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Journal of Nursing Administration:
doi: 10.1097/NNA.0b013e3181ae9653

On the Ball: Leadership for Patient Safety and Learning in Critical Care

Tregunno, Deborah PhD, RN; Jeffs, Lianne MSc, RN; Hall, Linda McGillis PhD, RN; Baker, Ross PhD; Doran, Diane PhD, RN; Bassett, Sue Bookey MEd, RN

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Authors' Affiliations: Associate Professor (Dr Tregunno), York University School of Nursing; Director of Nursing/ Clinical Research, Scientist, Li Ka Shing Knowledge Institute (Ms Jeffs),St Michaels' Hospital, Toronto, Ontario; Professor (Dr Doran), Associate Professor (Dr Hall), Doctoral Student (Ms Bassett), Faculty of Nursing, and Professor (Dr Baker), Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

This research was supported by a grant from the Canadian Health Services Research Foundation.

Corresponding author: Dr Tregunno, York University School of Nursing, 4700 Keele St, Toronto, Ontario M3J 1P3 (

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Objective: To explore nursing leadership for patient safety in critical care and identify opportunities to improve leadership that promotes patient safety.

Background: There is limited systematic evidence about how nurses lead the microsystem of critical care and to the creation of a culture of patient safety.

Methods: Focus groups of multidisciplinary frontline providers and managers were used to gain insight into leadership that promotes patient safety and learning.

Results: Gains in critical care patient safety require a skilled nursing leader who is mindful of bedside situations and has real-time decision-making authority. Patient safety is seen as management of the moment, rather than a function of organizational systems and processes.

Conclusion: Leadership for improved patient safety resides primarily with nurses who provide direct patient care. These nurse leaders play 3 critical roles: they are the "go-to," they are "on the ball," and they "keep the ball rolling."

While patient safety is fundamental to nursing care, the job of keeping patients safe is becoming more and more difficult. We ask nurses to work in chaotic practice environments, where patient acuity is high, needs are increasingly complex, and fiscal and human resources are strained. Furthermore, nurses who have held more than 1 position have firsthand experience of the different ways in which nursing is conceptualized and care is delivered and the variation in quality of patient outcomes. Over the past decade, efforts have been made by healthcare organizations to improve patient safety outcomes. For instance, the question of how leaders create a culture of safety in which healthcare professionals feel safe to have open discussions about patient safety without fear of repercussions1-3 has received much attention. Although nurses, out of all healthcare professionals, are the most likely to report patient safety events,4,5 inconsistencies in reporting through unit-based or organizational-wide reporting mechanisms2,4-10 remain. Although there is no question that nurses' surveillance, early detection, and timely interventions keep patient safe, variation in enactment of surveillance prevails because unsafe practices have become the norm in many healthcare organizations.11,12

Several factors contribute to variation in surveillance and error reporting among healthcare providers. First, there seems to be a lack of recognition by nursing staff with respect to what actually constitutes unsafe practice, or errors. For instance, have you ever heard a nurse say that a medication error was a "near miss" because nothing bad happened to the patient? Second, nurses do not understand the importance of reporting, including the ways in which others can learn from their reports to prevent similar situations in the future.13-17 Third, nurses may actually lack the knowledge and skills required to detect threats to the safety of their patients.18,19 A paradox looms for nurse executives as they consider ways in which to improve patient safety: patients depend on early detection and timely intervention by individual nurses to keep them safe. At the same time, nurses at the bedside may not understand how system-level issues contribute to patient safety and improved outcomes. How do nurse executives respond to the increasing demands placed on them "from above" to improve patient safety, whereas "from below," nurses may not have a shared understanding of patient safety? How do nurse leaders mobilize their staff to improve safety outcomes when there are so many different ways of seeing and thinking about patient safety?

The study reported here was undertaken by one of the authors (D.T.) when working with a senior leader who expressed an interest in "doing something" about the culture of patient safety in critical care-implement a program, develop leadership for patient safety, and get the staff to be more open to error reporting. The list of potential interventions was long, with little or no evidence to support the effectiveness of most of the activities on the list. Specifically, although there was widespread recognition that healthcare leaders play a central role in creating the infrastructure and momentum required to improve patient safety outcomes,20 there was limited systematic evidence about how leaders establish and contribute to patient safety culture and learning. Ultimately, we agreed that before we could determine the appropriate intervention, we needed to understand how nurses and other critical care providers view nursing leadership for patient safety culture.

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To address the question of nursing leadership for patient safety in critical care, we conducted focus groups of frontline providers and managers in 6 Ontario teaching hospitals in the Canadian province of Ontario. Ethics approval was received from the university and participating hospitals. In each hospital, we conducted 4 to 6 homogeneous13 focus groups, with 6 to 8 participants. In total, we conducted 31 focus groups, with 188 participants, between February and September 2005. Focus group participants were recruited through sign-up sheets that were posted on the unit 2 weeks before the schedule meeting. In addition, an honorarium was provided to individuals who attended outside regularly scheduled hours of work. A summary of the number of focus groups, sex, work experience, and employment status of participants by stakeholder group is provided in Table 1. On average, participants had 16 years of healthcare work experience (range, 1-37 years), with an average of 10 years in critical care. Most participants worked full time (65%) or part time (25%); about 10% of participants work in casual positions.

Table 1
Table 1
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All focus groups were moderated by the research associate and were recorded and transcribed. Extensive field notes were also made. This article reports on 2 of the questions that were used to guide focus group discussion: (1) who are the nurse leaders for patient safety? And (2) how do they support safe practice and learning?

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Given the large number of focus groups conducted, the qualitative analysis began with reading and annotations of a small sample of focus group transcripts by 2 members of the research team. This was followed by discussion and comparisons, from which our coding framework emerged. This structure was used to code the remainder of the transcripts, and QSR NUD*IST (QSR International, Cambridge, MA) computer software was used to facilitate data management and analysis. An audit of the coding was conducted by an external expert in qualitative analysis.

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Three key themes emerged from the focus groups in response to our 2 questions regarding leadership for patient safety in critical care. The first theme identifies and describes patient safety nurse leaders, thus answering the "who" question. The next 2 themes describe nurse leaders' patient safety behaviors.

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Theme 1: The Leader Is the "Go-to"

Our findings suggest that the leader is the experienced nurse who providers "go to" for help. The go-to is someone who can manage any situation, who is well informed, and who knows what is happening on the unit at all times. Specifically, focus group participants told us that the go-to knows a lot about nursing and critical care, leads by example, is respected by the staff, is approachable, can be counted on to get things done, and has a track record in providing safe care. The leader has extensive experience and in-depth understanding of clinical practice in the intensive care environment.

As illustrated in the following narratives, the go-to is called upon to manage safe practices, knows exactly how to get things done, and leads in the context of a specific situation.

Someone with a large knowledge base of the area that they're working in that would be available for that person or another nurse to go-to as a resource for any questions they may have which probably would go hand in hand with someone with a lot of experience in that area. (staff nurse)

Another participant said,

I observe that, as bedside nurses, there are people who have the personality and experience and skills who will just say, "you know what, if a situation happens at my bedside, it's my bedside, I'm going to take a leadership role"; they don't wait for the whatever the job title is person to swoop in. (staff nurse)

Nurses in formalized roles (eg, charge nurse, educator, advanced practice nurse, clinical practice leader, team leader, etc) are also seen as an important go-to for all members of the multiprofessional team. In contrast, managers and executives are not seen as being close enough to the patient, nor do they interact frequently enough with the care team, to be a go-to leader. However, managers and executives are seen as important players in promoting patient safety "at the top" of the organization.

That also includes the executive vice presidents and the directors; they're the ones who are going to be able to push the organization to see that safety is important and that safety does have a monetary feature to it. (staff nurse)

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Theme 2: The leader Is "On the Ball"

This theme describes what the go-to nurse does that makes colleagues see them as a leader for patient safety. The nurse leader for patient safety is described as being "on the ball," aware of everything on the unit, having a "global perspective."

They're very good at flagging situations that may have not been noticed… they seem to be very involved and aware of everything that's going on, like they just seem like they're on the ball, and if you go to them about a patient, they know what's going. (manager)

At the bedside, the go-to understands their responsibilities in relation to the provision of safe and appropriate care, and they get their "hands dirty" by flagging situations as a potential risk, and by intervening to prevent or remedy threatening situations.

They are there at the right place at the right time pointing out the potential errors. It's those people that can see, oh I don't like what's going on here, I have a bad feeling, I'm going to call… right. Those are the people who can assess the situation and say, "I'm not going to let a first-year resident whose never put in a central line do this by himself or herself, or whatever the scenario is. (physician)

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Theme 3: Leaders Keep the "Ball Rolling"

Nurse leaders engage in a range of behaviors to keep patients safe. In particular, nurse leaders bring the team together in ways that balance competing safety and operational priorities which occur daily. Once safety issues are identified, the nurse leader keeps the "ball rolling," making sure that tests and procedures do not get overlooked. They advocate for patients, help junior nurses negotiate with the other members of the team, and willingly teach and communicate the rationale behind changes designed to improve patient care. In addition, the patient safety leader sets the tone for the unit, is respectful of divergent perspectives, is nonjudgmental when responding to safety events, and fosters critical thinking.

…they're very good at coordination and keeping the ball rolling so things don't get delayed for 1, 2, 3 days. I see that as a very important role for our team in terms of maintaining any continuity of care between divisions and then also just the day-to-day activity and patient care. (allied health)

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The present study reports the views of frontline providers, managers, and physicians on the question of nursing leadership for patient safety in the context of critical care nursing. On the whole, findings from our study draw attention to one side of the paradox for nurse executives as they lead efforts to improve patient safety. The 3 themes identified in this study support the notion that patients depend on early detection and timely intervention by individual nurses to keep them safe. Specifically, theme 1 tells us that nurses and other healthcare providers see the patient safety nurse leader as the one they go to for help. This leader is the most senior or experienced nurse who has substantive knowledge and experience and who can answer questions and manage difficult clinical and operational situations in the intraprofessional and interprofessional context. The go-to provides leadership in the moment-at the point in time when a threat to patient safety is identified or when immediate assistance is required by colleagues. Moreover, theme 2 tells us that patient safety leaders have a well-developed sense of awareness of their own work, the work of other direct-care providers, and of the intensive care system as a whole. Theme 3 speaks to the ways in which nurse leaders recognize and respond to unexpected events and the ways in which they work with frontline providers to improve patient safety outcomes.

Our findings highlight the contribution to patient safety that nurse leaders make at the point of care, in the clinical microsystem. Patient safety at the bedside requires a leader who is mindful to the current situation and who has real-time decision-making authority. Viewing leadership for patient safety as primarily a frontline activity that is provided by nurses with the most expertise, regardless of rank, is consistent with the notion of "deference to expertise" found in the literature on high-reliability organizations.21,22 Deference to expertise occurs when operations are being carried out at very high tempo and decisions migrate to the people with the greatest expertise or knowledge about the events in question.22-24 These findings are also consistent with the idea that well-respected opinion leaders make important contributions to patient safety by providing "on-the-spot leadership" rather than waiting for "whatever job title" to swoop in to make things happen.25

The other side of the manager's paradox, that nurses at the bedside may not understand how system-level issues contribute to patient safety and improved outcomes, was not overtly articulated by our study participants. However, our findings highlight differences in perspectives on the ways in which nurse leaders influence patient safety that might explain why nurses at the bedside may not appreciate system-level issues. At the bedside, patient safety is seen primarily as "in the moment" intervention by nurse leaders and other members of the healthcare team to minimize a patient's exposure to unnecessary risk and to alleviate harm.

Nursing leadership in the microsystem, at the point of care, focuses on intradisciplinary and interdisciplinary teamwork support for high-quality real-time clinical decision making. In contrast, while senior managers and nurse executives are often seen as being removed from the bedside and too busy with meetings to have a direct influence on patient safety, they have an important role to push the patient safety agenda at higher levels of influence in the organizations. The direct-care providers in our study focused more on issues of individual skill, knowledge, proximity to the patient, and multidisciplinary team than on system weaknesses. It seems that the system perspective on patient safety may be too distal from safe bedside care to be viewed as important to nurses who lead the microsystem of care.

However, the need for a systems approach to identify patient safety solutions in the work environment is widely recognized. For example, technical failures, inadequate policies and procedures, organizational knowledge transfer, and staffing issues are all significant factors26 that dramatically affect the nurse's ability to lead the microsystem toward the delivery of safe care. Education levels27 and long hours of work28 are system-level factors that influence safe outcomes. In addition, much of the patient safety literature directs us toward the development of a culture of safety in which nurses and other care givers are encouraged to report safety occurrences such as errors and in which these can be discussed without fear of retribution. In this context, errors are viewed as opportunities for learning about how and why the event happened, with the goal of preventing reoccurrence.

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This study has 2 key implications for nurse executives who want to mobilize their staff to improve safety outcomes. Ultimately, we suggest that gains in patient safety require attention to both sides of the paradox highlighted at the outset of this article. First, to address surveillance, early detection, and timely intervention by individual nurses to keep patients safe, expert frontline nurses need to be upheld in their clinical leadership roles, supported as they recognize and react flexibly to threats to patient safety, and encouraged to develop advanced communication and conflict resolution skills. Accordingly, frontline managers need to create structures and processes that support and empower nurses to lead the clinical microsystem of care. At the same time, executives have to address the other side of the paradox, where nurses at the bedside may not understand how system-level issues contribute to patient safety and improved outcomes. In this context, executives are called upon to develop and sustain evidence-informed safety cultures where the knowledge of safety science is mobilized and valued, and evidence is used by nurse leaders at all levels to deliver safer care.

Finally, a number of opportunities to develop leaders for patient safety were identified when we shared our findings with a panel of expert reviewers. Specifically, in the context of the critical care units collaborating in this study, we explored mechanisms to increase frontline staff involvement in decision making about patient flow and staffing, in quality improvement activities, in error analysis and feedback, and in critical incident debriefing. Other opportunities include patient safety rounds, the use of simulation and drills to improve clinical skills, and increased participation of the multidisciplinary team in morbidity and mortality rounds.

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Generalizability of the findings is a limitation. Specifically, all data were collected from critical care units in academic acute care hospital settings and do not necessarily reflect the general population in other healthcare settings. Further research could explore nursing leadership in other patient-specific microsystems of care and define specific interventions required to strengthen nursing leadership in these microsystems.

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Our findings demonstrate that nurses involved in direct-care activities are central to improved patient safety at the bedside. Findings also demonstrate that critical care providers and managers see the delivery of safe care more as "management in the moment," than as an outcome related to potentially inadequate systems and processes. What is apparent from this study is the perspective that leadership for patient safety resides primarily with nurses providing direct patient care. When it comes to keeping patients safe, these direct-care providers play 3 critical roles: they act as the go-to, they are "on the ball," and they "keep the ball rolling." Furthermore, what may be most pressing at this time is for nurse executives to "get into the game" by attending to both sides of the leadership paradox: the need to create supportive and empowering work environments, including teaching and learning about the science of safety, so that all patients receive safer care.

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© 2009 Lippincott Williams & Wilkins, Inc.



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