Journal of Nursing Administration:
Authors' Affiliations: Assistant Professor (Dr Vogelsmeier), Sinclair School of Nursing, University of Missouri, Columbia; Professor and Area Chair (Dr Scott-Cawiezell), College of Nursing, University of Iowa, Iowa City.
Corresponding author: Dr Vogelsmeier, S314 Sinclair School of Nursing, University of Missouri, Columbia, MO 65211 (firstname.lastname@example.org).
This study was funded by AHRQ 5 UCI S1428102 (secondary study).
Dr Vogelsmeier is a John A. Hartford predoctoral scholar.
As systems have been explored to improve patient safety, technology has become a critical part of these discussions. In response to meet ongoing patient safety challenges, healthcare leaders have implemented a variety of technologies; however, implementation efforts have often been unsuccessful1 and have introduced unintended risks to patient safety.2-5 The high rate of failure and the unintended consequences have raised awareness and focused attention upon implementation and integration of technology to positively impact patient safety.
Recognizing that staff are the end-users of technology, Ash et al6 suggested that successful technology implementation can be largely influenced by organizational leaders who create a shared vision with their staff, ensure an environment of collaboration and trust where the voice of staff is valued, and establish an ongoing process for problem solving that includes the input of staff. The leadership characteristics described by Ash are consistent with transformational leadership where leaders and staff work interdependently to achieve improvement.7 Scott-Cawiezell and colleagues8 found that these behaviors were present in nurse leaders who facilitated successful technology implementation to improve medication safety practices in the nursing home setting.
Achieving Medication Safety Through Technology
Scott-Cawiezell and colleagues studied the effects of technology and quality improvement on medication safety practices in 5 Midwestern nursing homes over a 2-year period. While each nursing home implemented a complete electronic health record, the research team focused on the implementation of an electronic medication administration record and how this element of the technology impacted medication safety practices. The research team worked closely with 5 medication safety teams providing strategies for effective quality improvement and observing nurse leader and team member activities during the large-scale change process. Ongoing and extensive observation found that technology, independent of quality improvement processes, could not solve chronic medication administration structure and process issues and ultimately could not improve workflow. Although not a primary research question, the study findings suggest that the nurse leader had a large impact and critical contribution in facilitating successful integration and maximization of technology to improve medication safety. In successful integration, the nurse leader created a shared vision for the priority of medication safety, facilitated open communication, provided advocacy for the team's recommendations, and role-modeled systematic problem solving.8
Influence of the Nurse Leader in Technology Implementation
In facilities that successfully integrated technology, the nurse leader facilitated a common goal of medication safety by working with the team to define medication error and to critically explore underlying causes of error. By focusing on underlying causes of error, the nurse leader role-modeled good problem solving, facilitated open communication, and advocated for the team and their recommendations across the facility. The nurse leader was able to build trust, which facilitated dialogue about error disclosure that led to more effective problem solving and without risk of blame. Because underlying causes of medication error and opportunities for error were often related to existing error-prone processes, the nurse leader and team members strategically integrated technology to redesign these processes to minimize the real risk for error. Moreover, as the team became innovative in problem solving through technology, the nurse leader advocated the team's recommendation to facilitate organization-wide implementation. The nurse leader's ability to lead the team through systematic problem solving resulted in large-scale improvements that maximized the benefits of technology to improve medication safety practices across the organization.
In contrast, when nurse leaders hindered open communication by not seeking input from the team, team members did not openly share what they knew about medication safety concerns and risks for medication error. The lack of open discussion limited the team's ability to identify problematic processes at the root of the errors. Furthermore, this lack of discovery limited the team's ability to safely integrate technology to redesign the existing problematic processes to create safer systems. Thus, because technology was "laid over the top" of existing medication processes, chronic problems that existed prior to technology were exacerbated. As a result, little to no improvement in medication safety practices occurred.
Nurse leaders played a critical role in achieving quality improvement and medication safety through technology.5,8,9 Notably, when nursing leaders guided the implementation process by working with teams to integrate the technology to redesign and improve existing medication processes, organization-wide improvement occurred.
To achieve improvement with large-scale change, nurse leaders must work alongside staff to interdependently improve processes, challenge existing rules that impede open communication, and collectively work to achieve a common goal. These characteristics exemplify a transformational leadership style, where leaders and staff work together toward a greater good. Transformational leaders strive to raise their followers up by working interdependently as a team.7 Nurse leaders who create an environment conducive to open communication and information sharing will ultimately lead to a cohesive, goal-directed team environment. Importantly, when nurse leaders facilitate teamwork and goal achievement, not by controlling the team, but rather empowering the team through seeking ongoing team member input and feedback, improvement can occur.
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8. Scott-Cawiezell J, Madsen R, Pepper GA, Vogelsmeier A, Petroski G, Zellmer D. Using an electronic medication administration record to improve nursing home medication safety. Jt Comm J Qual Patient Saf
9. Scott-Cawiezell J, Vogelsmeier A, McKenney C, Rantz M, Hicks L, Zellmer D. Moving from a culture of blame to a culture of safety in the nursing home setting. Nurs Forum
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