Developing Safe Systems in

Long-Term Care

Duke University School of Nursing

• Ruth A. Anderson, RN, PhD, FAAN

• Lisa Day, RN, PhD, CNRN

• Eleanor S. McConnell, RN, PhD, GCNS, BC

• Kristie Porter, MPH

Kirsten N. Corazzini, PhD, FGSA

Funded by NCSBN R30010, R5007 (Corazzini, PI)

University of Minnesota School of Nursing

• Christine Mueller, PhD, RN, FGSA, FAAN

• Kristin L. Hjartardottir, DNP, RN

Collaborating partners

• Executive Director, MN Board of Nursing,

Shirley Brekken, RN, MS

• Executive Director, NC Board of Nursing,

Julia L. George, RN, MSN, FRE

Safety in Long-term Care:From rules-based to safety culture

• Traditional view of management in long-term care– Rules-based, hierarchical

– Punitive enforcement of rules

• Contemporary view of management for ‘patient safety culture’ (IOM 2004; Castle et al, 2006)

– Fostering learning from errors and near-misses

– Reduce opportunities for error

Management, Reconsidered

Planning,

Organizing,

Controlling

versus

Fostering

Safety Culture

Residential Long-term Care Settings as Complex Adaptive Systems

• The interaction of many people give rise to the whole of the system

– Holistic properties

– Not found in any single person

• Key terms:

– Agents

– Interconnections

– Self-Organization

– Emergent properties “Stone Soup”

Stone Soup StoryThere is a folktale that tells of a man who finds his cupboard & his stomach very empty. All he finds in the kitchen is a stone. But, being a clever fellow, he calls his friends & invites them for a special meal: "stone soup." Each friend should bring something to add to the soup. So the friends arrive with carrots, tomatoes, beans, meat, & so forth, & soon there is a delicious soup which they all enjoy together.

Agents & Interconnections

• Individuals-

– Life experience, education, values, beliefs, culture, socioeconomic

• Relationships - Strength, frequency, quality

• Strong, Weak, Aware, None

• Positive & negative

Self Organization

• Naturally occurring in the system

• Arises through relationship patterns

• Solves problems to reach goals

• OR! Works against goals

Pair & Share #1: Rule-based Solutions

• Share a care problem that you tried to address with additional rules or regulations and the problem was not resolved

• Why do you think adding rules did not work?

Emergent Properties

• A feature of the system appears that was not previously observed as a characteristic of a single member of the entity.

A Common Pattern

Opportunities

for Informal

Interaction

(e.g., Chance

Encounters;

Rounds;

spontaneous

meetings) Avoid

Ignore

Local Interaction Patterns:

Agents interacting and self-organizing

Work Environment Being behind

Care planning w/o

information

“Heavy lifting”

Individual Staff Dissatisfaction

Burnout & Stress

Exhaustion

Frustration

Not feeling valued

Resident Care Poor quality

outcomes

Poor Safety climate

Emergent Characteristics

(RA Anderson et al 2012)

Every so often….

Something outstanding

A Positive Pattern

Work Environment Safe Systems

Teamwork

Learning

Better care processes

(e.g., planning, decision

making)

Individual Staff Feeling good

Satisfaction

Resident Care Better safety and quality

outcomes

Emergent Characteristics

Opportunities for

Informal

Interaction

(e.g., Chance

Encounters;

Rounds;

spontaneous

meetings)

CONNECTION

Local Interaction Patterns:

Agents interacting and self-organizing

Examples of Connection Strategies

for Safe SystemsStrategies What to do…

Information Exchange

Listen, Explain, Give information

Cognitive Diversity Seek other perspectives, give and receive feedback, brainstorm, engage in sense-making

Pay Attention Ask questions, directly observe,notice & act (sensitivity), be persistent

Weick (2003) “Look while you leap”

• Why are there so few errors in organizations facing high risk, highly unpredictable environments (e.g., nuclear power plant, air traffic control)?

– Connection strategies• Paying attention

– Noticing and acting

– Detecting small changes

• Sensemaking– “What does this mean?”

What was he

thinking?

What we can foster: ‘Safe systems’ through shaping

CONNECTIONS

•Global patterns are created through local interactions

•Bottom up versus top down impact on safety

Pair & Share #2: Connection Strategies

• Share a care situation when a small change had a large effect in your organization (…or, conversely, a large initiative had a small or no effect)

Scope of Practice and Fostering Connection Strategies for Safe

Systems: A data-based example

• Describe the role of local interaction strategies in how Directors of Nursing (DONs), RNs, and LPNs enact their scopes of practice in nursing homes

• Discuss the implications for safe systems

Design & Data

Comparative, multiple case study of RN and LPN

nursing practice

10 NC and MN nursing homes sampled

by Area Health Education Region

• 10 RN Directors of Nursing

• 34 Additional RNs and LPNs

Individual, semi-structured telephone interviews

Elicited strategies and behaviors used

to enact scope –assessing, planning care,

supervising and delegating

Analysis• Immersion/crystallization qualitative data

analysis (Crabtree & Miller, 1999)

– Data coded by multiple team members for strategies and behaviors

• “Strategies Interpersonal/Informal” code

– Defined as interpersonal, informal, or personal qualities/attitudes/behaviors of DON, RN, or LPN to manage nursing process.

• Examples: connection, empower, information exchange, noticing and acting, cognitive diversity, vigilance

• Coded data read by team and analyzedfor themes in relation to LIS

• Assessment• Care Planning• Supervision• Delegation

Connection Strategies / Local Interactions

• Safety climate

Enacting Practice

Safer systems

Information Exchange

Pay Attention

Cognitive Diversity

Enacted Practice: Overall• DON: Cognitive Diversity

There's a scripture that I like to think about...,'there's wisdom in a multitude of council.' In other words, there's no way that I know it all. …. Even if I think I know something…I will call and say, 'hey. This is what's going on. … somebody that we can bounce it off each other. .…So I don't think anybody should ever get to the point where they feel like they got it. And they don't need any help. I wouldn't want to work for somebody like that.

Enacted Practice: Assessment and Care Planning

• RN: Cognitive Diversity

I follow up on occurrence reports, infections, … then I ask questions about the resident, because a lot of times [front line staff] have a lot more information from the family or [about] follow up than I have to determine a plan of care...So we all have different pieces of puzzle.

Enacted Practice: Assessment and Care Planning

• LPN: Paying Attention

I saw a change in a patient. I couldn’t quite put my finger on it but she was not quite as alert and she was acting different. Well, the nurse practitioner was there so I stopped what I was doing and I went in and said, “Can you please come and just look at her…...

Enacted Practice: Assessment & Care Planning

– LPN: Cognitive Diversity; CNA: Paying Attention

[CNAs are] our eyes and our ears and they see things that we don’t see ... So, they’re the ones that if there’s a change in the patient, they usually tell us right away... so you have to have a good relationship with your CNAs..

RN: Information Exchange, Cognitive Diversity & Paying Attention

About assessment.... it’s investigation…*asking staff+ “Why are we doing this this way?” and they have great information … individualized care has to be asking the staff why...*for example+…this dressing change is supposed to be changed every 12 hours, but I see that it’s been14 hours. Why is that? [staff explain] this patient does not want it done at this time because it interferes with [a favorite activity]. Ok we need to contact the doctor. We need to get that changed.

Enacted Practice: Assessment & Care Planning

Enacted Practice: Care Planning• RN: Info Exchange, Cognitive Diversity & Paying Attention

Well, if you change [an approach] for a fall, like a mat on the floor… not only is it your job to make sure that the care plan reflects that, you should be passing it on to the aides, to the LPNs… so people will know what’s changed in that care plan... Just because the care plan is up to date doesn’t mean that you’re done... You need to make sure that everybody knows…If you have to teach them about something, you teach them.

Enacted Practice: Supervision & Delegation

– LPN: Cognitive Diversity; CNA: Paying attention

The CNAs are as important as the RNs, even more so because they’re actually out there doing the work. ...When I ask them to do something, I’ll ask them in a nice way instead of ordering them … because they’ll make sure that they come and tell you things that you need to know *and+ they’re usually right; they’re right on the money.

Enacted Practice: Supervision & Delegation

• DON: Cognitive Diversity & Paying Attention

I try to be out with the staff. I take the approach, ‘Do they really understand how to do the job?’ and will sit with a nurse and review policy and procedure, go over an incident report that doesn’t seem to be completed accurately or in depth, rather than just jumping to corrective actions.

• RN: Cognitive Diversity

There is a checklist of everything … we’ll go through and make sure *items are+ done…If *it’s not done+, then we …discuss again at the Monday meeting, why it wasn’t done. Is there another approach? We have to go to the CNAs and ask how they’re doing *it+.We’ve got to reassess and retake a look at it and …see if we have to change anything..

Enacted Practice: Supervision & Delegation

• LPN: Paying attention & Cognitive Diversity

On a day to day basis *it’s the+ little things—if I’m in and out of a room and then the beds aren’t made …or the resident says they didn’t get their shower … and I can go to the staff directly and ask them, “what’s the situation, what’s going on.” *Because I was a CNA before], we have a good rapport --I have that first hand understanding.

Enacted Practice: Supervision & Delegation

Discussion

• Nurses at all levels were using local interaction strategies to improve their practice

– How assessment, care planning, delegation and supervision enacted relates to safety culture (e.g., Castle et al, 2010)

• RNs in management positions have capacity to effect change at a systems-level

– Improving the practice of others (LPNs, CNAs)

Ensuring Safe Systems for Quality Care

– Implications for Regulation and Practice

• Fostering effective local interactions shapes how RN and LPN scopes of practice are enacted

– Moves us beyond rules-based approach to ensuring safe systems

– Acknowledges residential care settings as complex adaptive systems

– Use of connection strategies to improve quality of relationships may occur at any staff level

– Capacity for clinical leadership at all levels of staff

– E.g., better assessments, care plans, supervision