Most nurses work in hospitals or other acute settings, where they are patients’ primary, professional caregivers and the individuals most likely to intercept medical errors. However, because hospital systems and acute care settings are often complex and chaotic, many nurses spend unnecessary time hunting for supplies, filling out paperwork, and coordinating staff time and patient care, reducing the time they are able to spend with patients and delivering care.
Figure 1.4 Incorporating Institute of Medicine (IOM), Quality and Safety Education for Nurses (QSEN), Interprofessional Education Collaborative (IPEC), and TeamSTEPPS to develop safety competencies.
This public recognition of the complex and essential role nurses have in health also reveals more about that complexity. Increasing nurses’ awareness of quality and safety developed within new science applications will help them recognize quality and safety concerns in their practice and in their settings. Many remain largely unaware of the scope of the problems. Many completed their academic programs before implementation of the QSEN and IPEC competencies and must learn on the job how to identify, report, and systematically analyze a near miss or sentinel event or lead a QI team (Chenot and Christopher, 2019; Yang and Liu, 2021). Nurses have a key role in improvement work because they see the variability in care with results that do not match benchmarks. Two approaches for change are teaching nurses ways to speak up as a change agent and learning measurements to demonstrate gaps in care.
A mindset of inquiry, of asking questions, is the first step in leading system improvements. Openness to be receptive to feedback, willingness to see the consequences of one’s actions, and willingness to change can prompt discussions among staff to examine processes for improvement. Reflective practice is a change process using systematic questions to examine experiences in the context of what one knows and values, other perspectives, and the situational context (see Chapter 12). Asking questions opens the capacity for innovation and the application of evidence‐based practice standards and QI projects.
Developing awareness of their practice empowers nurses to acknowledge repetitive work‐arounds, near misses, and outdated procedures (Yang and Liu, 2021). Nurses need to know what and how to report and ways to initiate discussions for change. Conducting an annual safety culture survey can identify areas for workplace improvement, such as the suite of surveys available from AHRQ, Surveys on Patient Safety Culture (SOPS, https://www.ahrq.gov/sops/index.html). Scorecards, dashboards, and report cards are other useful strategies for collecting and monitoring data about services and care provided in key areas. In academic settings, educators should establish a culture of safety and quality for their own educational processes, such as a reporting system of learner near misses and errors to assess processes and increase safety awareness.
Nurses also need more preparation for engaging patients as active participants in their care and effectively including patients and families in decision‐making. Patients and their families should be informed of all care, with access to information to achieve transparency in the system, and have full disclosure of any safety events.
The more that nurses are empowered with shared decision‐making about creating a work environment where they feel accepted with a sense of belonging, the higher their sense of satisfaction will be. Nurses want to work in organizations known for quality; they want to know that their work has meaning, that it makes a difference. It is this way of meaningful recognition that provides joy and satisfaction, which serve to further inspire good work (www.aacn.org; Lucien Leape Institute, 2013).
Educator Development
Education transformation cannot happen in isolation. The IOM recommendations demand interprofessional learning experiences for both academic (see Chapter 10) and clinical learning situations (see Chapter 12). Slowly education is moving out of silos, with more shared learning opportunities among the many health disciplines with which nurses are expected to work (see Chapter 14). Knowing what each discipline contributes is crucial to high performance and flexible team leadership that works through authority gradients, so that all team members have equal opportunity to share information in establishing patient care goals (see Chapter 5; IPEC, 2016). Education transformation applies to all settings—academic and clinical, and all educational entry programs—to prepare nurses in practice as well as those in academic programs (see Chapter 15).
Multiple resources assist educators in developing what and how to teach (see Chapters 10, 11, and 12). The AACN offered a series of QSEN faculty development workshops and maintains a list of resources on its website. The QSEN institute continues to present an annual national forum in which participants share outcomes and strategies for integrating the QSEN competencies in academic and clinical settings. The QSEN website offers teaching strategies, annotated bibliographies, demonstration projects, videos, learning modules, practice strategies, and a facilitator panel for individual or group assistance. Educators and organizations responsible for accreditation, licensing, and certification of health professionals have embedded the competencies into nursing education standards to help lead transformation of how we prepare students and nurses to be proficient in these competencies, to lead change that will be reflected in future progress reports on patient safety and quality.
Safety Challenges in the COVID‐19 Pandemic
The COVID‐19 pandemic that consumed much of health care and society as well over 2020 and 2021 led to rapid and substantial changes in all types of delivery systems (Fitzsimons, 2021). Anecdotally, many systems report unintended consequences from changes to operating procedures. For example, to try to limit the spread of the virus, many systems eliminated visitors. With no family member to stay with patients who may have confusion or need mobility assistance, the incidence of falls escalated. Nurses and other providers became family surrogates, scheduling daily video calls with anxious family members or providing comfort in the absence of loved ones. These additional expectations on the health care workforce have taken an extreme toll, with many reporting burnout, physical and emotional exhaustion, and stress from constant vigilance to not contract the virus or take it home to their families (Ross, 2020). Effective leadership was a moderator for stress and psychological safety (Zhao et al., 2020).
Still, there were many reports of the satisfaction of being able to meet the challenge and the opportunity to shift roles within the hierarchy. Nurses were on the front lines using skills developed as leaders in quality safety: taking charge of setting up COVID units, monitoring quality and safety data, sifting evidence as it became available to maintain current standards and procedures, leading daily safety briefings and rounds, and joining in countless other contributions that helped to keep patients and environments safe (Staines et al, 2020). Competency in teamwork and collaboration was evident as nurses were included in interprofessional briefings and updates at the center of the action (Carenzo et al., 2020; Tannenbaum xi., 2020).
All areas of health care delivery were impacted, as noted in
