Theories of risk and safety: what is their relevance to nursing?

Managing ongoing swallow safety through information-sharing: An ethnography of speech and language therapists and nurses at work on stroke units

BACKGROUND

Speech and language therapists and nurses need to work together to keep patients with swallowing difficulties safe throughout their acute stroke admission. Speech and language therapists make recommendations for safe swallowing following assessment and nurses put recommendations into practice and monitor how patients cope. There has been little research into the everyday realities of ongoing swallow safety management by these two disciplines. Patient safety research in other fields of healthcare indicates that safety can be enhanced through understanding the cultural context in which risk decisions are made.

AIMS

To generate new understanding for how speech and language therapists (SLTs) and nurses share information for ongoing management of swallows safety on stroke units.

METHODS & PROCEDURES

An ethnographic methodology involving 40 weeks of fieldwork on three stroke wards in England between 2015 and 2017. Fieldwork observation (357 h) and interviews with 43 members of SLT and nursing staff. Observational and interview data were analysed iteratively using techniques from the constant comparative method to create a thematically organized explanation.

OUTCOMES & RESULTS

An explanation for how disciplinary differences in time and space influenced how SLT and nursing staff shared information for ongoing management of swallow safety, based around three themes: (1) SLTs and nurses were aligned in concern for swallow safety across all information-sharing routes; however, (2) ambiguity was introduced by the need for the information contained in swallowing recommendations to travel across time, creating dilemmas for nurses. Patients could improve or deteriorate after recommendations were made and nurses had competing demands on their time. Ambiguity had consequences for (3) critical incident reporting and relationships. SLTs experienced dilemmas over how to act when recommendations were not followed.

CONCLUSIONS & IMPLICATIONS

This study provides new understanding for patient safety dilemmas associated with the enactment and oversight of swallowing recommendations in context, on stroke wards. Findings can support SLTs and nurses to explore together how information for ongoing dysphagia management can be safely implemented within ward realities and kept up to date. This could include considering nursing capacity to act when SLTs are not there, mealtime staffing and SLT 7-day working. Together they can review their understanding of risk and preferred local and formal routes for learning from it.

WHAT THIS PAPER ADDS

What is already known on the subject It is known that information to keep swallowing safe is shared through swallowing recommendations, which are understood to involve a balance of risks between optimizing the safety of the swallow mechanism and maintaining physiological and emotional health. There is increasing appreciation from patient safety research, of the importance of understanding the context in which hospital staff make decisions about risk and patient safety. What this paper adds to existing knowledge The paper provides new empirical understanding for the complexities of risk management associated with SLT and nursing interactions and roles with respect to ongoing swallow safety. What are the potential or actual clinical implications of this work? Findings can underpin SLT and nurse discussion about how swallow safety could be improved in their own settings.

Nursing perception of risk in common nursing practice situations

As health care organizations seek to be highly reliable, systems that include layers of redundancy have been created to protect patients from harm. Many of these layers of protection are dependent on nurses making a decision to follow or adhere to the human aspects of the process. Because these decisions begin with a perception and identification of risk, understanding what nurses perceive to be a risk to patients is an essential part of designing safer health care systems. The purposes of this qualitative study were to (1) describe what nurses perceive as risky to patients in common nursing practice situations, (2) describe the effects of the perceptions of risk on clinical decision making and behavior, and (3) identify what factors nurses perceive as increasing or decreasing risk.

Collegiate presence: explaining homogenous but disparate nursing relationships

This paper examines the notion of collegiate presence. Collegiate presence is defined as a mutual connection between two or more professional individuals or groups who share a common work focus and who are mindful of cultural differences. This concept emerged as a result of an ethnographic study of two groups of triage nurses; emergency department, and mental health nurses. Data analysis exposed a number of concepts and themes including collegiality and presence. These two concepts were seen to be so closely connected that the term collegiate presence was constructed. This paper explores the notion of collegiate presence and examines factors that affect this phenomenon between what are homogenous (nurses) but disparate cultural groups (emergency department nurses and mental health triage nurses) in a health-care organization. Findings indicate that culturally disparate groups are challenged to develop functional and collaborative working relationships without a deep understanding of, and appreciation for, each other's culture. Developing collegiate presence requires effective communication, social and professional conversations, and physical presence.

Perceived patient safety culture in a critical care transport program

BACKGROUND

The purpose of this study was to examine the association among selected safety culture dimensions and safety outcomes in the context of a critical care transport (CCT) program.

METHODS

A descriptive cross-sectional correlational design used the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture to validate perceived safety culture among personnel (n = 76) in a large Midwestern CCT program.

RESULTS

Findings revealed significant associations between 1) teamwork and frequency of error reporting (r = .428, P < .001), overall perception of safety (r = .745, P < .001), and perceived patient safety grade (r = -.681, P < .001); 2) between perception of manager actions promoting safety and frequency of error reporting (r = .521, P < .001), overall perception of safety (r = .779, P < .001), and perceived patient safety grade (r = -.756, P < .001); and 3) between communication openness and frequency of error reporting (r = .575, P < .001), overall perception of safety (r = .588, P < .001), and perceived patient safety grade (r = -.627, P < .001).

CONCLUSION

The study supports other literature showing significant associations among safety culture dimensions and safety outcomes and provides a framework for future research on safety culture in CCT programs.

Making the nursing curriculum more inclusive for students with specific learning difficulties (SpLD): embedding specialist study skills into a core module

BACKGROUND

Wray et al. (2012) found that providing specialist 'add on' study skills sessions to students with SpLD increased the likelihood of progression and earlier identification. However, 48% of students identified as 'at risk' of having a SpLD did not pursue further assessment/support, which is of concern. OBJECTIVES/DESIGN/PARTICIPANTS/SETTINGS: The study aimed to explore the impact of embedding nine study skills sessions designed for students with SpLD into the mainstream curriculum on pre-registration nursing students in one HEI in the north of England. Two cohorts (September 2009 (n=257) and February 2010 (n=127)) took part; a total of 300 students completed a student feedback questionnaire (201 from September 2009, 99 from February 2010 (response rates of 87% and 80%)). The study used an outcome evaluation approach (Watson et al., 2008) to explore the impact of the sessions using a range of measures: (i) a student feedback questionnaire, (ii) length of time from registration to first contact with Disability Services, and (iii) progression data.

RESULTS

Overall, the sessions were received very positively, especially those on essay writing, reflection and learning techniques. Students in the study cohorts made contact with Disability Services 4-6 weeks earlier than other cohorts; referrals were also higher. Equally, students with SpLD with access to study skills had higher rates of progression (e.g. 87% in 2009) than in years with no sessions (e.g. 62% in 2008); progression rates were comparable to their non-disabled peers.

CONCLUSIONS

Mainstreaming what had previously been a reasonable adjustment made time- and resource-savings for the institution. Such approaches to embedding are important in encouraging and retaining talented and able students.