Preparing the Next Generation of Nurse Leaders: High Reliability, Safety Organizing and Emotional Exhaustion Indiana Nursing Summit October, 3, 2014 Mary Sitterding, PhD, RN, CNS Linda Q. Everett, PhD, RN, NEA-BC, FAAN 9/23/2014 1
Learning Objectives Describe the relationship between safety organizing, high reliability and emotional exhaustion. Discuss the development and implementation of one CNE s system-wide demonstration projects aimed at maximizing the contribution of the registered nurse in the face of economic burden. Identify competencies necessary for the next generation of nurse leaders to meet the expectations for high reliability in nursing and patient care delivery. 9/23/2014 2
On Any Given Day 9/23/2014 3
Background: Burning Platform Patient care error and harm experienced by hospitalized persons (Classen, et.al. 2011) Patient and payor expectations that we operate in a nearly error-free manner (Vogus, et.al, 2012) Improvement experts, researchers, the Joint Commission, and the Agency for Healthcare Research and Quality looking to high reliability organizations (HROs) - for guidance on how to reduce the epidemic of patient care error (Vogus, et.al, 2012) 9/23/2014 4
Background: Burning Platform Studies suggest a positive relationship between safety organizing (high reliability behaviors) and decreased patient harm Studies of HROs imply that safety organizing maybe especially demanding High reliability behaviors relies heavily on discretionary effort. We posited that safety organizing is associated with higher levels of emotional exhaustion. 9/23/2014 5
Research Questions Research question 1: What is the effect of safety organizing on nurse-sensitive quality and safety outcomes? Research question 2: What is the effect of safety organizing on nurse emotional exhaustion? 9/23/2014 6
Methods IRB approved Sample of 1,390 registered nurses within three urban hospitals 55% response rate 50 nursing units Critical care Medical-surgical Operating room Emergency department Methods and measures Harm: injury rate (patient outcomes) as the number of injuries (the sum of bloodstream infections, urinary tract infections, pressure ulcers, and falls) on the unit per 1,000 patient days prior to the administration of the survey Emotional exhaustion: Maslach Burnout Inventory High reliability: Safety Organizing Scale Tested hypotheses using hierarchical linear modeling (HLM), given multilevel nature of data (individuals nested within units within hospitals). 9/23/2014 7
Methods Data anonymous and confidential Data stored on password-protected computer in passwordprotected folder Only investigators had access to data Participant confidentiality assured by anonymous and confidential survey No specific identifying information collected; analyses of data conducted at workgroup (i.e., nursing unit) level, further masking individual information 9/23/2014 8
Safety Organizing High Reliability Framework Hazard anticipation Preoccupation with failure Reluctance to simplify Sensitivity to operations Hazard containment Resilience Deference to expertise 9/23/2014 9
Safety Organizing High Reliability Survey When giving report to another employee, we usually discuss what to look out for. We spend time identifying activities we do not want to go wrong. We discuss alternatives as to how to go about our normal work activities. We have a good understanding of each other s talents and skills. We discuss our unique skills with each other so we know who on the unit has relevant specialized skills and knowledge. We talk about mistakes and ways to learn from them. When errors happen, we discuss how we could have prevented them. When attempting to resolve a problem, we take advantage of the unique skills of our colleagues. When a patient crisis occurs, we rapidly pool our collective expertise to attempt to resolve it. 9/23/2014 10
Findings Results support the positive relationship between mindful organizing and nurse-sensitive outcomes. Even more interesting, results suggest that safety organizing (high reliability behavior) is associated with higher levels of emotional exhaustion (β= 1.78, p < 0.001). 9/23/2014 11
Imagine the Conversation Dr. Everett, We have analyzed our data from the high reliability safety organizing study. Our nurses are emotionally exhausted. All the best, Mary 9/23/2014 12
CNE Response Of course they are emotionally exhausted! We have not designed for safety organizing or high reliability. We need to understand how we can maximize the role of the RN by eliminating non-value added RN work. We need to understand how to enable a culture of innovation to meet the needs of the nurse at the point of care delivery. We need to understand the nursing work environment and how we can support their work, the idea of team their mindset. 9/23/2014 13
CNE Response: Three- Prong Approach Lean transformation Innovation Inquiry 9/23/2014 14
Lean Transformation: Riley Hospital for Children at IU Health Executive sponsor: Marilyn Cox, MSN, RN, NEA-BC, FAAN, chief nursing officer Project facilitators: Melanie Cline, MSN, RN Teresa Stanley, MSN, RN, director of Nursing Practice and Quality Jennifer Sargent, master black belt, Six Sigma and Lean management Project co-leads: Elizabeth L. Paxton, MSN, RN, NE-BC, Peds Spec II director Dave Harrison, MSN, 8W clinical manager 9/23/2014 15
Lean Transformation: Riley Hospital for Children at IU Health Lean methods and approach Value stream mapped current/future state phases of care (admission, diagnoses, treatment, discharge) Affinity diagram/sort delays of care and Kaizens within phases of care Time/motion studies and spaghetti diagrams of nursing work Created groups based on affinity themes and time/motion data Placed work groups/themes on impact-to-effort matrix Three work groups redesigned direct and indirect unit staff roles that were merged into one care delivery straw model Five pulmonary specific patient scenarios were developed Education on communication, delegation and new roles provided to pilot team New care delivery model tested in simulation lab using patient scenarios 9/23/2014 16
Lean Transformation: The Difference It s Making at Riley 7.6% reduction in LOS from 2012 to 2013 ; 2014 YTD currently at 6.3% 21% decrease in 30-day readmits from 2012 to 2013; 12% decrease in 30-day readmits from 2012 to 2014 YTD 53% decrease in asthma 30-day readmissions from 2012 to 2013. 2012=6.83%, 2013=3.17%, 2014 (through July)=.99% Patient Satisfaction Date Results Jan-April (pre) 80% May (go-live) 90% 2013 YTD 82.6% 2014 YTD 81.6% 7.6% reduction in cost/equivalent discharge from 2013 to 2014 YTD 9/23/2014 17
Innovation: IU Health Methodist Hospital Executive sponsor: Linda Chase, PhD, RN, NEA-BC, chief nursing officer Project facilitator: Jennifer Dunscomb, MSN, RN, CCRN, director of Nursing Practice and Quality Project co-leads: Jill Payne, MSN, RN, NE-BC, director, Surgical Division Pam Redd, BSN, RN, CMSRN, 6S clinical manager 9/23/2014
Innovation: IU Health Methodist Hospital Redesign of nursing work and role innovation Nurses serve as boundary spanner managing patient care needs at the patient access point Quality/safety strategist assures constant scanning of defects with rapid problem resolution and building front-line capability Redefined work to align with professional development and career advancement Integration of patient self-care into care assignment and care management Care teams assigned based on Synergy Model and NOT set number of nurse/patients ratio Training on change management, high reliability, motivational interviewing, team effectiveness, and situated coaching to pilot team; simulation used to help with training Pilot testing June 2013 9/23/2014 19
Innovation: The Difference It s Making at IU Health Methodist Hospital Outcomes Fall reduction from 1.23 to 0, with 147 days since last fall HAPU reduction from 9 to 0 478 days since last CABSI, and 633 days since last CAUTI 92% reduction in rapid response calls (0 code blues) only 2 since implementation Increase in bar code scanning from 92% to 98% Skill mix shift from 81/19 to 70/30 (RN/UAP) Decreased labor costs per patient day from average $12,942 to $4,034 9/23/2014 20
Inquiry: IU Health University Hospital Executive sponsor: Lori Knarr, DNP, RN, NEA-BC, chief nursing officer Project facilitator: Ginette Budreau, RN, MA, MBA, BC, director of nursing operations Project lead: Amanda Noth-Matchett, BSN, RN, CMSRN, Krannert clinical manager 9/23/2014 21
Inquiry: IU Health University Hospital and the Difference We Will Examine Are there differences in safety organizing/high reliability and emotional exhaustion on those nursing units participating in stress mindset interventions? 9/23/2014 22
Inquiry: IU Health University Hospital and Stress Mindset Rethinking Stress with Crum, Achor, Vogus, Broome, Everett, Knarr, Messick, McCarter, Schultz and Sitterding Although stress and uncertainty often provoke an individual into a state of anticipatory anxiety, diminishing productivity, and burnout, these same ingredients comprise the essential tools for eliciting transformational change, peak performance, and physiological thriving (Crum, A. and Achor, 2013) 9/23/2014 23
IU Health University Hospital Inquiry: ReThinking Stress Learning to acknowledge, welcome, and utilize stress can literally transform the stress curve. ReThinking Stress was designed to give employees the information and research necessary to shift their mindsets about stress-- from focusing on the deteriorating aspects to focusing on the enhancing aspects. 9/23/2014 24
CNE Response: Summarizing the Three- Prong Approach Lean transformation Innovation Inquiry 9/23/2014 25
Discussion Impact -- begins to answer questions that should be asked in healthcare Impact -- high reliability or safety organizing on the nursing workforce Costs of high reliability -- known in aviation and military, but remain unexplored among healthcare scientists Designed for high reliability -- military, aviation and air traffic control industries recognize emotional cost of the work (limit shift length, handoffs, flight deck limits) Consider: the nursing work environment and safety organizing/high reliability, emotional exhaustion, and harm on any given day 9/23/2014 26
Because On Any Given Day At Indiana University Health 9/23/2014 27
Discussion What have we missed? How has your experience positively influenced your work with high reliability? Thank you for rich discussion influencing idea generation, innovation and problem solving! msitterd@iuhealth.org leverett@iuhealth.org 9/23/2014 28
References Crum, A., Salovey, P., Achor, S (2013). Rethinking Stress: The Role of Mindsets in Determining the Stress Response. Journal of Personality and Social Psychology, 104 (4): 716 733. Everett, L. and Sitterding, M. (2013). Building a Culture of Innovation by Maximizing the Role of the RN. Nursing Administration Quarterly. Vol. 37, (3): 194 202. Gilmartin MJ. Thirty years of nursing turnover research: looking back to move forward. Med Care Res Rev. 2013;70:3-28. Maslach C, Jackson SE. The measurement of experienced burnout. J Organiz Behav. 1981;2:99-113. Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol. 2008;93:498-512. Sitterding, M. and Lopez, M. (2011). Nursing and Patient Care Safety: Strategies for Enterprise-Wide Assessment and Improvement. Voice: September Issue. Sitterding, M., (September 30, 2011) "Overview and Summary: Creating a Culture of Safety: The Next Steps" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Overview and Summary. Sitterding, M., Broome, M., Everett, L. & Ebright, P. (2012). Situation Awareness in Nursing: A Hybrid Concept Analysis. Advances in Nursing Science. 35 (1): 77-92. Sitterding, M., Ebright, P., Broome, M., Patterson, E.& Wuchner, S. (in press). Situation Awareness and Interruption Handling during Medication Administration. Western Journal Nursing Research. Vogus, T., Cooil, B., Sitterding, M., Everett, L. (in press).safety Organizing, Emotional Exhaustion, and Turnover in Hospital Nursing Units (in press). Medical Care. Vogus TJ, Sutcliffe KM. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Med Care. 2007b;45:997-1002. Vahey DC, Aiken LH, Sloane DM, et al. Nurse burnout and patient satisfaction. Med Care. 2004;42:II57-II66. Vogus TJ, Sutcliffe KM. The safety organizing scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Med Care. 2007a;45:46-54. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in and Age of Uncertainty, Second Edition. San Francisco, CA: Jossey-Bass; 2007. 9/23/2014 29