Optimizing Situation Awareness to Reduce Emergency Transfers in Hospitalized Children.

BACKGROUND AND OBJECTIVES: Interventions to improve care team situation awareness (SA) are associated with reduced rates of unrecognized clinical deterioration in hospitalized children. By addressing themes from recent safety events and emerging corruptors to SA in our system, we aimed to decrease emergency transfers (ETs) to the ICU by 50% over 10 months. METHODS: An interdisciplinary team of physicians, nurses, respiratory therapists, and families convened to improve the original SA model for clinical deterioration and address communication inadequacies and evolving technology in our inpatient system. The key drivers included the establishment of a shared mental model, psychologically safe escalation, and efficient and effective SA tools. Novel interventions including the intentional inclusion of families and the interdisciplinary team in huddles, a mental model checklist, door signage, and an electronic health record SA navigator were evaluated via a time series analysis. Sequential inpatient-wide testing of the model allowed for iteration and consensus building across care teams and families. The primary outcome measure was ETs, defined as any ICU transfer in which the patient receives intubation, inotropes, or ≥3 fluid boluses within 1 hour. RESULTS: The rate of ETs per 10 000 patient-days decreased from 1.34 to 0.41 during the study period. This coincided with special cause improvement in process measures, including risk recognition before medical response team activation and the use of tools to facilitate shared SA. CONCLUSIONS: An innovative, proactive, and reliable process to predict, prevent, and respond to clinical deterioration was associated with a nearly 70% reduction in ETs.

The Future of Onboarding: Implementation of Immersive Virtual Reality for Nursing Clinical Assessment Training.

An immersive virtual reality curriculum was piloted with new nurse graduates that focused on improving clinical reasoning and situational awareness for pediatric respiratory distress and impending respiratory failure. Learnings from this pilot could inform strategies for development of standardized, efficient, and safe onboarding curricula to increase the likelihood of successful transition to practice.

Safety organizing, emotional exhaustion, and turnover in hospital nursing units.

CONTEXT: Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on how engaging in safety organizing affects caregivers. OBJECTIVES: While we know that organizational processes can have divergent effects on organizational and employee outcomes, little research exists on the effects of pursuing highly reliable performance through safety organizing on caregivers. Specifically, we examined whether, and the conditions under which, safety organizing affects RN emotional exhaustion and nursing unit turnover rates. SUBJECTS: Subjects included 1352 RNs in 50 intensive care, internal medicine, labor, and surgery nursing units in 3 Midwestern acute-care hospitals who completed questionnaires between August and December 2011 and 50 Nurse Managers from the units who completed questionnaires in December 2012. RESEARCH DESIGN: Cross-sectional analyses of RN emotional exhaustion linked to survey data on safety organizing and hospital incident reporting system data on adverse event rates for the year before survey administration. Cross-sectional analysis of unit-level RN turnover rates for the year following the administration of the survey linked to survey data on safety organizing. RESULTS: Multilevel regression analysis indicated that safety organizing was negatively associated with RN emotional exhaustion on units with higher rates of adverse events and positively associated with RN emotional exhaustion with lower rates of adverse events. Tobit regression analyses indicated that safety organizing was associated with lower unit level of turnover rates over time. CONCLUSIONS: Safety organizing is beneficial to caregivers in multiple ways, especially on nursing units with high levels of adverse events and over time.

Situation Awareness and Interruption Handling During Medication Administration.

Medication administration error remains a leading cause of preventable death. A gap exists in understanding attentional dynamics, such as nurse situation awareness (SA) while managing interruptions during medication administration. The aim was to describe SA during medication administration and interruption handling strategies. A cross-sectional, descriptive design was used. Cognitive task analysis (CTA) methods informed analysis of 230 interruptions. Themes were analyzed by SA level. The nature of the stimuli noticed emerged as a Level 1 theme, in contrast to themes of uncertainty, relevance, and expectations (Level 2 themes). Projected or anticipated interventions (Level 3 themes) reflected workload balance between team and patient foregrounds. The prevalence of cognitive time-sharing during the medication administration process was remarkable. Findings substantiated the importance of the concept of SA within nursing as well as the contribution of CTA in understanding the cognitive work of nursing during medication administration.

Building a culture of innovation by maximizing the role of the RN.

By the year 2020, as hospitals morph into entirely different kinds of service providers, nurses too will look altogether different. Those with the capacity to embrace disruptive innovation, along with all the unknowns that accompany it, will be successful at guiding their organizations into the future. Nurse executives must act now to build nursing cultures capable of massive and transformational change--change that will alter the way patient care is perceived, delivered, and evaluated. One hospital system is using a Think Tank approach to pilot demonstration projects that aim to maximize the role of the registered nurse and redefine expectations around patient care delivery. Early work indicates that new thinking combined with "permission to fail" from nursing leadership is essential to success. Lean Six Sigma principles and creativity tools from inside and outside of health care are being adopted with promising results. Exemplars show that by creating a sense of urgency around a big opportunity, this health care system is developing change initiatives that are literally transforming culture.

Understanding situation awareness in nursing work: a hybrid concept analysis.

Eighty percent of medical error are attributed to human factors. Human factors experts suggest the least explored factor in patient errors is attention, specifically, situation awareness. The purpose of this article was to analyze the concept of situation awareness using a hybrid concept analysis. The experience of situation awareness among nurses was elicited during the fieldwork phase through semistructured interviews. Content and relational analyses yielded 9 themes: perception, comprehension, projection, knowledge and expertise, cognitive overload, interruption management, task management, instantaneous learning, and cognitive stacking. A conceptual definition of situation awareness emerged along with recommendations for application in nursing.

Engaging and developing research leaders in practice: creating a foundation for a culture of clinical inquiry.

This article describes the first formative year experience of a research council in a children's hospital within a Magnet-designated hospital system. The vision, transformational leadership structure, and implementation strategies used during the first year of formation of a Nursing Research and Evidence-Based Practice Council (NREBPC) are delineated and reflect Magnet components and sources of evidence (American Nurses Credentialing Center [ANCC], 2008). The use of the nursing excellence framework (ANCC, 2008) coupled with principles of adult learning to expand the knowledge and skills of nurses on the NREBPC are described and examples provided. Initial outcomes in terms of nurses' leadership for research studies and planned documentation of additional metrics that have the potential to improve care through the development of a culture of inquiry are proposed.

Transformational leadership required to design and sustain evidence-based practice: a system exemplar.

In a pay-for-performance environment, implementing and sustaining evidence-based practice (EBP) is no longer a luxury but a necessity. A critical driving force for EBP is that our communities-the people we serve-expect to receive care based on the best available evidence. Transformational nursing leadership is required to create an infrastructure that influences organizational factors, processes and expectations, thus enabling the sustainability of EBP. The American Nurses Credentialing Center and the American Organization of Nurse Executives provide a framework for nursing leaders to consider when designing EBP implementation structures. This exemplar illustrates nursing leadership competencies with regard to implementation and sustainability of EBP within a multihospital system.

Achieving magnet redesignation: a framework for cultural change.

Magnet recognition is the highest award that the ANCC bestows on an institution and exemplifies a hospital's accomplishments in providing commitment, support, and resources for nursing excellence throughout the organization. Magnet hospitals attain their status based on structure and outcome criteria known as the 14 Forces of Magnetism. The authors discuss one hospital's journey and the outstanding models integrated in their organization that paved the way for their first award, followed by their journey toward redesignation.