AACN News—March 2000—Opinions

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Vol. 17, No. 3, MARCH 2000

President's Note: Making It Safe for Patients Means a Culture of Safety for Nurses
By Anne W. Wojner
President, AACN

This issue of AACN News includes an article on the Institute of Medicine’s (IOM) report titled “To Err Is Human: Building a Safer Health System.” Medical errors result in more than 44,000 deaths annually in the U.S. More people die each year from medical errors than from breast cancer, AIDS or motor vehicular trauma. Such numbers quickly catch the attention of consumers and providers of healthcare.

The IOM report cites fragmented organizational systems as the primary cause of healthcare errors. The report also identifies individual blame, instead of thorough organizational assessment, as the chief mechanism to deal with errors. Unfortunately, these findings come as no surprise to nurses.

Most staff nurses can readily recite an almost endless list of organizational contributors to practice errors, including:

• Stifling, noncollaborative environments, where providers’ egos often prohibit clear, two-way communication about patient problems
• Supplies, medications and stocking systems that do not ensure safe labeling and distribution to prevent misuse

• Removal of purposefully redundant “double-check” systems aimed at error prevention through downsizing efforts that view duplication of services as inefficient
• Reduction in clinical manager positions responsible for day-to-day safety and systems issues
• Outdated belief systems that suggest “a nurse, is a nurse, is a nurse” at a time when increased specialization and high patient acuity are the norm
• Reduction in the availability of expert, “hands-on” nurses to oversee clinical practice and improve the knowledge and skill sets of less experienced staff
• Undecipherable handwriting that makes reading the medical record akin to deciphering hieroglyphics
• Unscientific, nonstandardized procedures and practice rituals
• Inappropriate use of less skilled providers, and use of multiskilled labor that does not have the capacity to develop the needed expertise to satisfy high-quality standards

Of course the list could go on and on. However, the single most significant factor associated with healthcare error is the deliberate reduction of the nursing workforce through downsizing. Considering that a fundamental function of a hospital is nursing care, this fact is nothing short of ironic. For a hospital to downsize the very commodity that allows it to remain in business is absolutely senseless.

Many of us have had the displeasure of observing some of the processes used by hospitals to determine staff nurse reductions. I recently had the opportunity to observe the use of the “stopwatch” method, which attempts to quantify nurse efficiency through time and motion studies. Quantifying the nursing care experience across heterogeneous groups of nurse providers, from novice to expert, and across even more diverse patient populations, is an extremely challenging task that can only be supported by a rigorous scientific framework, if results are to be valid and reliable. Sadly, validity and reliability were greatly lacking in the process that I observed. Instead, nursing care was viewed outside a holistic framework, while general accounting principles seemed to guide the methods used by the data collectors. Something is obviously wrong when providing caring, humane support for the family of a brain-dead patient is deemed “nonproductive time.” I found myself sickened that any hospital would even consider resorting to the use of such ridiculous methods to determine adjustments in nurse staffing.

What is clearly at the heart of the medical error problem is a dramatic shift in culture within our workplaces. Cultures supporting safety and cultures supporting productivity lie at opposite ends of a continuum. For many years, hospitals endorsed a culture of safety. This culture gave birth to critical care units in the late 1950s, when it was recognized that patients with high-intensity needs should be cared for in environments that provided close surveillance and rapid intervention. Later, when nurses and physicians recognized that critical care units needed the support of hands-on clinical nursing experts, clinical nurse specialist positions were developed. Over time, staff development positions and clinical nurse manager positions were expanded in this safety culture to ensure that nurses were well prepared to serve their patients and families. Nursing research was also embraced and began to thrive, as phenomena to enhance our practice were explored.

Today, we have swung to the other end of the continuum, replacing the culture of safety with one that emphasizes productivity. Cultures of productivity focus on reduced duplication of services and stopwatch-perfect performance, assuming a production line mentality of one size—nurse skill set and patient and family needs—fits all. The result has placed critical care nurses in the difficult position of deciding which needs should be only partially met, because multiple patient loads have taken away the ability to attend to the greater whole.

If we truly intend to reduce errors in our workplace, we must return to the other end of the continuum. Cost reduction is significantly more effective when hospitals bravely work toward resolution of the difficult, highly political issues that drive up the price of critical care, including futile care, inappropriate utilization of intensive care services, inefficient support services that slow patient movement through the system and substandard medical practice patterns.

Nurses are protectors of quality, living monitors of patient and family needs and champions of doing the right thing for those in their service. Let’s work to reestablish a culture of safety in our practice settings by partnering with our bedside nurses to identify innovative, new strategies that dramatically reduce healthcare errors. Such a charge is consistent with our proud tradition of caring, and is embedded in the heart and soul of what it means to be a nurse.

My Turn: Honor Nursing’s ‘Tribal Leaders’

By Judy Davidson

I recently attended a meeting with nursing leaders from several area hospitals and schools of nursing to discuss employee recruitment and retention issues.
During the discussion part of the meeting, I was particularly moved by the comments made by Jennifer Jacoby, nurse executive at Sharp Memorial Hospital, San Diego, Calif. She described the evolution of a bimodal workforce, in which a large number of older nurses are blended with younger, less experienced nurses.

Most of us agreed that this description matched the demographics of our own departments, where many nurses are 46 years of age or older. The literature and media refer to this phenomenon as the “graying of the workforce.”

Jacoby referred to these older nurses as our “tribal leaders,” and stressed the need to keep them in the workplace, because of their wisdom and knowledge. At the same time, she acknowledged the fact that, as we age, our bodies cannot take the full impact of physical labor as well as they could when we were younger.

I was initially offended by the term “tribal leader.” However, Jacoby explained that this was a more honorable way to describe these nurses—not as old or seasoned or burned out, but as something better. They are wise, knowledgeable and full of more to give, with life experiences that exceed anything that can be read in a textbook.

Although I am not yet a tribal leader, I thought about my backache after a 12-hour shift, and how I’ve converted to support hose on days when I pull a patient assignment. I thought about how I have been wondering if, in 10 years, I would be able to handle the physical labor of a full complement of 12-hour shifts. I thought of my many older and wiser colleagues, the nurses to whom I look for advice on a daily basis, to whom I would truly entrust the care of my own mother if she were ill—the nurses without whom our unit would be lost if they left.

To retain the wise ones and avoid physically burning out the tribal leaders before their time, we may need to totally rethink the way we do business. Eliminating some of the physical labor associated with nursing and using the brain power where it counts is one way to address the problem. For instance, what about bringing back transport or turning teams? I recently spoke to a nurse from an east coast hospital where strong individuals were hired or teams were assigned to turn comatose patients every two hours.

In addition to deflecting the labor to others, routine workouts with a physical therapist or a back strengthening program could help our tribal leader group. Routine ergonomic evaluations of the workplace are indicated. Purchasing equipment, supplies and workstations that decrease bodily stress are well worth the decrease in workmen’s compensation insurance, disability and attrition. Remodeling plans for any area should be reviewed by the tribal leaders to identify potential areas of stress prior to committing to construction. Those in charge of building projects must ask themselves:

• How far do supplies need to be carried to be cleaned or stored?
• Are there places that have to be reached from an angle?
• Does a person’s head have to be in an awkward position to see the monitors?
• Are the computer terminals ergonomically correct?
• How much effort does it take to open doors or turn handles?
• How many pounds of pressure are necessary to push a bed on the new carpet?
• Is there a lighter portable defibrillator/monitor on the market?

• Do the chairs at the nurses’ station have lumbar support?
• Are step stools available?

We must also think about how we train new nurses. Our nursing positions never seem to be filled, and many of the applicants have no experience. Wouldn’t it make sense to assign a tribal leader to precept each new nurse who, in turn, could perform the bulk of the manual labor while in training?

The drawback to this plan is that research has shown that the expert nurse may not be the best preceptor. The nurse who has been practicing three to five years may have an easier time explaining the details of decision making than the nurse with 20 to 30 years’ experience.

In some ways, nursing at the expert level is like knowing how to drive a manual transmission car. You may not be able to explain how you knew it was time to shift into third. You probably could have explained the process better when you had only been driving for a year or two.

Knowing this, our next step could be to spend some time and energy (even a little money) to finely hone the precepting skills of the tribal leaders so that they could decode their reflexive nursing movements into concrete, learnable steps. As a complement to physical exercise, cognitive exercises like these might help the tribal leader retrain the brain to recognize the cues that are deeply embedded in the subconscious of the nurse expert:

1. List 20 things you think of when you walk in the room of a patient with a ventilator.
2. List five things that could go wrong with your patient today, based on what you heard during report.
3. Think about the worst thing that has happened to a patient in the past with this same diagnosis
4. If a patient’s blood pressure began to fall, what would you do first, and why? Name 10 different factors that came to mind to help you make this decision.
5. List and prioritize the first 10 things you will do in your assignment today; then explain how you came up with that decision.

In summary, our tribal leaders in nursing are a valued and substantial segment of our workforce. We must make every effort to retain these experienced nurses. This means providing a workplace that decreases the impact of physical labor, while supporting them to strengthen their bodies to endure physical labor, and honoring them for the wisdom they possess.

Judy Davidson, RN, MSN, MBA, CCRN, is a clinical nurse specialist, coordinating a 12-bed ICU at Pomerado Hospital, Poway, Calif. She is president of the San Diego Chapter of AACN.

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