Quality improvement, orientation for new nurses

Beth A. Duthie, RN, PhD, director of patient safety at NYU Langone Medical Center, wasn't surprised by findings in the study "New nurses' views of quality improvement education" published in the Jan. 10 issue of The Joint Commission Journal on Quality and Patient Safety.

"Actually, that pretty much affirms what I'm seeing here. It's both physicians and nurses coming out of school, and there has been on both the medical and the nursing side an emphasis that we have to begin this process. Because, again, practice drives education in a lot of respects and so we have been saying they're not as exposed to it as they should be," she says.

She says the belief at NYU Langone is that quality improvement should be embedded into the center's daily life. So they focus on teaching new nurses coming into the hospital. There are classes for orientees in both patient safety and quality, and when they are promoted into leadership positions, they get additional lessons on different topics in quality and safety.

"One year after they've been on board, we do a class on critical thinking and failure-to-rescue errors and how to prevent them. And then there is an organizationwide program for new managers on systems, theory, and how to approach errors from a systems approach instead of blaming the individual," she says.

Empowering nurses is a portion of the education. And that means emphasizing teamwork and training physicians to let the nurses know that they welcome their help. She identified fast-moving, tense working situations such as in cardiovascular ORs or heart surgery. Everyone is involved in huddles.

"And both the nurses and physicians now feel there's such a comfort zone that if I say something it's going to be welcomed whereas in the past it was contentious if the nurse spoke up; there was going to be some negative feedback. Now because they have these huddles, they talk about the fact if you call something out to help me, I understand that that's what you're doing. It's more the spirit of what we had hoped. We don't want it to be a, 'gotcha, you screwed up,' but more 'how can I help you?'

"And so both by changing the attitudes of the nurses who are bringing the information forward and by having the physicians be welcoming of it, that is really where I think you have to go to get into a culture of safety," she says.

She also recognized the opportunity for education when a new nurse makes an error and has worked with leadership to understand "if it's going to be a good learning experience in a difficult situation, that means the response from the manager has to be nurturing and supportive. And I also talked to the new nurses about the fact that when someone makes an error, if we are judgmental and blaming, that person begins to lose self-esteem and may not be able to do as well and learn from it as well as they take on that whole shame concept. So that when we see someone else making an error to be supportive of them," she says.

She recalls a near-fatal medication error made by a new nurse. She thought it could be a procedural error. But the nurse realized the error quickly and called a skilled practitioner to help her. "It was very encouraging to me to hear her say it was a very frightening experience for me but my preceptor really helped me learn from it," she says.

Speaking to the nurse, she told her she had good instincts and good thought processes to recognize the problem and ask for help. The problem was caused because the nurse was pulled away from what she was doing. And she told her it's often hard to say to people, "I can't do that right now," but that it's OK and sometimes necessary.

If you're looking to educate new nurses on safety and quality, Duthie suggests supporting error rates from the front line. "The way in which you get your error rates up is by showing people the good outcomes that come from error reporting," she says, and by emphasizing that we're all human, we make mistakes, and it's safe in this organization to report errors. And then taking the focus off of the individual and analyzing the context.

The average orientation program is two months; for some areas such as labor and delivery and the ICU it is longer.

Where does she see the biggest gap between real-world and classroom experience? "The biggest gap is understanding how to measure accurately what you want. So when you're doing a quality improvement project, are you going to be monitoring the correct information, and is your data collection a meaningful, reasonable process?" She says it's important to help frontline workers design measurements that will help them with their clinical questions.