Patrick Albert Palmieri

Performance in Nursing

Nurses spend more time with patients than do any other health care providers, and patient outcomes are affected by nursing care quality. Thus, improvements in patient safety can be achieved by improving nurse performance. We review the literature on nursing performance, including cognitive, physical, and organizational factors that affect such performance, focusing on research studies that reported original data from nurse participants. Our review indicates that the nurses work system often does not accommodate human limits and capabilities and that nurses work under cognitive, perceptual, and physical overloads. Specifically, nurses engage in multiple tasks under cognitive load and frequent interruptions, and they encounter insufficient lighting, illegible handwriting, and poorly designed labels. They spend a substantial amount of their time walking, work long shifts, and experience a high rate of musculoskeletal disorders. Research is overdue in the areas of cognitive processes in nursing, effects of i...

The anatomy and physiology of error in adverse health care events

Recent reports by the Institute of Medicine (IOM) signal a substantial yet unrealized deficit in patient safety innovation and improvement. With the aim of reducing this dilemma, we provide an introductory account of clinical error resulting from poorly designed systems by reviewing the relevant health care, management, psychology, and organizational accident sciences literature. First, we discuss the concept of health care error and describe two approaches to analyze error proliferation and causation. Next, by applying transdisciplinary evidence and knowledge to health care, we detail the attributes fundamental to constructing safer health care systems as embedded components within the complex adaptive environment. Then, the Health Care Error Proliferation Model explains the sequence of events typically leading to adverse outcomes, emphasizing the role that organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction. Subsequently, we discuss the critical contribution health care leaders can make to address error as they strive to position their institution as a high reliability organization (HRO). Finally, we conclude that the future of patient safety depends on health care leaders adopting a system philosophy of error management, investigation, mitigation, and prevention. This change is accomplished when leaders apply the basic organizational accident and health care safety principles within their respective organizations.

Safety culture as a contemporary healthcare construct: theoretical review, research assessment, and translation to human resource management

Through a number of comprehensive reviews, the Institute of Medicine (IOM) has recommended that healthcare organizations develop safety cultures to align delivery system processes with the workforce requirements to improve patient outcomes. Until health systems can provide safer care environments, patients remain at risk for suboptimal care and adverse outcomes. Health science researchers have begun to explore how safety cultures might act as an essential system feature to improve organizational outcomes. Since safety cultures are established through modification in employee safety perspective and work behavior, human resource (HR) professionals need to contribute to this developing organizational domain. The IOM indicates individual employee behaviors cumulatively provide the primary antecedent for organizational safety and quality outcomes. Yet, many safety culture scholars indicate the concept is neither theoretically defined nor consistently applied and researched as the terms safety culture, safety climate, and safety attitude are interchangeably used to represent the same concept. As such, this paper examines the intersection of organizational culture and healthcare safety by analyzing the theoretical underpinnings of safety culture, exploring the constructs for measurement, and assessing the current state of safety culture research. Safety culture draws from the theoretical perspectives of sociology (represented by normal accident theory), organizational psychology (represented by high reliability theory), and human factors (represented by the aviation framework). By understanding not only the origins but also the empirical safety culture research and the associated intervention initiatives, healthcare professionals can design appropriate HR strategies to address the system characteristics that adversely affect patient outcomes. Increased emphasis on human resource management research is particularly important to the development of safety cultures. This paper contributes to the existing healthcare literature by providing the first comprehensive critical analysis of the theory, research, and practice that comprise contemporary safety culture science.

Technological iatrogenesis: New risks force heightened management awareness

Iatrogenesis is a term typically reserved to express the state of ill health or the adverse outcome resulting from a medical intervention, or lack thereof. Three types of iatrogenesis are described in the literature: clinical, social and cultural. This paper introduces a fourth type, technological iatrogenesis, or emerging errors stimulated by the infusion of technological innovations into complex healthcare systems. While health information technologies (HIT) have helped to make healthcare safer, this has also produced contemporary varieties of iatrogenic errors and events. The potential pitfalls of technological innovations and risk management solutions to address these concerns are discussed. Specifically, failure mode effect analysis and root cause analysis are discussed as opportunities for risk managers to prevent problems and avert errors from becoming sentinel events.

Technological Iatrogenesis: The Manifestation of Inadequate Organizational Planning and the Integration of Health Information Technology

The Institute of Medicine (IOM) views Health Information Technology (HIT) as an essential organizational prerequisite for the delivery of safe, reliable, and cost-effective health services. However, HIT presents the proverbial double-edged sword in generating solutions to improve system performance while facilitating the genesis of novel iatrogenic problems. Incongruent organizational processes give rise to technological iatrogenesis or the unintended consequences to system integrity and the resulting organizational outcomes potentiated by incongruent organizational-technological interfaces. HIT is a disruptive innovation for health services organizations but remains an overlooked organizational development (OD) concern. Recognizing the technology-organizational misalignments that result from HIT adoption is important for leaders seeking to eliminate sources of system instability. The Health Information Technology Iatrogenesis Model (HITIM) provides leaders with a conceptual framework from which to consider HIT as an instrument for organizational development. Complexity and Diffusion of Innovation theories support the framework that suggests each HIT adoption functions as a technological change agent. As such, leaders need to provide operational oversight to managers undertaking system change via HIT implementation. Traditional risk management tools, such as Failure Mode Effect Analysis and Root Cause Analysis, provide proactive pre- and post-implementation appraisals to verify system stability and to enhance system reliability. Reconsidering the use of these tools within the context of a new framework offers leaders guidance when adopting HIT to achieve performance improvement and better outcomes.

Attribution theory and healthcare culture: Translational management science contributes a framework to identify the etiology of punitive clinical environments

The Institute of Medicines seminal report, To err is human: Building a safer health system, established the national patient safety framework and initiated interest in changing the traditionally punitive healthcare culture. This paper reviews a multidisciplinary literature and offers an attribution framework to explicate the organizational processes that contribute to an industry-wide culture where clinicians are routinely blamed for adverse patient events. Attribution theory is concerned with the manner in which people explain the behaviors of others or themselves by assigning causality for events. To date, attribution theory, though well established in the management literature, has yet to be translated to healthcare. In this paper, we first describe the historical evolution of attribution theory in relation to human behavior in clinical practice and healthcare management and then discuss the work environments in contemporary healthcare organizations. Next, we demonstrate the applicability of attribution theory to healthcare by providing two adverse event exemplar cases. Then, the Healthcare Attribution Error Model is offered to demonstrate how concepts from attribution theory serve as antecedents to the employee cynicism, learned helplessness, organizational inertia, and the emerging Just Culture perspective. We conclude by suggesting attribution theory offers an important theoretical framework that warrants further conceptual development and empirical research. In the quest to produce exceptional healthcare environments where safety and quality are fundamental employee concerns, healthcare managers and clinical professionals need theoretically supported knowledge and evidence-based insights.

The Experience of Pregnancy in Women Living With HIV: A Meta-Synthesis of Qualitative Evidence

&NA; The lived experience of pregnancy from the perspectives of women living with HIV (WLWH) is not well understood. We aimed to understand the meaning of pregnancy for WLWH. A meta‐synthesis was conducted to review and integrate qualitative studies about the phenomena; 12 databases were used to perform the search in English, Spanish, and Portuguese. Articles using qualitative methods published in peer‐reviewed journals were included. Data were analyzed using the meta‐synthesis method. We found that, for pregnant WLWH, pregnancy evolved as a mediated experience of commitment and dedication. The vital life experience of pregnancy was defined as an interplay of emotions, coping strategies, and feelings of satisfaction. Pregnancy in WLWH was experienced and impacted by societal beliefs, as the women focused all their efforts to take care of themselves and their babies.

Safety Culture as a Contemporary Healthcare Construct: Theoretical Review and Research Assessment

TITLE. Safety Culture as a Contemporary Healthcare Construct: Theoretical Review and Research Assessment AUTHORS. Patrick A. Palmieri, consultor de salud, Division de Negocios de Salud, Pacifico Peruano Suiza and professor, Center for American Education, Universidad San Ignacio de Loyola, Lima, Peru; and Lori T. Peterson, assistant professor of Health Care Administration, Department of Management and Labor Relations, Nance College of Business, Cleveland State University, Cleveland, Ohio. GOAL. To analyze the theoretical underpinnings of safety culture and to provide an assessment about the state of safety culture research in healthcare. METHODS. First, we reviewed the concept of safety culture, including its origination, disciplinary influences, and associated theoretical tenets. By describing the literature and discussing the interchangeable use of the terms “safety attitude,” “safety climate,” and “safety culture,” we are able to present the conceptual attributes associated with safety culture and present a definition of safety culture. Then, we discuss the psychometric properties for the most widely used instruments in healthcare. The article concludes with a discussion of the current state of safety culture research in healthcare and future opportunities for research. PRINCIPAL FINDINGS. Over time, theoretical development has been limited, which has restricted safety culture research. Reviews of measurement instruments indicate a significant degree of inconsistency in the conceptual and thematic basis. Although a number of instruments are available for research, these instruments vary considerably with regard to general characteristics, the dimensions covered, the availability of psychometrics, and the applicability in studies. The instrument debacle may be responsible for contradictory findings within and between studies. We found that conceptual fragmentation and incomplete theoretical grounding has impeded safety culture research and will continue to hamper further advancement. APPLICATIONS TO PRACTICE. Poor safety management practices represent the root cause of most adverse events. Safety culture is an organizational concept important to the future of the healthcare industry. Yet to date, there are no expert panel recommendations, such as Institute of Medicine reports, to guide healthcare organizations in selecting a valid and reliable safety culture instrument. Researchers have an opportunity to establish a clear conceptual framework, develop valid and reliable measurement instruments, conduct intervention studies, and recommend robust monitoring systems. Safety culture is an important tenet to improve patient safety. By better understanding how to implement organizational changes that impact safety, healthcare administrators, clinical professionals, and ancillary staff can collectively contribute to a better-functioning healthcare system. Photocopying and distributing this PDF of the Journal of Healthcare Management is prohibited without the permission of Health Administration Press, Chicago, Illinois. For permission or reprint, please contact the Copyright Clearance Center at www.copyright.com. 430 Journal of Healthcare Management 55:6 November/December 2010 CONTACT. Patrick A. Palmieri at palmieripa@gmail.com This article was nominated as one of best presented to the Health Care Management Division of the Academy of Management at its 2009 Annual Meeting. For more information about the Academy of Management, visit www.aomonline.org. Photocopying and distributing this PDF of the Journal of Healthcare Management is prohibited without the permission of Health Administration Press, Chicago, Illinois. For permission or reprint, please contact the Copyright Clearance Center at www.copyright.com.