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What do you get when you combine the wisdom of Mark Twain with the humor of Billy Crystal, the timing of Carol Burnett, with 20 years of experience in the healthcare profession, all packaged in the style of Diane Sawyer… well, meet Karyn Buxman!
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Discussions about a culture of patient safety abound, yet nurse leaders continue to struggle to achieve such a culture in today’s complex and fast-paced healthcare environment. It has been more than 10 years since the Institute of Medicine (IOM) released its report, To Err is Human: Building a Safer Health System. The IOM report (Kohn, Corrigan, & Donaldson, 2000) quickly elevated awareness of patient safety. An organizational culture consists of the values, beliefs, and norms that are important in the organization. The Joint Commission holds hospital leaders responsible and accountable for regularly assessing the safety culture within their organizations (TJC, 2011). Regular, front-line cultural measurements related to safety, followed by action, allow healthcare organizations to compare their safety record with other organizations, promote safety-focused attitudes, initiate interventions, and measure intervention effectiveness (Sexton, 2006). The following scenario, gleaned from a study of patient safety and the experiences of nursing unit leaders, describes a fictional hospital (Hospital Hope) and the hospital experience of a fictional patient (Mrs. Hospital Hope’s mission was to be the community pace setter for providing patient-centered care with the highest safety and quality standards. The hospital’s senior executive leadership believed that safety culture measurement and improvement processes could act as the tipping point for superior patient safety.
Hospital Hope leadership determined to advance the hospital’s mission by becoming an evidence-based organization. While searching the nursing and healthcare literature, the nurse manager learned about the Comprehensive Unit-Based Patient Safety Program (CUSP), a structured framework for safety improvement developed by Johns Hopkins Hospital (Pronovost et al., 2006). The staff began embracing the driving factors of a safety culture, such as teamwork and evidence-based care.
Situation-Background-Assessment-Recommendation (SBAR) communication became the standard reporting practice.
The SICU nurse manager wanted to assure that the patient was always the center of care even in the face of all the culture changes that were being made. In this article, a hypothetical scenario has illustrated how nursing leaders can translate theory into practice at the bedside.
This paper is rather longer and less of a rant than the other pages in this section; it was originally given at a seminar at the University of Lincoln in February 2010 and formed the basis of a round-table session (with Peter Hadfield) at the 2010 ISSoTL Conference in Liverpool in October.
Here's a presentation with the broad outline of the argument—the more detailed discussion can be found down the page.
Reflective practice is a potent shibboleth in teaching, nursing and social work, in particular. What actually delivers the goods in terms of changed practice outcomes is a process of continuous review and development of which reflection may indeed be a part, but only a small part of an iterative action-research cycle. Tutors on courses which promote and even demand reflective practice of their students, using tools such as reflective journals for assessment purposes, often complain that it is rarely done well. To a certain extent the act of writing, because it externalises the thought processes (and prompts memory) does encourage one to organise one's thoughts, but not necessarily to add depth or complexity to them.Not only do they have to be confident enough of their own knowledge (and practice, of course) to be able to subject it to scrutiny without fear that it will all fall apart, but they are also expected to do this through an internal dialogue. As the Reynolds model (see below) suggests, the initial reaction to attempting to do anything relatively complex for the first time is likely to be a degree of self-consciousness.
Spinning your wheels in the mud is more likely to lead to entrenched ruts than real progress. And of course if everyone is doing her or his own thing in terms of reflective learning, then they are going to come to different conclusions. In such closely-coupled systems, personal reflection is—beyond the recognition of gross personal mistakes—pretty futile. But there is more to this than simply the pragmatic value of existing theory to rein in the flights of an individual's reflective fantasy. Our research shows that even the most gifted performers need a minimum of ten years (or 10,000 hours) of intense training before they win international competitions.
His work, since the early '90s, has principally been among sports professionals, musicians and chess-players.
Ten thousand hours is an enormously long time, particularly in our world of instant gratification, and of TV shows which purport to show that novices can fake performance as an orchestral conductor, a weaver or a chef within six weeks. Frankly, seen within this perspective of gradual development, reflection takes its place as perhaps a necessary component of the learning process, but no big deal and one certainly unworthy of the adulatory attention it often commands.
It is taken for granted that A is good, and D is bad, but is the reflection the (or even a) magical ingredient? The consummation devoutly to be wished; and if you believe the evangelists of reflection, what necessarily follows from espousing it.
That reflection in isolation is not much use; reference was made to the Kolb cycle, and the significance of completing that cycle through to Active Experimentation. That reflective work produced by many students was indeed largely descriptive, and may well need to be carefully scaffolded.
That it is often difficult to tell what is genuine reflection and what is produced to meet tutor expectations; and of course the issue of assessment is fraught.
Whether it applies across all disciplines—there does not seem to be much room for it in hard sciences, such as physics. How undertaking it in isolation (both from practice and the community of practice) can lose touch with reality; reflection then becomes a reflection of oneself rather than on practice. Working with others in particular calls for the creation of an environment in which there is time and space to reflect. Does reflection look different and need to be practised differently at different stages of one's career? Picking up from Jude Carroll's plenary, that the lens needs to be turned on the practitioner's values and assumptions, as much as on those brought by students, clients or patients. The distinction between critical thinking, which we are also concerned to encourage in students, and reflection, has something to do with the emotional component of the reflective process.
Very many thanks to all who contributed; as you can see, I have tidied up and re-arranged the discussion somewhat, and I was not taking any more than very cryptic notes, so if I have misrepresented anyone or any position, please get in touch and I'll correct it. As an alternative perspective to set alongside reflection, see this very accessible Edge piece by Gary Klein, also on video on the same page. On a large piece of paper or the board, write or draw (or use pictures or photos) the key concepts (leave enough space between them so that the connecting lines are long enough to be seen and can have words written on them). Connect the concepts (circles) with a line (or an arrow depending on the relationship you want to represent). She delivers inspiring life lessons in a fun, laugh-out-loud kind of way that is powerful, practical and memorable.
In this article the authors discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in the above scenario. This report, edited by Kohn, Corrigan, and Donaldson (2000) laid out a four-tiered approach for improving patient safety: (a) establish a national focus to create leadership, research, tools, and protocols around patient safety, (b) identify and learn from errors, (c) raise performance standards for improvements through the action of oversight organizations, purchasers of healthcare, and professional groups, and (d) create safety systems at the delivery level.
A safety culture survey, specifically a unit-based survey, can assess conditions in a work setting that may lead to adverse events and patient harm. Jackson, a 73 year old widow, mother of two adult daughters, grandmother of four, and great-grandma to three children, was admitted to Hospital Hope, a typical suburban hospital viewed by the community as a good hospital.
Jackson was active in her community, volunteered at the local library, and enjoyed sharing blooms from her showcase flower garden. Jackson did have a well-documented, Grade 6, systolic heart murmur stemming from a childhood illness. Jackson survived hospitalization without permanent injury despite experiencing three preventable conditions during her hospital stay, namely pneumonia, a central line infection, and episodes of hypoglycemia, all of which could have been prevented if established, evidence-based care had been practiced.
To that end, the hospital leadership administered a patient safety survey, the SAQ, to the front-line staff to assess the existing culture.
She found the CUSP principles, described in an on-line tool kit, to be a helpful resource for training her entire multidisciplinary team, including physicians.
Handoffs, whether shift-to-shift, unit-to-unit, or between multidisciplinary team members, became clear and transparent.


She began to collect, analyze, and report quality data to drive performance improvement and to share lessons learned with nurse manager colleagues throughout the hospital. The SICU nurse manager and the staff were pleased with the safety changes that were occurring. The entire SICU multidisciplinary team designed a Safety and Quality Bulletin Board which they placed in a central location that was easily visible to care providers and visitors alike. At a staff meeting she reminded the SICU nurses of the final phrase of the Nightingale pledge. Just as the nurse manager had empowered her nurses to lead in patient care, the staff nurses committed to empowering their patients, and families, to be partners in their own care.
Yet, the success of providing patients with the safest and highest quality of care is becoming recognized as being dependent upon a strong cultural foundation at the unit level (Smits, Wagner, Spreeuwenberg, van der Wal, & Groenewegen, 2009). It has used a patient safety culture framework that defines safety culture driving factors as leadership, evidence-based practice, teamwork, communication, and a learning, just, and patient-centered culture. Sammer has had a leadership role in the quality and safety arena since 2002, first in a community hospital and currently as Director for Quality and Patient Safety at Adventist Health System, a forty three-campus, healthcare system covering 10 states.
James is an experienced nurse educator, having served as an undergraduate faculty member, as a clinical coordinator, and as a graduate faculty member focusing on nursing education until her appointment as Dean of the School of Nursing at Southern Adventist University in 2005. I have mused about possible reasons for that in this blog post, but it also has some standing in other more senior professions including medicine and the law. So far, I have not come across any studies which show empirically that in any discipline reflective practitioners have better outcomes from their practice than do those who probably think just as much—or indeed as little—as their reflective colleagues but just don't make as big a deal of it.
Perhaps—this was one of the outcomes of the discussion at the seminar where this paper was originally delivered—it is an emergent property of good practice, an (on the whole) desirable epiphenomenon or symptom rather than a component to be cultivated.
This shift from concern about oneself (am I going to catch this ball?) to looking outwards (keep your eye on the ball, not on your hand!) is the major necessary move for reliable and effective practice. It can be done in groups, and the potential for team development is high, but so are the costs, in terms of bringing people together and of facilitating the process. The danger of this of course is that it can become self-obsessed, self-indulgent and even solipsistic. I am indeed concerned about the dead hand of compliance on many forms of professional practice nowadays, but the alternative is not idiosyncratic anarchy. Disasters and failures (and of course glorious successes) are not personal—they are the products of team effort. But without detracting in any way from Sullenberger's achievement, he shows how the protocols built into the aircraft, the training, the checklists, the simulations, and the roles of co-pilot and other crew did not only contribute to the fantastic outcome—but had been designed to do so from the start.
But it is not quite as naive as, pace the post-modernists, believing that any theory is as good as any other.Of course, a further difficulty with that is that reflection is not informed by theory. Really there is no currency we can use to balance the claimed fragmented and individualised insights of reflection against the received wisdom of the past (theory); but that wisdom often consists as much of questions as of answers.
Consider how much more tiring driving would be if you had to concentrate as hard on changing gear as you did when you were just learning. In some fields the apprenticeship is longer: It now takes most elite musicians 15 to 25 years of steady practice, on average, before they succeed at the international level.
Contrary to the reflection model his research suggests that expertise remains focused on the area or skill which has been the object of such deliberate practice and does not generalise.
The novice's panoply of possibilities becomes a more manageable set of variations on a theme.
But we have discussed confirmation bias in reflection; neither model has any built-in prophylaxis against that. Of course I would not wish to deny that it exists, but would want to assert that the reflection is not a pre-condition for effectiveness. Its contribution is marginal, ideologically driven, and sometimes deleterious to developing proficiency in performing best practice.
They testified both to the necessity of Reflection and to its difficulty, particularly for younger students.
And there are occasions and areas of practice where there is no premium on dithering, where reflection has to be separated from action—the military and firefighting were cited as examples. At the beginning—when first introduced in training—students may not have a stock of experience with which to work. Sometimes it may be necessary to explain and teach without using the word itself, which has become devalued and diluted. Next, put words or pictures in large circles or boxes (concepts could also be written on 3-x-5 cards). This discussion is offered within a framework consisting of seven driving factors of patient safety. Because creating safety systems at the point-of-care delivery was the ultimate target of all the IOM recommendations, the IOM committee continued to emphasize that healthcare organizations should create an environment in which safety was a top priority. This type of cultural assessment can raise awareness about patient safety issues, assess the current status of the culture related to safety, prompt interventions, and track the effectiveness of improvements over time.
Because culture is often viewed as somewhat nebulous in nature, a patient safety culture tool, such as a framework, may help the nursing unit leader enhance the unit’s patient safety culture by making more tangible the specific driving factors of a culture of safety. As the story unfolds, the reader is permitted multiple opportunities to witness both individual actions and system-wide occurrences that led to negative outcomes. She was proactive in maintaining her health through regular activity, such as walking and water aerobics, and by healthy eating.
Her recovery was slow and her two daughters, one a nurse educator and the other a lawyer, were at her bedside as often as SICU visiting hours allowed. The Board members understood that their role included not only responsibility for the financial health of the hospital, but equally as important, for assuring patient safety and the provision of quality care (Conway, 2008). The survey results were clear: fewer than 50% of SICU care providers believed there was a strong culture of safety and teamwork within their unit.
Mutual respect among all the team members allowed for structured information exchange opportunities, such as a quick debriefing following a near miss adverse event (Leonard, Graham, & Bonacum, 2004). The SICU nurses agreed to hold each other accountable for improved outcomes on their unit through teamwork and good communication. The nurse manager became even more determined to continue building a safety culture within her unit. The nurse manager was responsible for keeping the data reports current and for including national and state benchmarks.
As a unit, the nurses chose to implement one process they believed would demonstrate a compassionate, caring approach to patient-centered care.
Jackson’s hospital admission, Hospital Hope leadership re-administered the cultural assessment survey.
This article has provided a model of the driving factors that are important in creating a culture of patient safety. Choosing a validated and widely used safety culture assessment instrument offers nursing leaders the opportunity to not only learn about the safety culture within their units, but also to address specific behaviors and values that need to be strengthened and to work with their staff in developing action an plan for improvement.
It is recognized that this scenario may well be unrealistic in terms of the nurses’ immediate willingness to change their behavior.
This story exemplifies the importance of the nursing unit leader and validates the notion that nurses are leaders whether in the board room or at the bedside—they lead from wherever they stand. Her responsibilities include supporting the system hospitals in the areas of healthcare quality and patient safety agendas. Her current responsibilities as Dean include oversight of AS, BS completion, and MSN degree programs. Vital Signs: Central line-associated blood stream infections --- United States, 2001, 2008, and 2009. Measuring patient safety culture: An assessment of the clustering of responses at unit level and hospital level.
It has even assumed the hegemonic status of an idea which cannot be questioned, like the the terrorist threat or man-made climate change. But it is the kind of reflection which does take place, as opposed to that which ought to take place (I contend this on the basis of having read—and marked—hundreds of such pieces).
It is necessary for any artisan in whatever discipline both to have access to an appropriate range of tools, and to select the appropriate one for the particular job in hand (and stretching the metaphor just a little, to keep them in good condition, by evaluating their performance and re-honing or replacing where necessary).


It is more suited to the practice of experienced practitioners and even experts, and in their cases it will arrive spontaneously without any need to force it.
As one member recounted about a family member who was encouraged to reflect on her actions, she tried it and found it uncomfortable and didn't like it, so she resolved never to do it again!
Suggestions for new pages and corrections of errors or reasonable disagreements are of course always welcome. These factors include leadership, evidence-based practice, teamwork, communication, and a learning, just, and patient-centered culture. It described a safety culture as one that focused on preventing, detecting, and minimizing hazards and error without attaching blame to individuals (Kohn, Corrigan, & Donaldson).
One framework available to nursing leaders offers seven driving factors related to a patient safety culture. In the subsequent section (Leadership Response) the actions of a nursing leader, as demonstrated by the fictional SICU nurse manager, illustrate how performance within the framework of a safety culture could have yielded different results. Jackson had no reason to suspect either that nearly one in every 20 hospitalized patients in the US each year develops a hospital-acquired infection or that central-line-associated blood-stream infections (CLABSIs) are among the most deadly types of hospital-acquired infections with a mortality rate of 12-25% as reported by the Centers for Disease Control and Prevention (CDC) (2011c). She had not been a hospitalized patient since an abdominal hysterectomy 20 years previously. She was admitted to Hospital Hope for diagnosis and treatment and soon scheduled for an aortic valve replacement. They were eager to help in their mother’s recovery by assisting her with bathing, feeding, and ambulation.
The Board was also aware of The Joint Commission (2011) leadership standard that specified the Board’s role in quality and safety oversight. The SICU team embraced the evidence and incorporated the central line insertion standards, consisting of good hand hygiene, full barrier precautions, skin preparation using chlorhexidine for disinfection, avoidance of the femoral artery, and a daily evaluation for line necessity (CDC, 2011b), into their daily routine. They collaborated with the unit respiratory therapists to standardize care with the goal of preventing hospital-acquired pneumonia. Techniques included showing mutual respect for comments or queries from any and all team members, from the young nursing students to the chief of staff. She wanted her staff to feel safe to report not only patient safety issues, but also errors and patient harms. At first, the staff was hesitant to post outcomes that could reflect poorly on the care they were providing. They chose to review daily, with the patient, his or her plan of care for the day and to encourage family participation in the care as appropriate. This time, 87% (well within the goal range of 80% or greater) of the SICU staff responded positively to the teamwork and safety culture, hand-off communication, and non-punitive reporting items on the assessment.
The scenario was presented in this manner, however, to serve as a useful model to guide nursing leaders as they lead their patient care units toward increased nursing satisfaction, improved patient experiences, and safe and excellent quality outcomes. Specifically this role includes: (a) leading and managing innovative quality and safety redesign initiatives, including measurement, analysis, and outcomes reporting, (b) sharing best practices and outcomes through publication and presentations, and (c) providing education and training for hospital executives, medical executive committees, and governing boards. She serves on major decision-making bodies within the university, teaches a core class at the MSN level, and serves as a mentor for graduate student research. The human factor: The critical importance of effective teamwork and communication in providing safe care. If the reference points are not clear (see the notes on the knowledge base below) then the process says nothing about the real world, just the world inside your head.
Many tasks happen too fast for much in the way of reflection-in-action, in any case, and there is no premium on dithering. It is seen in those whose reflection provides ex post facto justification for their failings, or who have re-invented the wheel on the basis of their musings, but have not done it very well. The report emphasized the need for leaders at the clinical, the executive, and the governing board levels to take ownership for patient safety. These groups, along with many other federal, state, and professional organizations, recognized that a patient safety culture was integral to improved safety outcomes and became the drivers for new policies and standards. It is important that nursing leaders adequately assess the safety culture in their workplace and clearly articulate a framework to guide personnel as they work to increase safety within their work settings. These factors include: (a) leadership, (b) evidence-based practice, (c) teamwork, (d) communication, (e) a learning culture, (f) a just culture, and (g) a patient-centered culture (See Figure). However, the doctors and nurses appeared to be reluctant to involve them in their mother’s daily plan of care.
In a unit meeting the SICU nurse manager asked the front-line staff to identify their patient safety concerns. They asked the nurse manager to arrange an inservice with the diabetes educator so they could learn more about preventing hypoglycemia.
For example, a new graduate nurse, upon observation of a doctor who was not following best practice for infection prevention while inserting a central line, felt safe speaking up and asking the doctor to follow safety standards.
However, as they continued to embrace a culture of safety, they learned that transparency leads to awareness and awareness leads to change.
Nurse managers will find practical examples illustrating how leaders can help their teams establish a culture that offers the patient quality care in a safe environment.
In this article the authors will discuss the concept of a patient safety culture, present a fictional scenario describing what happened in a hospital that lacked a culture of patient safety, and explain what should have happened in this scenario. Jackson was admitted to the Surgical Intensive Care Unit (SICU) for recovery and post-operative care. Jackson and her family, and the discomfort and inconvenience of her preventable morbidity, were unnecessarily high.
She discovered that some of the nurses had attended a continuing education program on the prevention of CLABSIs and that these nurses had become increasingly concerned about the incidence of CLABSIs on the unit. The nurse was confident she would be respected and supported by the unit manager and by executive leadership. She received her BS in Nursing from Southern Adventist University, Collegedale, TN, her MSN degree from the University of Texas at Arlington, and her DSN in Nursing Education and Occupational Health from the University of Alabama at Birmingham.
The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Use different colors for circles and links to help children see these as different types of information. This discussion will be offered within a framework consisting of seven driving factors of patient safety culture. Jackson was discharged to an extended care facility for continued recovery and rehabilitation and eventually returned to her home.
The nurse manager asked these nurses to give a report at the next SICU staff meeting on what they had learned.
In this ideal culture of safety, the physician deferred to the evidence-based expertise presented by the new graduate. The staff nurse was pleased to be asked and prepared an informative presentation for her colleagues.
The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. These seven factors are presented in the Figure, originally published by Sammer, Lykens, Singh, Mains, & Lackan (2010). In this way the entire team learned that CLABSIs are now considered mostly preventable and that each CLABSI carries excess healthcare costs of $16,550 and a mortality rate of up to 25% (CDC, 2011a). That meant that one of every four patients who developed a central line infection was at risk of dying! Following the presentation, the SICU nurse manager encouraged the staff to share ideas for safe reporting of errors and to describe what it would feel like to work in a non-punitive environment. The staff acknowledged that using a non-arbitrary and transparent model to guide in decisions related to human fallibility would help to build trust.
They asked the nurse manager to provide them with additional information on evidence-based best practices for preventing CLABSIs.



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