Nurses may be your best tool for improving quality of care

Don’t rely too much on policies nurses might overlook

Nurses can greatly improve the quality of care by reporting their concerns about patient care, but all too often, those comments never reach the ears of hospital management or quality leaders. Even when you have policies and procedures in place that encourage nurses to report concerns, you might be surprised at how many nurses think no one wants to hear from them.

The problem plagues many hospitals and other health care providers, says Sharon LaDuke, RN, patient documentation analyst at Claxton-Hepburn Medical Center in Ogdensburg, NY. The health care community often talks about "empowerment" of nurses and other staff, and most hospital leaders accept the idea that employees in the trenches should be encouraged to report concerns about patient care. Many facilities even have a policy in place that officially encourages such reporting, sometimes with a specific procedure for doing so.

Most hospitals have developed what administrators would consider plenty of opportunities for nurses to report concerns about patient care, but they might not be working. A policy may look good on paper, LaDuke says, but that won’t necessarily improve the quality of care.

"The leaders are very aware of these policies and imagine that those resources also are very available to the nurses. But nurses don’t participate in these processes at the level that makes them intimately familiar with them," she says. "They didn’t sit in on a committee that formulated them, and they don’t have time to study the policies when they’re handed out. So you have leaders who think they have plenty of resources and processes available, but the nurses are not sufficiently aware and comfortable with those processes."

As a result, nurses often don’t use the reporting systems that the hospital has set up, she says. And then, the hospital leaders often think that a lack of reports means there are no problems.

"I recently asked a lawyer at another facility about a hotline they set up for staff to report their concerns anonymously," LaDuke says. "He said the only calls they’d gotten were from visitors. No one was using the hotline the way the hospital leaders expected."

Part of the problem involves how policies and procedures sometimes are presented to nursing staff, she says. Administrators and committees often overlook the workplace demands on nurses, as well as some of the cultural divisions that have been in place for many years in the health care profession. Time constraints are a major concern, LaDuke says. No matter how well designed the policy, nurses won’t know about it if they have to read a three-page memo. Most nurses are so overworked by their primary concern — taking care of too many patients at once — that they can’t take the time to study a lengthy memo.

"Many nurses will stop reading the policy after the first couple of sentences, especially if the title or policy statement contains phrases that don’t resonate with them," she says.

"If you send out a policy that encourages nurses to report their patient care concerns on a hotline but you introduce it with a term like corporate compliance,’ you’ll lose your audience unless considerable care is taken upfront to explicate the connection between this term and what the nurse observes at the bedside," LaDuke adds.

Another common problem is that the policy and process are never fully disseminated to the nursing staff who work off-site or odd hours. 

Any effort to improve nurses’ reporting of patient concerns must start at the top of the leadership ladder, says Maureen Connor, RN, MPH, director of risk management and infection control, at Dana-Farber Cancer Institute in Boston. This kind of change is so dependent on an overall culture within the organization, not just a few well-meaning individuals, that the CEO and similar leaders must buy in from the start, she says.

"If you don’t have the support of executive leaders, I don’t think you can make this happen," she says. "You have to have leaders who make patient safety a top priority, who believe that supporting a nonpunitive culture is fundamental to getting staff to discuss errors."

Connor agrees that a written policy is only a starting point. In fact, Dana-Farber doesn’t yet have a formal written policy establishing a nonpunitive reporting environment, depending instead on a process that has occurred over time. (It is creating a formal policy now.) A 1995 sentinel event, involving two patients who received overdoses of chemotherapy drugs, spurred the institute to revamp its efforts.

"We looked at our systems and realized that when errors occurred, it is often not that staff are careless or don’t care, it’s because you have systems in place that set the staff up to fail," she says. "It is very important that you promote an atmosphere in which people are willing to tell you that, to show you the weaknesses, before a tragedy occurs."

One strategy employed at Dana-Farber is a system of multidisciplinary patient safety rounds. Begun in the last year, these rounds involve a number of staff from risk management, nursing, and pharmacy. The team visits patient care units and encourages nurses to share any concerns they have about quality of care. If a problem is identified, a team quickly gets to work on the issue and — here’s a crucial element — reports back to the nursing staff about what action was taken. Connor says it is vitally important that nurses see some result from their reports.

Dana-Farber also enlists nurses to participate in its medication event subcommittee. This group meets monthly and reviews every medication event (an error or near miss) reported in the previous month. Each event is analyzed in great detail, almost like a miniroot-cause analysis, and the nurses are encouraged to voice their practical insights regarding how processes work on the patient care units.

"Not only is their input valuable, but they can see the systems approach we take to error investigations, that it’s not about pointing the finger at someone," Connor says.

"They can take that back to their colleagues and tell them how this system works," she adds.

Nurses have long felt stymied by their relatively low ranking in the health care community, too often feeling that physicians and administrators don’t value their opinions. Overcoming that perception is the biggest hurdle to implementing any policy that encourages nurses to speak up. Nurses are highly motivated to do the right thing, but they can feel that no one else wants to hear from them, LaDuke says, or that there will be retaliation for pointing a finger at someone higher on the ladder.

"Sometimes, the nurses either do nothing, feeling they have no influence over the system and nobody cares. They think they have no avenue or organizational standing to address the issue," she says. "Or they will do things that are ineffective and expose themselves to various kinds of unfortunate consequences, making them vulnerable. They feel they have to do something, so they do something ineffective and ultimately self-destructive, all because they lacked the system savvy to use the channels that were already in place to address their concerns."

No matter how many times you tell nurses that you want them to be "empowered" and that you value their input, they won’t believe it until they see evidence. That means that changing the culture of a health care organization takes time. Fortunately, that culture change has been under way at many hospitals for years now, and some nurses are becoming more comfortable with the idea that the administration really wants to hear their concerns.

"This isn’t something that can happen overnight, but you can get fooled into thinking you’ve had a good system in place for years and it’s working fine," LaDuke says. "The big message here is that you can’t just write a policy and think that’s it. You have to make sure nurses understand it, know that you’re serious, and know how to use it and feel protected when they do."

[For more information, contact:

Sharon LaDuke, RN, Patient Documentation Analyst, Claxton-Hepburn Medical Center, 214 King St., Ogdensburg, NY 13669. Telephone: (315) 393-8880.

Maureen Connor, RN, MPH, Director of Risk Management and Infection Control, Dana-Farber Cancer Institute, 454 Brookline Ave., Boston, MA 02115. Telephone: (617) 632-4263.]