Case Study

23Jan 2022 by

CASE STUDY 13-2 Creating a Culture of Safety within a Microsystem
Patient safety is of paramount importance to the operations of any nursing unit. Nurses who work in direct patient care must be trained in patient safety techniques and need a curriculum to help guide their development and acquisition of these skills. An important component of the nurse leaders role is to exert a positive influence on the culture of safety within the nursing environment to promote optimal outcomes. Nurse leaders must help their nurses recognize and report potential patient safety and quality issues. The Heart and Lung Transplant unit identified opportunities in their annual employee survey that addressed issues surrounding the culture of patient safety. The unit experienced low scores in the following areas: this organization is committed to patient safety, this organization makes every effort to deliver safe, error-free care or service, I feel empowered to report patient safety and quality issues, and my unit works well as a team to promote patient safety. Further assessment of the unit allowed the nurse leaders to discover that many nurses who were employed in the unit were not trained in patient safety techniques and skills as part of their formal nursing education. This created an opportunity for nurse leaders to introduce new patient safety ideas and techniques to the nursing unit. The Heart and Lung Transplant ICU is a complex environment where many different healthcare disciplines interact to provide care for vulnerable patients. One issue identified by leadership involved nurses who were not speaking up about a suggestion or observation when a key safety practice was not being followed. For example, nurses felt that they could not speak up to other healthcare workers when they observed that someone did not wash his or her hands. At the same time, patient safety goals identified by The Joint Commission were being implemented in the unit to improve how healthcare workers hand off patients to each other and use a time-out during high-risk procedures to safeguard patient care. The leadership discovered that some nurses were frustrated by the lack of understanding and appreciation for how these practices could transform care when they are implemented as intended. Many nurses lacked the attitude and ongoing commitment needed to prevent adverse patient safety and quality events. To transform the culture of patient safety, the unit leadership identified a patient safety curriculum called Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). This program was developed by the Agency for Healthcare Research and Quality and the U.S. Department of Defense. TeamSTEPPS is a comprehensive program that includes a set of modules and exercises designed to engage healthcare workers in understanding how they can assume their roles in a more collaborative teamwork approach that supports and promotes patient safety. The program teaches healthcare workers skills like situation monitoring and mutual support to promote a culture that embraces patient safety. In addition, important concepts, such as communication and conflict management negotiations, are taught to all disciplines to instill a common language surrounding patient safety. A strategic plan was written to implement the TeamSTEPPS program. The plan was shared with key hospital and medical leadership, and support was given to develop a set of TeamSTEPPS master trainers. The strategic plan included a training budget and plan. The nursing unit leadership decided to implement the complete TeamSTEPPS modules in a 1-day training class. As a result of implementing TeamSTEPPS, pre- and postsurvey assessment measurements included in the program indicated that the nurses attitudes toward teamwork and perceptions of teamwork improved. The unit leadership observed that the nurses were able to use a common language surrounding patient safety to make a difference in patient care. For example, as a result of learning about and practicing huddles and debriefings in the TeamSTEPPS class, nurses were able to identify when these activities should be included to promote patient safety. Reflecting on the experience, the unit leadership was proud of the adoption of TeamSTEPPS to improve teamwork and patient safety. The leadership recognized that the adoption of such a program requires ongoing attention to employees new to the teamwork curriculum and to continuing to develop the entire teams knowledge and attitudes of teamwork.
Case Study Questions
1. What obligations do nurse leaders have to develop their own understanding of patient safety within their areas of responsibility? How could nurse leaders position themselves to demonstrate ongoing support for teamwork and patient safety? 2. Research materials on programs such as TeamSTEPPS. How could a teamwork intervention program make a difference within your microsystem? 3. What evidence should nurse leaders look for that could indicate their teams and microsystems could benefit from improving their culture of patient safety? 4. Describe how a nurse manager could develop a plan to have his or her staff members participate in a teamwork intervention program. What key elements would need to be included in the plan?