Teamwork—that is, collaboration and communication—is an important factor for safe healthcare, but professions perceive the quality of teamwork differently.
To examine the relationship between simulation-based team training (SBTT) and different professions’ self-efficacy, experienced quality of collaboration and communication, perceptions of teamwork and safety, together with staff turnover.
All staff (n=151; physicians, nurses and nurse assistants) in an intensive care unit (ICU) at a university hospital were systematically trained over 2 years. Data on individual self-efficacy were measured using the self-efficacy questionnaire; the experienced quality of collaboration and communication, teamwork climate, safety climate and perception of working conditions were sampled using the ICU version of the safety attitudes questionnaire (SAQ). Staff turnover and sick leave was measured using the hospital's staff administration system for the intervention ICU and a control ICU in the same hospital.
The perception of safety differed between professions before training. Nurses’ and physicians’ mean self-efficacy scores improved, and nurse assistants’ perceived quality of collaboration and communication with physician specialists improved after training. Nurse assistants’ perception of the SAQ factors teamwork climate, safety climate and working conditions were more positive after the project as well as nurses’ perception of safety climate. The number of nurses quitting their job and nurse assistants’ time on sick leave was reduced in comparison to the control ICU during the study period.
Results for SAQ factors must be interpreted with caution given that Cronbach's α and inter-correlations for the SAQ factors showed lower values than benchmarking data.
All team members benefited from the SBTT in an authentic composed team, but this was expressed differently for the respective professions.
Team training; Crew resource management; Critical care; Safety culture; Simulation
A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.
Key Words: teamwork; nursing autonomy; interprofessional working; quality of care
The traditional role of the acute care staff nurse is changing. The new norm
establishes an expectation that staff nurses base their practice on best
evidence. When evidence is lacking, nurses are charged with using the research
process to generate and disseminate new knowledge. This article describes the
critical forces behind the transformation of this role and the organizational
mission, culture, and capacity required to support practice that is based on
science. The vital role of senior nursing leaders, the nurse researcher, and the
nursing research committee within the context of a collaborative governance
structure is highlighted. Several well-known, evidence-based practice models are
presented. Finally, there is a discussion of the infrastructure created by
Yale-New Haven Hospital to advance the scholarly work of the nursing staff.
acute care hospital; clinical setting; evidence-based practice; nursing; research; staff nurse
Communication and teamwork failures are a common cause of adverse events. Residency programs, with a mandate to teach systems-based practice, are particularly challenged to address these important skills.
To develop a multidisciplinary teamwork training program focused on teaching teamwork behaviors and communication skills.
Internal medicine residents, hospitalists, nurses, pharmacists, and all other staff on a designated inpatient medical unit at an academic medical center.
We developed a 4-h teamwork training program as part of the Triad for Optimal Patient Safety (TOPS) project. Teaching strategies combined didactic presentation, facilitated discussion using a safety trigger video, and small-group scenario-based exercises to practice effective communication skills and team behaviors. Development, planning, implementation, delivery, and evaluation of TOPS Training was conducted by a multidisciplinary team.
We received 203 evaluations with a mean overall rating for the training of 4.49 ± 0.79 on a 1–5 scale. Participants rated the multidisciplinary educational setting highly at 4.59 ± 0.68.
We developed a multidisciplinary teamwork training program that was highly rated by all participating disciplines. The key was creating a shared forum to learn about and discuss interdisciplinary communication and teamwork.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0793-8) contains supplementary material, which is available to authorized users.
teamwork; communication; patient safety; multidisciplinary; hospital
Background: Despite the emphasis on patient safety in health care, few organizations have evaluated the extent to which safety is a strategic priority or their culture supports patient safety. In response to the Institute of Medicine's report and to an organizational commitment to patient safety, we conducted a systematic assessment of safety at the Johns Hopkins Hospital (JHH) and, from this, developed a strategic plan to improve safety. The specific aims of this study were to evaluate the extent to which the culture supports patient safety at JHH and the extent to which safety is a strategic priority.
Methods: During July and August 2001 we implemented two surveys in disparate populations to assess patient safety. The Safety Climate Scale (SCS) was administered to a sample of physicians, nurses, pharmacists, and other ICU staff. SCS assesses perceptions of a strong and proactive organizational commitment to patient safety. The second survey instrument, called Strategies for Leadership (SLS), evaluated the extent to which safety was a strategic priority for the organization. This survey was administered to clinical and administrative leaders.
Results: We received 395 completed SCS surveys from 82% of the departments and 86% of the nursing units. Staff perceived that supervisors had a greater commitment to safety than senior leaders. Nurses had higher scores than physicians for perceptions of safety. Twenty three completed SLS surveys were received from 77% of the JHH Patient Safety Committee members and 50% of the JHH Management Committee members. Management Committee responses were more positive than Patient Safety Committee, indicating that management perceived safety efforts to be further developed. Strategic planning received the lowest scores from both committees.
Conclusions: We believe this is one of the first large scale efforts to measure institutional culture of safety and then design improvements in health care. The survey results suggest that strategic planning of patient safety needs enhancement. Several efforts to improve our culture of safety were initiated based on these results, which should lead to measurable improvements in patient safety.
Communication and teamwork problems are leading causes of documented preventable adverse outcomes in perinatal care. An essential component of perinatal safety is the organizational culture in which clinicians work. Clinicians’ individual and collective authority to question the plan of care and take action to change the direction of a clinical situation in the patient’s best interest can be viewed as their “agency for safety.” However, collective agency for safety and commitment to support nurses in their advocacy role is missing in many perinatal care settings. This paper draws from Organizational Accident Theory, High Reliability Theory, and Symbolic Interactionism to describe the nurse’s role in maintaining safety during labor and birth in acute care settings, and suggests actions for supporting the perinatal nurse at individual, group, and systems levels to achieve maximum safety in perinatal care.
Patient safety; Perinatal nursing; High reliability
Safety activities have been initiated at many hospitals in Taiwan, but little is known about the safety culture at these hospitals. The aims of this study were to verify a safety culture survey instrument in Chinese and to assess hospital safety culture in Taiwan.
The Taiwan Patient Safety Culture Survey was conducted in 2008, using the adapted Safety Attitude Questionnaire in Chinese (SAQ-C). Hospitals and their healthcare workers participated in the survey on a voluntary basis. The psychometric properties of the five SAQ-C dimensions were examined, including teamwork climate, safety climate, job satisfaction, perception of management, and working conditions. Additional safety measures were asked to assess healthcare workers' attitudes toward their collaboration with nurses, physicians, and pharmacists, respectively, and perceptions of hospitals' encouragement of safety reporting, safety training, and delivery delays due to communication breakdowns in clinical areas. The associations between the respondents' attitudes to each SAQ-C dimension and safety measures were analyzed by generalized estimating equations, adjusting for the clustering effects at hospital levels.
A total of 45,242 valid questionnaires were returned from 200 hospitals with a mean response rate of 69.4%. The Cronbach's alpha was 0.792 for teamwork climate, 0.816 for safety climate, 0.912 for job satisfaction, 0.874 for perception of management, and 0.785 for working conditions. Confirmatory factor analyses demonstrated a good model fit for each dimension and the entire construct. The percentage of hospital healthcare workers holding positive attitude was 48.9% for teamwork climate, 45.2% for perception of management, 42.1% for job satisfaction, 37.2% for safety climate, and 31.8% for working conditions. There were wide variations in the range of SAQ-C scores in each dimension among hospitals. Compared to those without positive attitudes, healthcare workers with positive attitudes to each SAQ dimension were more likely to perceive good collaboration with coworkers, and their hospitals were more likely to encourage safety reporting and to prioritize safety training programs (Wald chi-square test, p < 0.001 for all).
Analytical results verified the psychometric properties of the SAQ-C at Taiwanese hospitals. The safety culture at most hospitals has not fully developed and there is considerable room for improvement.
To investigate how nurses and physicians perceive organizational culture, their integration into the organizational processes, and relations within a health care team.
We performed a cross-sectional study that included 106 physicians and 558 nurses from 14 Slovenian hospitals in December 2005. The hospitals were randomly selected. We distributed the questionnaires on the same day to physicians and nurses during a morning shift. The total number of distributed questionnaires represented a 20% of each personnel category at each hospital. The following variables were studied: organizational culture, integration of nurses and physicians in hospital processes, and subordination of nurses to physicians.
Physicians and nurses favored a culture of internal focus, stability, and control. Both groups estimated that they had a low level of personal involvement in their organizations and indicated insufficient involvement in work teams, while nurses also thought that they were subordinated to physicians (mean ± standard deviation, 3.6 ± 0.9 on a scale from 1 to 5) more than physicians thought so (2.7 ± 1.0; P<0.001). Control orientation correlated positively with the subordination of nurses (P<0.005) and negatively with personal integration in an organization (P<0.005).
We found out that subordination of nurses can be explained by market culture, level of personal involvement, and the level of education. Our research showed that the professional growth of nurses was mainly threatened by organizational factors such as hierarchy, control orientation, a lack of cooperation and team building between physicians and nurses, as well as insufficient inclusion of both physicians and nurses into change implementation activities.
The arrival of a computerized medical information system on the health care scene has created new performance demands on nurses. Not only must nurses be able to use the computer to document medical and nursing care, but they must be able to contribute to the overall design of the nursing data base. This paper describes how nurses must be educated to perform these new job responsibilities. Discussion will center on the educational process developed by the Clinical Center at the National Institutes of Health to meet the needs of its nurses to design a nursing data base and learn the technical skill required to utilize a computerized medical information system. Recommendations are offered to the academic community charged with the formal education of nursing professionals and the staff development and continuing educational planners who share the accountability for educating the already licensed nurses.
To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture.
Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control).
A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop.
Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeated-measures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture.
A statistically significant improvement in one of three safety culture measures was shown for the study group (p<.001) and a significant decline was seen on one of the safety culture measures for the control group (p<.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R2 for the three full hierarchical regression models ranged from 0.338 and 0.554.
Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.
Patient safety; safety culture; leadership; training intervention
Purpose: Although nursing homes (NHs) are criticized for offering poor quality continence care, little is known about the organizational processes that underlie this care. This study investigated the influence of organizational culture on continence care practices in two NHs. Design and Methods: This ethnographic study explored continence care from the perspectives of NH stakeholders, including residents and interdisciplinary team members. Data were collected through participant observation, interviews, and archival records. Results: Human relations dimensions of organizational culture influenced continence care by affecting institutional missions, admissions and hiring practices, employee tenure, treatment strategies, interdisciplinary teamwork, and group decision making. Closed system approaches, parochial identity, and an employee focus stabilized staff turnover, fostered evidence-based practice, and supported hierarchical toileting programs in one facility. Within a more dynamic environment, open system approaches, professional identity, and job focus allowed flexible care practices during periods of staff turnover. Neither organizational culture fully supported interdisciplinary team efforts to maximize the bladder and bowel health of residents. Implications: Organizational culture varies in NHs, shaping the continence care practices of interdisciplinary teams and leading to the selective use of treatments across facilities. Human relations dimensions of organizational culture, including open or closed systems, professional or parochial identity, and employee or job focus are critical to the success of quality improvement initiatives. Evidence-based interventions should be tailored to organizational culture to promote adoption and sustainability of resident care programs.
Organizational culture; Incontinence; Interdisciplinary teams; Qualitative research
Data from a two-wave panel study of staff nurses in two hospitals are used to assess the relative importance of several types of independent variables as determinants of job satisfaction. Both organizational and nonorganizational determinants are examined, with the formed including both perceptual and structural measures. Job satisfaction is measured in two ways using both Overall and Multi-Facet indicators. The independent variables were measured five months before the dependent variables were measured in order to attenuate contamination problems. Findings indicate that perceptions of job and nursing unit attributes, particularly autonomy and task delegation, predict satisfaction most strongly. In addition, a nurse's own characteristics are found to be more important than either structural attributes of nursing units or job characteristics in predicting job satisfaction.
Although teamwork is known to optimise good health care, organisational arrangements and funding models can foster, discourage, or preclude functional teamworking. Despite a new, enhanced population-based funding system for primary care in New Zealand, bringing new opportunities for more collaborative practice, fully implemented healthcare teamwork remains elusive.
To explore perceptions of interprofessional relationships, teamwork, and collaborative patient care in New Zealand primary care practice.
Design of study
Eighteen nurses and doctors working in primary care, Wellington, New Zealand.
Data were collected using in-depth interviews with individual nurses and doctors working in primary care settings. Perceptions of, and attitudes about, interprofessional relationships, teamwork, and collaborative patient care were explored, using an interactive process of content analysis and principles of naturalistic enquiry.
Nurses and doctors working in New Zealand primary care perceive funding models that include fee-for-service, task-based components as strongly discouraging collaborative patient care. In contrast, teamwork was seen to be promoted when health services, not individual practitioners, were bulk-funded for capitated healthcare provision. In well-organised practices, where priority was placed on uninterrupted time for meetings, open communication, and interprofessional respect, good teamwork was more often observed. Salaried practices, where doctors and nurses alike were employees, were considered by some interviewees to be particularly supportive of good teamwork. Few interviewees had received, or knew of, any training to work in teams.
Health system, funding, and organisational factors still act as significant barriers to the successful implementation of, and training for, effective teamwork in New Zealand primary care settings, despite new opportunities for more collaborative ways of working.
primary health care; New Zealand; teamwork
To examine the effects of nurse, infant, and organizational factors on delivery of collaborative and evidence-based pain care by nurses.
Two Level III neonatal intensive care units in 2 large tertiary care centers in Canada.
A convenience sample of 93 nurses completed survey data on procedures they performed on ill neonates. The 93 nurses performed a total of 170 pain producing procedures on 2 different shifts.
Nurse use of evidence-based protocols to manage procedure related pain using a scorecard of nurses’ assessment, management, and documentation.
Procedural pain care was more likely to meet evidence-based criteria when nurse participants rated nurse-physician collaboration higher (odds ratio, 1.44; 95% confidence intervals 1.05–1.98), cared for higher care intensity infants (odds ratio, 1.21; 95% confidence intervals, 1.06–1.39), and experienced unexpected increases in work assignments (odds ratio, 1.55; 95% confidence intervals, 1.04–2.30). Nurses’ knowledge about the protocols, educational preparation and experience were not significant predictors of evidence-based care for the most common procedures: heel lance and intravenous initiation.
Nurse-physician collaboration and nurses’ work assignments were more predictive of evidence-based care than infant and nurse factors. Nurses’ knowledge regarding evidence-based care was not a predictor of implementation of protocols. In the final statistical modeling, collaboration with physicians, a variable amenable to intervention and further study, emerged as a strong predictor. The results highlight the complex issue of translating knowledge to practice, however, specific findings related to pain assessment and collaboration provide some direction for future practice and research initiatives.
evidenced-based; neonatal procedural pain; nurses; nurse-physician collaboration; knowledge transfer
Goals of health care are patient safety and quality patient outcomes. Evidence based practice (EBP) is viewed as a tool to achieve these goals. Health care providers strive to base practice on evidence, but the literature identifies numerous challenges to implementing and sustaining EBP in nursing. An initial focus is developing an organizational culture that supports the process for nursing and EBP. An innovative strategy to promote a culture of EBP was implemented in a tertiary center with 152 critical care beds and numerous specialty units with diverse patient populations. A multi-disciplinary committee was developed with the goal to use evidence to improve the care in the critical care population. EBP projects were identified from a literature review. This innovative approach resulted in improved patient outcomes and also provided a method to educate staff on EBP. The committee members have become advocates for EBP and serve as innovators for change to incorporate evidence into decision making for patient care on their units.
Evidence based practice; quality; multi-disciplinary teams; critical care nursing
This study aimed to determine the perception and level of safety satisfaction of staff nurses with regards to Occupational Safety and Health (OSH) management practice in the Sabah Health Department, and to associate the OSH management dimensions, to Safety Satisfaction and Safety Feedback.
A cross-sectional study using a validated self-administered questionnaire was conducted among randomly respondents.
135 nurses responded the survey. Mean (SD) score for each dimension ranged from 1.70 ± 0.68–4.04 ± 0.65, with Training and Competence dimension (mean [SD], 4.04 ± 0.65) had the highest while Safety Incidence was the least score (mean [SD], 1.70 ± 0.68). Both mean (SD) scores for Safety Satisfaction and Safety Feedback was high, 3.28 ± 0.51 and 3.57 ± 0.73, respectively. Pearson’s correlation analysis indicated that all OSH dimensions had significant correlation with Safety Satisfaction and Safety Feedback (r coefficient ranged from 0.176–0.512) except for Safety Incidence.
The overall perception of OSH management was rather low. Significant correlation between Safety Satisfaction and Safety Feedback and several dimensions, suggest that each organization to put in place the leaders who have appropriate leadership and supervisory skills and committed in providing staff training to improve staff’s competency in OSH practice. In addition, clear goals, rules, and reporting system will help the organization to implement proper OSH management practice.
hospital administration; nurses; occupational health; safety management; workplace
Voluntary nurse turnover, which is costly and disrupts patient care, has not been studied as an organizational phenomenon within substance abuse treatment organizations. In this exploratory study, we examined the frequency and correlates of nurse turnover within treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network (CTN). During face-to-face interviews conducted in 2005–2006, 215 program administrators reported the number of nurses currently employed. Leaders of programs with nursing staff then described the number of nurses who had voluntarily quit in the past year, the degree to which filling vacant nursing positions was difficult, and the average number of days to fill a vacant position. About two-thirds of these programs had at least one nurse on staff. In programs with nurses, the average rate of voluntary turnover was 15.0%. Turnover was significantly lower in hospital-based programs and programs offering adolescent treatment, but higher in facilities offering residential treatment. The majority of administrators indicated that filling vacant nurse positions was difficult and took more than two months to complete. These findings suggest that nurse turnover is a significant issue facing many substance abuse treatment facilities. Efforts to improve retention of the addiction treatment workforce should be expanded to include nursing professionals.
Nursing; turnover; workforce retention; substance abuse treatment
This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.
focus group; demand; supply; nursing home care; public policy; community-based needs; China
Within a single district health authority all the general practitioners and community registered general nurses were asked to complete a questionnaire regarding awareness and perceptions of a domiciliary hospice service. Responses were received from 127 doctors (71%) and 58 nurses (80%). Awareness of resources offered by the domiciliary hospice service was high, especially among the 102 respondents with access to the service. Eighty per cent or more of general practitioners and community nurses were satisfied with the amount of information received concerning changes in the patient's condition and who was involved in the care process. However, 33% of nurses agreed that it was difficult to know who had overall responsibility for the patient's care and 28% of nurses felt that their own contribution was under-rated. These findings were reinforced by a number of written statements submitted by the nurses. There was a desire expressed by both general practitioners and community nurses for more educational input from the domiciliary service. Overall, assistance from the service was welcomed and its special skills acknowledged. In the future planning of a comprehensive hospice service the differing needs expressed by doctors and nurses should be taken into account.
Adequate nutritional support is important for the comprehensive management of patients in intensive care units (ICUs).
The study was aimed to survey prevalent enteral nutrition practices in the trauma intensive care unit, nurses’ perception, and their knowledge of enteral feeding.
The study was conducted in the ICU of a level 1 trauma center, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India. The study design used an audit.
Materials and Methods:
Sixty questionnaires were distributed and the results analyzed. A database was prepared and the audit was done.
Forty-two (70%) questionnaires were filled and returned. A majority (38) of staff nurses expressed awareness of nutrition guidelines. A large number (32) of staff nurses knew about nutrition protocols of the ICU. Almost all (40) opined enteral nutrition to be the preferred route of nutrition unless contraindicated. All staff nurses were of opinion that enteral nutrition is to be started at the earliest (within 24–48 h of the ICU stay). Everyone opined that the absence of bowel sounds is an absolute contraindication to initiate enteral feeding. Passage of flatus was considered mandatory before starting enteral nutrition by 86% of the respondents. Everyone knew that the method of Ryle's tube feeding in their ICU is intermittent boluses. Only 4 staff nurses were unaware of any method to confirm Ryle's tube position. The backrest elevation rate was 100%. Gastric residual volumes were always checked, but the amount of the gastric residual volume for the next feed to be withheld varied. The majority said that the unused Ryle's tube feed is to be discarded after 6 h. The most preferred (48%) method to upgrade their knowledge of enteral nutrition was from the ICU protocol manual.
Information generated from this study can be helpful in identifying nutrition practices that are lacking and may be used to review and revise enteral feeding practices where necessary.
Enteral nutrition; intensive care; nursing; tube feeding
The behaviour of individuals is affected by the social networks in which they are embedded. Networks are also important for the diffusion of information and the influence of employees in organisations. Yet, at the moment little is known about the social networks of nursing staff in healthcare settings. This is the first study that investigates informal communication and advice networks of nursing staff in long-term care. We examine the structure of the networks, how they are related to the size of units and characteristics of nursing staff, and their relationship with job satisfaction.
We collected social network data of 380 nursing staff of 35 units in group projects and psychogeriatric units in nursing homes and residential homes in the Netherlands. Communication and advice networks were analyzed in a social network application (UCINET), focusing on the number of contacts (density) between nursing staff on the units. We then studied the correlation between the density of networks, size of the units and characteristics of nursing staff. We used multilevel analyses to investigate the relationship between social networks and job satisfaction of nursing staff, taking characteristics of units and nursing staff into account.
Both communication and advice networks were negatively related to the number of residents and the number of nursing staff of the units. Communication and advice networks were more dense when more staff worked part-time. Furthermore, density of communication networks was positively related to the age of nursing staff of the units. Multilevel analyses showed that job satisfaction differed significantly between individual staff members and units and was influenced by the number of nursing staff of the units. However, this relationship disappeared when density of communication networks was added to the model.
Overall, communication and advice networks of nursing staff in long-term care are relatively dense. This fits with the high level of cooperation that is needed to provide good care to residents. Social networks are more dense in small units and are also shaped by characteristics of staff members. The results furthermore show that communication networks are important for staff's job satisfaction.
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
Cross sectional surveys.
Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
Main outcome measures:
Perceptions of error, stress, and teamwork.
Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
Objective: We explored nurses' experiences when they encounter patients from cultures other than their own and their perception of what helps them deliver culturally competent care.
Methods: Registered nurses from all shifts and units at Kaiser Permanente Santa Clara Medical Center were invited to complete a questionnaire. Within the time frame allowed, 111 nurses participated by returning completed questionnaires.
A descriptive survey was conducted using a questionnaire that contained multiple-choice, fill-in-the-blank, and open-ended items.
Results: A large majority of respondents reported that they drew on prior experience, including experience with friends and family, and through their education and training, and more than half also included travel experience and information obtained through the Internet and news media. They also expressed a desire for more training and continuing education, exposure to more diverse cultures, and availability of more interpreters. When respondents were asked to enumerate the cultures from which their patients have come, their answers were very specific, revealing that these nurses understood culture as going beyond ethnicity to include religious groups, sexual orientation, and social class (eg, homeless).
Discussion: Our research confirmed our hypothesis that nurses are drawing heavily on prior experience, including family experiences and experiences with friends and coworkers from different cultures. Our findings also suggest that schools of nursing are providing valuable preparation for working with diverse populations. Our research was limited to one geographic area and by our purposeful exclusion of a demographic questionnaire. We recommend that this study be extended into other geographic areas. Our study also shows that nurses are drawing on their experiences in caring for patients from other cultures; therefore, we recommend that health care institutions consider exposing not only nurses but also other health care professionals to different cultures by creating activities that involve community projects in diverse communities, offering classes or seminars on different cultures and having an active cultural education program that would reach out to nurses. The experiences provided by such activities and programs would help nurses become more sensitive to the differences between cultures and not immediately judge patients or make assumptions about them.
Adverse events that place patients at risk for harm are common in intensive care units. Clinicians’ level of knowledge and judgment appear to play a role in the prevention, mitigation, and creation of adverse advents. Research suggests a possible association between nurses’ specialty certification and clinical expertise. The relationship between specialty certification and clinical competence of registered nurses and safety of patients is a relatively new area of inquiry in nursing.
To explore the relationship between the proportion of certified staff nurses in a unit and risk of harm to patients.
Hierarchical linear modeling was used in a secondary data analysis of 48 intensive care units from a random sample of 29 hospitals to examine the relationships between unit certification rates, organizational nursing characteristics (magnet status, staffing, education, and experience), and rates of medication administration errors, falls, skin breakdown, and 3 types of nosocomial infections. Medicare case mix index was used to adjust for patient risk.
Unit proportion of certified staff registered nurses was inversely related to rate of falls, and total hours of nursing care was positively related to medication administration errors. The mean number of years of experience of registered nurses in the unit was inversely related to frequency of urinary tract infections; however, the small sample size requires that caution be exercised when interpreting results.
Specialty certification and competence of registered nurses are related to patients’ safety. Further research on this relationship is needed.
Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules.
Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews.
Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines.
Conclusions: While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.