensity, and stress of the situation. When confronted with nonverbal
innuendos such as eyebrow raising, rolling of eyes, and long sighs by peers, one can be
direct and say, “I sense that there is something that you want to say to me. I learn best
when people are direct. It’s okay if you are direct with me” (Griffin, 2004). This type of
response directly addresses the horizontal violence in a civil manner without aggres-
sion. It indicates to the violator that his or her body language is perceived as negative
and that it is preferable for the recipient to discuss the reason for it rather than ignore
it. It should be said in earnest and not with anger to de-escalate the situation and open
the lines of communication. When de-escalation strategies are not successful, Griffin
and Clark (2014) suggest using the CUS acronym stating “I’m concerned with the way
you are speaking to me, I’m uncomfortable with where this conversation is going, and
I don’t think it is safe for us to continue.” Using this strategy allows the exchange to
end in a civil manner before it escalates further.

Those in leadership positions have a crucial role in creating a workplace envi-
ronment where horizontal violence and hostile communications are not tolerated.
Promoting a team structure where power is shared among all members improves deci-
sion making and workload distribution (Rittenmeyer et al., 2013). Leaders need to set
the standard for realistic expectations regarding workload so that their staff can meet
those expectations and have a sense of accomplishment and satisfaction with their
work and their work environment rather than feeling discouraged. Nursing leaders
within the organization have an obligation to their direct care nurses to establish poli-
cies that discourage horizontal violence and help staff feel comfortable in confronting
such behavior without fear of retaliation (Rittenmeyer et al).

CRITICAL THINKING 8.3

A new-to-practice nurse who is on orientation is assigned a complex patient to care for
with his preceptor. During a stressful exchange, the preceptor states, “You’re way too
slow! You are never going to make it here if you don’t pick up the pace.”

1. What strategies for difficult communications would be most appropriate to
use in this instance?

2. When should the new-to-practice nurse address this with the preceptor?
3. What would be the new-to-practice nurse’s best communication approach

with the preceptor?

232 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Communicating With Preceptors

Preceptors are experienced nurses who provide orientation and support to new-to-
practice nurses as they learn the roles and responsibilities of a new job. Preceptors have
increased responsibilities of caring for patients while providing instruction to new
nurses. They are frequently chosen for this important role because of their expertise in
caring for patients and because they exemplify professional behaviors. New-to-practice
nurses rely heavily on their preceptors to guide them in learning how to communicate
with other team members and become a productive member of the healthcare team.
Communicating with team members requires that nurses maintain a professional pres-
ence and act with confidence. During the orientation period, communication can be
intimidating for the new nurse. It is difficult to feel like a valued member of the team
when one is not sure about what to anticipate next. It can be a stressful time for both the
preceptor and the orientee, particularly during challenging patient care situations. To dif-
fuse any stressful communication, an honest and open exchange between the preceptor
and the orientee at a quiet moment later will provide an opportunity to clarify concerns
and reach an understanding about expectations. The new nurse can open the discussion
by identifying his or her desire to learn and understand the situation. New nurses need
to maintain realistic expectations regarding their knowledge base and expertise and seek
feedback that will help them develop skill and effective clinical judgment. Accepting
that he or she has knowledge gaps will allow the new nurse to ask questions without
injury to self-esteem. Collaboration skills improve as the nurse develops a better under-
standing of the work expectation and unit routine.

Cognitive Rehearsal

It is most important to continually promote an environment of respect and collabora-
tion. Nurses must challenge themselves to use respectful negotiation when disagree-
ments occur between members of the healthcare team and to remain civil in the face of
incivility as part of their professional development. Cognitive rehearsal is one strategy
that the nurse can use when confronted with incivility from a coworker or another
person. Cognitive rehearsal is a prepared response that one practices ahead of time
that would address a negative comment or situation in a civil manner. It allows one to
not react emotionally but to pause and respond with a rehearsed, intellectually driven,
civil response. For instance, if a coworker harshly criticizes the speed with which you

CRITICAL THINKING 8.4

The nurse is caring for a patient with an extensive burn injury. The patient has a
decreased white blood cell count and is scheduled for skin grafting at the end of the
week. The patient is receiving a regular diet but has a poor appetite and has not been
able to eat enough to meet his required calorie intake.

1. How can the nurse involve the patient and the family to address the
patient’s nutrition?

2. Which members of the interprofessional team would have the expertise to
address the patient’s nutritional status?

3. How can the interprofessional team work together to meet the patient’s
nutritional needs?

REAL-WORLD INTERVIEW

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 233

complete a task, rather than react emotionally and become hurt and angry, you might
respond by saying, “This is different from how I learned. Can you help me to under-
stand how you complete it so quickly?”

As mentioned earlier, reflection and the ability to gain insight into one’s actions
can facilitate powerful, effective change. Specifically, reflecting on your ability to com-
municate with colleagues and other members of the interprofessional team provides
an opportunity to consider behaviors that build consensus among colleagues and
behaviors that create barriers to communication and interfere with safe patient care.
During reflection, one should ask oneself, “What went well?” “What could have gone
better?” “What could I have done to improve this situation?”

Being a new nurse had its challenges. I had worked as an extern and then as a
technician, but when I transitioned to an RN, I realized how much I was respon-
sible for and had to learn quickly how to deal with the stress. The hardest part
was knowing the right thing to do for the patient and who I could comfortably
go to for questions. Even though I felt I had a good education, it took a good
year to feel comfortable with my practice and confident with my knowledge
and skills. I was hired at the same time as another nurse and we supported each
other during orientation. My hospital also had a nurse residency program and
it helped me to know that my peers on other units were having the same feel-
ings and difficulties that I was having. In the program, we talked about com-
munication and about working with complex patient and family situations. We
supported each other a lot through my first year of nursing practice.

Katie Bicknell
Children’s Hospital of Pennsylvania

Philadelphia, Pennsylvania

REAL-WORLD INTERVIEW

You and a senior colleague are assigned to the same patient room. You are caring
for the patient in Bed B and she is caring for the patient in Bed A. You notice that
the patient in Bed A is sleeping. On the bedside table, there is a filled medication
syringe and an empty vial labeled heparin, 10,000 units/mL. You carry the medi-
cation syringe and heparin out to the nurse’s station and state to your colleague,
“These were on the bedside table.” She takes them from you and states, “Yes, I
have to remember to give the heparin to him when he wakes up” and returns
them to the patient’s bedside table.

1. What standard is your colleague violating?
2. Recognizing that your colleague did not react to your implied concern for the patient’s

safety and the standard of practice, what communication strategy would you imple-
ment to maintain this patient’s safety?

3. How can you address practice concerns like this from an organization’s point of view
to prevent this type of practice?

CASE STUDY 8.2

234 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Hospital and Nursing Leadership

Hospital and nursing leadership have a significant influence on how teams function.
Leaders can set the tone for communication, role model effective conflict management,
and create and foster an environment that facilitates safety and quality care. Nurse
managers, preceptors, and other leaders within the healthcare organization can sup-
port new-to-practice nurses by providing effective feedback. Nurses can approach
leaders to facilitate needed change when a chain of command authority is needed.
Most leaders continually assess their environment as well as the people that report to
them to determine if adequate support is provided for their subordinates to do their
jobs. However, leaders can miss subtle signs of trouble or inefficiency. In that case,
nurses must take it upon themselves to approach the leader to ask for help. Effective
communication and team building help ensure the message for requesting help or
clarification will be heard.

The responsibility of the nurse manager to serve as a role model for team building
and collaboration cannot be understated. The nurse manager will be the leader that
direct care nurses will have the greatest amount of interaction with, making it essen-
tial that he or she demonstrate active listening and partnership in solving problems.
Engagement is supported by feedback that builds rather than tears down so skills
in delivering and receiving constructive feedback can be demonstrated by the nurse
manager so that others can emulate them. Behaviors that demonstrate respect and col-
legiality will build and sustain a civil work environment and set the expectation for
the interprofessional team.

Interprofessional teamwork and collaboration is essential to ensure quality
healthcare for patients and maintain safety. Nurses are valued members of the inter-
professional healthcare team. Nurses’ contribution to the patient’s care include knowl-
edgeable assessments, reflective thinking, effective planning, thoughtful interventions
based on evidenced-based practice, and careful evaluation of care. Nurses’ communi-
cation skills play a pivotal role in team building. Nurses who communicate concerns
and address problems enhance their ability to prevent errors, achieve positive patient
outcomes and patient satisfaction, and improve the system in which they work.

KEY CONCEPTS

1. An interprofessional healthcare team consists of people who have a stake or interest
in and contribute to the well-being of the patient, for example, physicians, nurses,
family members, those who provide support services, such as pharmacists, social
workers, dieticians, and those from departments such as housekeeping, radiology,
the laboratory, transport services, and physical and occupational therapy.

2. A rapid response team (RRT) is a team that includes specific healthcare profes-
sionals with specialized skills, who can mobilize and deliver immediate patient
assessment and intervention if needed at the patient’s bedside any time of day
or night, 7 days a week at the beginning signs of deterioration in the patient’s
health status.

3. Recognizing the value of nursing, the Institute of Medicine (IOM), now known as
the National Academy of Medicine, in collaboration with the Robert Wood Johnson

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 235

Foundation (RWJF), published its report, The Future of Nursing: Leading Change,
Advancing Health (IOM, 2010). The four key recommendations from the report were
focused on the role that nursing should have in providing care (Table 8.1).

4. To effectively care for and coordinate care delivery, interprofessional healthcare
professionals require repeated blended educational experiences to achieve four
interprofessional educational competencies, that is, understand the scope of
responsibilities of each team member, maintain ethical conduct and quality of
care within the team to develop respect and trust, communicate effectively with
patients, families, and healthcare team members, and utilize teamwork behaviors
in executing patient care requirements.

5. Root cause analysis (RCA) discovers the root of a problem by not stopping at the
first answer it arrives at for its cause, but by delving deeper into why the problem
occurred, asking questions until there are no more questions to ask.

6. Six Sigma, used to improve existing healthcare processes, involves five steps, also
referred to as DMAIC.

7. In healthcare, poor outcomes occur when there are breakdowns in communica-
tion, poor teamwork, or inefficient communication “handoffs” that create situa-
tions that can lead to errors.

8. Forming, storming, norming, and performing are terms used to describe the stages
experienced by teams as they progress from formation to functioning as high-
performance teams (Tuckman, 1965).

9. When delegating, the nurse employs the following steps: assess and plan; commu-
nicate what needs to be done; ensure availability to assist and support; and finally,
evaluate effectiveness.

10. Originating in the aviation industry for the cockpit crew, crew resource manage-
ment (CRM) develops communication, leadership, and decision-making safety
strategies to combat the potential for human error that is inherent in high-stress
systems and its devastating effects.

11. Situational awareness is having the right information at the right time alongside
the ability to analyze that information to appropriately and effectively take action.
The vehicle for this attentiveness is effective communication between interprofes-
sional healthcare team members.

12. TeamSTEPPS is a program designed to teach interprofessional teams how to com-
municate with each other to promote situational awareness and patient safety
(AHRQ, n.d., p. 2).

13. Situation, background, assessment, and recommendation (SBAR; AHRQ, n.d.)
was developed by the military and is now applied to healthcare as a means to relay
significant information regarding a patient’s condition or to be used as patients’
care is communicated and handed off from one caregiver to another (Table 8.2).

14. Time-outs are an opportunity for everyone in the room to stop and ensure that the
correct patient is having the correct procedure done to the correct site.

15. Safety huddles allow those caring for the patient to review pertinent information
and the plan of

16. Cross-monitoring, callout, two-challenge rule, concerned, uncomfortable, and
safety (CUS), check back/read back, and handoff are developed by the AHRQ
which provides reference videos for clinicians, administrators, and educators
demonstrating TeamSTEPPS tools, strategies, and techniques at its website, www.
ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/
videos/index.html (Table 8.3).

17. Timely reporting of errors and near misses, also known as close calls where an
error could have occurred but was stopped before it caused harm, provides an

236 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

opportunity for the team to learn from them. In most cases, errors and near misses
are often the result of a failure within a healthcare system.

18. There are many available web resources funded by government agencies and
national healthcare organizations that are designed to improve teamwork and col-
laboration, prevent error, promote patient safety, and improve the quality of the
care that patients receive (Table 8.4).

19. Debriefing is the process of reviewing performance effectiveness following chal-
lenging patient care situations.

20. Feedback, whether positive or negative, should always be an unbiased reflection
of what occurred, opening the door to a discussion of evidence-based practice
(Clynes & Raftery, 2008). Constructive feedback should carefully detail events as
they occurred and avoid opinion.

21. Teams can work together to conduct audits and other organizational studies that
measure quality, safety, and patient outcomes which can have a significant impact
on the process of quality improvement (QI).

22. Providing feedback to team members allows the team to identify strengths and
weaknesses, make changes to the healthcare system, and adjust practice for indi-
vidual growth and development.

23. Self-evaluation of one’s communication and decision making is a crucial element
of professional growth and strengthens one’s ability to contribute to the team’s
decisions by employing strong clinical judgment.

24. Tanner’s model of Thinking Like a Nurse (2006) demonstrates how clinical judg-
ment is developed through reflection, enhancing critical thinking skills.

25. Mindfulness implies staying focused with the ability to see the significance of
early and weak signals as well as to take strong and decisive action to prevent
harm (Weick & Sutcliff, 2001).

26. Communication between the healthcare team, the patient, and the patient’s family
during times of stress and illness can be challenging but it is essential to safety and
a key factor in patient satisfaction.

27. Many barriers can interfere with communication, such as knowledge gaps, edu-
cation levels, culture, language barriers, or stress. It is important for nurses to
develop strategies to identify and overcome these barriers.

28. Effective communication is essential to maintaining a safe and protected environ-
ment for patients. Ineffective communication continues to be identified as the root
cause for many sentinel events reported to The Joint Commission (2016).

29. Destructive events such as physicians who will not respond to pages, nurses who
are resistant to carrying out legitimate orders, or pharmacists who do not move
quickly to fill STAT prescriptions, create difficult communications among health-
care providers that can negatively impact patient care (Table 8.5).

30. One of the most troubling conflicts for nurses is nurse-to-nurse aggression, also
known as lateral violence or horizontal violence (Rittenmeyer et al., 2013).

31. New-to-practice nurses are more vulnerable to horizontal violence and hostile
work conditions in the healthcare environment due to their lack of experience.

32. Preceptors are experienced nurses who provide orientation and support to new-
to-practice nurses as they learn the roles and responsibilities of a new job.

33. Reflection and the ability to gain insight into one’s one actions can facilitate pow-
erful, effective change.

34. Hospital and nursing leadership have a significant influence on how teams function.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 237

KEY TERMS

Collaboration
Cross monitoring
Debriefing
De-escalation strategies
Hand-off
Interprofessional education

Mindfulness
Near miss
Rapid Response Teams
Root cause analysis
Situational awareness

REVIEW QUESTIONS

1. A nurse receives a telephone order from a physician for specific x-ray tests. The
nurse established the identity of the patient involved and the name of the ordering
physician. Which of the following should she do next?

A. Write the order on the order sheet in the chart.
B. Repeat what the physician says and then write it down on the order sheet.
C. Ask the physician to directly place the order with the radiology department.
D. Write the order on the order sheet and then perform a read back to the physi-

cian to verify the order is accurate.

2. The nurse is informed that an RRT will be initiated at the hospital to better meet
the needs of patients. Which of the following best describes the way in which the
nurse should utilize the RRT?

A. Provide support for medical-surgical nurses and decrease the number of
patient arrests requiring ICU admission.

B. Rapidly move patients through the hospital system at time of transfer.
C. Notify the attending physician of the client’s deteriorating status.
D. Provide immediate assistance to patients in the ICU.

3. The nurse is transferring a patient from the ICU to the step-down patient care unit.
When the ICU nurse calls report to the receiving unit, what is the best way for the
nurse to provide the handoff information?

A. Situation, Background, Assessment, Requirements
B. Situation, Background, Assessment, Recommendations
C. Systems, Background, Activities, Recommendations
D. Systems, Background, Activities, Requirements

4. The nurse pages a physician due to the patient’s change in status. When the physi-
cian calls the unit, the physician yells at the nurse for interrupting dinner. Which
of the following would be the nurse’s best approach?

A. Tell the physician that she is going to report him to the nursing supervisor.
B. Tell the physician that she is doing her job and does not deserve to be

yelled at.
C. Refocus the communication on the patient and the reason for the call.
D. Apologize for interrupting the dinner and page his partner.

238 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

5. The nurse attends an interprofessional meeting to discuss the care of a patient who
is a paraplegic after an automobile accident. Which of the following best describes
the purpose of assembling an interprofessional team?

A. To provide multiple perspectives to contribute to the patient’s care and well-being
B. To divide the work appropriately among disciplines
C. To ensure that the physician controls the patient outcome
D. To provide support in difficult patient care situations

6. Following a serious medication error that resulted in patient injury, a nurse is
assigned to a team assembled to investigate the cause. The nurse knows which of
the following represents the best method for doing so?

A. Root cause analysis
B. Debriefing
C. Six Sigma
D. Crew resource management

7. The nurse on the oncology unit cares for a patient who frequently comments that
she would like better pain control through the night. The nurse tells the patient
that a note will be placed on the front of the patient’s chart alerting the physician
in case the nurse misses the physician during her rounds. Which of the following
represents a better process to ensure the patient’s needs are met?

A. Nursing rounds
B. Team huddle
C. Debriefing
D. Root cause analysis

8. A patient’s family is angry about their family member’s deteriorating condition
and tells the nurse that they are not satisfied with the patient’s care. Which of the
following would be the most appropriate action by the nurse?

A. Notify the hospital administration
B. Explain to the family that the patient’s condition is complex and that the patient

is receiving appropriate care
C. Convey understanding and notify members of the healthcare team so that a

family meeting with the team can be provided
D. Ask the family members why they feel that way

9. Which of the following processes would best assist the nurse to increase expertise,
adjust practice, and improve self-regulation?

A. Conduct a RCA
B. Elicit constructive feedback from others
C. Participate in debriefing
D. Use the CUS technique

10. Skilled communication is essential to patient safety for which of the following
reasons?

A. Patients need to be convinced to receive specific treatments.
B. Nurses need to explain procedures to patients.
C. Miscommunication is responsible for many harmful events in the hospital.
D. Poor quality is associated with poor communication.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 239

REVIEW ACTIVITIES

1. A patient calls the nurse into the room and complains of shortness of breath. The
patient was admitted yesterday for pulmonary edema and has been successfully
treated with nasal oxygen at 4 L, and furosemide (Lasix) 40 mg IV every 12 hours.
The nurse determines that the patient’s respiratory rate is 30, the pulse oximetry
reading is 91%, and auscultation of the lungs reveals crackles halfway up the back.
Using SBAR technique, provide report to the physician regarding the previously
mentioned patient.

2. The nurse believes the dose of a medication ordered for a patient is too high and
may be dangerous for the patient to receive. What communication strategy would
the nurse implement to verbalize this? How would it be implemented?

3. The nurse receives a critical lab result via telephone from the laboratory. What safety
strategy should the nurse implement to ensure safety regarding the lab value?

CRITICAL DISCUSSION POINTS

1. During your last clinical experience, what interprofessional teamwork and col-
laboration initiatives were underway on the nursing unit or within the department
of nursing?

2. What interprofessional teamwork and collaboration resources are available to
nurses within the nursing unit or department of nursing where you have your
clinical rotation?

3. How has interprofessional teamwork and collaboration improved for patients and
families in your clinical site?

4. How do the nurses feel about the culture of interprofessional teamwork and col-
laboration within their work environment?

5. How are nurses involved in interprofessional teamwork and collaboration in the
health system?

6. How are patients, nurses, and the interprofessional team included in daily inter-
professional rounds in your clinical site?

7. If a nurse has an idea that will improve the interprofessional teamwork and col-
laboration regarding patient care delivery, where would he or she take that idea
within the organization?

8. Interprofessional teams include physicians and nurses that provide direct patient
care but also include the patient, family members, and many others who provide
support services such as pharmacists, dieticians, social workers, and physical and
occupational therapists.

9. All members of the interprofessional team should be valued for their contribution
of a specific expertise to the plan of care for the patient.

10. Interprofessional education as well as quality and safety standards can improve
the collegial interactions of members of the team.

11. Attention to quality and safety improvement have resulted in national organiza-
tions promoting the implementation of processes such as RCA, Six Sigma, and
RRTs to raise the standard of care.

12. The human factors associated with providing healthcare contribute to the poten-
tial for errors but effective teams incorporate safety strategies to communicate,
monitor each other’s work, and prevent injury to patients.

13. Good communication skills for exchanging information and delegating are an
essential element of successful teamwork and collaboration.

240 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

14. Giving and receiving feedback provides an opportunity for individuals and teams
to identify areas for improvement and alter their practice.

15. Healthcare team members have an ethical duty to work together for the patient’s
well-being.

16. Difficult or strained communications place patients at risk because team members
are afraid to ask questions or confirm practice standards.

17. Nurses can promote teamwork and prevent communication barriers by using
strategies to de-escalate tense situations, by framing their communications in
safety language, by using cognitive rehearsal, and by reflecting on events to con-
sider opportunities for building consensus.

QSEN WEBSITE EXERCISES

1. Introduction to the QSEN Competencies. Review presentation available at: qsen
.org/quality-and-safety-education-for-nurses-an-introduction-to-the-competencies-
and-the-knowledge-skills-and- attitudes/

Discussion: This PowerPoint presentation is a brief overview for individu-
als that are unfamiliar with the IOM/QSEN competencies and wish to introduce
ideas that promote development of the knowledge, skills, and attitudes that sup-
port the competencies. It includes direct links to helpful resources such as the First
Touch website, to Infection Control Bundles at The Joint Commission website, and
to the TeamSTEPPS video collection at the Agency for Healthcare Research and
Quality website.

2. Giving and Receiving Constructive Feedback. Review this 18-minute narrated
presentation to learn how to give and to receive constructive feedback to improve
practice and build teamwork: qsen.org/giving-and-receiving-constructive-
feedback/

Discussion: This is a narrated presentation focused on helping students to
understand the importance of learning to give and to receive constructive feed-
back. Key points include understanding constructive feedback’s role in quality
improvement and patient safety, and learning to view constructive feedback as an
opportunity for improvement. Students may listen to it online, at home, or in the
classroom with a faculty member. The presentation can be loaded into Electronic
Course Frameworks and assigned. If assigned as an out of class activity, faculty
can have students blog or post in discussions about what they gained from the
presentation.

EXPLORING THE WEB

1. Go to qsen.org and find the Teamwork and Collaboration Competency. Review
the knowledge, skill, and attitude a graduate nurse should exhibit. Then go to
the Publication tab and review the various articles, toolkits, and other resources.
Do you find something that could help you with a current group of people/
classmates/colleagues you are working with?

2. Access the web resources in Table 8.4.

8 INTERPROFESSIONAL TEAMWORK AND COLLABORATION • 241

3. Review the websites listed in Table 8.4. What do you identify as the consistent
theme or focus of all of these websites?

4. What strategies do you see on these websites that would enhance teamwork?

REFERENCES

Agency for Healthcare Research and Quality (AHRQ). (n.d.). TeamSTEPPS™ fundamentals
course: Module 1. Introduction: Instructor’s slides. Retrieved from https://www.ahrq.gov/
teamstepps/instructor/fundamentals/module1/igintro.html

Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. Medsurg Nursing, 21(4), 210–213.
Clynes, M. P., & Raftery, S. E. C. (2008). Feedback: An essential element of student learning in

clinical practice. Nurse Education in Practice, 8, 405–411.
Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention

for newly licensed nurses. The Journal of Continuing Education in Nursing, 3(6), 257–263.
Griffin, M., & Clark, C. (2014). Revisiting cognitive rehearsal as an intervention against incivil-

ity and lateral violence in nursing: 10 years later. Journal of Continuing Education in Nursing,
45(12), 535–542.

Hattie, J., & Timperley, H. (2007). The power of feedback. Review of Educational Research, 77(1),
81–112.

Hood, K., Cant, R, Baulch, J., Gilbee, A., Leech, M., Anderson, A., & Davies, K. (2014). Prior experi-
ence of interprofessional learning enhances undergraduate nursing and healthcare students’
professional identity and attitudes to teamwork. Nurse Education in Practice, 14, 117–122.

Institute for Health Care Improvement (IHI). (2012). Deploy rapid response teams. Retrieved from
http://www.ihi.org/explore/RapidResponseTeams/Pages/default.aspx

Institute of Medicine (IOM). (2010). The future of nursing: Leading change advancing health. Retrieved
from http://nationalacademies.org/HMD/Reports/2010/The-Future-of-Nursing-Leading-
Change-Advancing-Health.aspx

The Joint Commission. (n.d.). The universal protocol for preventing wrong site, wrong procedure,
and wrong person surgery: Guidance for health care professionals. Retrieved from http://www.
jointcommission.org/assets/1/18/UP_Poster.pdf The Joint Commission. (2016). Sentinal
events statistics released for 2015. Joint Commission Perspectives, 36(4).

McBride, A. B. (2010). Toward a roadmap for interdisciplinary academic career success. Research
and Theory for Nursing Practice: An International Journal, 24(1), 74–86.

National Council of State Boards of Nursing. (2016). National Guidelines for Nursing Delegation.
Retrieved from https://www.ncsbn.org/NCSBN_Delegation_Guidelines.pdf

Petri, L. (2010). Concept analysis of interdisciplinary collaboration. Nursing Forum, 45(2), 73–81.
Rittenmeyer, L., Huffman, D., Hopp, L. & Block, M. (2013). A comprehensive systematic review on

the experience of lateral/horizontal violence in the profession of nursing. The JBI Database
of Systematic Reviews and Implementation Reports. 11. 362. doi:10.11124/jbisrir-2013-1017.

Stanton, P., Gough, R., Ballardie, R., Bartram, T., Bamber, G., & Sohal, A. (2014). Implementing
lean management/six sigma in hospitals: Beyond empowerment and work intensification?
The International Journal of Human Resource Management, 25(21), 2926–2940.

Tanner, C. A. (2006). Thinking like a nurse: A research based model of clinical judgment in nurs-
ing. Journal of Nursing Education, 4(6), 204–211.

Tuckman, B. (1965). Developmental sequence in small groups. Psychological Bulletin, 63(6),
384–99. doi:10.1037/h0022100

Unknown participant. (2007, June). Quality and safety education for nurses collaboration. Chicago, IL.
U. S. Department of labor. (2013). Occupations by gender shares of employment. Retrieved from

https://www.dol.gov/wb/stats/occ_gender_share_em_1020_txt.htm
Weick, K. E., & Sutcliffe, K. M. (2001). Managing the unexpected. San Francisco, CA: Jossey-Bass.

242 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

SUGGESTED READINGS

Agency for Healthcare Research and Quality (AHRQ). (2011). Preventing avoidable readmissions.
Retrieved from http://www.ahrq.gov/qual/impptdis.htm

Altmiller, G. (2012). The role of constructive feedback in patient safety and continuous quality
improvement. Nursing Clinics of North America, 47(3), 365–374. doi:10.1016/j.cnur.2012.05.002

American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive statements.
Retrieved from http://nursingworld.org/MainMenuCategories/EthicsStandards/
CodeofEthicsforNurses/Code-of-ethics.pdf

Barr, H. (2002). Interprofessional education, today, yesterday and tomorrow. Retrieved from
https://www.unmc.edu/bhecn/_documents/ipe-today-yesterday-tmmw-barr.pdf

Carter, P. (2010). Six sigma. American Association of Occupational Health Nurses Journal, 58(12),
508–510.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J.
(2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 112–131. doi:10.1016/
j.outlook.2007.02.006

Douglas, M. (2016). Bridging gaps in rapid response systems. Nursing Management, 47(12), 26–31.
doi:10.1097/01.NUMA.0000508260.11605.47

Halbesleben, J. R. B., Wakefield, D. S., & Wakefield, B. J. (2008). Work-arounds in the health
care setting: Literature review and research agenda. Health Care Manager Review, 33(1), 2–12.
doi:10.1097/01.HMR.0000304495.95522.ca

Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington,
DC: National Academies Press.

Leach, L. S., & Mayo, A. M. (2013). Rapid response teams: Qualitative analysis of their effective-
ness. American Journal of Critical Care, 22(3), 109–210. doi:10.4037/ajcc2013990

Lim, F., & Pajarillo, E. J. Y. (2016). Standardized handoff report form in clinical nursing education:
An educational tool for patient safety and quality of care. Nurse Education Today, 37(3), 3–7.
doi:10.1016/j.nedt.2015.10.026

Smith, P. L., & McSweeney, J. (2017). Organizational perspectives on rapid response team
structure, function, and costs. Dimensions of Critical Care Nursing, 36(1), 3–13. doi:10.1097/
DCC.0000000000000222

Upon completion of this chapter, the reader should be able to

1. Define nursing informatics.

2. Explore the data, information, knowledge, and wisdom framework that
guide nursing informatics.

3. Differentiate between an electronic medical record (EMR) and an electronic
health record (EHR).

4. Discuss evolving national initiatives that encourage use of EHRs.

5. Explore the utility of patient portals in providing healthcare.

6. Explain the role telehealth plays in the care of the homebound or rurally
located patients.

7. Describe how to evaluate the quality of health-related content on websites
and applications.

8. Explain technology initiatives that support the delivery of safe patient care
such as clinical decision support systems and clinical alerts.

9. Differentiate among the concepts of privacy, confidentiality, and security.

10. Discuss the future of health informatics.

9
INFORMATICS

Beth A. Vottero

The biggest waste in the healthcare system is not unnecessary treatment or duplicated test results; it is
that we collect data and never use it again.

— Chris Lehmann, Vanderbilt University Professor of Pediatrics and Biomedical Informatics

244 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

I
n November 2007, actor Dennis Quaid and his wife Kimberly walked into Cedars-Sinai
Medical Center to visit their newborn twins: Thomas Boone and Zoe Grace. To the Quaids’
horror, they were immediately greeted by a nurse who informed them that the twins had been
given an overdose of heparin (10,000 U/mL rather than 1,000 U/mL) not only once, but twice

during the hospitalization. Once the error was noticed, the children were treated with protamine
sulfate and they apparently suffered no long-term effects of the incident. The Quaids subsequently
sued the drug company for using drug labels on the high- and the low-concentration heparin vials
that were very similar and could cause confusion. Although they did not sue the hospital, they did
ask that the hospital review its policies and procedures (Rosen, 2008).

• What other healthcare professionals had an influence on this medication error?
• What are some low-technology and high-technology interventions that could have prevented

this medication error?
• What types of policies and procedures may have not been followed that allowed such an

error to have occurred.

A relatively new specialty in healthcare is the growing field of informatics. This growth is due in part
to the expanding capacity of technology leading to breakthroughs in communication and analytics.
Healthcare has embraced the known abilities and the potential of technology in supporting high-
quality, safe patient care nationwide. The full impact of technology on healthcare delivery will
never be known due to the continuing evolutionary nature of the field. Health informatics is the
collective term applied to various interprofessional health workers who focus on collecting, storing,
retrieving, transmitting, and analyzing health data to support high-quality patient care. While still a
new specialty, nursing informatics has grown to become a critical asset within health informatics.

This chapter defines nursing informatics and the data, information, knowledge, and wisdom
model that guides nursing informatics as a specialty as well as presents the sciences contributing
to nursing informatics: computer science, cognitive science, and nursing science. The impact of
existing and emerging national initiatives is discussed relative to nursing practice such as changes
to Meaningful Use, Medicare Access and CHIP Reauthorization Act (MACRA), and publicly
reportable data. From that vantage point, the role of technologies in hospitals and other healthcare
systems is explored. In addition to inpatient examples of nursing informatics, the role telehealth
plays in outpatient care is discussed. Health information technologies designed to support the
delivery of high-quality patient care are explored. Federal laws that protect identifiable information
are detailed, providing differentiation among the concepts of privacy, confidentiality, and security.
Finally, the future of informatics is discussed.

NURSING INFORMATICS DEFINED

While informatics is simply the science of collecting, managing, and retrieving informa-
tion, nursing informatics is “the specialty that integrates nursing science with multiple
information and analytical sciences to identify, define, manage, and communicate data,
information, knowledge, and wisdom in nursing practice” (American Nurses Association
[ANA], 2015). Information and analytical sciences that make up nursing informatics
include, but are not limited to, computer science, cognitive science, the science of ter-
minologies and taxonomies (including naming and coding conventions), information
management, library science, heuristics, archival science, and mathematics (ANA, 2015).
Management of health records dominates the discussion of health informatics; however,
computer technology offers a variety of ways to record and retrieve information to sup-
port the evidence-based needs and actions of the interprofessional team including:

9 INFORMATICS • 245

• Patient-decision support tools
• Laboratory and x-ray results reporting and reviewing systems
• Quality improvement (QI) data collection/data summary systems
• Disease surveillance systems
• Electronic bed boards that monitor bed availability
• Simulation laboratories

Quality and Safety Education for Nurses (QSEN) describes informatics as the use of
“information and technology to communicate, manage knowledge, mitigate error,
and support decision making” (Cronenwett et al., 2007). Newly licensed nurses are
expected to possess informatics knowledge, skills, and attitudes that reflect the abil-
ity of the nurse to competently provide high-quality, safe patient-centered care in a
technology-rich nursing care environment (Cronenwett et al., 2007).

METASTRUCTURE OF NURSING INFORMATICS

Nursing informatics draws from a variety of sciences such as information science,
computer science, cognitive science, library science, and information management as
well as human factors engineering. The guiding structure for nursing informatics, also
known as the metastructure, was built upon the way nurses interact and use clini-
cal information systems. In the ANA description, “data, information, knowledge, and
wisdom” form the metastructure, which increases in complexity as work increases in
interactions and interrelationships (2016). Both the sciences and the metastructure form
the framework for understanding nursing informatics. Figure 9.1 illustrates the data,
information, knowledge, and wisdom metastructure.

CRITICAL THINKING 9.1

A common misconception about nursing informatics is that the specialty involves
computer programming, computer system design, and networking. If someone said that
nursing informatics requires the nurse to know how to program a computer, how would
you respond?

Increased interactions and interrelationships

• Discreet numbers
or words

• Organized or
interpreted data

• Interpreted and
understood
information

• Understanding,
applying with
compassion

Wisdom

Information

Data

In
cr

ea
se

d
C

o
m

p
le

xi
ty

Knowledge

FIGURE 9.1 Data, information, knowledge, wisdom metastructure.

246 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

The ANA Scope and Standards for Nursing Informatics Practice describe what
constitutes each component of the metastructure (Table 9.1).

TABLE 9.1 DATA TO WISDOM METASTRUCTURE COMPONENTS

METASTRUCTURE
ELEMENT DESCRIPTION EXAMPLE

Data Discrete points
collected and
described
objectively without
interpretation
from a variety
of sources and
includes numbers
or words

Data collected for one point in time
during an assessment include the
following:
Heart rate: 76
Blood pressure: 118/64
Respiratory rate: 18
Mental state: alert and oriented
Eye and hair color: brown eyes, blonde

hair
Information Data that have

been organized,
structured, and
interpreted

Heart rate assessment findings
collected over the entire
hospitalization that are trended using
a graph to show highs and lows in
the data

Knowledge Synthesized
information so
that relationships
are identified and
formalized

Heart rate and blood pressure findings
for the morning assessment prior
to a beta-blocker dose then looking
at the same assessment findings
4 hours after the medication dose
to see if it had an affect on heart
rate and blood pressure findings.
Includes reviewing the same
information from previous mornings
to see the effect

Wisdom The appropriate use
of knowledge to
manage and solve
individual patient
problems with
consideration for
how and when to
apply knowledge
to complex patient
problems

Heart rate is 62 and blood pressure is
104/58 at 9 a.m. The trends over the
past 2 days for both vitals show that
medications do lower both the heart
rate and blood pressure within 1 hr
of taking the dose. The beta-blocker
dose is due at 10 a.m. The patient is
scheduled for a treadmill stress test
at 11:00 a.m. The patient’s
10 a.m. medications are metoprolol
50 mg (Lopressor) and furosemide 40
mg (Lasix). The nurse is concerned
that the medications may lower the
blood pressure too much and that
the medications may also affect the
treadmill stress test results. The
nurse calls the physician to discuss
concerns and ask if the medications
should be held until after the test.

Source: Adapted from American Nurses Association. (2015). Nursing informatics: Scope and standards of practice
(2nd ed.). Silver Spring, MD: Nursebooks.org.

9 INFORMATICS • 247

Denise is a new nurse on a medical-surgical unit. She is just beginning to
become comfortable providing nursing care to her assigned patients. She starts
her day by receiving a shift report on each of her patients. The shift report is
delivered at the bedside allowing Denise to introduce herself and start a plan
of care for the day with input from the patient. After report, she looks up the
patient’s laboratory results in the computer, noting both normal and abnor-
mal findings. Denise then completes a thorough nursing assessment on each
patient and documents her findings in the electronic documentation record.
Today Denise is providing nursing care for a 63-year-old man admitted 2 days
ago with heart failure and diabetes. Today the vital signs are blood pressure
90/54, heart rate 82, and respirations of 20. She knows the patient is due for a
dose of Lopressor 50 mg PO and Lasix 80 mg PO.

1. What questions or concerns do you have based on these data?
2. What additional data do you need to create information based on the Data to Wisdom

Metastructure?

Denise reviewed the electronic medical record (EMR) and noted the following
abnormal findings.

Denise looked at the patient’s medications including the following information:

• Lasix 80 mg PO BID (orally twice a day) at home. Lasix 80 mg IVP BID (intravenous
pyelogram twice a day) given yesterday as a one-time dose

• Levamir 72 u SQ BID (subcutaneous twice a day) at home. The same dose is resumed
while the patient is in the hospital

• Lopressor 50 mg BID (twice a day) at home. The same dose is resumed while the
patient is in the hospital

(continued)

CASE STUDY 9.1

Yesterday
6 a.m.

Yesterday
11 a.m.

Yesterday
4 p.m.

Yesterday
10 p.m.

Today
6 a.m.

Today
10 a.m.

Today
4 p.m.

Glucose 148 104 298 423 116 312 469

B-Type
naturetic
peptide
(BTNP)

620 280

Potassium
(K+)

3.2 4.2

248 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

EMR AND EHR

The Health Care Information Management and Systems Society (HIMSS) discrimi-
nates between an EMR and an EHR. An electronic medical record is a legal record
of what happened to a patient during one care encounter at a healthcare organiza-
tion (HIMSS, 2006). For example, an EMR includes data from one hospital stay, one
physician visit, or one instance of accessing healthcare. The EMR is confined to
one point in time or one range of dates. In contrast, an electronic health record is
a longitudinal electronic record of patient health information generated by one or
more encounters in any care delivery setting (Centers for Medicare and Medicaid

Vital signs charted on the patient and medications given over the past 2 days
included:

Denise takes the following actions based on the information provided. She calls
the physician to relate the blood glucose reading and asks for a sliding scale insu-
lin dose in addition to the normal Levamir dose. Denise requests that the nursing
assistant records strict intake and output levels and documents findings in the
EMR every shift. Denise gives the patient the regularly scheduled medications of
Lasix, Levamir, and Lopressor.

Answer the following questions based on the given data.

1. What is the difference between having data from one assessment and having trended
data over several days during the hospitalization? Why is it important to have access
to trended data?

2. Why did Denise give the patient his scheduled dose of Lopressor and Lasix if the blood
pressure was 98/60? What might be her rationale?

3. How does technology help change data to information? Information to knowledge?
Knowledge to wisdom?

4. How did Denise demonstrate knowledge and wisdom in providing care for her patient?

CASE STUDY 9.1 (continued)

Yesterday
6 a.m.

Yesterday
12 p.m.

Yesterday
6 p.m.

Today
12 a.m.

Today
6 a.m.

Today
12 p.m.

Today
6 p.m.

Blood
pressure

88/52
Lopressor

50 mg
Levamir

72 u
Lasix 80
mg IVP

112/80 96/58
Lopressor

50 mg
Levamir

72 u
Lasix 80
mg PO

102/62 102/84
Lopressor

50 mg
Levamir

72 u
Lasix 80
mg PO

124/78 90/54

Heart rate 88 72 74 72 90 96 78
Respirations 20 18 18 16 16 18

9 INFORMATICS • 249

Services [CMS], 2012). Included in this record are patient demographics, provider
progress notes, health problems, medication lists, vital signs, the patient’s past
medical history, past or current immunizations, laboratory data, and radiology
reports. In order for an EHR to exist, there must be an EMR in place that captures
data from the healthcare encounter. The EHR has the ability to generate a com-
plete record of a clinical patient encounter, as well as supporting other care-related
activities including evidence-based decision support, quality management, and
outcomes reporting.

EHRs will form the basis of the National Health Information Network (NHIN),
which is a plan that will enable the exchange of patient information electronically from
one healthcare provider to another healthcare provider. NHIN will allow the health-
care provider to access previous information such as the patient’s disease history,
the list of medications, the known allergies, and the prior test results. The electronic
exchange of patient information will eliminate delays that occur when paper records
must be copied and sent to another provider. The NHIN will also help exchange patient
information between healthcare providers and public health authorities. For example,
submission of reports to government vaccination registries and the reporting of com-
municable diseases will be done from the EHR. The reports will be done at the same
time care is provided (in real time) so agencies charged with protecting the health of
the public will be able to act quickly. If a particular lot of a vaccine is recalled, health
authorities will know which patients to contact. If a virulent strain of influenza occurs,
health authorities can issue public health warnings and close some public places to
prevent further spread of the disease. The electronic information exchange within
NHIN must protect patient privacy and the content of the data. Healthcare providers
have a legal and ethical duty to maintain the confidentiality of patient information. For
patient safety, data cannot be altered in any way. For example, information regarding
a medication must maintain the same name, dose, frequency, and route of administra-
tion as it is being transmitted to another provider. No one should be able to capture
data en route and change them.

The Department of Health and Human Services (HHS) predicts that the NHIN
will enhance the quality of care by reducing healthcare errors (especially those related
to medications), eliminating the need for duplicate testing, thus subjecting the patient
to less risk and reducing delays that occur from lack of information. If the efficiency
and effectiveness of care is improved, the costs of providing care should be reduced.

At the time of the 1991 IOM report (see Real-World Interview 9.1), the banking
industry already used highly sophisticated electronic information systems with the
ability to exchange information among banks with relative ease. Other industries such
as the airlines industry also had initiated advanced electronic information systems
that included the ability to make reservations and do flight scheduling. The airlines
had access to information about all the passengers on each plane, the names of the
staff members, and other important details about each flight. The 1991 IOM report
urged healthcare organizations to look at the technology used by other industries and
make investments in electronic information systems that would address some of the
problems associated with paper records and to move to electronic patient records.
With electronic patient records, information could be more easily exchanged in real
time (i.e., as it is happening) among healthcare providers, with legible records, and
documentation done at the point of care. Care could be streamlined with more effi-
cient methods of data collection, and computer programs could be written to improve
safety issues such as medication interactions.

250 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

NATIONAL INITIATIVES SUPPORT FOR EHRS

Although work in the informatics discipline started many decades ago, a landmark
1991 report by the Institute of Medicine (IOM) brought national attention to the topic of
informatics. The report titled The Computer-Based Patient Record: An Essential Technology
for Health Care stated it was time for the healthcare industry to catch up with other
industries with regard to its use of information technology (Dick & Steen 1991; IOM,
1997). In 1991, almost all healthcare records were on paper. If a patient visited three
different physician offices, there would be a paper healthcare record in each office.
Similarly, if the patient were hospitalized, there would be yet another paper healthcare
record at the hospital. The result was as follows:

• No one healthcare provider had a coordinated and complete view of the patient’s
health status; therefore, optimum care was more difficult to ensure.

• No one healthcare provider knew exactly what tests had been performed on the
patient; thus, there was duplicate testing that wasted healthcare dollars, created an
inconvenience for patients, and, in some cases, subjected patients to unnecessary risks.

• Paper healthcare records were mostly handwritten and frequently illegible; thus,
important information about patients was not readable and mistakes in care
resulted. In particular, physician orders for medications were sometimes incor-
rectly interpreted and/or sent to the pharmacy resulting in the wrong medications
being given and/or incorrect doses being administered.

• Human intervention was required to predict when adverse drug reactions might
occur due to contraindications and/or certain drug combinations. As the number
of available medications grew, it became more difficult for humans to remember
all the important aspects of each medication.

Recently, we created new workflows and job descriptions based on community
and population health needs. The core team is comprised of a physician, a nurse
manager, two nurse navigators, an actuary, and a clinical informatics analyst. The
goals are based on best available evidence and determined by large studies such as
healthy people 2020. The physician helps to determine the measures that could be
moved in a significant manner to measure care. The actuary determines goals set
at intervals throughout the change process. The manager determines the expected
scope and expansion rate to provider offices. The nurse navigators work with the
providers and the patients to achieve the goals. As a clinical informatics analyst,
I build, maintain, and update the software program to accommodate and measure
results in a meaningful way. We are a small close-knit group who acknowledge the
contributions each member. Sometimes there can be a different “pitch” regarding
the upcoming changes. Some providers will only listen to another physician with-
out regard to the best practice presented by another colleague. Some providers are
particularly competitive, so I will individually address documentation changes
that have the biggest effect in the shortest amount of time.

Elaine Brown, RN
Clinical Informatics Analyst

LaPorte Regional Health

REAL-WORLD INTERVIEW

9 INFORMATICS • 251

• Paper healthcare records were sometimes lost, resulting in no information being
available about the patient. In the case of a healthcare emergency, the treatment
team sometimes had to treat the patient symptomatically or just on the basis of
findings at that time and without knowledge of the patient’s past history, what
medications the patient was on, or what chronic diseases the patient had.

• Patients who had not been seen before by a healthcare provider had no healthcare
history on file with that provider. It was a manual process to try to obtain copies of
records from other providers. There was a delay in receiving these records so there
were also some delays in care.

• Documentation of the care given was a time-consuming process for all members
of the healthcare team. Time spent documenting care left less time to actually care
for the patient.

Progress on implementing electronic patient records has been slow, in part
because of concerns for patient privacy and the perceived lack of funding for informa-
tion technology. In 2001, the IOM published a series of landmark reports called the
Quality Chasm series in which it identified ways the healthcare system could change to
reduce the number of errors. The 2001 report titled Crossing the Quality Chasm: A New
Health System for the 21st Century devoted an entire chapter to information technology
(Committee on Quality of Health Care in America, 2001). Among the recommended
changes for healthcare technology were the following:

• Computerized provider order entry (CPOE)-automated reminder systems to
improve compliance with clinical practice guidelines

• Computer-assisted diagnosis
• Computer-assisted patient management
• Computer-assisted patient education
• Computerized clinical decision support systems (CDSSs; National Research

Council, 2001, p. 164)

To effectively address this list of recommended changes, the computer system is used
as a tool to alert the healthcare provider to problems with the patient; to remind the

CRITICAL THINKING 9.2

A 65-year-old man comes to the ED via ambulance after being in a car accident. He
is currently unresponsive and has no family members present. He does have a wallet
and identification and his car had out of state plates. Without a medical record of past
history, medications, test results, or previous medical diagnoses, it is difficult to know
how to treat the patient. At this hospital they do have links to a national EHR database.
By entering his name and birthdate, the healthcare provider can see that the patient
has a history of an ischemic stroke and is on Coumadin. The patient also has diabetes
and a history of heart failure. The healthcare provider can review the patient’s current
medications, previous test results, past history, and assessment findings.

1. How does having access to a patient’s previous medical records improve
patient care?

2. Why do you think the EHR is not currently in place in the United States?
3. Create a concept map with the patient at the center that shows how an EHR

can impact the delivery of safe, high-quality patient care.

252 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

provider about clinical practice guidelines, allergies, or potential adverse effects of
drug combinations; to help the provider arrive at an accurate diagnosis and an effec-
tive treatment plan; and to present educational information to patients either by an
onsite computer or via the Internet.

Committee on Patient Safety and Health Information Technology

A 2011 IOM report titled Health Information Technology and Patient Safety: Building Safer
Systems for Better Care identified a series of characteristics that computer software
developers should consider to make electronic information systems easier for the
healthcare professional to use.

The suggestions made included the following characteristics:

• The data within the system are accurate, timely, reliable, and native.
• The system is easy to navigate and use as well as one with which users want to

interact.
• The system, as well as data displays, are simple and intuitive to the user.
• The evidence at the point of care is available to aid clinical decision making.
• The system works only to enhance workflow, automate mundane tasks, and

streamline work rather than increase physical or cognitive workload.
• The time required for upgrades is minimal and limited.
• The data are easily imported and exchanged between systems (Committee on

Patient Safety and Health Information Technology, 2011, p. 62).

Native, Accurate, Reliable, and Timely Data

The Committee’s work clearly focused on increasing the efficiency and efficacy of
computer and electronic information systems to aid and augment the work of the
clinician and healthcare professional. The Committee wanted to ensure the highest
standards for protecting patient information. For example, in the first bullet in the
preceding list, “native data” is that information entered directly into the electronic
computer system. Native data might include information about vital signs entered
by the nursing staff; whereas imported data would include data coming from another
electronic information system such as the electronic laboratory result information
system. In most healthcare organizations, laboratory tests are done on a completely
different electronic system specific to the laboratory within the healthcare organiza-
tion, or a laboratory outside the organization does them. For the data to be considered
“accurate and reliable,” the data could not have been changed in any way. Within this
requirement, assurance is needed that no one is able to hack into the computer system
and/or alter the data.

The Committee also recognized the importance of “timely” data. Data are timely ifa-
vailable as soon as they are created. For example, laboratory test results are needed imme-
diately for patients in critical-care units such as intensive care. Once a blood chemistry test
such as the serum level of potassium is completed, the information must be relayed to the
healthcare provider immediately, especially if it is abnormal. For example, if the potassium
level in a patient is low, IV administration of potassium would probably be necessary (low
potassium levels may cause the patient’s heart to beat irregularly). Quality care depends
on having the results as soon as possible so interventions can be taken as the patient’s con-
dition warrants. A laboratory result sent 2 weeks after the blood chemistry was drawn will
be of little use in caring for the intensive care patient.

9 INFORMATICS • 253

Easy to Use

An electronic record system must be easy to learn and easy to use so healthcare pro-
viders will want to use it as part of patient-care activities. Healthcare providers will
not want to work with electronic systems that are difficult to learn and that do not
make sense to them. The way information is entered and used in the electronic sys-
tem should match the way the provider works. For example, a provider might have a
standard set of questions to ask a patient with diabetes. The electronic record system
should have the same set of questions in the same order so the provider can easily add
the patient’s answers as they are given. In some cases, a checklist of probable answers
can be listed in the electronic patient record so all the provider has to do is check off the
applicable answer. Ideally, providers should be able to customize the electronic record
system to match the way they do their work.

Intuitive Displays

The Committee suggested that the computer system incorporates “simple and intui-
tive” data displays referring to what is usually on a computer screen or a smartphone.
Intuitive data displays are those that present the information in the form the user
needs it. For example, a nurse might want to see the blood pressure readings displayed
in a table, whereas a physician might prefer that same information be displayed on a
graph. If either the physician or the nurse wants to change the display format, it should
be easy to toggle or change between the table and the graph. The master electronic
information system will need to know what device the user has, so that the informa-
tion will be properly displayed on their device. Some information such as graphs can
easily be read on a personal computer (PC) screen but may not be easily adapted to
small displays such as on a smartphone.

Navigation

Another characteristic the Committee suggested was that EHRs be easy to “navigate.”
Navigation refers to the way the computer user moves from one part of the electronic
patient record to the next part. For example, if a nurse wants to look first at patient
assessment data and then look at the care plan data, it should be easy to make that
move in the patient’s electronic record. This is usually done through a navigation bar
that may be on the side of the screen or across the top of the screen.

Evidence at the Point of Care

Availability of “evidence at the point of care” was yet another characteristic suggested
by the Committee. Evidence at the point of care refers to the availability of scientific evi-
dence at the bedside or in the exam room to aid the provider. The availability of this evi-
dence to aid with decision making is crucial to providing quality care. For example, the
provider may be confronted with an unusual clinical situation and may want to consult
the existing professional literature on that topic. The provider should be able to access
the literature or “evidence” from the same computer or workstation they are using to
enter data into the patient’s EHR. In another instance, a wound care nurse who is treat-
ing a stage IV decubitus ulcer may want to see the latest articles available in full text from
the National Library of Medicine. The nurse should be able to access those articles at the
patient’s bedside without having to go to the organization’s library. This process is known

254 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

as knowledge utilization, a method of bringing evidence to the bedside. Informatics is
uniquely positioned to provide this knowledge utilization feature.

Another means of providing evidence at the point of care is to base assessment find-
ings and interventions on the best available evidence. Ideally, when the nurse selects an
intervention, an option for viewing the evidence that supports the intervention is dis-
played. The convenience of having the best available evidence supporting patient care
interventions at the bedside, where care is provided, is the optimal scenario. Although
we are not quite optimizing technology to support evidence-based nursing care at the
bedside, there is a push toward making this a reality. This is one way that electronic docu-
mentation can facilitate the use of evidence at the point of care.

Enhance Workflow

Electronic information systems transform data into information that is meaningful for the
user. A simple example of the electronic transformation of data into information is the list
of deposits and withdrawals made to a bank account. The transactions of deposits and
withdrawals are the data. When those transactions result in an addition and/or subtrac-
tion of the money in the account, the data are processed electronically and information
results. The information is the balance in the bank account. The balance information guides
the owner of the bank account in managing finances. Likewise, in healthcare when infor-
mation is combined with experience and understanding, it becomes knowledge that can
be used to make informed decisions (LaTour & Maki, 2010). Knowledge becomes wisdom
when it is “applied in a practical way or translated into actions” (Kenney & Androwich,
2012, p. 63) and state that a nurse is applying knowledge in a practical way when a patient
care plan is developed (p. 124).

Limit Inefficiencies

Electronic information systems should introduce efficiencies in the way work is done
so no new physical demands will be placed on the nurse. For example, a nurse should
not have to travel to a separate computer or be required to be in a library to access
scientific literature. Likewise, it is important not to make the nurse’s work anymore
mentally demanding than it already is. Rather than creating a delay in patient care,
new electronic technologies should enhance patient care efficiently for all involved.
Information in healthcare is expanding exponentially and although healthcare provid-
ers are highly educated, no one provider can be expected to know everything. Point-of-
care technology, for example, provides reliable information to fill the knowledge gap
of providers at the time they need it most—while they are interacting with the patient.

All electronic information systems will need some downtime for routine hardware
and software updates and/or maintenance. The computer will not be available during
those times. However, this downtime should be for a short duration of time and the nurs-
ing and healthcare staff need to know when this downtime will occur. Planned downtime
is usually in the middle of the night when the least number of users will be affected. As
healthcare is delivered round the clock, any necessary downtime should be for a relatively
short duration. Healthcare facilities try to prevent excessive downtime by having backup
generators for power failures and by running parallel computer systems so if one computer
system goes down, another computer system immediately kicks into action. Disaster plan-
ning requires that provisions be made for unusual situations such as hurricanes, power
outages, and other large-scale problems. Accreditation standards also require healthcare
facilities to determine how they will provide essential services under extreme conditions.

9 INFORMATICS • 255

“Provisions” and “essential services” must include protecting data within electronic health
systems from unauthorized access or getting lost due to systems failure.

Exchange of Information

Since patients are often treated across many different healthcare organizations, it should
be quick and easy to obtain information from another organization. The coordination
of the access and exchange of patient information occurs through the establishment of
health information exchanges (HIEs), where a patient’s vital health data are shared
electronically on both regional and national levels (HealthIT.gov, 2014). HIEs usually
operate on a regional level such as by cities or counties since most health information is
shared among local healthcare providers. HIEs are not-for-profit organizations formed
by a variety of vested healthcare professionals from healthcare organizations, institu-
tions, and practices. At the regional level, these HIEs are referred to as regional health
information organizations (RHIOs). When health information is shared over a longer
distance, it is shared among HIEs. Thus, information about a patient in Syracuse, New
York, can be shared with providers in Los Angeles, California. The RHIOs or network
of HIEs forms the basis of the NHIN discussed earlier in this chapter. Patients have a
choice to sign an authorization to have their information shared or can opt out of the
HIE if they do not want their information shared (Bass, 2011).

HEALTH INFORMATICS LEGISLATION

The reports of the IOM inform Congress about important legislation needed to bring
about change in health informatics. As a result, several important laws have been
passed to advance the health informatics agenda. These laws include the following:

• Health Insurance Portability and Accountability Act (HIPAA, 1996), which con-
tains important provisions for privacy and security of health information (Pub. L.
104–191, Aug. 21, 1996, 110 Stat. 1936).

• Health Information Technology for Economic and Clinical Health Act (HITECH
Act; Pub. Law 111–5, div. A, title XIII, div. B, title IV, February 17, 2009, 123 Stat.
226, 467 [42 U.S.C. 300jj et seq.; 17901 et seq.]), which was part of the American
Recovery and Reinvestment Act of 2009 (ARRA; Pub. L. 111–5). The HITECH Act
provided billions of dollars of federal money in the form of grants to advance
widespread use of health information technology.

• The Patient Protection and Affordable Care Act (PPACA) of 2010 (Public Law
111–148), often called the Affordable Care Act (ACA). The ACA provides ongo-
ing funding for health information technology (www.congress.gov/111/plaws/
publ148/PLAW-111publ148.pdf).

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a
federal law requiring healthcare providers to use several privacy protections for
patients and their records (HHS, 2013). HIPAA protects an individual’s identifi-
able health information that is in oral, written, and/or electronic form. HIPAA
also requires that each healthcare facility have a designated privacy officer. There
are two aspects to HIPAA, information privacy and security of private health
information.

256 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Information Privacy

Information privacy is the patient’s right to limit the amount of personal healthcare
information accessible to and known by others (HIPAA, 1996). Within this right of
patients, providers are mandated to maintain confidentiality. Confidentiality is the duty
the provider has to hold patient information private. Although the patient’s right to
information privacy is not stated in the U.S. Constitution, various court cases such as
Griswold v. Connecticut (1965) interpret sections of the Bill of Rights (the first 10 amend-
ments to the Constitution) as giving the patient this right. In particular, the fourth
amendment to the Constitution, which protects against unreasonable search and seizure
of papers and effects, is thought to provide information privacy. Attention to privacy is
extremely important because if patients think their privacy will not be protected, they
will be reluctant to share information needed to provide quality care. An excellent online
resource for staff training on privacy is available from the National Institutes of Health
(NIH). Courses relevant for the new or novice nurse include NIH Information Security
Awareness Course and NIH Privacy Awareness Course. Users can take the course on the
website (irtsectraining.nih.gov/publicUser.aspx) and receive a certificate of completion.

Security

HIPAA requires that healthcare organizations have specific measures in place to safe-
guard patient’s health information. First, there must be access controls in place such as
passwords and PIN numbers to limit unauthorized access to sensitive patient informa-
tion. Second, health organizations must encrypt patient health information, meaning
information cannot be read or understood unless the person is authorized and has a
decryption key. Most times, the decryption key is linked to the person’s password or
PIN number. Security is the set of protections placed on a computer system to prohibit
unauthorized access and to prevent any loss or distortion of the data (HIPAA, 1996).
HIPAA also requires that security measures be in place in an organization and that
there is a designated security officer. The NIH training website (irtsectraining.nih.gov/
publicUser0.aspx) also offers a course to the public on the topic of computer security.

The Health Information Technology for Economic and Clinical Health Act

The HITECH Act is a federal law that provides money to healthcare provid-
ers, institutions, and organizations to encourage the use of EHRs (HHS, 2017).
However, the federal government also wanted to make sure its money was wisely
spent. It will only give providers enhanced payments if they use certified EHRs.
In addition, the provider must show the EHR is being used in a meaningful way.

A patient complains to the nurse about the amount of personal data collected in
the admissions office. The patient states that too much data are collected and he
is concerned about the protection of his privacy.

1. What should the nurse explain to the patient about the amount of personal data
collected?

2. What should the nurse explain to the patient about how his data are protected?

CASE STUDY 9.2

9 INFORMATICS • 257

To assist providers in determining if their use of the EHR met the federal expecta-
tion, the CMS of the HHS developed criteria showing meaningful use.

As new healthcare legislation is enacted, both HITECH and Meaningful Use are
being integrated into the newer laws. This does not mean that the objectives of each act
are no longer relevant—they are still required of healthcare organizations and provid-
ers and have been integrated within other regulations. The Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015 includes requirements from the EHR Merit-
Based Incentive Payment System, or MIPS, began in January of 2017 and includes
requirements for reimbursement and payment based on the following:

• Quality of care
• Resource use
• Clinical practice improvement activities
• Meaningful use of certified EHR technology

Both MACRA and MIPS replace certain initiatives set by the EHR Incentive Program
(Meaningful Use) and HITECH so that organizations working toward meeting the
requirements can continue moving forward without an interruption in requirements.

Meaningful Use

The CMS (2011) initiated a program called the EHR Incentive Program, also known as
Meaningful Use. Meaningful Use was an initiative designed to encourage the use of
EHRs by using data collected in the clinical setting such as hospitals, clinics, or physi-
cian offices, to improve patient-care outcomes (HealthIT.gov, 2015). It was an incentive
program from CMS that provided reimbursements based on the ability to meet three
stages of the initiative. Stage 1 ran from 2011 to 2012 and involved data capture and
sharing. Stage 2 started in 2014 and involved advanced clinical processes based on
data. Stage 3 started in 2016 and included improved patient outcomes. Demonstrating
achievement of requirements for each stage resulted in substantial reimbursements
from the CMS. Select specific criteria for each stage are shown in Table 9.2.

The Meaningful Use initiative was beneficial in forcing healthcare providers and
organizations to adopt and integrate EMRs in the care provision setting. Each stage of
Meaningful Use is categorized under five major domains:

• Improve quality, safety, and efficiency.
• Engage patients and families.

TABLE 9.2 MEANINGFUL USE STAGE CRITERIA

STAGE 1 STAGE 2 STAGE 3

• Electronically
capture health data

• Use data to track
clinical conditions

• Report quality
measures and
publicly reportable
health measures

• Use data to engage
patients and families
in their care

• Rigorous health
information
exchanges

• Increased requirement
for e-prescribing and
lab reporting

• Share patient-care
summaries across
care settings

• Increased patient-
controlled data

• Improved quality, safety,
and efficiencies based on
electronic information

• Develop decision supports
for high-priority conditions

• Patient access to self-
management tools

• Access to comprehensive
patient data through health
information exchanges

• Improve population health

Source: https://www.healthit.gov/providers-professionals/how-attain-meaningful-use.

258 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

• Improve care coordination.
• Improve public and population health.
• Ensure privacy and security for personal health information.

Although the EHR Incentive Program has ended, the initiatives from the program
are still required for reimbursement from CMS. Major outcomes from the initiative
include using electronically captured health data to improve quality of care processes
and patient outcomes, clinical decision supports, e-prescribing, and improved patient
engagement in healthcare decisions through patient portals.

Data Capture to Improve Quality

Data are continuously captured during patient-care encounters through patient assess-
ments and documentation of interventions. Using these data to improve healthcare
processes is a key part of Meaningful Use. Consider all the data captured during one
patient care encounter. Data could include height, weight, age, heart rate, blood pres-
sure, respiratory rate, lung sounds, level of consciousness, oxygenation, orientation,
level of activity, ability to ambulate, color of urine, frequency of bowel movements,
and so on. This vast amount of data is inputted into a computer documentation system
and placed by the program into logical categories. The data in the categories can be
extracted into trends within a category (heart rate data over time) or compared against
other data using reports. A report can combine data from different categories to deter-
mine relationships or cause and effects.

For example, a patient is admitted to a hospital and is on bed rest. Nursing care
based on the evidence includes skin care and turning the patient every 2 hours to
prevent hospital-acquired pressure ulcers. The nurse would document that the
patient is on bed rest, turning the patient every 2 hours, and that skin care is pro-
vided. By documenting each of these items the electronic system is able to run
reports on the data. This is also a measure of quality nursing care; therefore, a
report could be generated to include the number of patients on bed rest who are
turned every 2 hours. An example of findings might show that of the 70 patients
on bed rest, 55 patients had documentation in their record of being turned every
2 hours. To calculate a percentage, 55 divided by 70 is 0.786, or 79%. The unit can
say that patients on bed rest are turned every 2 hours 79% of the time. If theigoal is
to have 100% of patients on bed rest turned every 2 hours then the data show that a
problem exists. This same measure can occur every month to give a trended report of
compliance.

Clinical Decision Support Systems

A clinical decision support system (CDSS) is an integrated database of clinical and
scientific information to aid healthcare professionals in providing care (Agency for
Healthcare Research and Quality [AHRQ], 2016). The CDSS is designed to look at a
set of data and then lead the user through a decision-making process. For example,
asking the user a set of questions that narrow possible choices to one choice that is
the most effective. A CDSS might be used to arrive at a correct diagnosis or it might
be used to determine the most effective treatment plan for the patient. Clinical deci-
sion supports can take the form of alerts, alarms, hard stops (the nurse is unable to
continue charting until a specific item is addressed), clinical guidelines, order sets,
and clinically relevant evidence to support decisions. For example, a doctor might be
treating a patient who is a recovering drug addict with postoperative pain. By using
the CDSS on the hospital’s health information system, the provider is able to enter

9 INFORMATICS • 259

assessment data and confounding factors such as opiate addiction to decide the best
alternative medication to prescribe.

For example, a hospital collects data on patient falls per month. Upon admission and
once a day afterward, every patient receives a fall risk assessment. When using the fall
risk assessment tool the results are categorized into low, medium, or high risk for falls.
The hospital has a set group of interventions for patients who score at either the medium-
or high-risk categories. To meet stage 1 of meaningful use, the hospital would integrate
the interventions with the fall risk assessment. When the nurse completes a patient fall
risk assessment in the electronic documentation system and the finding is high risk,
specific interventions based on the best available evidence automatically appear. The
nurse must select the interventions in place for the patient before moving forward with
the electronic charting. This form of clinical decision support not only reminds the nurse
of evidence-based interventions needed for the patient, but also requires implementing
the evidence-based interventions before continuing with charting.

e-Prescribing

An objective of Meaningful Use included e-Prescribing by clinicians in both the hospi-
tal and clinical setting. Whenever the letter “e” precedes a word it means “electronic.”
The goals of e-Prescribing were to reduce redundancies, prevent errors in transcrip-
tion, increase efficiencies in medication acquisition, and share medications across all
care settings. To achieve this goal, a nation-wide computerized sharing of medication
data among all pharmacies, healthcare organizations, and clinics was established. This
allowed the sharing of medication across all healthcare settings. Once data sharing
was in place, all healthcare providers in all settings had to use e-Prescribing in order
to capture all medications.

For example, a patient provides a home medication list upon admission to the hos-
pital. During the course of the hospitalization some medications are discontinued, new
medications are added, and doses changed. Upon discharge, the medication list may
look completely different than when the patient was admitted. The hospital physician
uses e-Prescribing to order all medications from the patient’s pharmacy to be used at
home. The new medication list is sent electronically to the pharmacy so that the new
medications can be prepared. Additionally, the new medication list is also electroni-
cally stored and sent to all the patient’s physicians. After discharge the patient will
see his or her primary and specialty physicians. During each physician visit, the new
medication list is available for review or revision based on the patient’s health needs.
The seamless sharing of medications helps facilitate consistent and patient-centered
care during every healthcare encounter.

CRITICAL THINKING 9.3

View the video at youtu.be/zoxpuzH4B_0 (or go to YouTube and search for the
video titled “Clinical Decision Support for Evidence-Based Care”). Watch the short
11-minute video that demonstrates the use of a CDSS for the “Safe and Sound”
program.

1. How was a CDSS used in the video?
2. How did the CDSS demonstrate integrating evidence-based practice to

guide decision making?

260 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Patient Portals

One objective of Meaningful Use was to create patient portals that allow patients
timely access to health data and education (CMS, 2016). Electronic documentation
vendors along with healthcare organizations create access controls to allow healthcare
organizations to decide what and how much information to allow patients to access
electronically. Although the objective did not specify what information should be
available, the objective did require that patients use the information to make informed
health decisions.

For example, a patient sees an orthopedic physician about knee pain. The physi-
cian orders a MRI diagnostic test. During the appointment, the nurse asks the patient to
sign up for the patient portal, explaining that the patient can access health information
through the portal. The patient signs up for the portal and establishes a login and pass-
word. The patient has the MRI the next week and is scheduled to see the physician in
2 weeks. A day after the MRI the patient receives an email from the patient portal system
that a new test is available to view. The patient accesses the patient portal and is able to
review the MRI report. When the patient attends the appointment with the physician the
patient is able to discuss MRI findings and ask questions based on the report.

Standards for Interoperability

Interoperability is an agreed-upon standard of communication among hardware
and software companies that allows for the effective exchange of patient information
among various health information systems (HIMSS, 2017). HITECH and Meaningful
Use both rely on systems to be interoperable in order for the regulations to work. For
example, different hospitals use different EMR vendors; however, with interoperabil-
ity standards in place, these various EMRs are able to exchange patient information
seamlessly and accurately. The telephone system is an excellent example of interoper-
ability. Regardless of the type of phone used or the service vendor selected, anyone is
able to communicate via phone. That is because all the phone makers and all the ser-
vice providers adhere to a common set of standards. The same level of interoperability
is needed for the computer exchange of health information.

Many computer standards are currently available to facilitate communication
between different health information systems and even more standards are under
development. Policies, procedures, and development of standards for health infor-
mation systems arecoordinated by the American National Standards Institute (ANSI;
ansi.org) and its Healthcare Information Technology Standards Panel (HITSP; www.
hitsp.org). Standards development groups include representatives from government,
the healthcare industry, and health informatics system vendors.

The NHIN is a federal certification program in place to make sure vendors develop
EHR products that meet interoperability and formatting standards. The ANSI sets the
standards; however, the federal government provides the certification that the health
information system meets meaningful use provisions.

For an EHR product to be certified, the vendor must submit the product for a
technical evaluation by an expert panel from a certifying organization recognized by
the federal government. Medicare and Medicaid are currently offering enhanced pay-
ments to healthcare providers who adopt certified EHRs. These financial incentives
are being used to speed EHR adoption so the vision of an NHIN can become a reality.

9 INFORMATICS • 261

The NHIN would be a structure that would allow for secure sharing of confidential
healthcare information among healthcare providers across the country.

TELEHEALTH

The Health Resources and Services Administration (HRSA) of the HHS defines
telehealth as the use of electronic information and communications technologies to
support and facilitate clinical- and population-based healthcare, patient health edu-
cation, and health administration from long distances (2015). Technologies include
videoconferencing, the Internet, imaging sharing, streaming media, and wireless
communications (www.hrsa.gov/ruralhealth/telehealth/).

Telehealth uses some type of computer or communication device at both the sending
end and the receiving end of the communication. Cameras and microphones may also be
used to send pictures and sound. Technology allows a patient’s home to serve as an exten-
sion of the healthcare facility in that it removes time and distance barriers in the provision
of healthcare services (Dewsburys, 2012). The typical telehealth scenario has nurses inter-
acting with patients over telephone systems. The patients are usually in their homes and
they may have home monitoring equipment connected to their phone lines. This monitor-
ing equipment is used to gather data on the patient such as blood pressure, pulse oximetry,
blood glucose, and weight. Originally, only telephones with landlines were used but now
it is possible to use mobile devices such as cellular phones, satellite phones, phones con-
nected over television cable systems, and the Internet (Dewsburys, 2012).

Some telehealth devices prompt the patient at a certain time of the day to obtain
specified data for transmittal to the healthcare provider. For example, the patient may
attach a blood pressure cuff to his or her arm, press a button, and then wait while the cuff
inflates. The monitoring device records the blood pressure and transmits it over phone
lines to the nurse who usually works for a home care agency. A pulse oximeter is attached
to the patient’s finger and, again, the data are transmitted to the nurse. For patients with
conditions such as congestive heart failure, it is important to check the patient’s weight
to determine if he or she is retaining fluid. Thus, a scale may also be attached to the
monitoring device. Patient data may be transmitted through cables attached to the home
monitoring station or the data may be transmitted wirelessly to the station.

On the receiving end, a nurse uses a telehealth computer workstation to monitor
the data coming in from the patient. The telehealth computer software will provide
alerts if any information falls outside the parameters set for that patient. The nurse
will usually phone the patient after the data arrive to discuss how the patient is feeling
and to see if there are any problems that need to be addressed. If the nurse is unable
to reach the patient, the nurse may contact family members and/or call 911 to check
on the patient. The home health agency may also send a nurse to the patient’s home.

One of the many benefits of telehealth use is among patients with chronic diseases.
For example, identification of small changes that may signify a problem before it becomes
life-threatening is critical. Telehealth can draw prompt attention to the patient’s health-
care status to decrease the risk of exacerbation of the disease. Telehealth can improve
patient outcomes and can be delivered at a lower cost than home healthcare. Along with
reducing the burden on patients to travel to receive healthcare, Anguita (2012) notes
other benefits of telehealth. These include increased patient independence, increased
collaboration with other community organizations, and increased opportunities for
nurses to provide education to patients and families.

262 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

EVIDENCE FROM THE LITERATURE

Citation

Totten, A. M., Womack, D. M., Eden, K. B., McDonagh, M. S., Griffin, J. C.,
Grusing, S., & Hersh, W. R. (2016, June). Telehealth: Mapping the evidence for patient
outcomes from systematic reviews (Technical Briefs, No. 26). Rockville, MD: Agency
for Healthcare Research and Quality. Retrieved from https://www.ncbi.nlm.nih.
gov/books/NBK379320/

Discussion

The purpose of this report was to create an overview of the body of evidence
about telehealth for use by decision makers and to assess the impact of telehealth
on clinical outcomes. Fifty-eight systematic reviews met the authors’ inclusion
and exclusion criteria. The authors created an evidence map based on findings
from the included studies using weighted estimates of effect. The authors found
that sufficient high-quality evidence exists to support the effectiveness of tele-
health for specific uses with some types of patients, including:

• Remote patient monitoring for patients with chronic conditions
• Communication and counseling for patients with chronic conditions
• Psychotherapy as part of behavioral health

The most consistent benefit was found when telehealth was used for communi-
cation and counseling with patients and the remote monitoring of chronic con-
ditions such as cardiovascular and respiratory diseases, with improvements in
outcomes such as mortality, quality of life, and reductions in hospital admissions.

Implications for Practice

The use of telehealth for patient populations with a high risk for readmission
such as heart failure or chronic obstructive pulmonary disease can help reduce
hospitalizations and improve quality of life. For chronic conditions, both remote
monitoring and communications with health providers were found to have a
positive effect on outcomes.

A newly hired nurse is assigned to work at the telehealth workstation. The nurse
is monitoring the data coming in from home-based patients, checking to see if
there are any situations that require nurse intervention, and taking action as
appropriate. One patient with type 2 diabetes reports fasting blood glucose of 52.
Another patient who has congestive heart failure and normally reports in on a
daily basis does not transmit any data.

(continued)

CASE STUDY 9.3

9 INFORMATICS • 263

HEALTH-RELATED WEBSITES

A growing number of consumers use the Internet as a handy way to access health-
related information. Some health-related Internet sites provide high-quality infor-
mation to help consumers understand health problems, make informed health
decisions, and provide insights about healthcare expectations. Although the infor-
mation is convenient and generally accessible, most health-related information on
the Internet is not monitored for quality. The average consumer generally may not
have the knowledge to judge the quality of the source or the health information
found on the Internet. This raises concerns about the type of information available to
guide consumer health decisions.

An expectation of nurses is that they have the knowledge to guide patients toward
accessing the best and highest quality health-related websites available on the Internet.
There are several types of website evaluation tools available with varying levels of reli-
ability and validity. One widely recognized website evaluation tool specific to health-
related sites was developed by the Health on the Net Foundation (HON). HON is a
nonprofit, nongovernmental, and international foundation that developed a set of cri-
teria to judge the quality of health information available on the Internet. There are a set
of eight principles for evaluating a health website. The HON Foundation uses the eight
principles to certify if the principles are met. If the website does meet the standards
they are considered HON certified and can display the HON logo on their website. To
note, the user can click on the symbol and see how the website meets the criteria. The
principles include the following:

1. Authority: The qualifications of the authors or contributors are clearly stated.
2. Complementarity: A statement is included on the website that states the informa-

tion is not meant to replace the advice of a healthcare provider.
3. Privacy: Confidentiality of personal information.
4. Information: Information is marked with date of last modification and external

references.
5. Justification: Claims made on the website have supporting justification.
6. Contact: Website contact information is clearly stated.
7. Disclosure: All funding sources are clearly described.
8. Advertising: Website clearly discloses advertising sources and funding as well as

differentiates between advertising and website content (www.hon.ch/HONcode/
Patients/Visitor/visitor.html#accreditation).

Healthcare applications have also gained popularity with mHealth (mobile
health information). Criteria for appraising the quality of health-related applica-
tions are varied in the literature with almost all agreeing upon certain character-
istics. Using a structured and standardized approach to appraising mobile health

1. What is the best course of action for the nurse to take regarding the patient with
diabetes?

2. How should the nurse proceed regarding the lack of information obtained from the
patient with heart failure?

CASE STUDY 9.3 (continued)

264 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

applications is critical to ensuring patients are guided to appropriate information.
The following is a list of characteristics typically used to appraise health-related
mobile applications.

1. Confidentiality and security of health information
2. Graphics and layout appeal, ease of use
3. Engagement, entertainment, and customization of information
4. Functional design
5. Quality of information presented, attribution to experts
6. Subjective quality (BinDihm, Hawkey & Trevena, 2014; Stoyanov et al., 2015)

Nurses should be familiar with the need to appraise health-related websites and
mobile applications. Understanding this need and possessing skills in appraisal help
the nurse guide patients in selecting appropriate electronic medical information.

TECHNOLOGIES AND INFORMATION SYSTEMS
IN HOSPITALS

A hospital has many information systems that feed into the EHR and that support
healthcare safety and quality. Among the information systems of most interest to nurs-
ing staff are admission/discharge/transfer (ADT) and patient registration systems;
messaging/communication technology; CPOE; bar-code medication administration
(BCMA); and radio frequency identification (RFID).

The ADT and patient registration systems are used to collect demographic data
about patients being admitted to the hospital or being registered as outpatients. ADT
systems are used for inpatients; patient registration systems are used for outpatients.
Demographic data contain facts that identify a patient as a unique individual. They
include name, address, phone numbers, date of birth, sex, race, ethnicity, religion, and
insurance information. In addition, ADT and patient registration systems collect dates
and times healthcare services were provided. If a patient is transferred from one inpa-
tient unit to another, the ADT system will track the change. Data accuracy in these
systems is extremely important to make sure appropriate care is given to the correct
patient.

CRITICAL THINKING 9.4

Watch the short 4-minute video at youtu.be/DAQ2CnjL7tQ. You can also access
the video by going to YouTube and searching for “Beacon Community Program:
Improving Health Through Health Technology.” When watching the video, take note
of how technology improves the quality and safe delivery of patient care.

1. What technological advances have improved communication in the
healthcare setting?

2. Why is it important to understand technology advances in the patient care
setting?

9 INFORMATICS • 265

Communication Technologies

In almost every hospital patient care setting you will find that nurses carry assigned
phones on their person. The phones are linked to the hospital phone system to facilitate
communication between the nurse and others, such as the unit secretary, the patient,
other hospital departments, and other care providers. The intent of the phone is to
facilitate direct communication with the nurse and to eliminate delays in communica-
tion and miscommunication about the patient-care team. Of concern is that the phones
can cause an additional distraction or interruption to the nurse, which may result in
delay of care or errors (Koong et al., 2015).

Technology that facilitates communication includes more than phones; another
major type of communication technology is the EMR. Most EMR systems have an area
for notes from the interprofessional team about care of a patient. This form of communi-
cation enhances patient care by sharing information among the healthcare workers who
need it at the point of care. For example, a nurse can access dietary education, physical
therapy, and respiratory therapy notes on a patient. Having this information available at
the point of care helps the nurse identify any gaps in care or additional education needed.

Computerized Physician Order Entry

A computerized physician (provider) order entry (CPOE) is considered any system that
allows the physician to directly transmit an order electronically to a recipient (AHRQ
PSNet, 2017). The CPOE is a software component of an EMR that allows the clinician to
enter patient-care orders directly into the computer system, thus eliminating any illeg-
ibility problems that can potentially occur with handwritten orders. Patient orders can
be entered from any location so there is no longer a need for verbal orders or telephone
orders. In addition, the CPOE issues alerts about various aspects of the patient’s condi-
tion. For example, the CPOE might alert the clinician to a low heart rate currently being
experienced by a patient. The CPOE also checks orders against the hospital formulary to
determine if a medication is stocked by the hospital pharmacy and then checks known
allergies, medication–medication interactions, and appropriate dosages of medication.
Delays in care are avoided because orders for lab tests are immediately transmitted to
the lab, medication orders are immediately transmitted to the pharmacy, and blood
transfusion orders are immediately transmitted to the blood bank.

The nursing staff at your hospital is upset because computerized provider order
entry (CPOE) was implemented 3 months ago. However, only about half of the
healthcare providers are using the new system. The rest of the healthcare provid-
ers continue to handwrite orders as well as only give verbal and/or telephone
orders. This creates confusion for the nursing staff because they have to remember
which providers are using the new system. For providers not using the new CPOE
system, the nurses must read the handwritten orders and make sure they are prop-
erly executed. In addition, the nurses feel that they have a greater liability when
they receive verbal or telephone orders and the physician has not yet signed them.

1. What should the nurses do in this situation?
2. What could have prevented this problem?

CASE STUDY 9.4

266 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Bar-Code Medication Administration

Bar-code medication administration (BCMA) links the electronic medication admin-
istration record (eMAR) with medication-specific identification in the form of bar
codes to help with compliance of the five “rights” of medication administration: right
patient, right dose, right route, right time, and right medication (healthit.ahrq.gov/
ahrq-funded-projects/emerging-lessons/bar-coded-medication-administration).
BCMA is a system that receives orders from the CPOE system, which prints bar-coded
labels that contain the patient’s identification number (usually the patient’s health-
care record number). BCMAs may also print the specifics of the medication order
(i.e., name of the medication and dose). The patient identification bar-code label is
then attached to the medication sent from the pharmacy to the nursing unit. Before
the nurse administers the medication, the bar code on the patient’s wrist bracelet is
scanned and the bar code on the medication packet is scanned. The computer system
will check to make sure that the packet contains the right medication for the patient
and that the medication is being given according to the clinician’s order; that is, the
right time and frequency, right dose, and the right route of administration (Sharma,
2018). Poon et al. (2010) studied an academic medical center and found BCMA systems
reduced the number of potential adverse drug events by more than half.

Radio Frequency Identification

Radio frequency identification (RFID) is a technology that uses radio waves to trans-
fer data from an electronic tag to an object for the purpose of identifying and tracking
the object (Ajami & Rajabzadeh, 2013). The use of RFID tags in healthcare involves a
small computer chip worn on the patient’s body like a bracelet or necklace. The RFID
device transmits radio waves that can be picked up by sensors located throughout a
healthcare facility. A common application of RFID is with Alzheimer’s patients in a
nursing home setting. RFID technology used in the patients’ wrist bracelets can be
used to sound an alarm when patients try to leave the unit or when an external door
is opened. The computer chip used in an RFID can also store much more information
than a bar code so an RFID provides the ability to have even more detail about the
patient in a medication administration system. This additional information comes at a
higher cost than associated with bar-code technology.

RFID chips are used in surgical sponges to determine if any sponges are left in the
patient at the end of the surgical procedure. This RFID technology ensures the patient
will not have to return to surgery to remove a missed sponge (Lazzaro et al., 2017).
It also protects the healthcare facility from liability and unnecessary costs. The CMS
(2008) determined it would no longer pay for higher costs of hospitalization associated
with events such as objects left in an operative wound. Surgical sponge RFID chips
help healthcare facilities meet the goal of zero sponges left postsurgery.

Technology in Direct Patient Care

Electrophysiological monitoring technology collects vital signs and other related data
such as heart rhythms about the patient and immediately sends them to the EHR to
give the clinician faster access to the data. The EHR can also issue clinical alerts to the
clinician. The alerts might be present when the clinician signs on to the EHR or the

9 INFORMATICS • 267

EHR might send an electronic page, an email message, or a phone call to the clinician.
The EHR systems eliminate the transcription errors that occur when vital signs data
are handwritten and then later documented in the record.

Smart Healthcare Devices

The miniaturization of computer chips allows their use in a number of healthcare
devices. These devices are called smart devices because they are able to monitor cer-
tain parameters about a patient and transmit that information to the healthcare pro-
vider. In some cases, the smart devices are programmed to take corrective action when
problems occur. An implantable cardioverter defibrillator (ICD) is one example. If the
patient experiences ventricular tachycardia or ventricular fibrillation, the smart device
will immediately evaluate the situation and deliver an electric impulse to the heart. If
the heart rhythm does not convert to an acceptable level, the smart device will deliver
another, stronger impulse (National Heart, Lung, and Blood Institute, 2012). These
smart devices save lives because they can identify and/or treat abnormal conditions
much faster than the healthcare provider can.

Other common devices with smart technology include infusion pumps and
implantable insulin pumps. Smart pumps are IV pumps in the clinical setting that are
programmed with a library database of IV medications (Harrison, 2016). Each medica-
tion has hard limits (i.e., the clinician cannot program the pump to deliver more than
a specified range) and soft limits (an alert is given when a range of medication dose is
reached but the pump will continue to deliver the medication). When used correctly,
smart pumps have shown to reduce medication errors (Stephenson, 2016).

In each case, a computer processor is an essential component of the smart device.
The use of smart devices will continue to expand with the advent of nanotechnol-
ogy. According to the National Nanotechnology Initiative (2012), a nanometer is
one billionth the size of a meter. It describes nanotechnology as the science involved
with understanding, manipulating, and manufacturing materials of this small size.
This will make it possible to have extremely small computer processors for smart
devices.

TO ALERT OR NOT TO ALERT

Although automatic EHR alerts within hospitals can be very helpful, care should be
taken in the electronic system design and implementation to make sure the physicians
and the nursing staff are not receiving too many alerts. Otherwise, a problem known as
alarm fatigue can occur. Alarm fatigue happens when the nurse becomes desensitized
to the alarm because of the high volume of alarms that occur in the clinical setting that
results in staff ignoring the alerts (Turmell, Coke, Catinella, Hosford, & Majeski, 2017).
Staff may try to turn the alerts off and can become increasingly annoyed with the sys-
tem. The actual users of the electronic system should determine which alerts will be
the most beneficial to them. For example, in a cardiac ICU the interprofessional team
may determine cardiac parameters they want alarms for such as heart rates decreasing
or increasing by 10%. The presence or absence of an alert does not relieve the nurse or
the providers of the duty to provide quality care. Alerts are only tools. The responsi-
bility to deliver quality care remains with the healthcare professional rather than the
device.

268 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

EVIDENCE FROM THE LITERATURE

Citation

Rouleau, G., Gagnon, M., Côté, J., Payne-Gagnon, J., Hudson, E., & Dubois, C.
(2017). Impact of information and communication technologies on nursing care:
Results of an overview of systematic reviews. Journal of Medical Internet Research,
19(4), e122. Retrieved from http://www.jmir.org/2017/4/e122/

Discussion

An overview of systematic reviews was conducted to understand how nurs-
ing care is influenced by information and communication technologies (ICTs).
Twenty-two qualitative, mixed methods, and quantitative reviews met inclusion
criteria and were reviewed. Findings from all reviews were synthesized into
nursing care indicators that were influenced by ICT and included the following:
time management; time spent on patient care; documentation time; information
quality and access; quality of documentation; knowledge updating and utiliza-
tion; nurse autonomy; intra- and interprofessional collaboration; nurses’ com-
petencies and skills; nurse-patient relationship; assessment, care planning, and
evaluation; teaching of patients and families; communication and care coordina-
tion; perspectives of the quality of care provided; nurses’ and patients’ satisfac-
tion or dissatisfaction with ICTs; patient comfort and quality of life related to
care; empowerment; and functional status.

Implications for Practice

The 19 nursing indicators identified as influenced by ICTs should be kept in
mind when considering implementing new technologies that affect nurses.

CRITICAL THINKING 9.5

The nurse is reviewing orders and completing the medication reconciliation in the EHR on
a patient just admitted to the medical–surgical floor. Medication reconciliation is a process
for double checking medications, where the nurse verifies that the details of the medications
written on the provider’s orders match those recorded in the medication administration
record used by the nurse. During the reconciliation process, several system alerts go off.

1. Does the use of electronic health records (EHRs) guarantee error-free patient
care?

2. What types of nursing behavior regarding the use of EHRs might contribute
to jeopardizing patient safety?

3. What are the dangers of excessive system alerts in computer charting
systems? How can the nurse guard against the potential effect?

9 INFORMATICS • 269

FUTURE OF INFORMATICS

Nursing curricula at both the undergraduate and graduate level are changing to include
more knowledge of informatics. This is due in large part to the work of the Technology
Informatics Guiding Educational Reform (TIGER), which is a national plan to enable
practicing nurses and nursing students to fully engage in the unfolding digital electronic
era in healthcare. The purpose of the initiative is to identify information/knowledge man-
agement best practices and effective technology capabilities for nurses. TIGER’s goal is to
create and disseminate action plans that can be duplicated within nursing and other mul-
tidisciplinary healthcare training and workplace settings and is focused on using infor-
matics tools, principles, theories, and practices to enable nurses to make healthcare safer,
more effective, efficient, patient-centered, timely, and equitable (TIGER, 2012, para. 1).

Today’s nurse must be prepared to embrace rapidly changing technology.
Technology in all forms, including informatics, is the future of healthcare that, when
used properly, can effectively help to ensure patient safety and quality of care by nurses.

KEY CONCEPTS

1. EMRs are used to document one instance of care, whereas EHRs follow a person
from birth to death.

2. EMRs and EHRs are replacing paper records as a result of a federal initiative.
3. When properly implemented, EHRs improve the quality of care and reduce health-

care costs.
4. EHR is the preferred term that will be replacing the term EMR as a national health

record is implemented.
5. Several different information systems in a hospital feed data to the EHR.
6. Telehealth keeps patients in their homes, improves patient outcomes, reduces the

number of hospital days used, and reduces healthcare costs.
7. Nurses should participate in the development of computer system alerts to make

sure they are useful and not an annoyance. Nurses retain responsibility for the care
they provide, regardless of the presence or the absence of an alert.

CRITICAL THINKING 9.6

It has been a very busy shift and the nurse is a bit overwhelmed with five assigned
patients. It is 6 hours into the shift and the nurse has only charted initial assessments.
She must remain in a room to monitor an IV medication but believes she can also begin
charting, even if just for the patient whose room she is in. The challenge is the patient’s
family is also in the room.

1. What team members would have important input on this team?
2. What principles should the nurse consider in completing bedside charting in

the presence of the patient’s family?

270 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

8. The HIPAA and its rules on privacy and security apply to EMRs and EHRs. Nurses
have a duty to protect patient privacy.

9. Nursing curricula must change to incorporate the study of new technologies.
10. Lifelong learning is essential for practicing nurses to keep up with technology.

KEY TERMS

Bar-code medication administration
Clinical decision support system
Computerized provider order entry
Electronic health record
HIPAA

HITECH
Medical identity theft
Radio frequency identification
Telehealth
TIGER

QSEN ACTIVITIES

1. A self-paced module that illustrates the professional responsibilities inherent in
informatics: qsen.org/heath-informatics-and-technology-professional-responsi-
bilities/

2. Electronic health record case studies: qsen.org/effectively-using-ehrs-with-inter-
disciplinary-teams-improving-health-quality-of-care/

REVIEW QUESTIONS

1. The nurse is caring for a patient and preparing to administer scheduled medica-
tions. Which of the following represents a benefit of using informatics technology
with regard to medication administration?
A. Automated medication systems alleviate the need for cross-checking allergies.
B. Using automated medication systems prevents medication errors.
C. Automated medication systems provide decision-making aids that alert the

nurse to potential problems.
D. Automated medication administration systems prevent the nurse from admin-

istering the wrong medication.

2. The nurse uses the electronic medical record (EMR) to review key components of
the patient’s health. What most directly impacts the nurse’s ability to effectively
utilize the EMR?

A. The functional design of the EMR system as described by the manufacturer.
B. The national guidelines for every nurse using an EMR system.
C. The state and federal initiatives mandating the use of EMR systems.
D. Local policies, training, and institutional guidelines on the EMR.

3. The facility is using a newly implemented electronic medical record (EMR) for
patient care. The nurses have expressed some frustrations with the high volume of
system alerts that are generated throughout the day. Which of the following dem-
onstrates the most appropriate response to excessive alerts by the nurse?

A. Turn alerts off so they do not slow down the data processing capability.
B. Report excessive alerts to the software designer.

9 INFORMATICS • 271

C. Collaborate with the nurse informaticist in the institution to make necessary
adjustments.

D. Just ignore the alerts and they will eventually go away.

4. The nurse wants to decrease the rate of medication errors for patients and advo-
cates for use of a computerized provider order entry (CPOE) system. Which of the
following best indicates the benefit of CPOE systems?

A. Eliminates the need for the nurse to decipher illegible handwriting.
B. Assists the nurse in receiving verbal orders from the providers.
C. Eliminates the need for the nurse to chart.
D. Takes the guesswork out of knowing when to call the provider.

5. A patient presents to the ambulatory surgery clinic for scheduled rhinoplasty.
During the admission interview, the patient notes a history of an allergic reaction
to an antibiotic medication 3 years prior. The patient states that she does not know
the name of the drug. Which of the following actions is best for the nurse to take?

A. Call the surgeon and share that the patient’s allergy history remains incomplete.
B. Ask the patient to describe what the pills looked like.
C. Consult the patient’s EHR.
D. Chart that the patient has an allergy to antibiotics.

6. A nurse on the cardiac unit overhears the licensed practical nurse explain to a
coworker how to check the status of patients in the labor and delivery unit even
though the computer system should not provide this access. Where does the
responsibility for system security reside to guard against this type of access?

A. With the nurse who will maintain patient privacy and avoid Health Insurance
Portability and Accountability Act (HIPAA) violations.

B. With the nurse informaticist who will make certain the electronic medical
record (EMR) maintains confidentiality.

C. With the federal government who will make sure no laws are violated.
D. With the designated security officer who will make sure the entire system is

secure.

7. One feature of some electronic medical records (EMRs) is decision-making pop
ups. For example, the nurse will be alerted to the patient’s medication allergies
when administering medications. Which of the following best describes the poten-
tial work place benefit for the nurse?

A. It is time saving and eliminates the need to ask the patient about allergies.
B. It is safer and provides a double check opportunity for the nurse to remember

to ask the patient.
C. It helps with communication and eliminates cross checking with Pharmacy.
D. It is cost-effective and reduces the time the nurse spends in transcribing

medications.

8. The nurse is preparing a patient for discharge. Which of the following represents
the nurse’s most effective application of the information technology at the bedside?

A. Accessing the best available evidence in preparation to answer the patient’s
questions upon discharge.

B. Using the computer to print a list of websites that may be of interest to the
patient.

272 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

C. Posting the patient’s questions to a social media website and compiling the
response for the patient.

D. Referring the patient to his or her healthcare provider so the provider can
answer the patient’s questions.

9. The nurse is monitoring the telehealth computer and notices that the patient’s
pulse oximetry reading drops below 90%, which is the predetermined action crite-
rion for this patient. Which of the following depicts the most appropriate next step
the nurse should take?

A. Call the patient’s family and alert them to administer oxygen immediately.
B. Call 911 to send emergency responders to the home.
C. Call the patient and assess how the patient is feeling and what is currently

happening.
D. Call the primary care provider to obtain treatment orders.

10. Nurses need to increase awareness of the implementation of technology and infor-
matics in patient care. Which of the following best represents a collaborative effort
to ensure best practices in nursing informatics?

A. HIPAA
B. TIGER
C. VISTA
D. EHR

REVIEW ACTIVITIES

1. Search the web for position descriptions for a Nurse Informaticist. Consider the edu-
cation requirements, position description, and required experience. Compare your
findings with other classmates. What similarities did you find? What differences?

2. Form groups of three to five students. Create a brochure that helps explain the
patient portal to a patient or family member. Consider the literacy level, under-
standing, knowledge, and prior experience of your patient population. Present
your brochure to the class.

3. Go to Health on the Net (www.healthonnet.org/HONcode/Conduct.html).
Review the HON code of conduct for health-related websites. Select a website or a
health-related application and examine the content based on the HON principles.
Select a website or application that does not currently have HON certification (can
typically be seen at the bottom of the webpage by the HON Code symbol found on
the website). What suggestions can you give to improve the website or application?
Does the HON code work for applications as well as it works for websites? How
would you evaluate the quality of health-related information on an application?

CRITICAL DISCUSSION POINTS

1. Consider a recent clinical experience. Describe how the data, information, knowl-
edge, and wisdom framework were used in practice (e.g., technology supported

9 INFORMATICS • 273

gathering and communicating data, transformed data to information, helped the
nurse take the information and use knowledge in patient care, and how technology
did or could help the nurse use wisdom when providing care).

2. Discuss the use of the EHR and the EMR when providing patient care. Explain how
each might facilitate the delivery of safe patient care.

3. Patient portals are becoming mainstream for communicating with patients in the
community setting. What are the benefits and drawbacks of using patient portals
for nurses? For patients? For providers (e.g., physicians)?

4. Access the Why Not the Best website at www.whynotthebest.org. Compare two
different hospitals on the key indicators provided. What do the data tell you about
the outcomes from care provided in the selected area? Does the website provide a
clear picture of patient-care outcomes? If yes, why? If no, what is missing?

EXPLORING THE WEB

1. Visit the HealthIT Buzz Blog at www.healthit.gov/buzz-blog. This blog is run by
the Office of the National Coordinator (ONC) of Health Information Technology.
It contains blogs on the latest topics in health informatics. Follow the links to read
three blogs. Be prepared to participate in a class discussion on these topics.

2. Visit the ONC’s YouTube channel on www.youtube.com/user/HHSONC. Watch
five videos about patients and their experiences with health information technol-
ogy. Most videos are only 2 to 3 minutes long.

3. Prepare a list of five benefits that patients might experience as a result of the
implementation of this health information technology. Draft a one-page, double-
sided, trifold brochure that could be given to patients to educate them on the topic.
Title the brochure “Health IT and You.” Insert photos or graphics as you think
appropriate.

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Upon completion of this chapter, the reader should be able to

1. Describe the importance of developing basic literature search strategies
when looking for the best available evidence.

2. Explain how research topics and questions are used to search the literature.

3. Explain how the patient/population, intervention, comparison, outcome, time
(PICOT) model for structuring evidence-based practice clinical questions is
used to search the literature.

4. Identify high-quality electronic databases and online resources for basic
literature searches.

5. Identify high-quality patient-care information tools including point-of-care
databases and practice guideline sources for basic literature searches.

6. Utilize keywords and subject headings in electronic databases and online
resources.

7. Utilize Boolean Operators and other search techniques in electronic
databases and online resources.

8. Develop broad literature search strategies.

9. Access high-quality evidence resources for lifelong learning.

10
BASIC LITERATURE
SEARCH STRATEGIES

Kimberly J. Whalen

For clinicians to get the answers they need to provide the best care to their patients, they must choose appropriate
databases; design an appropriate search strategy using keyword, title, and subject headings; use limits; and
successfully navigate in the databases they are searching. In addition, clinicians must consider the cost of not
searching for the best evidence. Commitment to finding valid, reliable evidence is the foundation for developing
the skills that foster a sound search strategy which, in turn, helps to reduce frustration and save time.

—(Melnyk and Fineout-Overholt, 2015)

278 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

Y
ou are spending time on a surgical inpatient unit as one of your clinical rotation
assignments. You observe that peripheral IV catheters are left in patients for 3 days prior
to being changed. In a previous clinical rotation at a different organization, you recall
that the policy for changing peripheral IV catheters was to change them every 4 days.

You ask your preceptor about this as part of your efforts to better understand which organization
has the safer practice. The preceptor appreciates your question and reports wondering the
same thing. The preceptor comments that patients often dread having their IVs restarted on
the third day when most of them are going home the next day. You and your preceptor decide
to speak with your nurse manager about looking into the recommended practice for the timing
for peripheral IV catheter changes. You review the literature and find that many studies report no
increase in infection rates, infiltration risk, and so on, if an IV is changed every 96 hours instead
of every 72 hours. You and your preceptor summarize key points from the literature, determine
the expected cost savings from fewer IV replacements, and highlight the potential impact on
patient satisfaction. You present your findings to the nursing practice committee. As a result,
nursing practice is modified to reflect the best evidence for a safe experience for patients requiring
peripheral IV catheters.

1. What opportunities are there in nursing to ask questions about current practice?
2. What opportunities are there in nursing to facilitate dissemination of information?
3. What other nursing actions should you take when adopting practice changes like this?

Basic literature search strategies are
used to search the literature for research
and evidence that will improve patient
care and fill knowledge gaps. High-
quality literature searches are needed
to ensure that the most up-to-date
research and best available evidence
are being used to shape patient care.
Nurses and healthcare delivery institu-
tions use research to shape practice and
ensure that the care delivered is at the
forefront in terms of safety and quality.
“As evidence-based practice becomes
more integrated into routine care, sys-
tematically searching of the literature
is essential to making informed clinical
decisions. To uncover all the evidence

and get the most unbiased sense of what is known about a particular phenomenon
or caregiving practice, a clear method of searching that is systematic is needed”
(McGrath, Brown, & Samra, 2012). This highlights the need for nurses to have skills
in basic literature search strategies.

This chapter discusses the importance of basic literature search strategies as they
relate to nursing. How to form research questions and use a structured patient/popu-
lation, intervention, comparison, outcome, time (PICOT) model for searching the lit-
erature is described. High-quality electronic databases, point-of-care databases, and
practice guideline sources are explored. Search strategies including the use of key-
words, subject headings, Boolean Operators, and other search techniques are described.
Techniques and support for broad literature search strategies are identified. Finally, the
chapter identifies literature search resources for lifelong learning.

FIGURE 10.1 A nurse at work in a student health
center.

10 BASIC LITERATURE SEARCH STRATEGIES • 279

BASIC LITERATURE SEARCH STRATEGIES

Healthcare practitioners use basic literature search strategies to answer a clini-
cal question or explore a research question (Boss & Williams, 2014). Librarians and
other experienced literature searchers approach the literature search process differ-
ently than novice or inexperienced searchers. Experienced searchers think about the

topic of interest and plan their systematic search before beginning the literature search
(Stillwell, Fineout-Overholt, Melnyk, & Williamson, 2010b). Nurses who follow a simi-
lar approach to the literature search process can decrease the time a literature search
takes and increase the relevancy of search results.

DEVELOPING RESEARCH TOPICS AND QUESTIONS

According to Melnyk and Fineout-Overholt, the first step of the evidence-based prac-
tice (EBP) process is to cultivate and maintain a spirit of inquiry within the nursing
profession. Nurses should be encouraged to demonstrate a spirit of inquiry by ques-
tioning what is known and not known about a topic of interest, clinical care, and
unit-based or institutional practice. Nurses should start by reviewing the policies and
practices related to patient-centered care within their organization. Gathering addi-
tional information through literature searches can help a nurse better understand the
topic or research question. A preliminary research topic can be as simple as pain man-
agement in children. Research topics are used at the start of a literature search process.
Once the searcher begins to understand an area of interest more, a research question is
often developed. A preliminary research question developed from the pain manage-
ment in children topic can be as simple as, “What are nonpharmacologic ways to man-
age postoperative pain in children?” Once the topic or question to be researched is
identified, an experienced literature searcher would conduct a simple and broad pre-
liminary literature search for published information using the most relevant words or
phrases. This simple and preliminary literature search provides the searcher with a
better understanding of the topic or question and provides a sense of the information
available. After a review of the results, the literature searcher would refine the topic
or question further, adjust the keywords or phrases used, rerun the search, review
the results again, and repeat the process as often as necessary until the results are

CRITICAL THINKING 10.1

Using an internet search engine, search for a professional nursing organization that
represents the clinical practice area you are interested in, for example, Emergency
Nurses Association. Visit the professional organization’s webpage to see what kind of
literature they create, share, or publish.

1. What are some topics currently being discussed by the professional
organization?

2. If the organization publishes a professional journal, what is the journal title?
3. How can research and information published by organizations like the one

selected be useful to your practice?

280 • II THE USE OF QUALITY AND SAFETY EDUCATION CONCEPTS

relevant. An experienced literature searcher would repeat this process with as many
sources of information as appropriate for the topic, the question, and the needs of the
research.

EVIDENCE FROM THE LITERATURE

Citation

Baker-Rush, M. (2016). Reducing stress in infants: Kangaroo care. International
Journal of Childbirth Education, 31(4), 14–17.

Discussion

Evidence-based practice (EBP) involves either testing a new idea against existing
practice or extending a proven EBP into real-world use. Research studies are one
type of evidence used to inform EBP. The study of the care of preterm infants is
a good example of how ongoing research and published studies can shape and
inform patien