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Speaking Up for Quality and Safety
PAT I E N T SA F E T Y FIRST
Speaking Up for Quality and Safety SUZANNE C. BEYEA, PHD, RN, FAAN
I
n past months, this column has addressed a number of safety goals for nurses. One issue not specifically discussed concerns the importance of nurses being willing to speak up in the interest of improving patient care. On its own, speaking up is not enough, however. To be effective in improving safety, nurses must be knowledgeable and articulate about current guidelines and evidence, actively participate in peer review, and work on communication style.
SCIENTIFIC RATIONALE To make significant gains in creating safe clinical environments and processes of care, nurses must be able and willing to provide a scientific rationale that is reflective of the best research evidence when dealing with policy or behavior changes. Perioperative nurses should be informed about patient safety science, as well as clinical practice guidelines. They also should carefully review AORN’s Perioperative Standards and Recommended Practices,1 and implement changes in clinical practice based on the latest updates. New research findings can contribute to improving practice, but only if they are applied to clinical practice. For example, a group of nurses attending a recent educational session argued that a faculty member was incorrect when he said patients with major traumatic illness should be prevented from becoming hypothermic during surgery. The nurses stated their belief that it was important to keep the patient cool to avoid surgical complications. To explain, the faculty member cited the latest research, which states patients should be maintained in a
© AORN, Inc, 2008
normothermic condition to prevent adverse outcomes.2 A review of AORN’s “Recommended practices for the prevention of unplanned perioperative hypothermia”2 provided a rationale for this recommendation and helped clarify the issues for the nurses. With this knowledge, the nurses could return to their clinical setting and work toward making changes in their clinical practice. A guidance of particular significance to perioperative nurses is the Joint Commission’s National Patient Safety Goals (NPSGs).3 Each year, the NPSGs are determined New research by a panel of experts based on data collected as findings can part of the Sentinel Event Program. Data derived contribute to from that program help identify which patient improving practice, safety hazards are the highest priorities for but only if they health care organizations and clinicians. Nurses are applied to need to understand the NPSGs and serve as adclinical practice. vocates in implementing the recommendations in clinical practice. Nurses must be knowledgeable about the recommendations and the rationale for the various recommendations and then be willing to speak up about their importance.
PEER REVIEW It is important that nurses actively participate in safety initiatives and peer review to ensure patient safety and high quality of care. Nurses need to speak up to address safety issues with their peers
JULY 2008, VOL 88, NO 1 • AORN JOURNAL • 115
JULY 2008, VOL 88, NO 1
Speaking up requires knowing and understanding the best practices and scientific rationale. It requires a nurse to be a risk taker and to serve as an advocate for the patient.
and hold each other accountable. Peer review requires nurses to confront behavior that is not consistent with the recommendations for safe or high quality practice. This may consist of simply stating, “You just broke sterile technique” or “We need to complete a time out before the incision is made.” Sometimes, however, it is not so simple. Occasionally, clinicians work with an individual who violates rules or ignores policies and procedures, despite their coworkers’ best efforts to speak up and correct the behavior. The individual may ignore a reminder to follow the correct procedure or may respond negatively to peer review, saying, “I don’t have time” or “That policy is ridiculous; I know what I am doing.” In this type of situation, coworkers may simply stop speaking up or trying to change behaviors, practices, or attitudes. Ignoring the behavior or accepting it as a normal variation in practice, however, will not result in changes or improvement in practice. Nurses must continue to speak up and collaborate with members of the leadership team to ensure that the best possible care is provided, and in difficult situations, team members may need to work within the chain of command to address a potential safety or quality issue. This could include using resources within the risk management or quality department to help explore strategies. For example, a nurse from a small, rural hospital recently shared her concern about a general surgeon who was performing procedures for which he was not credentialed. She spoke up but the surgeon was not receptive. She then spoke to the department nurse man-
116 • AORN JOURNAL
Patient Safety First
ager, who told her not to cause trouble because the surgeon is a good doctor. The nurse persevered and discussed the issue with the hospital’s risk manager, who addressed the issue with the chief of surgery and the department manager. The surgeon was asked to stop performing certain procedures until he obtained the appropriate credentials.
COMMUNICATING EFFECTIVELY Communication style also can have an effect on positive outcomes when nurses are speaking up for quality. To be more effective, nurses need to be assertive rather than aggressive in their communication style. Also, they should have an explanation for a directive ready—simply telling a coworker, “Don’t do that,” will not have the same positive effect as explaining that washing one’s hands can decrease infection risks. Explaining why there are certain rules and procedures can help increase compliance and cooperation. Speaking up as a professional requires a nurse to be well informed and knowledgeable, doing more than just speaking his or her mind. Speaking up requires knowing and understanding the best practices and scientific rationale. It requires a nurse to be a risk taker and to serve as an advocate for the patient, especially when the patient is unable to speak for himself or herself. Nurses serve an important role when they speak up in efforts to provide expert knowledge about clinical practices that result in safe, effective, and high quality care.
REFERENCES 1. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008. 2. Recommended practices for the prevention of unplanned perioperative hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:407-420. 3. National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/Patient Safety/NationalPatientSafetyGoals/. Accessed May 20, 2008. SUZANNE C. BEYEA PHD, RN, FAAN DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH
Speaking Up for Quality and Safety SUZANNE C. BEYEA, PHD, RN, FAAN
I
n past months, this column has addressed a number of safety goals for nurses. One issue not specifically discussed concerns the importance of nurses being willing to speak up in the interest of improving patient care. On its own, speaking up is not enough, however. To be effective in improving safety, nurses must be knowledgeable and articulate about current guidelines and evidence, actively participate in peer review, and work on communication style.
SCIENTIFIC RATIONALE To make significant gains in creating safe clinical environments and processes of care, nurses must be able and willing to provide a scientific rationale that is reflective of the best research evidence when dealing with policy or behavior changes. Perioperative nurses should be informed about patient safety science, as well as clinical practice guidelines. They also should carefully review AORN’s Perioperative Standards and Recommended Practices,1 and implement changes in clinical practice based on the latest updates. New research findings can contribute to improving practice, but only if they are applied to clinical practice. For example, a group of nurses attending a recent educational session argued that a faculty member was incorrect when he said patients with major traumatic illness should be prevented from becoming hypothermic during surgery. The nurses stated their belief that it was important to keep the patient cool to avoid surgical complications. To explain, the faculty member cited the latest research, which states patients should be maintained in a
© AORN, Inc, 2008
normothermic condition to prevent adverse outcomes.2 A review of AORN’s “Recommended practices for the prevention of unplanned perioperative hypothermia”2 provided a rationale for this recommendation and helped clarify the issues for the nurses. With this knowledge, the nurses could return to their clinical setting and work toward making changes in their clinical practice. A guidance of particular significance to perioperative nurses is the Joint Commission’s National Patient Safety Goals (NPSGs).3 Each year, the NPSGs are determined New research by a panel of experts based on data collected as findings can part of the Sentinel Event Program. Data derived contribute to from that program help identify which patient improving practice, safety hazards are the highest priorities for but only if they health care organizations and clinicians. Nurses are applied to need to understand the NPSGs and serve as adclinical practice. vocates in implementing the recommendations in clinical practice. Nurses must be knowledgeable about the recommendations and the rationale for the various recommendations and then be willing to speak up about their importance.
PEER REVIEW It is important that nurses actively participate in safety initiatives and peer review to ensure patient safety and high quality of care. Nurses need to speak up to address safety issues with their peers
JULY 2008, VOL 88, NO 1 • AORN JOURNAL • 115
JULY 2008, VOL 88, NO 1
Speaking up requires knowing and understanding the best practices and scientific rationale. It requires a nurse to be a risk taker and to serve as an advocate for the patient.
and hold each other accountable. Peer review requires nurses to confront behavior that is not consistent with the recommendations for safe or high quality practice. This may consist of simply stating, “You just broke sterile technique” or “We need to complete a time out before the incision is made.” Sometimes, however, it is not so simple. Occasionally, clinicians work with an individual who violates rules or ignores policies and procedures, despite their coworkers’ best efforts to speak up and correct the behavior. The individual may ignore a reminder to follow the correct procedure or may respond negatively to peer review, saying, “I don’t have time” or “That policy is ridiculous; I know what I am doing.” In this type of situation, coworkers may simply stop speaking up or trying to change behaviors, practices, or attitudes. Ignoring the behavior or accepting it as a normal variation in practice, however, will not result in changes or improvement in practice. Nurses must continue to speak up and collaborate with members of the leadership team to ensure that the best possible care is provided, and in difficult situations, team members may need to work within the chain of command to address a potential safety or quality issue. This could include using resources within the risk management or quality department to help explore strategies. For example, a nurse from a small, rural hospital recently shared her concern about a general surgeon who was performing procedures for which he was not credentialed. She spoke up but the surgeon was not receptive. She then spoke to the department nurse man-
116 • AORN JOURNAL
Patient Safety First
ager, who told her not to cause trouble because the surgeon is a good doctor. The nurse persevered and discussed the issue with the hospital’s risk manager, who addressed the issue with the chief of surgery and the department manager. The surgeon was asked to stop performing certain procedures until he obtained the appropriate credentials.
COMMUNICATING EFFECTIVELY Communication style also can have an effect on positive outcomes when nurses are speaking up for quality. To be more effective, nurses need to be assertive rather than aggressive in their communication style. Also, they should have an explanation for a directive ready—simply telling a coworker, “Don’t do that,” will not have the same positive effect as explaining that washing one’s hands can decrease infection risks. Explaining why there are certain rules and procedures can help increase compliance and cooperation. Speaking up as a professional requires a nurse to be well informed and knowledgeable, doing more than just speaking his or her mind. Speaking up requires knowing and understanding the best practices and scientific rationale. It requires a nurse to be a risk taker and to serve as an advocate for the patient, especially when the patient is unable to speak for himself or herself. Nurses serve an important role when they speak up in efforts to provide expert knowledge about clinical practices that result in safe, effective, and high quality care.
REFERENCES 1. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008. 2. Recommended practices for the prevention of unplanned perioperative hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:407-420. 3. National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/Patient Safety/NationalPatientSafetyGoals/. Accessed May 20, 2008. SUZANNE C. BEYEA PHD, RN, FAAN DIRECTOR OF NURSING RESEARCH DARTMOUTH-HITCHCOCK MEDICAL CENTER LEBANON, NH