Nurses’ systems thinking competency, medical error reporting, and the occurrence of adverse events: a cross-sectional study

Survey on nurse-physician communication gaps focusing on diagnostic concerns and reasons for silence

Diagnosis improvement requires physician-nurse collaboration. This study explored nurses' concerns regarding physicians' diagnoses and how they were communicated to physicians. This cross-sectional study, employing a web-based questionnaire, included nurses registered on Japan's largest online media site from June 26, 2023, to July 31, 2023. The survey inquired whether participants felt concerned about a physician's diagnosis within a month, if they communicated their concerns once they arose, and, if not, their reasons. The reasons for not being investigated were also examined. The nurses' frequency of feeling concerned about a physician's diagnosis and the barriers to communicating these concerns to the physician were evaluated. Overall, 430 nurses answered the survey (female, 349 [81.2%]; median age, 45 [35-51] years; median years of experience, 19 [12-25]). Of the nurses, 61.2% experienced concerns about a physician's diagnosis within the past month; 52.5% felt concerned but did not communicate this to the physician. The most common reasons for not communicating included concern about the physician's pride, being ignored when communicating, and the nurse not believing that a diagnosis should be made. Our results highlight the need to foster psychologically safe workplaces for nurses and create educational programs encouraging nurse involvement in diagnosis.

Implementation of High-Value Care for Physical Therapy Residents Through Systems-Based Practice Curriculum Development: Case Report

BACKGROUND AND PURPOSE

Systems-based practice is a core competency for physical therapy residents, best acquired through experiential learning. Peer health professions are further along than physical therapy in implementing curricula that support systems-based practice. Clinical and practice data in residency programs could provide for education in high-value care (HVC) as a foundation for systems-based practice. Our purpose was to develop and assess a HVC curriculum incorporating reflective practice to help residents achieve competency in systems-based practice.

CASE DESCRIPTION

The Logic Model, which evaluates key components needed for success and sustainability, was used to identify resources for a curriculum in HVC. Two orthopedic physical therapy residents and 5 faculty mentors participated in didactic and mentoring sessions. A practice dashboard for each clinician was developed to facilitate resident-mentor discussions. Focus group input was used to refine the curriculum. The validated Systems Thinking Scale, the Quality Improvement Knowledge Application Tool Rubric, and the American Physical Therapy Association Residency Core Competency Score were used to assess residents' progress and to make comparisons to prior years' residents.

OUTCOMES

The residents demonstrated increases in systems thinking and quality-improvement knowledge and improvements in clinical outcomes and practice efficiencies. Three themes emerged from semistructured interviews: challenges to HVC, current approach in HVC, and future-oriented thinking in HVC in practice.

DISCUSSION AND CONCLUSION

This study demonstrates that HVC activities and a personalized clinical dashboard in a physical therapy residency program can facilitate experiential learning of systems-based practice, a core competency for value-centered, inclusive practice.

Nurses' perceptions of patient safety competency: A cross-sectional study of relationships with occurrence and reporting of adverse events

Although, strengthening patient safety competencies in nursing has been emphasized for enhancing quality care and patient safety. However, little is known about the association of nurses' perceptions of patient safety competency with adverse nurse outcomes in Iranian hospitals. This study aimed to measure nurses' levels of patient safety competency in the hospitals of Iran and examines the relationship between patient safety competency with the occurrence and reporting of adverse events (AEs). This cross-sectional research was applied in eight teaching hospitals in Tehran, Iran, between August and December 2021. A sample of 511 nurses was randomly selected using the table of random numbers. The validated Patient Safety Competency Self-Evaluation questionnaire was used. Furthermore, two questions were used to measure the incidence and reporting of AEs. Data analysis was performed using descriptive statistics, independent t-tests, and two binary logistic regression models through SPSS version 24.0. The mean patient safety competency score was 3.34 (SD = 0.74) out of 5.0; 41.5% of nurses rated their patient safety competency as less than 3. Among subscales, "skills of patient safety" scores were the highest, and "knowledge of patient safety" scores were the lowest. Nurses with higher Knowledge and Attitude scores were less likely to experience the occurrence of AEs (OR = 1.50 and OR = 0.58, respectively). Regarding AEs reporting, nurses with higher Skill and Attitude scores were 2.84 and 1.67 times, respectively, more likely to report AEs (OR = 2.84 and OR = 3.44, respectively). Our results provide evidence that enhancing PSC leads to reduced incidence of AEs and increased nurses' performance in reporting. Therefore, it is recommended that managers of hospitals should enhance the patient safety competency of nurses in incidents and reporting of patient safety adverse outcomes through quality expansion and training. Additionally, researchers should carry out further research to confirm the findings of the current study and identify interventions that would strengthen patient safety competencies and reduce the occurrence of AEs, and rise their reporting among nurses.

Safety Competency: Exploring the Impact of Environmental and Personal Factors on the Nurse's Ability to Deliver Safe Care

BACKGROUND

Patient safety is a priority in health care systems. Nurses' safety competence along with environmental and personal factors plays a role in patient safety.

PURPOSE

The purpose of this study was to explore the relationships among safety competency, structural empowerment, systems thinking, level of education, and certification.

METHODS

A cross-sectional exploratory design was used to collect data from nurses (n = 163) practicing in a large Midwestern hospital system.

RESULTS

There were significant positive correlations between safety competency and ( a ) structural empowerment, ( b ) systems thinking, and ( c ) certification. Systems thinking explained 12.9% of the variance in the knowledge component of safety competency and 6.8% of the variance in the skill component of safety competency. Certification explained 2.4% of the variance in the skill component of safety competency.

CONCLUSIONS

Understanding factors that affect safety competency supports the development of effective interventions that may improve safety.

Concept Analysis of Systems Thinking in the Context of Interprofessional Practice and Improved Patient Outcomes

AIM

The purpose of this study was to explore the definition and application of systems thinking (ST) in interprofessional practice and improved patient outcomes.

BACKGROUND

Nurse educators need a universal definition of ST to implement in curricula to foster quality and safety while enhancing outcomes for nursing students.

METHOD

The QSEN RN-BSN Task Force used the hybrid model of concept analysis to identify the process of fostering ST in clinical and didactic learning experiences and how ST changed over time from the perspective of educators.

RESULTS

The definition of ST in the context of interprofessional practice and outcomes was "a dynamic, analytical process that looks at complex patterns, relationships, and connections within elements and structures, resulting in the ability to recognize the whole picture."

CONCLUSION

The concept of ST in the context of interprofessional practice and improved patient outcomes may be integrated within nursing curricula.

The impact of nurses' perceptions of systems thinking on occurrence and reporting of adverse events: a cross-sectional study

AIMS

To assess systems thinking level and its relationship with occurrence and reporting of adverse events in Iranian nurses.

BACKGROUND

Systems thinking has recently emerged important element of patient safety and quality improvement in health care systems. It helps healthcare professionals to understand the different elements of healthcare systems, the interrelatedness, and interdependencies of these elements in the healthcare systems.

METHODS

This cross-sectional survey was carried out in ten teaching hospitals in Tehran, Iran. A total of 511 nurses were selected using simple random sampling. Systems thinking was measured using the validated Systems Thinking Scale. Data analysis was performed by descriptive analyses, independent t-test, and logistic regression analysis.

RESULTS

The average score for total systems thinking was a mean of 49.45 (SD = 12.10; range 0-80). In total, 67.5% of participants reported the experience of the occurrence of adverse events leading to harm to patients and 65.2% of them responded as having appropriate adverse events reporting behaviors. Nurses who had higher scores in systems thinking were found to be more likely to report adverse events (Odds ratio = 1.07; 95% CI = 1.05 - 1.09), whereas they were less prone to experience adverse events (Odds ratio = 0.97; 95% CI = 0.95 - 0.98).

CONCLUSION

Our results indicated that the nurses' systems thinking level was moderate. Systems thinking had a significant role in preventing the occurrence of adverse events as well as improving the reporting of adverse events. Therefore, it is recommended to enhance the competency of nurses' thinking systems to prevent the occurrence of adverse events and to improve the reporting of adverse events.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers need to focus on the systems thinking weaknesses and the occurrence and the reporting of adverse events in policymaking, practice, and research. Also, systems thinking should be integrated with the health care system for preventing the occurrence of adverse events and improving reporting of adverse events. They should support, lead, and allocate the essential pragmatic strategies and resources for the involvement of all health care members in policymaking.

Safety culture and systems thinking for predicting safety competence and safety performance among registered nurses in Saudi Arabia: a cross-sectional study

BACKGROUND

Medical errors are a worldwide concern and the contribution of nurses' safety competence and performance to these errors is a high priority. It has been over 20 years since the first report of the need to address medical errors. New approaches are needed for enhancing safety competence and performance.

AIMS

This study explored the relationships among systems thinking, educational level, safety culture, safety competence and safety performance among registered nurses working in medical and surgical units in Saudi Arabia.

METHODS

A correlational cross-sectional design with a convenience sample of 84 registered nurses was used.

RESULTS

Systems thinking predicted 16% of safety knowledge (F[2, 81] = 7.61, P = 0.001), while safety culture, baccalaureate education and completion of safety training predicted 19% of safety skill (F[3, 78] = 2.80, P = 0.001). A safety culture that promoted learning from mistakes predicted 15% of safety performance measured based on nurses' self-report of the number of errors in the past 3 months (F[3, 75] = 2.86, P = 0.008).

CONCLUSIONS

Professional development including systems thinking and safety training are the necessary next steps for nurses. In addition, policy changes facilitating organisations to support learning from mistakes will contribute to reducing medical errors.

Nurses' perception of teamwork and its relationship with the occurrence and reporting of adverse events: A questionnaire survey in teaching hospitals

AIMS

To identify the levels of teamwork and its relationship with the occurrence and reporting of adverse events among Iranian nurses.

BACKGROUND

Strengthening teamwork is emphasized worldwide for enhancing quality care and patient safety.

METHODS

This study applied a cross-sectional survey design. A total of 327 Iranian nurses from eight teaching hospitals participated in a self-administered survey using simple random sampling. The Teamwork Perceptions Questionnaire was used to measure the teamwork. The frequency of occurrence and reporting of adverse events were measured with two questions. Data were analysed using descriptive analyses, independent t tests and logistic regression analysis.

RESULTS

The mean teamwork score was 3.81 out of 5. Among the nurses, 48.0% had experienced adverse events in the past 6 months and 79.8% reported having an appropriate performance in adverse events reporting. Teamwork was significantly associated with lower occurrences of adverse events and better adverse events reporting. Specifically, nurses with higher situation monitoring (odds ratio (OR) = 0.47), mutual support (OR = 3.18) and team leadership (OR = 2.09) scores were more likely to report adverse events. Nurses with higher situation monitoring scores were less likely to experience the occurrence of adverse events (OR = 0.38).

CONCLUSIONS

Nurses' perception of teamwork was moderate to high. Teamwork was associated with the occurrence and reporting of adverse events. Further study is needed to identify the effects of teamwork training on the learning outcomes, including teamwork, occurrence and the reporting of adverse events among nurses.

IMPLICATIOS FOR NURSING MANAGEMENT

Nursing managers should consider multiple educational strategies including structured teamwork training to improve staff nurses' teamwork competency. Administrative initiatives and quality improvement projects are needed to increase nurses' performance in the reporting of adverse events through an accreditation process.

Development and Validation of the Systems Thinking Scale

PURPOSE

Systems thinking is the ability to recognize and synthesize patterns, interactions, and interdependencies in a set of activities and is a key component in quality and safety. A measure of systems thinking is needed to advance our understanding of the mechanisms that contribute to improvement efforts. The purpose of this study was to develop and conduct psychometric testing of a systems thinking scale (STS).

METHODS

The development of the STS included obtaining national quality and safety experts' conceptual domains of systems thinking and the generation of a provisional set of items. Further psychometric analyses were conducted with interprofessional healthcare faculty (N = 342) and students (N = 224) engaged in quality improvement initiatives and education.

RESULTS

Of the 26 items identified in the development phase, factor analyses indicated three factors: (1) system thinking (20 items), (2) personal effort (2 items), and (3) reliance on authority (4 items). The six items from factors 2 and 3 were omitted due to low factor loadings. Test-retest reliability of the 20-item STS was performed on 36 healthcare professionals and a correlation of 0.74 was found. Internal consistency testing on a sample of 342 healthcare professionals using Cronbach's alpha showed a coefficient of 0.89. Discriminant validity was confirmed with three groups of healthcare professions students (N = 102) who received high, low, or no dose levels of systems thinking education in the context of process improvement.

CONCLUSIONS

The 20-item STS is a valid and reliable instrument that is easy to administer and takes less than 10 min to complete. Further research using the STS has the potential to advance the science and education of quality improvement in two main ways: (1) increase understanding of a critical mechanism by which quality improvement processes achieve results, and (2) evaluate the effectiveness of our education to improve systems thinking.