Why Quality Improvement Demands Healthcare Culture Supportive of Nurses

As healthcare reform focuses more attention on patient outcomes, nurses' importance in clinical outcomes and patient satisfaction is becoming more apparent. To make a lasting impact on patient safety and quality, hospitals need to recognize the value of nurses and other front-line staff in making process changes. In fact, hospital leaders need to go further — they need to lead by example, according to John Kauchick, RN, BSN, a practicing nurse for 33 years. He says that leadership should not only seek input on proposed agendas but also tap into nurses' ideas and let them define their practice under the umbrella of a "just" culture, where staff feel comfortable reporting adverse events.

By creating a "just" culture and holding all levels of leadership accountable, hospitals can demonstrate their sincerity in changing a culture that has traditionally been viewed by staff as an "entrenched hierarchy," Mr. Kauchick says. "The industry needs to be committed to protecting nurses who report. I know of only one state that has safe harbor for nurses sanctioned by its state board. Where is the leader who is calling for this on a national level?"


Hospitals need inspirational leadership to change a culture and environment that make nurses afraid to report errors and to voice ideas. "In order for hospitals' cultures to change, it's going to take somebody very powerful that has a lot of influence to shake things up," he says. He calls for a change "almost to the level of Martin Luther and the Reformation. Nurses are starving for authentic leadership: Leaders who can look themselves in the mirror and admit fallibility; leaders who can throw out the conventional wisdom that blinds an organization; those who consider the 'organizational radical' an asset instead of an adversary."

While many hospitals have improved the relationship between nurses and administration, there is still a long way to go. A recent study in the Journal of Nursing Care Quality found virtually no difference in nurses' participation in quality improvement activities from 2004 to 2008 despite the increase in the number of hospitals that participated in programs to engage nurses in quality and safety initiatives.

Cultivating a supportive environment
Nurses' work environment is critical to their ability to improve safety and quality. A study funded by the Robert Wood Johnson Foundation found that a supportive nursing practice environment — one with teamwork and involvement in hospital- and unit-level decision-making — was associated with fewer medication errors. Another study by the University of Pennsylvania School of Nursing showed that Medicare patients treated at hospitals with a positive work environment for nurses had a 10 percent lower risk of readmission than patients treated in hospitals with a poor work environment.

Hospital leaders can create a positive environment for nurses by involving them in decision-making and protecting them from retaliation against reports of adverse events, according to Mr. Kauchick. "If they're protected and feel safe to be able to report, they're more likely to. They must be able to trust their leadership." he says. A poor, unresponsive and unsupportive management is one of the top drivers of nurse dissatisfaction, with 31 percent of nurses reporting that as the principle cause of their dissatisfaction, according to a survey of 969 nurses by Jackson Healthcare.

Several quality improvement initiatives are structured to give nurses a leadership role in implementing change. For example, Robert Wood Johnson Foundation's Transforming Care at the Bedside program focuses on engaging nurses in quality improvement, and Lean process improvement principles include supporting front-line workers' leadership in improvement activities.

Some hospitals are making great strides in involving nurses in transforming healthcare delivery. For example, the Ohio State University College of Nursing in Columbus opened its first nurse practitioner-led health clinic in January. The clinic, Ohio State Total Health & Wellness at University Hospital East, is entirely run by nurse practitioners and offers primary care that addresses physical and mental health needs.

By creating an environment that includes a just culture and having leaders who support nurses, hospitals can make real gains in the quest for high-quality, low-cost care.

More Articles on Hospital Quality:

7 Guidelines to Ensure Productive Patient Safety Meetings
Patient Safety Tool: AHRQ's Health Literacy Precautions Toolkit

CDC: Hospitals Reduced Certain HAIs

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