Nursing Leadership and Management
Patient safety culture is a significant component in the delivery of quality health care services. In fact, it is considered an important component receiving much attention since many of the negative care outcomes are resultant of medical errors, an indicator of failing patient safety. For instance, the USA reports between 44,000 and 98,000 hospital deaths annually as a result of medical errors. Global statistics reveals that 10% of patients in developed countries are injured during care delivery. While there is an understanding that a patient safety culture is important for reducing medical errors, the prevalence of such errors still remain high. A significant obstacle to achieve the desired patient safety outcomes is the absence of an appropriate safety culture for the organization, especially with regards to presents behaviors, beliefs, perceptions, attitudes, and values that support safe conduct of medical activities. This includes having a common belief that safety is a common responsibility, being committed to detecting and analyzing patient injuries and errors, and creating an environment that balances the need for disciplinary action versus the need for error reporting (Khoshakhlagh et al., 2019). This paper presents a case analysis of patient safety culture scenario as presented in Sammer and James (2011).Nursing Leadership and Management Essay Example
Hospital Hope Scenario
The case involved a 73-year old widow who is a mother, grandmother and great-grandmother. She was admitted to a hospital perceived as good by the community. As a patient she was unaware of patient safety statistics for hospitalized patients. She lived a healthy lifestyle and her last hospitalization was 20 years ago. She was diagnosed with a grade 6 systolic heart murmur that has become more active so that she was hospitalized for an aortic valve replacement surgery. The surgery went well and she was admitted to the surgical intensive care unit (SICU) for recover and post-operative care. She had an 8-day stay in the SICU, during which time she developed hospital acquired pneumonia, had three episodes of hypoglycemia, and developed CLABSI. These three were preventable conditions. Her two daughters (a nurse educator and a lawyer) sought to be included in her active care during the hospitalization, but they were excluded. Following the occurrence of three preventable conditions (hospital acquired pneumonia, hypoglycemia and CLABSI), the patients care costs increased, she and her family experienced psychological stress, and endured discomfort and inconvenience from preventable morbidity (Sammer & James, 2011).
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Change in practice in the SICU
The hospital adopted a safety culture with the stakeholders taking responsibility for their roles in improving the safety culture, such as the executive leadership taking on the oversight role in assuring patient safety, providing quality care, and ensuring the financial health of the hospital. Towards this end, a new safety culture was adopted with a focus on routinely measuring safety and improving processes. The measurement revealed that only 50% of SICU care providers believed that the unit had a strong culture of safety and teamwork. To improve on this, the hospital targeted an increase in the figure to 100% by implementing the suggestions made by the providers, adopting evidence-based practices (CUSP program developed by Johns Hopkins Hospital), introducing care protocols for improving patient safety (such as Situation-Background-Assessment-Recommendation – SBAR), learning culture, accountability, and positive safety culture (Sammer & James, 2011).
In the Hospital Hope scenario, what do you think was the most important factor that led to the change in practice in the SICU?
In the Hospital Hope scenario, the most important factor that led to the change in practice in the SICU was measurement, particularly the survey revealing that only 50% of the SICU care providers believed that the unit had a strong culture of safety and teamwork. The survey acted as a tool for tracking measures of opinions concerning safety culture. The survey presented the information in a manner that made it personalized for the hospital so that everything that was indicated reflected the unique circumstances in the hospital. With this approach to measurement, the hospital was able to develop a safety culture change that works well and can be spread (Raingruber, 2017). In addition, the measurement engaged SICU care providers as the source of data in the survey. The providers are an important primary source of information as they are involved in care provision in the SICU and can objectively and subjectively evaluate patient safety performance in the unit even as they suggest opportunities for improvements. Besides that, the providers have an understanding of what an ideal patient safety culture implies, and they can leverage their professional knowledge, skills and competencies in matching actual performance with realistic expectations (Helming, Shields & Avino, 2020).Nursing Leadership and Management Essay Example
If you worked in a facility that needed a practice change, what framework would you use and why?
A change framework presents a structure and process that would be applied to generate insights and develop a change plan in the organization. In fact, having the right framework is vital of successful change as the framework offers a systematic approach that anticipates and prevents problems. In applying a change framework, there is an expectation of faster change implementation, lower budgets, higher motivation and productivity, lower change resistance, and increased changes of successful change. An appropriate change framework is Lewin’s three step model. It follows a three-step process. The first step is unfreezing whereby there is an awareness of how the current status quo and level of acceptability is hindering the organization from achieving certain goals. This step is intended to show that the change is necessary and urgent, thus motivating the stakeholders to support the change. The second step is changing whereby the change is implemented with the stakeholders guided through the changes as implemented even as they learn new ways of thinking, processes and behaviors. Time, support, communication and education are critical at this step to enable the stakeholders become more familiar with the change. Also, this step continues to remind stakeholders of the reasons for the change and how it benefits them. The final step is refreezing whereby the change is reinforced, stabilized and solidified as the new status quo or norm. This step ensures that the stakeholders do not revert back to the previous norm that preceded the change. The efforts applied guarantee that the change is not lost; rather, it cements the change in the organization’s culture and maintains it as an acceptable way of doing things or thinking (Zaccagnini & Pechacek, 2019).
Using Lewin’s change model is informed by three reasons. Firstly, it is easy to understand as it presents three steps. Secondly, it makes sense as successful change boils down to unfreezing, changing and refreezing. Finally, it incorporates behavioral elements of psychology that increases the odds of success as it involves stakeholders at every step and makes them a part of the change process (Zaccagnini & Pechacek, 2019).
References
Helming, M., Shields, D., & Avino, K. (2020). Dossey & Keegan’s Holistic Nursing: A Handbook for Practice (8th ed.). Jones & Bartlett Learning, LLC.
Khoshakhlagh, A.H., Khatooni, E., Akbarzadeh, I., Yazdanirad, S., & Sheidaei, A. (2019). Analysis of affecting factors on patient safety culture in public and private hospitals in Iran. BMC Health Services Research, 19, Article number 1009. https://doi.org/10.1186/s12913-019-4863-x
Raingruber, B. (2017). Contemporary Health Promotion in Nursing Practice (2nd ed.). Jones & Bartlett Learning, LLC.
Sammer, C. & James, B. (2011, September 30). Patient safety culture: The nursing unit leader’s role. OJIN: The Online Journal of Issues in Nursing,16(3), Manuscript 3. https://doi.org/10.3912/OJIN.Vol16No03Man03
Zaccagnini, M., & Pechacek, J. M. (Eds.) (2019). The Doctor of Nursing Practice Essentials: A New Model for Advanced Practice Nursing (4th ed.). Burlington, MA: Jones & Bartlett Learning, LLC.
Nursing Leadership & Management Module 7
Assignment Description:
A Culture of Patient Safety
Read this article:
Sammer, C. & James, B. (2011, September 30). Patient safety culture: The nursing unit leader’s role. OJIN: The Online Journal of Issues in Nursing,16(3), Manuscript 3.
In the Hospital Hope scenario, what do you think was the most important factor that led to the change in practice in the SICU?
If you worked in a facility that needed a practice change, what framework would you use and why?
Reading Materials:
- Weiss, S. A. & Tappen, R. M. (2015). Essentials of nursing leadership and management (6th ed.). F. A. Davis Company. Read chapter 9
- Sherman, R.O. (2015, August 20). Change management – A key leadership competency. Emerging RN Leader.
- Cagliostro, J. (2020, July 23). The role of nurses in cost savings & efficienc. Cost Savings, VIE Healthcare Blogs.
Start by reading and following these instructions:
- Study the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
- Review the Assignment Rubric and the specifications below to ensure that your response aligns with all assignment expectations.
- Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling, and review the rubric.
- When you submit this assignment, it automatically goes through Turnitin, a plagiarism software, to be sure that your work is less than 20% duplicated from other sources
The following specifications are required for this assignment:
- Length:1000 to 1250 words in length
- Structure: Include a title page and reference page in APA format. These do not count towards the minimum word count for this assignment. Your essay must include an introduction and a conclusion.
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Nursing Leadership and Management Essay Example