Small Troubles Adaptive Responses 2: Network Study Participation - One Site's Results

Purpose:
Identify the type and frequency of small problems (troubles) interfering with care provision detected by frontline nurses on clinical units. Examine the relationships among frontline nurse engagement, work environment and quality improvement outcomes.

Background/Significance:
Preventable medical errors hurt patients and are costly. Because nurses work in complex adaptive systems, inconveniences and “small troubles” are often handled by “workarounds” instead of taking the extra steps needed for robust resolution. Examining the nature of small troubles and their relationship to nurses' notions of the organization's quality and safety culture may help with the implementation of strategies to reduce workarounds that can lead to medical errors.

Methods:
This investigation was designed as a multisite cross-sectional study sponsored by the Improvement Science Research Network, an entity of the University of Texas, San Antonio. Fifteen medical-surgical units across five hospitals nation-wide in three phases, were selected for the study. Data was collected during a 33-day period from the RN staff on three units of our acute care hospital in southern California. Pocket cards to record “small troubles” and a survey packet consisting of five valid and reliable tools describing quality of care and the organizational safety culture were completed by consenting RNs. Data analysis used were descriptive and multivariate statistics, and path analysis.

Results:
On average, our nurses experienced 6.38 small troubles per 12 hour shift. The three most common troubles were communication with physicians, medication administration, and problems with equipment. They had neutral feelings about their hospital's safety culture but believed they could freely discuss safety concerns. A majority of nurses believed patient care quality was excellent or good and 73% rated job satisfaction as positive. Trouble categories in descending order were equipment/supplies (27.58%), medication (17.67%), communication (16.55%), other (16.01%), staffing/training (11.45%) and physical unit/layout (10.74%), which was consistent with other sites in the study.

Conclusions and Implications for Practice:
Findings show that small trouble prevalence is similar across multiple settings. Frontline nurses are a valuable resource in identifying trouble issues that can potentially lead to errors. Nurses need to be consulted in finding enduring solutions that will reduce and eliminate workarounds.