Nurse Sensemaking for Responding to Patient and Family Safety Concerns

Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: A factorial survey experiment

AIM

To test the influences of patient, safety event and nurse characteristics on nurse judgements of credibility, importance and intent to report patients' safety concerns.

DESIGN

Factorial survey experiment.

METHODS

A total of 240 nurses were recruited and completed an online survey including demographic information and responses to eight factorial vignettes consisting of unique combinations of eight patient and event factors. Hierarchical multivariate analysis was used to test influences of vignette factors and nurse characteristics on nurse judgements.

RESULTS

The intraclass coefficients for nurse judgements suggest that the variation among nurses exceeded the influence of contextual vignette factors. Several significant sources of nurse variation were identified, including race/ethnicity, suggesting a complex relationship between nurses' characteristics and their potential biases, and the influence of personal and patient factors on nurses' judgements, including the decision to report safety concerns.

CONCLUSION

Nurses are key players in the system to manage patient safety concerns. Variation among nurses and how they respond to scenarios of patient safety concerns highlight the need for nurse-level intervention.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Complex factors influence nurses' judgement, interpretation and reporting of patients' safety concerns.

IMPACT

Understanding nurse judgement regarding patient-expressed safety concerns is critical for designing processes and systems that promote reporting. Multiple event and patient characteristics (type of event and apparent harm, and patient gender, race/ethnicity, socioeconomic status, and communication approach) as well as participant characteristics (race/ethnicity, gender, years of experience and primary hospital area) impacted participants' judgements of credibility, degree of concern and intent to report. These findings will help guide patient safety nurse education and training.

REPORTING METHOD

STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Members of the public, including patient advocates, were involved in content validation of the vignette scenarios, norming photographs used in the factorial survey and testing the survey functionality.

Increasing a patient's sense of security in the hospital: A theory of trust and nursing action

Having a decreased sense of security leads to unnecessary suffering and distress for patients. Establishing trust is critical for nurses to promote a patient's sense of security, consistent with trauma-informed care. Research regarding nursing action, trust, and sense of security is wide-ranging but fragmented. We used theory synthesis to organize the disparate existing knowledge into a testable middle-range theory encompassing these concepts in hospitals. The resulting model illustrates how individuals are admitted to the hospital with some predisposition to trust or mistrust the healthcare system and/or personnel. Patients encounter circumstances increasing their emotional and/or physical vulnerability to harm, leading to experiences of fear and anxiety. Without intervention, fear and anxiety lead to a decreased sense of security, increased distress, and suffering. Nurse action can ameliorate these effects by increasing a hospitalized person's sense of security or by promoting the development of interpersonal trust, also leading to an increased sense of security. Increased sense of security results in diminished anxiety and fear, and increased hopefulness, confidence, calm, sense of value, and sense of control. The consequences of a decreased sense of security are harmful to patients and nurses should know that they can intervene in ways that both increase interpersonal trust and sense of security.

Patient Voices in Hospital Safety during the COVID-19 Pandemic

Hospitalized patients and their families may be reluctant to express safety concerns. We aimed to describe safety and quality concerns experienced by hospitalized patients and families and factors and outcomes surrounding decisions about voicing concerns, including those related to the COVID-19 pandemic. We conducted semi-structured interviews with 19 discharged inpatients or family members in a qualitative descriptive design. Some participants reported concern about staff competency or knowledge, communication and coordination, potential treatment errors, or care environment. Factors influencing feeling safe included healthcare team member characteristics, communication and coordination, and safe care expectations. Reasoning for voicing concerns often included personal characteristics. Reasons for not voicing concerns included feeling no action was needed or the concern was low priority. Outcomes for voicing a concern were categorized as resolved, disregarded, and unknown. These findings support the vital importance of open safety communication and trustworthy response to patients and family members who voice concerns.

A Novel Theory-Based Virtual Reality Training to Improve Patient Safety Culture in the Department of Surgery of a Large Academic Medical Center: Protocol for a Mixed Methods Study

BACKGROUND

Preventable surgical errors of varying degrees of physical, emotional, and financial harm account for a significant number of adverse events. These errors are frequently tied to systemic problems within a health care system, including the absence of necessary policies/procedures, obstructive cultural hierarchy, and communication breakdown between staff. We developed an innovative, theory-based virtual reality (VR) training to promote understanding and sensemaking toward the holistic view of the culture of patient safety and high reliability.

OBJECTIVE

We aim to assess the effect of VR training on health care workers' (HCWs') understanding of contributing factors to patient safety events, sensemaking of patient safety culture, and high reliability organization principles in the laboratory environment. Further, we aim to assess the effect of VR training on patient safety culture, TeamSTEPPS behavior scores, and reporting of patient safety events in the surgery department of an academic medical center in the clinical environment.

METHODS

This mixed methods study uses a pre-VR versus post-VR training study design involving attending faculty, residents, nurses, technicians of the department of surgery, and frontline HCWs in the operation rooms at an academic medical center. HCWs' understanding of contributing factors to patient safety events will be assessed using a scale based on the Human Factors Analysis and Classification System. We will use the data frame theory framework, supported by a semistructured interview guide to capture the sensemaking process of patient safety culture and principles of high reliability organizations. Changes in the culture of patient safety will be quantified using the Agency for Healthcare Research and Quality surveys on patient safety culture. TeamSTEPPS behavior scores based on observation will be measured using the Teamwork Evaluation of Non-Technical Skills tool. Patient safety events reported in the voluntary institutional reporting system will be compared before the training versus those after the training. We will compare the Agency for Healthcare Research and Quality patient safety culture scores and patient safety events reporting before the training versus those after the training by using descriptive statistics and a within-subject 2-tailed, 2-sample t test with the significance level set at .05.

RESULTS

Ethics approval was obtained in May 2021 from the institutional review board of the University of North Carolina at Chapel Hill (22-1150). The enrollment of participants for this study will start in fall 2022 and is expected to be completed by early spring 2023. The data analysis is expected to be completed by July 2023.

CONCLUSIONS

Our findings will help assess the effectiveness of VR training in improving HCWs' understanding of contributing factors of patient safety events, sensemaking of patient safety culture, and principles and behaviors of high reliability organizations. These findings will contribute to developing VR training to improve patient safety culture in other specialties.