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How a pilot applies aviation safety principles to nursing


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Rebecca Hendren, for HealthLeaders Media, March 22, 2011

Gary Sculli responds to both "nurse" and "captain" and the interesting juxtaposition of those titles gives him a unique voice in the patient safety world.

Sculli began his career in the U.S. Air Force Nurse Corps., but after 10 years of nursing, he left to pursue his other passion: flying. He spent seven years flying at regional and major airlines both as first officer and captain. He also served as an aircrew instructor, training flight crews in state-of-the-art aircraft simulators.

Sculli's career path changed again following Sept. 11, 2001, when he was furloughed from the airlines due to industry downsizing. Sculli realized his flying career would be grounded for some time so he returned to nursing. He worked first as a nurse educator and then as a nurse manager, and soon realized that his years in the airline industry had completely changed his approach to nursing.

"I transitioned from an industry that consistently perpetuates a culture of safety, back into nursing, a noble profession that articulates desired patient outcomes quite well, but often fails to provide its personnel with the tools, resources, and environmental conditions for such outcomes to take place," said Sculli.

Sculli believes that many of the principles and concepts he learned and practiced within aviation's Crew Resource Management (CRM) can be applied to nursing practice to reduce the risks that patients are exposed to in the clinical environment. He says that adopting the basic tenets of CRM within any nursing care delivery model will create a tipping point for a cultural shift that puts safety first.

"Let's face it, nurses can easily identify the impediments to safe care in their environment: Hierarchical leadership styles, poor nurse-physician communication, lack of psychological safety when communicating patient information to medical decision makers, and task loads that approach cognitive saturation," he says. "All of these issues can be addressed directly with CRM."

Sculli set about implementing CRM on his own unit, and following his success, now trains others around the country. Key CRM concepts he brings to nursing include:

  • Team building behaviors for frontline clinical nurse leaders
  • Adopting appropriate leadership styles when leading nursing teams
  • Followership and assertive communication techniques to resolve clinical problems
  • Strategies to maintain situational awareness in the clinical environment
  • Managing threats to situational awareness and recognizing when the quality of patient care decisions may be at risk
  • Methods to reduce distraction during critical phases of nursing practice
  • Briefings delivered by the RN to members of the nursing team
  • Developing and using checklists that support nurses as they practice and avoiding the tendency to create checklists that make work harder, not easier
  • Discussion of countermeasures to manage the effects of fatigue on performance

On his unit, Sculli applied CRM to the everyday responsibilities and challenges nurses face. One of his projects was to improve medication administration, an all-too-common source of errors that harm patients.

Nurses are subject to an incredible amount of distractions during their day—from patient and family requests to physicians arriving on the floor and needing information or supplies, to other staff members needing assistance. Then there is the ambient noise level on the unit created by televisions, loud hallway conversations, medical monitoring equipment, floor buffers, noisy carts, and nearby maintenance.

None of this is conducive to the completion of nursing tasks that require concentration and thoughtfulness. In particular, nurses are easy prey for distractions when they stand in front of their medication carts, and this increases the risk something will go wrong.

Sculli and his unit adopted a "do not distract" principle by designating one nurse a MedSafe nurse who was responsible for all medication administration on the unit. During peak medication administration times, the nurse wore a brightly colored vest labeled "do not disturb" to ensure others did not interrupt him or her during this period of deep concentration.

Sculli also worked on changing the way nurses on his team communicate—and to convince them that they were, in fact, a team. Information exchanges between RNs and nursing assistants—who often have trouble communicating—was improved through adopting briefings. Sculli and the staff developed a checklist with which RNs covered patient information that nursing assistants needed to know about their patients for that shift. The briefings were short and to the point to ensure RNs and assistants were on the same page for the upcoming shift.

A big emphasis for Sculli now as he teaches CRM to frontline nurses is the importance of communicating patient information in a manner that is specific, direct, and concise.

"I want nurses to understand that if a patient's condition is worsening and they need to communicate with physicians to obtain medical orders or treatment, the way they go about relaying that information can be the difference maker for the patient," says Sculli.

Sculli explains that nurses often engage in "hint and hope" communication, where rather than speaking directly and assertively, nurses send out hints to decision makers hoping they will catch on. This rarely works and just creates delays for patients. Sculli outlines specific tools and strategies nurses can use in communicating. He also discusses the importance of assertive communication techniques that can be used to respectfully escalate an interaction when physicians push back or fail to engage.

"Implementing respectful graded assertiveness in a structured manner gives nurses tools that ensures the patient gets what they need, right now," says Sculli.

CRM allowed the airline industry to address the human factor and cultural problems that led to adverse events. Sculli believes CRM can do the same on the nursing unit where the majority of patient care is delivered, but it's a paradigm shift that requires nurse leaders, nurse managers, directors, and nurse executives openly support frontline caregivers as they incorporate new tools into existing models of practice.
 

Source: HealthLeaders Media