Chapter 2. Nurses at the “Sharp End” of Patient Care 

Ronda G. Hughes 

 

Background 

The work environment in which nurses provide care to patients can determine the quality and 

safety of patient care.1

 As the largest health care workforce, nurses apply their knowledge, skills, 

and experience to care for the various and changing needs of patients. A large part of the 

demands of patient care is centered on the work of nurses. When care falls short of standards, 

whether because of resource allocation (e.g., workforce shortages and lack of needed medical 

equipment) or lack of appropriate policies and standards, nurses shoulder much of the 

responsibility. This reflects the continued misunderstanding of the greater effects of the 

numerous, complex health care systems and the work environment factors. Understanding the 

complexity of the work environment and engaging in strategies to improve its effects is 

paramount to higher-quality, safer care. High-reliability organizations that have cultures of safety 

and capitalize on evidence-based practice offer favorable working conditions to nurses and are 

dedicated to improving the safety and quality of care. Emphasis on the need to improve health 

care systems to enable nurses to not be at the “sharp end” so that they can provide the right care 

and ensure that patients will benefit from safe, quality care will be discussed in this chapter. 

The Everydayness of Errors 

Health care services are provided to patients in an environment with complex interactions 

among many factors, such as the disease process itself, clinicians, technology, policies, 

procedures, and resources.2

 When these complex factors interact, harmful and unanticipated 

outcomes (e.g., errors) can occur. Human error has been defined as a failure of a planned action 

or a sequence of mental or physical actions to be completed as intended, or the use of a wrong 

plan to achieve an outcome.2 By definition, errors are a cognitive phenomenon because errors 

reflect human action that is a cognitive activity. Near misses, or “good catches,”3

 are defined as 

events, situations, or incidents that could have caused adverse consequences and harmed a 

patient, but did not.4

 Factors involved in near misses have the potential to be factors (e.g., root 

causes) involved in errors if changes are not made to disrupt or even remove their potential for 

producing errors. 

Reason2 described errors as the product of either active (i.e., those that result primarily from 

systems factors, producing immediate events and involve operators (e.g., clinicians) of complex 

systems) or latent factors (i.e., factors that are inherent in the system). Latent factors (e.g., heavy 

workload, structure of organizations, the work environment) are embedded in and imposed by 

systems and can fester over time, waiting for the right circumstances to summate individual 

latent factors and affect clinicians and care processes, triggering what is then considered an 

active error (e.g., an adverse drug event). Leadership and staff within organizations essentially 

inherit and can create new latent factors through scheduling, inadequate training, and outdated 

equipment.5

 Latent factors or conditions are present throughout health care and are inevitable in 

organizations. These factors and conditions can have more of an effect in some areas of an 

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organization than others because resources can be “randomly” distributed, creating inequities in 

quality and safety.5

 The number of hazards and risks can be reduced by targeting their root 

causes. In doing so, the path between active failures when the error occurred would be traced to 

the latent defects in the organization, indicating leadership, processes, and culture. Then, if 

organizational factors (e.g., latent factors) become what they should be, few active causes of 

accidents will come about. 

The Institute of Medicine (IOM) stated that safety was dependent upon health care systems 

and organizations, and patients should be safe from injury caused by interactions within systems 

and organizations of care.6

 Organizational factors have been considered the “blunt end” and 

represent the majority of errors; clinicians are considered the “sharp end.” Therefore, to prevent 

errors, the organizations in which humans work need to be adapted to their cognitive strengths 

and weaknesses and must be designed to ameliorate the effects of whatever human error occurs. 

The most effective strategies to improve safety target latent factors within organizations and 

systems of care. This point is emphasized by the IOM, which further stated that the safety and 

quality of care would be improved by holding systems accountable, redesigning systems and 

processes to mitigate the effects of human factors, and using strategic improvements.7

According to Reason,2 a large part of mental functioning is automatic, rapid, and effortless. 

This automatic thinking is possible because we have an array of mental models (e.g., schemata) 

that are expert on some minuscule recurrent aspect of our lives (e.g., going to work). Many errors 

result from flaws in thinking that affect decisionmaking.8, 9 Ebright and colleagues10 assert that 

nurses’ ability to make logical and accurate decisions and influence patient safety is associated 

with complex factors, including their knowledge base and systems factors (e.g., distractions and 

interruptions), availability of essential information, workload, and barriers to innovation. The 

effects of these factors are complicated by the increasingly complex nature of nursing’s roles and 

responsibilities, the complex nature of preventing errors from harming patients, and the 

availability of resources.10

When errors occur, the “deficiencies” of health care providers (e.g., insufficient training and 

inadequate experience) and opportunities to circumvent “rules” are manifested as mistakes, 

violations, and incompetence.11, 12 Violations are deviations from safe operating procedures, 

standards, and rules, which can be routine and necessary or involve risk of harm. Human 

susceptibility to stress and fatigue; emotions; and human cognitive abilities, attention span, and 

perceptions can influence problem-solving abilities.2

 Human performance and problem-solving 

abilities are categorized as skill based (i.e., patterns of thoughts and actions that are governed by 

previously stored patterns of preprogrammed instructions and those performed unconsciously), 

rule based (i.e., solutions to familiar problems that are governed by rules and preconditions), and 

knowledge based (i.e., used when new situations are encountered and require conscious analytic 

processing based on stored knowledge). Skill-based errors are considered “slips,” which are 

defined as unconscious aberrations influenced by stored patterns of preprogrammed instructions 

in a normally routine activity. Distractions and interruptions can precede skill-based errors, 

specifically diverting attention and causing forgetfulness.2

 Rule-based and knowledge-based 

errors are caused by errors in conscious thought and are considered “mistakes.”13 Breaking the 

rules to work around obstacles is considered a rule-based error because it can lead to dangerous 

situations and may increase one’s predilection toward engaging in other unsafe actions. Workarounds are defined as “work patterns an individual or a group of individuals create to 

accomplish a crucial work goal within a system of dysfunctional work processes that prohibits 

the accomplishment of that goal or makes it difficult”14 (p. 52). Halbesleben and colleagues15

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assert that work-arounds could introduce errors when the underlying work processes and 

workflows are not understood and accounted for, but they could also represent a “superior 

process” toward reaching the desired goal. 

Clinicians’ decisionmaking and actions are also influenced by the “human condition.” 

Reason5, 16 asserted that because of the fallibility of the human condition, we can change the 

working conditions so that the potential for errors is reduced and the effect of errors that do 

occur is contained. Humans are limited by difficulty in attending to several things at one time, 

recalling detailed information quickly, and performing computations accurately.6 As discussed 

by Henriksen and colleagues,17 the scientific field of human factors focuses on human 

capabilities and limitations and the interaction between people, machines, and their work 

environment. The focus is on system failures, not human failures, and on meeting the needs of 

the humans interacting within it. Systems would be redesigned and dedicated to continuous 

improvement to protect against human error by employing simplification, automation, 

standardization of equipment and functions, and decreasing reliance on memory.18 The “work 

system” would account for the interrelatedness of the individual, tasks, tools and technologies, 

the physical environment, and working conditions.19 Conditions that make errors possible would 

be redesigned to reduce reliance on memory, improve information access, error-proof processes, 

standardize tasks, and reduce the number of handoffs.20, 21 Errors would be identified and 

corrected and over time there would be fewer latent failure modes and fewer errors. However, 

because patient outcomes are dependent upon human-controlled processes, health care settings 

will never be 100 percent safe. 

The IOM defined patient safety as freedom from accidental injury. 6 Adverse events are 

defined as injuries that result from medical management rather than the underlying disease.22, 23

While the proximal error preceding an adverse event is mostly considered attributable to human 

error, the underlying causes of errors are found at the system level and are due to system flaws;24

system flaws are factors designed into health care organizations and are often beyond the control 

of an individual.25, 26 In other words, errors have been used as markers of performance at the 

individual, team, or system level. Adverse events have been classified as either preventable or 

not,21, 27 and some preventable adverse events (fewer than one in three) are considered to be 

caused by negligence.28 The concept of an error being preventable has not been widely 

understood in its context, and definitions have been conflicting and unreliable,21, 29 partially 

because the source of the majority of errors have been ascribed to vague systems factors,30 and 

the relationship between errors and adverse events is not fully understood.30, 31

Although the true number of errors and adverse events may not be known because of 

underreporting, failure to recognize an error, and lack of patient harm, it is difficult to understand 

the pervasiveness of errors because there are differences in definitions of reportable errors and 

adverse events.32 Research and quality improvement initiatives have focused predominately on 

medication safety because of existing information systems and the potential frequency for which 

errors can occur. In the case of medications, the types and causes of errors describe how nurses 

are at the “sharp end.” Medications pose the largest source of errors, yet many do not result in 

patient harm.33, 34 Since errors actually occur during the process of medication therapies, the 

usual ‘practice’ has been to blame individuals.35, 36 A medication intervention goes from 

prescribing, transcribing, and dispensing to administration. Physicians are primarily responsible 

for prescribing medications and nurses are primarily responsible for administering medications 

to patients. Errors made by physicians can be intercepted by pharmacists and nurses, errors made 

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by pharmacists can be intercepted by nurses, and errors made by nurses could potentially be 

intercepted by peers or patients. 

Several classifications of health care errors have been posed.37–39 Classifications or 

categorizations of errors have been based on types of adverse events,40–42 incident reports,38, 39

individual blame,37 and system causes. Given what is known about error causation,1, 5, 6, 16

particularly what has been learned from root-cause analysis and failure modes and effects 

analysis, when errors/adverse events involve clinicians, classifications/taxonomies of errors 

would be centered on all the related systems factors and would consider them the major 

contributors of the error/adverse event.5, 16 For example, one classification of errors differentiates 

endogenous errors (i.e., arise within the individual or team) from exogenous errors (i.e., arise 

within the environment).43 Endogenous errors are generally either active or latent2

 and result 

from departure from normative knowledge-based, skill-based, or rule-based behaviors.44 

The complexity of factors involved in errors and adverse events is exemplified in medication 

safety. Researchers have found that between 3 percent and 5 percent,45 34 percent,46 40 percent,47

or 62 percent48 of medication errors are attributable to medication administration. For an 

administration error to not occur, the nurse would be at the “sharp end,” having the responsibility 

to intercept it. Administration errors have been found to be the result of human factors, including 

performance and knowledge deficiencies;49 fatigue, stress, and understaffing were found to be 

two major factors for errors among nurses.50 Administering medications can take up to 40 

percent of the nurse’s work time,51 and medication administration errors have been found to be 

due to a lack of concentration and the presence of distractions, increased workloads, and 

inexperienced staff.48, 52, 53 If we consider what has been learned in other industries, medication 

administration errors would also be caused by systems factors, such as leadership not ensuring 

sufficient training, maldistribution of resources, poor organizational climate, and lack of 

standardized operating procedures.54

Since the publication of the IOM’s To Err Is Human,

6

 millions of dollars of research funds—

e.g., from the Agency for Healthcare Research and Quality (AHRQ) and the Robert Wood 

Johnson Foundation—have been devoted to building the evidence base in patient safety research. 

Findings reported from the IOM and other related research is being disseminated on key aspects 

of patient safety. It is interesting to note that before the publication of To Err Is Human, the 

major focus of patient safety was on individual blame and malpractice.55 Since the publication of 

To Err Is Human, that has no longer been the case and there is more focus on the need to 

improve health care organizations,56 but the concerns associated with malpractice have not 

dissipated. In fact, concerns about malpractice have thwarted many patient safety improvement 

efforts primarily because of the need for data collection and analysis as well as performance 

measures to inform patient safety changes.57 

The focus on the responsibilities and influences of systems does not negate the challenge of 

understanding error and accepting the inevitability of many errors while concurrently increasing 

the quality of health care. It is not possible for every aspect of health care and every setting of 

care to be 100 percent error free, and leaders and clinicians are challenged to define what is an 

acceptable level of error. Because safety is foundational to quality,58 one way to define quality is 

providing “the right care, at the right time, for the right person, in the right way.”59 In doing so, 

efforts to improve safety and quality need to address concerns with potential overuse, misuse, 

and underuse of health care services that can threaten the quality and safety of care delivered to 

patients. Since patient safety, and quality in many respects, “is a new field, identifying which 

safe practices are effective has presented a significant challenge”60 (p. 289), in part because of 

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Nurses at the “Sharp End”

the resource requirements, the complex nature of changing practice, and the influences of units 

within the whole.60 

The Importance of High-Performing Organizations 

The quality and safety of care is associated with various factors within systems, 

organizations, and their work environments—the combination of which influences the type of 

quality and safety of care provided by nurses.1

 Donabedian’s61 definition of quality of care 

represents the entire continuum from structure to process and to outcome. Structures, processes 

and outcomes are interdependent, where specific attributes of one influence another according to 

the strength of the relationship.61–63 When organizational structure factors support the care 

processes and enable teamwork, nurses are more satisfied with their jobs64, 65 and patients receive 

higher-quality care.65 Leaders who engage in transactional (e.g., establish trust in relationships 

with staff, provide structure and expectations)66, 67 and transformational leadership (e.g., develop 

a stronger collective identity and commitment to change)68, 69 and who view change as 

opportunities to learn, adapt, and improve70 organizations to improve health care quality. When 

teams function well and organization structure factors support their work, outcomes are better, 

even at institutions that have a high intensity of specialized care for those particular needs.71, 72

The effectiveness of individuals and teamwork is dependent upon leadership, shared 

understanding of goals and individual roles, effective and frequent communication,72-74 having 

shared governance,75 and being empowered by the organization.76

In his seminal work, Shortell asserted that the characteristics of high-performing health care 

organizations included “a willingness and ability to: stretch themselves; maximize learning; take 

risks; exhibit transforming leadership; exercise a bias for action; create a chemistry among top 

managers; manage ambiguity and uncertainty; exhibit a ‘loose coherence;’ exhibit a well-defined 

culture; and reflect a basic spirituality”77 (page 8). These organizations are engaged in continuous 

improvement to improve outcomes. Since then, Shortell and colleagues78 furthered his seminal 

work, finding that what distinguished high-performing organizations was certain key factors, 

such as having a quality-centered culture, reporting performance, and the ability to overcome 

quality improvement redesign barriers by “(1) directly involving top and middle-level leaders, 

(2) strategically aligning and integrating improvement efforts with organizational priorities, (3) 

systematically establishing infrastructure, process, and performance appraisal systems for 

continuous improvement, and (4) actively developing champions, teams, and staff”79 (p. 599). 

The significance of these characteristics of high-performing organizations was furthered by 

findings from an evaluation of 12 health care systems, where factors critical to redesigning 

current systems to achieve quality and safety goals and improve patient outcomes were found to 

be successful when there was an “(1) impetus to transform; (2) leadership commitment to 

quality; (3) improvement initiatives that actively engage staff in meaningful problem solving; (4) 

alignment to achieve consistency of organization goals with resource allocation and actions at all 

levels of the organization; and (5) integration to bridge traditional intra-organizational 

boundaries among individual components”80 (p. 309). Yet to address these factors in redesigning 

care systems and processes, Lucas and colleagues found that organizations needed to have “(1) 

mission, vision, and strategies that set its direction and priorities; (2) culture that reflects its 

informal values and norms; (3) operational functions and processes that embody the work done 

in patient care; and (4) infrastructure such as information technology and human resources that 

support the delivery of patient care”80 (p. 309). 

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Yet, many organizations do not meet the standards of high-reliability organizations (HROs). 

Reason and colleagues81 described the “vulnerable system syndrome” as a cluster of 

organizational pathologies that interact, making some systems more liable to unsafe practices 

that threaten patient safety. These pathologies (e.g., blame, denial, and the pursuit of financial 

excellence) are perpetuated in work environments by leaders and peers targeting individuals at 

the “sharp end,” simultaneously failing to question core beliefs, recognize systemic causes, or to 

implement systemwide reforms. Reason and colleagues further asserted that indicators of 

vulnerabilities of the work environment, such as a culture of individual blame, were associated 

with workplace cultures that influenced safety and could be categorized as (1) high reliability 

(where recognizing how safety can be improved is rewarded), (2) pathological (where 

punishment and covering up of errors/failures are pervasive and new ideas are discouraged), or 

(3) bureaucratic (where failures are considered isolated, systematic reforms are avoided, and new 

ideas are problematic). An indicator of the presence of work environment vulnerabilities and 

patient safety improvements could be whether or not an organization has Joint Commission 

accreditation.82

Nurses perceive multiple and complex work environment factors that influence nurse and 

patient outcomes, including the quality of leadership and management, staffing resources, 

workload,83 job stress and anxiety, teamwork, and effective communication.84 Heath and 

colleagues asserted that in healthy work environments, nurses “feel valued by their organization, 

have standardized processes in place, have staff empowerment, have strong leadership, feel a 

sense of community, and recognize that strategic decision-making authority [influences] how 

their units were run and how scarce resources were disseminated”85 (p. 526–7). Healthy work 

environments are also places where safe and high-quality nursing care is expected and rewarded. 

Healthy work environments also need to foster effective communication, collaborative 

relationships, and promote decisionmaking among all nurses.85 Unhealthy work environments 

can have adverse consequences on the quality of care delivered as well as nurses’ intention to 

leave the profession.1, 86–88

As proposed by Stone and colleagues,89 there are microclimates (e.g., a unit or department) 

that function within the larger context of the organization. These microclimates or 

“microsystems” have a core team of health care professionals; a defined population of patients 

they are responsible for; and information, staff, and health technologies that provide support to 

the work of the clinicians.90

Yet, the majority of this research has examined outcomes at the hospital-wide level, and not 

at the unit level. Since the work environment within microclimates/microsystems can be 

different than that found organization-wide, it would be important to focus on these subunits to 

support efforts to standardize common care processes, to better examine process and outcome 

measures and what subunit factors and organization-wide factors contribute to less-than-optimal 

care, to emphasize the impact of multidisciplinary teams throughout the organization, and to 

ascertain how lessons learned in these subunits could be applied organization-wide.90 

High-Reliability Organizations 

Inherently related to high-performing organizations, HROs are defined as organizations that 

function daily under high levels of complexity and hazards. Reliable organizations have 

“procedures and attributes that make errors visible to those working in the system so that they 

can be corrected before causing harm”6

 (p. 152) and produce consistent results. Accordingly, the 

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Nurses at the “Sharp End”

IOM has advocated for hospitals to transition into HROs to improve the quality and safety of 

care.6

 In HROs, reliability and consistency are built into organizational routines where errors can 

have catastrophic consequences. In health care, reliability is defined as the “measurable ability of 

a health-related process, procedure, or service to perform its intended functions in the required 

time under commonly occurring conditions”91 (p. 82). Applying the theory behind high 

reliability organizations and normal accident theory (e.g., understanding how health system 

factors affect safety), patient safety improvements have been linked to high-reliability safety 

interventions, including double checking, and improving the validity of root-cause analyses.92 

Because improving safety is complex and should be continuous,2, 4, 11 HROs continually 

measure their performance, learn from experience, and take action to resolve problems when 

they are discovered. HROs have a (1) preoccupation with avoiding failure, (2) reluctance to 

simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) 

deference to expertise.93, 94 A preoccupation with avoiding failures is based on comprehensive 

error reporting, where human failure is accepted as being inevitable, and being overconfident 

because of successes is considered highly risky. A reluctance to simplify interpretations is 

supported by thoroughly examining situations. Being sensitive to operations involves being 

constantly concerned about the unexpected and recognizing that active errors result from latent 

errors in the system. Committing to resilience involves being able to identify, control, and 

recover from errors, as well as developing strategies to anticipate and responds to the 

unexpected. Having deference to expertise means that everyone is involved and decisions are 

made on the front line.94

Health care leaders and researchers have been looking to HROs in industry, such as the 

National Aeronautics and Space Administration, aviation, and the U.S. Postal Service,21, 94, 95 to 

apply their lessons learned to health care. HROs are known to approach safety from a systems 

perspective, involving both formal structures and informal practices, such as open inquiry and 

deep self-understanding that complement those structures.96 Through careful planning and 

design, HROs have been found to share common features: (1) auditing of risk—to identify both 

expected and unexpected risks; (2) appropriate reward systems—for safety-related behaviors; (3) 

system quality standards—evidence-based practice standards; (4) acknowledgment of risk—

detecting and mitigating errors; and (5) flexible management models—promoting teamwork and 

decentralized decisionmaking.97 Shapiro and Jay asserted that health care organization can 

become HROs though “(1) attitude change, (2) metacognitive skills, (3) system-based practice, 

(4) leadership and teamwork, and (5) emotional intelligence and advocacy”98 (p. 238). 

Implementing quality and safety improvement strategies in organizational 

microclimates/microsystems, and for that matter organization-wide, should be predicated on 

increasing the subunits’ awareness of how they function and mindfulness of the reliability of 

their outcomes. Mindfulness is a “combination of ongoing scrutiny of existing expectations, 

continuous refinement and differentiation of expectations based on newer experiences, 

willingness and capability to invent new expectations that make sense of unprecedented events, 

and a more nuanced appreciation of context and ways to deal with it, and identification of new 

dimensions of context that improve foresight and current functioning”94 (p. 42). Mindfulness 

speaks to the interrelationships among processes of perception and cognition that stimulate a rich 

awareness of and hypervigilance for emerging factors and issues that could threaten the quality 

of care and enable the identification of actions that might be taken to deal with the threats to 

quality.94 Weick and Sutcliff94 argue that organizations can become HROs when they become 

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mindful, as manifested by being preoccupied with failure, reluctant to simplify interpretations, 

sensitive to operations, committed to resilience, and deferent to expertise. 

What Is It Going To Take To Improve the Safety and 

Quality of Health Care? 

Changes in health care work environments are needed to realize quality and safety 

improvements. Because errors, particularly adverse events, are caused by the cumulative effects 

of smaller errors within organizational structures and processes of care, focusing on the systemic 

approach of change focuses on those factors in the chain of events leading to errors and adverse 

events.5, 99 From a systems approach, avoidable errors are targeted through key strategies such as 

effective teamwork and communication, institutionalizing a culture of safety, providing patientcentered care, and using evidence-based practice with the objective of managing uncertainty and 

the goal of improvement. 

The Right Work Environment 

The major focus of the IOM’s report, Keeping Patients Safe: Transforming the Work 

Environment of Nurses,

1

 was to emphasize the dominant role of the work environment within 

health care organizations and the importance of the work environment in which nurses provide 

care to patients. Research reviewed by the IOM committee reported that nurses were dissatisfied 

with their work and wanted better working conditions and greater autonomy in meeting the needs 

of patients. The significance of these and many other findings led to the committee 

recommending significant changes in the way all health care organizations were structured, 

including “(1) management and leadership, (2) workforce deployment, (3) work processes, and 

(4) organizational cultures”1 (p. 48). After the release of that report, the American Association of 

Critical-Care Nurses (AACN) expanded upon these concepts and put forth the following 

standards for establishing and sustaining healthy work environments: (1) effective, skilled 

communication; (2) true collaboration that is fostered continuously; (3) effective decisionmaking 

that values the contributions of nurses; (4) appropriate staffing that matches skill mix to patient 

needs; (5) meaningful recognition of the value of all staff; and (6) authentic leadership where 

nurse leaders are committed to a healthy work environment and engage everyone.100 To achieve 

these standards, many organizations will need to significantly change the work environment for 

nurses. 

The nursing “practice environment” is defined by organizational characteristics that can 

either facilitate or constrain professional nursing practice.101 Changes to the nurses’ work 

environment need to focus on enabling and supporting nurses to provide high-quality and safe 

care.102 To do so, there needs to be significant changes in the way health care is organized that 

also address nursing workforce resources, training, and competencies. Researchers have found 

that nurses may experience greater professional fulfillment when strategies are implemented that 

promote autonomous practice environments, provide financial incentives, and recognize 

professional status.103 Whether because of unequal distribution of nurses or expected nursing 

workforce shortages with the aging of practicing nurses and faculty,104, 105 staffing shortages 

increase a nurse’s stress, increases their workload, and can adversely impact patient outcomes. 

More important, clinicians in practice will need new skills and empowerment to work effectively 

with colleagues within their work environments. Nurses also need to possess certain 

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Nurses at the “Sharp End”

competencies that reflect the nature of nursing in improving patient and systems outcomes, 

including evidence-based practice, patient-centered care, teamwork and collaboration, safety, 

quality improvement, and informatics.106

Opportunity, power, and the composition of the workforce within organizations influence 

what nurses are able to do and how they are able to use resources to meet patients’ needs. 

Lashinger and colleagues76, 107–109 have found that the empowerment of staff nurses increased 

with greater responsibilities associated with job advancements and was related to the nurses’ 

commitment to the organization, burnout, job autonomy, their ability to participate in 

organizational decisionmaking, as well as job strain and work satisfaction.110 Because work 

environment factors influence the perceptions of nurses as being supported in their work, having 

a sense of accomplishment,111 and being satisfied with their work, it is important to empower 

staff to manage their own work, collaborate in effective teams,112 and practice nursing in 

“optimal” conditions.113 Professional empowerment in the workplace is derived from 

competence and interactions with colleagues and other clinicians within organizations—and with 

patients—as well as by demonstrating knowledge and gaining credibility.114 For nurses, 

structural empowerment can have a direct effect on their experience of providing care in their 

work environment.115 Models of care, such as a professional practice model, not only can 

improve work satisfaction, but they can facilitate patient and nursing outcomes.116 

Patient-Centered Care 

In Crossing the Quality Chasm, the IOM recommended that “all health care organizations, 

professional groups, and private and public purchasers should adopt as their explicit purpose to 

continually reduce the burden of illness, injury, and disability, and to improve the health and 

functioning of the people of the United States”7 (p. 39). For this recommendation to be realized, 

the IOM asserted that health care would have to achieve six aims: to be safe, effective, patientcentered, timely, efficient, and equitable. The IOM also asserted that health care for the 21st 

century would need to be redesigned, ensuring that care would be based on a continuous healing 

relationship, customized inclusion of patient needs and values, focused on the patient as the 

source of control, and based on shared knowledge and the free flow of information. Patientcentered care would improve health outcomes and reduce or eliminate any disparities associated 

with access to needed care and quality.117–119

Patient-centered care is considered to be interrelated with both quality and safety.7

 The role 

of patients as part of the “team” can influence the quality of care they receive120, 121 and their 

outcomes.122, 123 The IOM recommended that clinicians partner with patients (and the patient’s 

family and friends, when appropriate)124 to realize informed, shared decisionmaking, improve 

patient knowledge, and inform self-management skills and preventive behaviors. Patients seek 

care from competent and knowledgeable health professionals to meet their physical and 

emotional needs. Within this framework, the clinician’s recommendations and actions would be 

customized to the patient and informed by an understanding of the patient’s needs, preferences, 

knowledge and beliefs,125 and when possible, would enhance the patient’s ability to act on the 

information provided. It follows then that an effective clinician-patient partnership would include 

informed, shared decisionmaking and development of patient knowledge and skills needed for 

self-management of chronic conditions. 

Patients and families have been and are becoming more involved in their care. Findings from 

several studies have indicated that patients who are involved with their care decisions and 

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management have better outcomes than those patients who are not,126, 127 although some 

researchers indicate that the evidence concerning the impact of patient-centered care is 

variable.128 Patient self-management, particularly for chronic conditions, has been shown to be 

associated with improvements in quality of life129 and health status, decreased utilization of 

services,130 and improved physical activity.131, 132 The Chronic Care Model developed by Wagner 

and colleagues133–135 similarly emphasized the importance of actively engaging patients in 

achieving substantial improvements in care. Patient-centeredness is increasingly recognized as 

an important professional evolution124 and holds enormous promise for improving the quality 

and safety of health care. Yet, patient-centered care has not become the standard of care 

throughout care systems and among all clinicians as recommended by the IOM.7, 136 For patientcentered care to become the “standard” care process, care processes would need to be redesigned 

and the roles of clinicians would need to be modified137, 138 to enable effective teamwork and 

collaboration throughout care settings. 

Teamwork and Collaboration 

It is nonsensical to believe that one group or organization or person can improve the quality 

and safety of health care in this Nation. In that patient safety is inextricably linked with 

communication and teamwork,6 there is a significant need to improve teamwork and 

communication.139, 140 Teamwork and collaboration has been emphasized by the Joint 

Commission. The Joint Commission has found communication failures to be the primary root 

cause of more than 60 percent of sentinel events reported to the Joint Commission.141 Ineffective 

communication or problems with communication can lead to misunderstandings, loss of 

information, and the wrong information.142 There are many strategies to improve 

interdisciplinary collaboration (e.g., physician and nurse),140, 143 including using multidisciplinary 

teams as a standard for care processes. 

Interprofessional and intraprofessional collaboration, through multidisciplinary teams, is 

important in the right work environments. Skills for teamwork are considered nontechnical and 

include leadership, mutual performance monitoring, adaptability, and flexibility.144 Teamwork 

and interdisciplinary collaboration139 have the potential to mitigate error and increase system 

resilience to error.145 Clinicians working in teams will make fewer errors when they work well 

together, use well-planned and standardized processes, know team members’ and their own 

responsibilities, and constantly monitor team members’ performance to prevent errors before 

they could cause harm.6, 146, 147 Teams can be effective when members monitor each other’s 

performance, provide assistance and feedback when needed,147 and when they distribute 

workloads and shift responsibilities to others when necessary.144

The importance of training members to work effectively in multidisciplinary teams to 

achieve high reliability in patient (e.g., no adverse events) and staff outcomes (e.g., satisfaction 

working with team members and improved communication)145, 148–151 was found to be especially 

significant when team members were given formal training to improve behaviors.145 Resources 

such as AHRQ’s TeamSTEPPSTM (visit http://www.ahrq.gov/qual/teamstepps) can provide 

teams with the opportunities the members need to improve the quality and safety of health care. 

TeamSTEPPSTM is an evidence-based teamwork system that teams can use to improve 

communication and other essential teamwork skills. 

Conversely, lack of effective teamwork—such as poor communication and collaboration139

within and between disciplines—was found to have negative effects on patient outcomes (e.g., 

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surgical errors)152 and higher mortality.153 Poor teamwork as well as disrespectful, rude, and 

insulting behaviors have no place in health care and can potentially increase unsafe practices.154–

156 In a comparison of medicine to aviation, physicians were found to be significantly more 

supportive of hierarchical models of practice, where junior physicians would not question their 

seniors.152 Hierarchical structures have been found to have an adverse influence on 

communication among team members and patient outcomes.157, 158 Nursing’s participation in 

teams is further limited under a hierarchical, mechanistic structure when nurses focus on tasks.159

Other barriers that have been found to inhibit the effectiveness of nurses in teams were their 

perceptions of teamwork, having different teamwork skills, and the dominance of physicians in 

team interactions.160 When physicians view hospitals as a “platform[s] for their work and do not 

see themselves as being part of [the] larger organization”1 (p. 144), physicians may not only 

thwart the work of nurses, but the organization’s efforts to improve the quality and safety of care. 

When anyone within organizations exhibit intimidating or disruptive behaviors and when there 

are inappropriate hierarchies, breakdowns in teamwork, and loss of trust, decreased morale and 

turnover are expected among staff; patients can expect to be harmed and will likely seek care 

elsewhere.1, 161–163 

The work environment, communication and collaboration among clinicians, and 

decisionmaking are also linked to leadership and management within health care 

organizations.164–166 Some authors have argued that performance of organizations and the use of 

evidence in practice were factors dependent upon leadership, particularly among middle/unitbased clinical management.167–169 The personality and attitudes of leaders has been shown to 

have an impact on safety170, 171 and on perceptions about how safety is managed.172 Visible, 

supportive, and transformational nursing leadership to address nursing practice and work 

environment issues is critical as is nursing and medical leadership to ensure that the work 

environment supports caregivers and fosters collaborative partnerships. However, giving 

encouragement is not generally stated as a high-priority role of health care supervisors. 

Traditionally, technical skills and productivity on the job were aspects that received the 

supervisor's primary focus. However, there is a growing appreciation that encouragement is a 

transformational leadership technique that is related to productivity on the job and to quality 

work. Use of encouragement is a leadership technique that fits in today's people-oriented work 

climate.1

Evidence-Based Practice 

Evidence should be used in clinical decisionmaking whenever possible. The need for 

improving quality using evidence was described by Steinberg and Luce as “the recognition that 

there is much geographic variation in the frequency with which medical and surgical procedures 

are performed, the way in which patients with a given disease are managed, patient outcomes, 

and the costs of care, which cannot be explained by differences in patients’ demographic or 

clinical characteristics”173 (p. 80). Indeed, findings from research continue to provide 

information that illustrates that only some patients are receiving the recommended quality of 

care,117, 174–176 and errors continue to adversely impact patient outcomes. Steinberg and Luce go 

on to state that there is “strong evidence that much of the care that is being provided is 

inappropriate (that is, likely to provide no benefit or to cause more harm than good)” and that 

there are “indications that many patients are not receiving beneficial services”173 (p. 80). Some 

examples of these concerns are associated with determining health care interventions and 

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medication safety. Patients can be harmed if their symptoms and needs are not assessed 

accurately,177 if the wrong type of intervention is selected,178–180 and if patients do not receive 

information they need to manage their care.181 Certain types of medication errors, such as the 

wrong drug, wrong dose,182 and polypharmacy,183 threaten the quality of therapeutic 

interventions and the safety of patient care by aggravating the patient’s preintervention health 

status. 

Another reason that health care quality needs to improve and be based on evidence is 

“continuously rising health care costs”173 (p. 80). In a country that spends more per capita than 

anywhere else in the world, patients do not necessarily have better outcomes.184 Often without 

knowing it, clinicians have one of the greatest roles in controlling (or increasing) the cost of 

health care. What type of care is given to patients is sensitive to clinicians (e.g., nurses and 

physicians) as well as organizational structures, policies, and resources. The skill mix and 

number of nurses has been found to be associated with adverse events, longer lengths of stay in 

hospitals, and higher health care costs.185–187 Findings from research have indicated that 

understaffing is associated with an increase in errors and adverse events, such as medication 

errors, pressure ulcers, health care associated infections, and increased mortality rates in 

hospitalized patients. 86, 185, 188–195 To address workforce shortages, organizations have used 

financial and shift work incentives, used part-time workers, and improved the image and job 

satisfaction, among other things.196, 197 All of these strategies increase the cost of health care. 

The combined concern about the growing cost of care and the effects of poor-quality care on 

patients has resulted in action by the Centers for Medicare and Medicaid Services (CMS) and 

other insurers to put in place financial penalties for hospitals that have preventable events, such 

as readmission, never events (e.g., wrong-site surgery), health care associated infections,198

pressure ulcers, and patient falls with injury. These financial penalties reflect policy based on 

research that has indicated a significant association between nurse staffing and adverse patient 

outcomes,185, 187, 192 and quality measures that have been put forth as being sensitive to nursing 

care.199, 200 Adverse patient outcomes are also sensitive to the care directed by physicians, even 

when physicians and hospitals have a financial incentive to provide specific elements of quality 

care. This was recently found in a comparison of treatments and outcomes for 5 conditions at 54 

hospitals participating in a Medicare pay-for-performance pilot program to the treatments and 

outcomes at 446 hospitals not participating in the program. The researchers in this investigation 

found the financial incentive of pay-for-performance was not associated with significant 

improvement in quality of care or outcomes.201 Because health care costs are expected to 

continue to increase, it is important to ensure that costs of health care are not unnecessarily high 

and that patients receive quality care and are not exposed to preventable adverse events. Nurse 

leaders and clinical practitioners should be required to be actively engaged with other clinicians 

and leaders in assessing and monitoring the care of patients and their outcomes, as well as in 

driving quality improvement efforts to prevent the reoccurrence of these high-risk adverse 

events. 

However, not all evidence is equal. It can be based on research that is not generalizable to 

other settings and populations173, 202, 203 and may be difficult to translate into practice without 

further testing and the development of guidelines.203 Even when research is available, it is often 

not used in practice,204, 205 and adapting the research to practice can be challenging because of 

numerous barriers and deficits of facilitators to change.206, 207 A systematic review of 

interventions aimed at increasing the use of evidence in practice found that greater success was 

achieved when clinicians were involved in education about and in intervention strategies that 

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Nurses at the “Sharp End”

were centered on using evidence in practice with local opinion leaders and multidisciplinary 

teams. The investigators further asserted that to effectively use research in practice, nurses 

should use the right evidence to inform and evaluate practice change interventions, 

longitudinally assess the effects of the intervention using the measures for multiple outcomes, 

and use a methodologically rigorous approach to design the implementation and evaluation of 

the intervention.208

Evidence-based practice has been defined as using data and information, often from diverse 

sources, to guide practice. When evidence is available, clinicians must locate and then consider 

the generalizability of its findings and usability in the practice setting. Randomized controlled 

trials (RCTs) have been considered the best standard for clinical practice, but they are not 

available for many common clinical situations and are generalizable only to the population 

studied during the trial. Clinicians use a broad range of practice knowledge, especially when 

evidence is not available. Sandars and Heller209 proposed using the concept of knowledge 

management, which involves generating research-based evidence, synthesizing the evidence 

base, communicating that knowledge, and applying it to care processes. Another option would be 

to employ quality improvement methods, such as Plan-Do-Study-Act, to inform practice.50 Horn 

and Gassway210 proposed using practice-based evidence for clinical practice improvement that is 

based on the selection of clinically relevant alternative interventions, includes a diverse study 

population from heterogeneous practice settings, and utilizes data about a broad range of health 

outcomes.210 Thus, when evidence is not available, clinicians should use their experience and 

data and information from other forms of inquiry. 

A Culture of Safety 

The IOM encouraged the creation of cultures of safety within all health care organizations.6

A safety culture is defined as “the product of the individual and group values, attitudes, 

competencies and patterns of behavior that determine the commitment to, and the style and 

proficiency of, an organization’s health and safety [programs]”211 (p. 2). An organization’s 

culture is based on its history, its mission and goals, and its past and current leadership. Gadd 

and Collins211 found that organizations with a positive safety culture were characterized by 

communication guided by mutual trust, shared perceptions of the importance of safety, and 

confidence that error-preventing strategies would work. 

The terms “culture” and “climate” have been used interchangeably. Organizational climate 

refers to the atmosphere of aggregate attitudes and perceptions of how individuals feel about 

their places of work, which are associated with both individual and team motivation and 

satisfaction. The climate within an organization represents a moveable set of perceptions related 

to conditions within the workplace,212 which can be changed by the values, attributes, skills, 

actions, and priorities of organization leaders and mangers. A safety climate is a type of 

organizational culture and is the result of effective interplay of structure and processes factors 

and the attitude, perception, and behavior of staff related to safety. A climate of safety is 

represented by employee perceptions of: the priority of safety within the work environment on 

their unit and across the organization, and is influenced by management decisions; safety norms 

and expectations; and safety policies, procedures, and practices within the organization.211

It follows then that the higher the safety culture, the safer and better the quality of care. 

When researchers compared the safety cultures of hospitals to the aviation industry—which has 

been associated with high safety cultures—they found that the safety climate in hospitals was 

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worse; and within hospitals, the safety culture was worse in operating rooms and emergency 

departments.213, 214 The perceptions of safety within a hospital have been found to be more 

positive among leaders and managers than among those directly involved in care;215 nurses 

reported the lowest numbers for a safety culture.216 Hospital staff have been found to understand 

the importance of safety in their work and their role in patient safety, and to judge patient safety 

according to their perception of workplace safety and leadership commitment.217 The perceptions 

of hospital staff of the patient safety culture have also been found to be associated with 

empowerment (e.g., being able to practice nursing optimally) and characteristics of Magnet 

hospitals.113 Additionally, more errors were found in organizations and units with poor safety 

cultures. In fact, some researchers found that the safety climate predicted the occurrence of 

medication errors, that the level of safety was associated with the unit-specific and hospital-wide 

climates, and that a positive safety climate in a unit could compensate for the detrimental effects 

of a low hospital-wide climate.218

Developing and transitioning to a culture of safety requires strong, committed leadership by 

executives, hospital boards, and staff.5 According to the IOM, the essential elements of an 

effective safety culture include the commitment of leadership to safety and empowering and 

engaging all employees in ongoing vigilance through communication, nonhierarchical 

decisionmaking, constrained improvisation, training, and rewards and incentives.1

 The 

Association of Operating Room Nurses issued guidance about creating such a patient safety 

culture, emphasizing the necessity of the following components: (1) a reporting culture, (2) a 

flexible culture, (3) a learning culture, (4) a wary culture, and (5) a just culture.219

Yet, it should be understood that changing the culture within an organization is difficult and 

can happen only over time.2, 5 Throughout time, nurses have frequently been treated differently if 

they were involved in an error/adverse event, being at the sharp end of blame because they can 

stand between errors.220, 221 Thus, for nurses to not be at the sharp end of blame, it is important 

for organizational leaders and managers to establish a just culture that values reporting, where 

errors can be reported without fear of retribution;222-224 where staff can trust leaders to make a 

distinction between blameless and blameworthy; and where the organization seeks to ferret out 

the root causes of that error, focusing on systems and process factors. Just as important, 

organizational leaders, managers, and staff need to learn from the continuous assessment of 

safety culture and make efforts to continually improve organizational performance4, 5 and 

demonstrate success in safety improvements.215

If an organization’s culture is based on secrecy, defensive behaviors, professional 

protectionism, and inappropriate deference to authority, the culture invites threats to patient 

safety and poor-quality care.225 Several factors can impede the development of a culture of 

safety, including (1) a clinician’s tendency to view errors as failures that warrant blame, (2) the 

focus of nurse training on rules rather than knowledge, (3) punishing the individual rather than 

improving the system,226, 227 and (4) assuming that if a patient was not injured, that no action is 

required.227 Each of these factors stems from organizations and the people in them having 

unrealistic expectations of clinical perfection, refusing to accept the fallibility of humans, and 

discounting the benefit of effective multidisciplinary teams.1, 151 

Changing an organization’s culture of safety should begin with an assessment of the current 

culture, followed by an assessment of the relationship between an organization’s culture and the 

health care quality228, 229 and safety within the organization. Several tools have been developed to 

measure the safety culture within organizations to inform specific interventions and opportunities 

for improvement. They have focused on dimensions of a patient safety climate, including 

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leadership and management (e.g., personality and attitudes), teamwork, communication, staffing, 

attitudes/perceptions about safety, responses to error, policies, and procedures. Some of these 

tools could be used for individual or team assessment, or to compare organization-wide 

perceptions or unit-specific perceptions.230 A recent tool that was developed can be used to 

differentiate patient from staff safety and types of clinicians.218 Another of these tools 

(www.ahrq.gov/qual/hospculture/#toolkit) developed for AHRQ has been used to compare safety 

cultures among hospitals. 

The Challenge of Change 

The question has been whether efforts to improve the quality and safety of care have been 

moving quickly enough. Many leaders and researchers231–234 have raised concern that clinicians, 

administrators, policymakers, and researchers have not been moving quickly enough toward safe 

care. A few researchers have found improvements in some areas, but little if any change in 

others.32, 235–238 Amalberti and colleagues239argued that the cultural and historical emphasis on 

individualism and autonomy in health care, its drive for economic productivity, and structural 

elements such as chronic staff shortages must be overcome if rapid progress is to be made toward 

ultrasafe health care. These authors warn that, to achieve progress, we will need to identify 

closely held values and traditions that enforce the status quo and change them in support of 

safety and quality. 

Organizations such as the IOM, AHRQ, the Joint Commission, and CMS have been 

emphasizing the need for significant improvements in quality and patient safety. Yet depth and 

breadth of organizational quality and safety improvement changes are variable. For example, 

groups such as the Leapfrog Group have been influential in moving safety forward by setting 

standards for intensivist physician staffing levels in intensive care units,240, 241 yet many hospitals 

have been challenged to implement physician staffing standards because of the resource 

implications (e.g., financial and staffing)242, 243 and lack of clearly defined leadership.121 Also, 

efforts to improve safety by understanding and targeting systems factors through public reporting 

have been championed in some States, such as Texas (www.texashasp.org) and Pennsylvania 

(www.psa.state.pa.us), but other States lag behind. The Joint Commission has emphasized 

national patient safety goals (www.jointcommission.org/PatientSafety/ 

NationalPatientSafetyGoals) to improve safety in areas it has identified as high risk associated 

with sentinel events reported to the Joint Commission. Furthermore, starting in October 2008, the 

CMS (as well as other insurers) will begin to deny reimbursement to care providers for care 

delivered to patients that involved never events, such as health care–associated infections, 

wrong-site surgery, and hospital-acquired pressure ulcers. Given the role and influence of these 

various external drivers, health care leaders and managers will need to be actively engaged in 

quality and safety improvement efforts. 

Organizations should be flexible to keep pace with the rapid changes in health care and the 

growing evidence base. To do so, they need to be willing to adopt new knowledge and 

innovations, which entails “a social and political process, which nearly always involve[s] debate 

and reference to others’ views”168 (p. 44), a process that needs to include all leaders, managers, 

and staff. Those employees within organizations, particularly nurse leaders and staff, will need to 

redesign care processes and revisit the roles and responsibilities of team members.244 Pronovost 

and colleagues245 emphasized the importance of recognizing that creating change is complex and 

that improvement strategies need to (1) prevent errors from occurring, (2) raise awareness of 

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errors and near misses, and (3) be better at diminishing patient harm if an error occurs. For these 

reasons, changes to the error-producing structural factors of an organization by themselves do 

not lead to expected improvements in quality.246, 247 Several organizations have reported 

difficulties in improving patient safety because of the need for transparency in reporting on 

performance measures, lack of standardization and functionality of information technology, and 

no clear pathway identified for improvement.248 Other difficulties could be associated with the 

results of the improvement initiative itself. For example, the introduction of computerized 

provider order entry systems for medication therapy prevented some errors from happening (e.g., 

related to illegible handwriting), but introduced other errors that might have been avoided with 

better implementation strategies.249

There are many change strategies, from single focus to multifaceted, that have centered on a 

structural approach and have been used successfully to create quality and patient safety 

improvements. One approach would be to implement bundles of evidence-based interventions to 

simultaneously improve multiple outcomes,207 using health information technology when 

possible. Other strategies have focused on the components of the change process that need to be 

addressed. Caramanica and colleges250 asserted that a successful quality improvement strategy 

was based on the alignment of the goals of the organization with goals for quality and patient 

safety improvement, collaboration using interdisciplinary teams, applying evidence-based 

practice, and monitoring and assessing excellence. Quality improvement strategies that align 

with the values and beliefs of individuals and build on current processes can determine the pace 

and diffusion of change.251 As discussed in chapter 44, “Quality Methods, Benchmarking, and 

Measuring Performance,” many organizations have used the Plan-Do-Study-Act approach to 

implement change, particularly rapid-cycle improvement. A similar strategy used the ReachEffectiveness-Adoption-Implementation-Maintenance framework to translate research into 

practice.252 The Department of Veterans Affairs has approached patient safety improvement by 

targeting key strategies, including leaders creating an environment of acceptance, establishing 

clear goals, creating a fair system that does not focus on blame, creating a transparent system for 

decisionmaking, facilitating root-cause analysis, requiring leadership and management to be 

visibly involved, and evaluating performance.253, 254 While organizations’ characteristics differ, 

as do characteristics of leaders and managers, success can be realized through continuous 

improvement with careful attention to finding a balance that avoids so much change that change 

fatigue results.255

The IOM asserted that improvements must target organizational factors by using information 

technologies, developing effective teams, standardizing procedures with evidence, and using data 

and information to monitor performance.7

 Focusing on the role, the influence, and the 

complexity of health care systems by thinking about the “big picture” involves understanding 

how a specific issue or outcome of concern interacts with numerous factors, both within and 

external to the system. In doing so, it may be more feasible to solve recurring problems with 

ineffective processes and poor outcomes, even when previous attempts have failed.256 In the case 

of medication safety, efforts to significantly reduce medication administration errors must also 

consider errors associated with prescribing, transcribing, and dispensing errors, as well as errors 

associated with health information technologies, product labeling,257 therapeutic consistency 

across care settings (e.g., medication reconciliation), and miscommunication of drug allergies. 

For health care systems and organizations to improve safety and quality, they need to learn to 

improve existing knowledge and processes, understand what is and is not working well, and both 

adopt and discover better ways to improve patient outcomes.258

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Organizational changes should be targeted using multifaceted strategies and interventions 

that focus on redesigning structural factors (e.g., staffing levels, roles and responsibilities of 

nurses, etc.), revising policies and procedures,259 and using multidisciplinary teams.260 Because 

the factors and issues involved in patient safety and quality improvement are complex, mirroring 

the complexity of health care systems, no one single intervention will accomplish performance 

goals and standards. Using a systematic approach to changing practice based on evidence when 

possible is required to improve patient safety and contribute to the evidential knowledge base 

and generalizability that can be used eventually for purposes of diffusion.261 Improving the 

quality and safety of health care may require the use of mixed or multiple methodologies to 

continually monitor and evaluate the impact and performance, because no one single method 

would be expected to be appropriate for the depth and breadth of change interventions.262–264

Change can be slow because it is a process that involves many people and issues. Efforts to 

improve quality and safety need champions throughout the key areas within the organization as 

well as executive and midlevel managers.70, 259 Champions can also be found among individuals 

for whom adverse events have had incredible impact on their lives.265 It would follow then that 

when an opportunity is present to adopt new knowledge and evidence into practice, “that 

individual professionals and professional groups (particularly the doctors) have the power to 

impede or to facilitate the diffusion process”168 (p. 50). Adoption of new knowledge and 

evidence for change is a process that needs leadership involvement and support, fostering 

effective relationships and enabling action, utilizing ongoing monitoring and evaluation, and 

demonstrating flexibility according to findings from evaluation and changing needs.254, 258 Yet 

the effect of this could be mitigated by the commitment and direction of senior leadership, who 

co-lead/co-coach with clinical leaders266 to use evidence in practice, and to continuously evaluate 

progress and make changes accordingly, to therefore improve organizational performance and 

patient outcomes.267

For changes of care processes that support safe and quality care to be effective, interventions 

must not be first-order, short-term problem-solving that offers quick fixes but not lasting change. 

Instead, second-order problem-solving should be used, where the underlying causes and 

processes are examined.268 Even when processes and procedures have changed and demonstrated 

positive effects on patient outcomes, there is a concern about sustainability over time because the 

tendency of health care providers to deliberately deviate from the new standard of practice may 

be unavoidable.95 Ongoing monitoring and management of these new processes and procedures 

is required.95 How do you institutionalize change? Change initiatives are successful when they 

are built on the current way of doing things,251 are visible and have positive outcomes, are 

consistent with employees’ values and beliefs, are manageable,269 and are generalizable to the 

organization.270

Practice Implications 

To bring the effects of the sharp end away from nurses and put them squarely on the 

shoulders of health care organizations and systems, there needs to be significant changes in how 

health care is structured and how it is delivered to patients. While the roles and responsibilities of 

nurses have changed over the years, including “risk management, quality assurance, case 

management, clinical trials coordinator, and patient care manager among numerous others,”271

the diversity of skills, roles, and training272 places nurses in critical positions to lessen the 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 1

incidence of variation by collecting and assessing data, working with interdisciplinary teams, 

examining performance, and driving evidence-based practice. 

From the literature reviewed in this chapter, there are key strategies that can be used to effect 

change, and subsequently, the quality and safety of care will be improved. The major factor in 

creating improvement is understanding and accounting for the complexity of health care 

organizations, health care systems, care processes, and patient needs. To begin, senior nurse 

leaders need to work with staff to identify and prioritize areas and establish goals to address the 

issues that are associated with poor-quality and unsafe care. Executive leadership and managers 

need to be committed to investing both their time and resources to improving the safety and 

quality of care. As organizations begin plans and reassess the need for changes, nurses will need 

to be proactive in redesigning care models and redefining the work of nurses,273 whether the 

initiatives will initially impact only a single unit or group of clinicians, or are aimed at being 

systemwide. Furthermore, efforts to improve quality and safety must have involvement and 

commitment from all stakeholders. 

The foundation of quality and safety improvement initiatives needs to be centered on systems 

factors, not individuals. Nurse leaders, colleagues, and State boards of nursing registration 

should understand the significant impact of systems factors in any instance when individual 

culpability is sought, particularly when appraising and disciplinary action is unfortunately taken 

against an individual clinician (e.g., State boards of licensure and malpractice cases). The 

responsibility of nurse leaders and State boards of nursing is to determine when errors and 

adverse events result from deliberate malfeasance as opposed to a mixture of systems factors. 

Without considering the nature and effect of systems factors, action taken against an individual 

would not appear to be evidence-based and latent factors will continue, waiting to “ensnare” 

another nurse. 

To improve patient safety and the quality of care, it is important to determine the best 

strategy and be willing to alter the strategy if necessary to create change. Not all strategies that 

have been successful in other organizations will be successful in your organization; some 

interventions have too small a sample size or information about them to be considered as a 

possible strategy in your organization. As an initiative is implemented, it could be that what was 

thought to have been generalizable needs to be tailored to the unique characteristics of your 

organization. Change initiatives should be either evidence based or based on data and 

information internal to your organization (e.g., incident reports), and should address measures to 

evaluate improvements in patient safety and quality.199, 274 Throughout the process of 

implementing changes, it is important for data and information to be continually monitored and 

assessed to track performance. It is only through strategic decisions and interventions that the 

sharp end held against nursing will transition to the organizations in which nurses work. 

Research Implications 

The nurse’s role in and ability to change patient safety and quality improvement within 

health care systems is a relatively new field of research, but consideration must be given to more 

than 60 years of nursing research that has implications for both safety and quality processes and 

nursing, patient, and organizational outcomes. Future research will need to better define the 

theoretical foundations behind the relationships between organizational systems factors, clinical 

processes, and patient safety and quality outcomes. It is also important for future research to 

focus on improving and widening the assessment of the impact of patient safety and quality 

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Nurses at the “Sharp End”

improvements on the incidence of the broad array of errors that can and do occur in nurses’ work 

environments. For example, leaders and clinicians need to understand the association between an 

organization’s culture of safety and patient outcomes as well as how nurses can influence 

executives to lead working environment improvements. In addition, and probably more 

important, future research needs to address how research and evidence can be translated into and 

become the new standard of practice, avoiding the lengthy process now involved, which could 

take as long as 10 to 17 years.275

Conclusion 

Everything about health care is complex. There are complex care processes, complex health 

care technologies, complex patient needs and responses to therapeutic interventions, and 

complex organizations. There are tremendous opportunities and challenges in improving the 

quality and safety of health care, but the majority require purposeful redesign of health care 

organizations and processes. Organizations that are committed to high-quality and safe care will 

not place nurses at the “sharp end” of care, but will focus on system improvements. Recognizing 

the complexity of care and how several factors combine at a specific time and result in errors and 

adverse events, organizations, leaders, and clinicians will dedicate themselves to using data and 

evidence and to continuously improve the quality and safety of care, even when there are 

complex challenges. 

Author Affiliation 

Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for 

Healthcare Research and Quality. E-mail: Ronda.Hughes@ahrq.hhs.gov. 

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