Strengthening the capacity of nursing leaders through multifaceted professional development initiatives: A mixed method evaluation of the 'Take The Lead' program.

BACKGROUND: Effective nursing leadership is necessary for the delivery of safe, high quality healthcare. Yet experience and research tells us that nursing leaders are commonly unprepared for their roles. Take The Lead (TTL), a large-scale, multifaceted professional development program was initiated in New South Wales, Australia, to strengthen the capacity of Nursing/Midwifery Unit Managers (N/MUMs). The aim of this study was to examine the effects of TTL on job performance, nursing leadership and patient experience. METHODS: Nursing/Midwifery Unit Managers (n = 30) and managers of N/MUMs (n = 30) who had completed the TTL program were interviewed between August and December 2010. The semi-structured interviews included a combination of open-ended questions and questions that required respondents to rate statements using a Likert scale. Data from the open-ended questions were thematically analysed to identify and categorise key concepts. The responses to the Likert items were analysed via descriptive statistics. RESULTS: Nursing/Midwifery Unit Managers' participation in TTL engendered improvements in job performance and leadership skills, as well as some improvement in patients' experiences of care. The program facilitated role clarification and helped foster peer-support and learning networks, which were perceived to provide ongoing professional and personal benefits to participants. CONCLUSIONS: Our study revealed a consensus about the beneficial outcomes of TTL among those involved with the program. It supports the significant and ongoing value of widely implemented, multifaceted nursing leadership development programs and demonstrates that participants value their informal interactions as highly as they do the formal content. These findings have implications for delivery mode of similar professional development programs.

Nurses' workarounds in acute healthcare settings: a scoping review.

BACKGROUND: Workarounds circumvent or temporarily 'fix' perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses' use of workarounds in acute care settings. METHODS: A literature assessment was undertaken in 2011-2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses' workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses' conceptualisation and rationalisation of workarounds. RESULTS: The majority of studies examining nurses' workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses' workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, 'being competent', and collegiality influence the implementation of workarounds. CONCLUSION: Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses' individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses' use of workarounds.

Interprofessional learning and practice can make a difference.

Interprofessional learning and practice can be positively self-reinforcing and can promote improved care. Australia is showing leadership in the field of interprofessional collaboration. Changing attitudes to interprofessional collaboration is a key to improving health care. Implementing interprofessional collaboration requires a multifaceted approach, and research to underpin it.

Contested innovation: the diffusion of interprofessionalism across a health system.

OBJECTIVE: Interprofessionalism (IP) has emerged as a new movement in healthcare in response to workforce shortages, quality and safety issues and professional power dynamics. Stakeholders can push for IP (e.g. education providers to the health system) or pull (e.g. the health system to the education provider). Based on innovation theory, we hypothesized that there would be unequal forces within and across stakeholder domains which would work to facilitate or resist IP. The strongest pull pressures would be from the health system and services; push pressures for IP would come from government and higher education; with weaker push forces and levels of resistance, from protectionist professional bodies. SETTING AND PARTICIPANTS: /st> Our model was tested in a geographically bounded health jurisdiction. Information was gathered and analysed via individual (n= 99 participants) and group (n= 372 participants) interviews with stakeholders, and through document analysis. RESULTS: /st> The health system and services exerted the strongest pull in demanding IP. The strongest push factor was individual champions in positions of power. Professional bodies balanced their support of IP competencies with their role as advocates for their individual professions. A weak push factor came from government support for health workforce reform. CONCLUSIONS: /st> Our hypothesis was supported, as were our predictions that the strongest pull would be from the providers and the strongest push from government and higher education. Our original model should be extended to account for contextual factors such as large-scale workplace and professional reform, which worked both for and against, IP.

Can questions of the privatization and corporatization, and the autonomy and accountability of public hospitals, ever be resolved?

Although there is a long-standing international debate concerning the privatization and corporatization of health services, there has been relatively little systematic analysis of the ways these types of reform manifest. We examine the impact of privatization and corporatization on public hospitals, and in particular on hospitals' autonomy and accountability, with two aims: to uncover the key themes in the literature, and to consider implementation issues. The review of 2,319 articles was conducted using content analysis and a discussion of selected key issues. Several major themes appear in the privatization and corporatization literature, including their use as tools in health systems reform, and the role of governments in sponsoring the processes. We show that much of the underlying argument is ideological rather than evidence based. Those who promote versions of privatization or corporatization claim that decreased government involvement in the management of hospitals leads inter alia to benefits such as greater efficiency, better quality services, and increased choice for patients. Those who argue against say that increased privatization leads to deleterious outcomes such as decreased equity, compromised efficiency and poorer quality of care. The evidence is often weak and at times conflicting. Privatization and corporatization are difficult to implement, and at best produce mixed results, and their impact seems to depend more on the motivation of the evaluator than the standard of the results. These debates are of a type that is to a large extent only resolvable ideologically.

Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals.

Incident reporting systems have become a central mechanism of most health services patient safety strategies. In this article we compare health professionals' anonymous, free text responses in an evaluation of a newly implemented electronic incident management system. The professions' answers were compared using classic content analysis and Leximancer, a computer assisted text analysis package. The classic analysis identified issues which differentiated the professions. More doctors commented on lack of feedback following incidents and evaluated the system negatively. More allied health staff found that the system lacked fields necessary to report incidents. More nurses complained incident reporting was time consuming. The Leximancer analysis revealed that while the professions all used the more frequently employed concepts (which described basic components of the reporting system), nurses and allied health shared many additional concepts concerned with actual reporting. Doctors applied fewer and more unique (used only by one profession) concepts when writing about the system. Doctors' unique concepts centred on criticism of the incident management system and the broader implications of safety issues, while the other professions' unique concepts focused on more practical issues. The classic analysis identified specific problems needing to be targeted in ongoing modifications of the system. The Leximancer findings, while complementing the classical analysis results, gave greater insight into professional groups' attitudes that relate to use of the system, e.g. doctors' relatively limited conceptual vocabulary regarding the system was consistent with their lower incident reporting rates. Such professional differences in reaction to healthcare innovations may constrain inter-disciplinary communication and cooperation.

Should patient safety be more patient centred?

In a patient-centred health system the views, experiences and rights of the patient drive the way that care is delivered. There is now an increasing emphasis on patient-centredness as an essential characteristic of safe and high quality care, but to date the involvement of patients in patient safety activities has been limited. The views and priorities of patients are not always valued in safety and quality work, and their perspectives are rarely included in activities such as incident investigation. We propose six areas of action to make patient safety more patient centred and hypothesise that the replacement of industrial safety models with a patient-centred model of safety culture will improve clinicians' ability to engage with safety initiatives.

Analysing the "field" of patient safety employing Bourdieusian technologies.

PURPOSE: This paper aims to analyse the development of patient safety as a field within which patients are peripheral stakeholders. DESIGN/METHODOLOGY/APPROACH: The authors examined the patient safety movement from the perspective of a field in which agents struggle for control over various forms of capital, including economic, social, cultural and symbolic capital. In order to undertake this analysis the authors drew on the literature on errors and patient safety, key inquiries into patient safety, and research conducted with health professionals in New South Wales, Australia. FINDINGS: The patient safety movement has created a heightened sense of awareness of errors and risk across health systems, thereby attracting and creating significant amounts of capital. The authors argue that in the process of struggle to constitute and contain a new field of health, patients and their narratives are rendered vulnerable to appropriation and incorporation. RESEARCH LIMITATIONS/IMPLICATIONS: By considering patient safety from a sociological rather than a technical framework, it is possible to gain new insights into why reducing the levels of medical errors have proven so difficult. PRACTICAL IMPLICATIONS: Improved knowledge of how patient safety operates as a field may contribute to more effective strategies in reducing those types of errors. ORIGINALITY/VALUE: Despite the growth in the number of publications in patient safety there has been only minimal analysis of the field itself, rather than its technical or organisational components. This paper contributes to a new way of conceptualising and enacting patient safety, one that acknowledges the vulnerability of the parties involved, particularly patients.

An overview of clinical governance policies, practices and initiatives.

OBJECTIVE: To map the emergence of, and define, clinical governance; to discuss current best practices, and to explore the implications of these for boards of directors and executives wishing to promote a clinical governance approach in their health services. METHODS: Review and analysis of the published and grey literature on clinical governance from 1966 to 2006. Medline and CINAHL databases, key journals and websites were systematically searched. RESULTS: Central issues were identified in the literature as key to effective clinical governance. These include: ensuring that links are made between health services' clinical and corporate governance; the use of clinical governance to promote quality and safety through a focus on quality assurance and continuous improvement; the creation of clinical governance structures to improve safety and quality and manage risk and performance; the development of strategies to ensure the effective exchange of data, knowledge and expertise; and the sponsoring of a patient-centred approach to service delivery. CONCLUSIONS: A comprehensive approach to clinical governance necessarily includes the active participation of boards and executives in sponsoring and promoting clinical governance as a quality and safety strategy. Although this is still a relatively recent development, the signs are promising.

Promoting safety: longer-term responses of three health professional groups to a safety improvement programme.

PURPOSE: Patient safety has been addressed since 2002 in the health system of New South Wales, Australia via a Safety Improvement Programme (SIP), which took a system-wide approach. The programme involved two-day courses to educate healthcare professionals to monitor and report incidents and analyse adverse events by conducting root cause analysis (RCA). This paper aims to predict that all professions would favour SIP but that their work and educational histories would result in doctors holding the least and nurses the most positive attitudes. Alternative hypotheses were that doctors' relative power and other professions' team-working skills would advantage the respective groups when conducting RCAs. DESIGN/METHODOLOGY/APPROACH: Responses to a 2005 follow-up questionnaire survey of doctors (n = 53), nurses (209) and allied health staff (59), who had participated in SIP courses, were analysed to compare: their attitudes toward the course; safety skills acquired and applied; perceived benefits of SIP and RCAs; and their experiences conducting RCAs. FINDINGS: Significant differences existed between professions' responses with nurses being the most and doctors the least affirming. Allied health responses resembled those of nurses more than those of doctors. The professions' experiences conducting RCAs (number conducted, leadership, barriers encountered, findings implemented) were similar. RESEARCH LIMITATIONS/IMPLICATIONS: Observational studies are needed to determine possible professional differences in the conduct of RCAs and any ensuing culture change that this may be eliciting. PRACTICAL IMPLICATIONS: There is strong professional support for SIPs but less endorsement from doctors, who tend not to prefer the knowledge content and multidisciplinary teaching environment considered optimal for safety improvement education. This is a dilemma that needs to be addressed. ORIGINALITY/VALUE: Few longer-term SIPs' assessments have been realised and the differences between professional groups have not been well quantified. As a result of this paper, benefits of and barriers to conducting RCAs are now more clearly understood.

Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice.

PURPOSE: The purpose of this study is to evaluate the effects of a health system-wide safety improvement program (SIP) three to four years after initial implementation. DESIGN/METHODOLOGY/APPROACH: The study employs multi-methods studies involving questionnaire surveys, focus groups, in-depth interviews, observational work, ethnographic studies, documentary analysis and literature reviews with regard to the state of New South Wales, Australia, where 90,000 health professionals, under the auspices of the Health Department, provide healthcare to a seven-million population. After enrolling many participants from various groups, the measurements included: numbers of staff trained and training quality; support for SIP; clinicians' reports of safety skills acquired, work practices changed and barriers to progress; RCAs undertaken; observation of functioning of teams; committees initiated and staff appointed to deal with adverse events; documentation and computer records of reports; and peak-level responses to adverse events. FINDINGS: A cohort of 4 per cent of the state's health professionals has been trained and now applies safety skills and conducts RCAs. These and other senior professionals strongly support SIP, though many think further culture change is required if its benefits are to be more fully achieved and sustained. Improved information-handling systems have been adopted. Systems for reporting adverse incidents and conducting RCAs have been instituted, which are co-ordinated by NSW Health. When the appropriate structures, educational activities and systems are made available in the form of an SIP, measurable systems change might be introduced, as suggested by observations of the attitudes and behaviours of health practitioners and the increased reporting of, and action about, adverse events. ORIGINALITY/VALUE: Few studies into health systems change employ wide-ranging research methods and metrics. This study helps to fill this gap.

Learning from disasters to improve patient safety: applying the generic disaster pathway to health system errors.

In a previous paper we developed a generic disaster pathway model drawing from disaster inquiries in the space, shipping, aviation, mining, rail and nuclear industries. To test our hypothesis that our generic disaster model can be applied to healthcare errors, we ustilised three exemplar cases featuring different types and sources of errors. We found that it is possible to apply our generic disaster pathway to healthcare errors, and to identify the combination of human, organisational and design risk factors which contribute to the severity and speed at which errors occur. We conclude that error pathways provide a useful tool from which healthcare services can learn to appreciate and potentially circumvent or ameliorate errors, prior to their reaching the no-return threshold.

Cultural and associated enablers of, and barriers to, adverse incident reporting.

AIM: Following the introduction of an electronic Incident Information Management System (IIMS) in New South Wales, Australia, the authors investigated enablers and barriers to the use of IIMS and factors associated with increased, static and decreased reporting rates. METHODOLOGY: An online and paper-based, anonymous survey of 2185 health practitioners collected information about their reporting behaviour and experiences of enablers/barriers: training, system accessibility, ease of use, system security, feedback, perceived value of IIMS and workplace safety culture. FINDINGS: The 79.3% of respondents who reported on IIMS were distinguished from non-reporters by having undertaken IIMS training and evaluating this highly. Users reporting more incidents post-IIMS were more likely than those with static or decreased reporting rates to evaluate their training highly and to have experienced all enablers. Users reporting fewer incidents were least likely to do so. The relative likelihood of the three reporting groups experiencing various enablers was similar. Those most frequently experienced by all groups were system security and accessibility. Barriers most frequently encountered were more culturally embedded-for example, poor workplace safety culture. The 'more' reporting group actually reported most, and the 'static' group least, incidents. LIMITATIONS/IMPLICATIONS: The sample was large but not randomly selected, which limits the generalisability of findings. PRACTICAL IMPLICATIONS: Interventions to increase reporting should target provision of training that endorses and fosters conditions shown to enhance reporting rates. ORIGINALITY: Enablers to incident reporting have been shown to be associated not only with reporting per se but also with changes to reporting patterns and rates.

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.

BACKGROUND: Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited. OBJECTIVE: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP). HYPOTHESIS: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety. DESIGN, SETTING AND PARTICIPANTS: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia. OUTCOME MEASURES: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired. RESULTS: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training. CONCLUSIONS: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.