for weaknesses in the care delivery system that allow errors to occur. When weaknesses are identified, leaders allocate resources to prevent harm. For example, the automated medication dispensing system may be in a hallway on a medical surgical unit. When making rounds, the nurse leader may see that the nurse is interrupted by physicians, patients, visitors, and other staff while obtaining medications from the dispensing system. Nurses on the unit may express concern about this process, which interferes with their ability to concentrate on preparing the medications. The nursing leader may resolve the problem by allocating funds to create a small medication room to house the automated medication dispensing system and minimize distractions.
Commitment to Resilience
Commitment to resilience is the ability to overcome problems, learn from mistakes, and move forward. It allows nurses and clinicians to recover when a serious safety event occurs. Because we are humans, mistakes will happen. Rather than blaming others, nurses in HROs discuss how the error occurred and what can be done to prevent such an error in the future. Transparency is essential; errors are openly discussed and used to improve health care processes. In HROs, nurses learn to perform quick situational assessments when an error occurs, work as a team to contain or manage the error, and then take steps to reduce the harm.
In HROs, clinicians are offered support when they are involved in a safety event. Nurses and other clinicians feel guilty when they make an error that harms a patient. The term “Second Victim” is used to describe the pain and anguish experienced by the clinician (Wu, 2000). Programs have been developed to assist clinicians to build resilience and recover from these safety events. The forYOU program (Scott, 2015) is an evidence‐based second victim intervention that provides immediate emotional and social support. Members of the forYOU team provide emotional support using three levels: local support from a colleague, support from specially trained peers, and support through a network of chaplains, social workers, and employee assistance programs. Resources that help build resilient nurses are also available through the Academy of Medical‐Surgical Nurses (n.d.) and the American Association of Critical Care Nurses (2014).
Simulation learning is used in HROs to practice responses to errors or safety events. Drills for environmental disasters, active threats, rapid responses, and cardiopulmonary resuscitation allow nurses and other clinicians to practice as an interprofessional team and build resilience for emergency situations (Figure 4.3).
Source: Used with permission.
Deference to Expertise
Deference to expertise acknowledges that collective knowledge is better than the proficiency of one individual. This allows a team to recognize and use the unique skills of everyone involved. HROs minimize the authority gradient and hierarchy so that everyone feels comfortable about speaking up. Authority gradients exist in nursing and in other health care professions. Consider the difference in perceived authority between direct care nurses, nurse managers, nurse directors, and the Chief Nursing Officer (CNO). Hierarchy also exists in health care settings and refers to the perceived level of power across groups. Consider, for example, the perceived power for a housekeeper compared to a direct care nurse, or a direct care nurse and a physician. Health care has been and remains hierarchical. Physicians have been historically viewed as the “captain of the ship,” with nurses and other clinicians viewed as less powerful.
Regardless of authority gradient, or hierarchy, deference to expertise stipulates that team members with the most expertise about the issue have the authority to make decisions. In an HRO, decisions about nursing practice are informed by and driven by practicing nurses rather than by the CNO or by physicians. Deference to expertise also requires open communication with information flowing in all directions among all team members.
Real World Interview
When nursing staff is asked the question “what can leadership improve upon?”, the answer is often related to communication and education with respect to change. While safe staffing ratios are vitally important, adverse safety events and job dissatisfaction may come from implementing a new process, device, or expectations without properly notifying or educating staff. Providing up‐to‐date information—even laying the framework to changes or potential concerns coming in the future, can help nurses adapt to and implement changes quickly.
We love our unit newsletter because it allows us to look at where we are and where we are going while always keeping safety in the front of our minds. It is a collaborative effort between the educators, management, infection control, and various other departments (like pharmacy and the vascular team). Fun articles celebrating employee birthdays, anniversaries, and humor segments along with unit pride pieces help make the newsletter fun to read as well as educational. Creating a graph of catheter‐associated urinary tract infections (CAUTI) rates has been largely unsuccessful in convincing nurses of the importance of HAIs. Writing a short article on the number of CAUTIs the hospital has had for the month and on which units they occurred gets everybody talking about the problem. It's a different spin on the same material. The hope is that in combination with staff meetings, education sessions, huddle alerts, updated intranet splash pages, and other communication strategies, we are bombarding our staff with information to keep their patients—and themselves—SAFE. When we are consistently safe, we improve patient outcomes and nurses are more engaged in their work and their hospital.
Bonny Dieter, MS, RN, CMSRN
Clinical Leader and Creator of PMU Newsletter
Pulmonary Medicine Unit
Edward Hospital
Naperville, IL Figures and
Source: Bonny Dieter.
Nursing's Role in High Reliability Organizations
Every nurse, at every level of the organization, plays a role in an organization's journey toward high reliability. Each nurse and each member of the interprofessional health care team must be committed to high reliability. Direct Care nurses are essential in HROs. While many contributing factors lead to errors, an actual error occurs when the nurse or another clinician interacts with the patient, at the “sharp end” of care. The nurse is often the last line of defense against health care errors. As such, the nurse must be cognizant of personal behaviors to enhance safety and communication techniques that can be helpful in preventing errors and patient harm.
However, individual actions are not sufficient. Committed nurse leaders are needed to implement system changes that are essential for becoming an HRO. In collaboration with other organizational leaders, nurse leaders are accountable for the provision of effective and efficient care while protecting the safety of patients, employees, and visitors. Leadership's failure to create an effective safety culture is a contributing factor for many types of adverse events (The Joint Commission, 2018a, 2018b, 2018c). Shaping an organization
