Linda Q. Everett

Understanding situation awareness in nursing work: a hybrid concept analysis.

Eighty percent of medical error are attributed to human factors. Human factors experts suggest the least explored factor in patient errors is attention, specifically, situation awareness. The purpose of this article was to analyze the concept of situation awareness using a hybrid concept analysis. The experience of situation awareness among nurses was elicited during the fieldwork phase through semistructured interviews. Content and relational analyses yielded 9 themes: perception, comprehension, projection, knowledge and expertise, cognitive overload, interruption management, task management, instantaneous learning, and cognitive stacking. A conceptual definition of situation awareness emerged along with recommendations for application in nursing.

Safety Organizing, Emotional Exhaustion, and Turnover in Hospital Nursing Units

Context:Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on how engaging in safety organizing affects caregivers. Objectives:While we know that organizational processes can have divergent effects on organizational and employee outcomes, little research exists on the effects of pursuing highly reliable performance through safety organizing on caregivers. Specifically, we examined whether, and the conditions under which, safety organizing affects RN emotional exhaustion and nursing unit turnover rates. Subjects:Subjects included 1352 RNs in 50 intensive care, internal medicine, labor, and surgery nursing units in 3 Midwestern acute-care hospitals who completed questionnaires between August and December 2011 and 50 Nurse Managers from the units who completed questionnaires in December 2012. Research Design:Cross-sectional analyses of RN emotional exhaustion linked to survey data on safety organizing and hospital incident reporting system data on adverse event rates for the year before survey administration. Cross-sectional analysis of unit-level RN turnover rates for the year following the administration of the survey linked to survey data on safety organizing. Results:Multilevel regression analysis indicated that safety organizing was negatively associated with RN emotional exhaustion on units with higher rates of adverse events and positively associated with RN emotional exhaustion with lower rates of adverse events. Tobit regression analyses indicated that safety organizing was associated with lower unit level of turnover rates over time. Conclusions:Safety organizing is beneficial to caregivers in multiple ways, especially on nursing units with high levels of adverse events and over time.

Building a culture of innovation by maximizing the role of the RN.

By the year 2020, as hospitals morph into entirely different kinds of service providers, nurses too will look altogether different. Those with the capacity to embrace disruptive innovation, along with all the unknowns that accompany it, will be successful at guiding their organizations into the future. Nurse executives must act now to build nursing cultures capable of massive and transformational change—change that will alter the way patient care is perceived, delivered, and evaluated. One hospital system is using a Think Tank approach to pilot demonstration projects that aim to maximize the role of the registered nurse and redefine expectations around patient care delivery. Early work indicates that new thinking combined with “permission to fail” from nursing leadership is essential to success. Lean Six Sigma principles and creativity tools from inside and outside of health care are being adopted with promising results. Exemplars show that by creating a sense of urgency around a big opportunity, this health care system is developing change initiatives that are literally transforming culture.

Letter to editor response.

We appreciate the time and effort Ms Fore took to read and think about our article, as well as share some of her thought with us and the ANS readers. We are pleased to have the opportunity to continue the dialogue about this important concept. Ms Fore raises a legitimate point in terms of retrospective analysis of situation awareness. Although retrospective analysis does have some limitations, it is currently one of the most viable methods available to study situational awareness (SA). “Real” time measurement and analysis can only be done in the laboratory, with a simulated situation, which has its own set of inherent limitations, such as when measuring momentary SA. Momentary SA is measured when the observer interrupts a particular activity to test current SA. The interruption is then itself a cognitive interruption and not a reflection of the real world context. The SAGAT has been previously described along with its inherent limitations, including but not limited to, interruptions resulting from the probe technique. Critical decision method (CDM) is also commonly used to describe and explain situation awareness. Experts in the field, such as Klein, contend that CDM is a valid method to examine the connection between SA and decision making. In CDM, incidents are probed carefully with the subject and the researcher examines SA as the incident unfolded, the interpretation of each stage, and alternative interpretations that were considered but rejected. We are confident that in the future other techniques such as “talking aloud” may be able to be used, but it is likely that this method will also suffer some limitation as all methodologies do. The researcher must weigh carefully the issues and limitations and make the best choice possible—we believe we did this. We appreciate the discussion points raised by Ms Fore related to her interpretation of our premise absent consideration of automatic decision making and complacency. We still believe Benner’s novice to expert model provides a very useful framework for the study of

Knowing When to Refuel and Renew

Nurse leaders are frequently called upon to deal with challenging and distressing human resource (HR) issues. Throughout my career, some of my most critical learning opportunities have been HR-related. What I’ve learned is that it’s easy to talk the talk of “do the right thing for the patients always,” but it takes a true leader and principled individual to walk the walk each day. One HR crisis in particular literally rocked me to my personal core. Under my watch, a nursing practice issue surfaced that required swift and deliberate action, including the termination of well-intentioned leaders and nursing board sanctions for several RNs. Timing compounded the issue: A very public and important announcement about nursing practice was set to take place, and the fallout from the terminations and sanctions prompted disgruntled staff to consider a remonstrative demonstration at a ceremonial event. My leadership style and my decision-making practice were publicly called into question. Even though regulatory compliance, legal, and HR departments were in agreement with the corrective actions being taken, I was a primary target for complaints that escalated to include all of hospital administration. Drama built over a series of weeks, while the nursing ceremony loomed large. On the day of the ceremony, I was emotionally drained. I hadn’t slept well for weeks, and it was taking a physical toll. A colleague and friend recognized that I was near implosion and took me aside to say, “Stop. It’s time to take care of you. You have to get out of here and clear your head. If you don’t take care of you, you can’t continue to lead this department.” Truer words had never been spoken. But as a nurse is wont to do, I had a million reasons why I couldn’t just step away, even briefly. Thankfully, my colleague and friend prevailed, and after the ceremony (no demonstration occurred— whew!), I packed a bag and my dog and went on a short RV vacation with my husband. The woods and time away had never been more therapeutic. I needed to care for myself and renew. In retrospect, I can clearly see the steps that exacerbated my stress and anxiety. What I’ve learned over time is that failure to care for yourself makes any bad situation worse. If you’re not taking time off, getting away, and focusing on something other than work, you’re doing yourself a disservice and ultimately setting yourself up for failure. Another friend and colleague, Dan Pesut from the Indiana University School of Nursing, recently spoke to a retreat of my nursing leadership team and tackled this very issue. He suggested that it is way too easy to get caught up in day-to-day trials and tribulations that can trip up the best of us and leave us wondering, “What the heck am I doing here?” But we can all get back to purpose by asking, “What am I truly trying to accomplish? Why am I really here?” The answer for me is always the same: the patients. I am here for the patients, who make the work worthwhile. Even as an executive, I feel that I can make a difference in their lives by supporting nurses and working with them to make a meaningful difference in the care patients receive. To take the best care of patients, we have to first take care of ourselves. Only that will allow us to live a good life—living where we belong, with the people we love, doing the right work, on purpose. For me, that is nursing in a nutshell: good work, good people, right reasons. As you strive to meet goals related to patient satisfaction and patient expectations, ask yourself what matters most. And then do something for yourself to help you get there.