Veterans Health Administration
How Reducing Distractions Can Make All the Difference
Nurse At Work — Something as simple as a “Do Not Disturb” sign can go a long way to ensuring that the nurse responsible for dispensing medication can do so without unnecessary interruptions or distractions.
Imagine, for a moment, you’re a VA nurse rolling your medicine cart down a busy hospital hallway. It’s your job to deliver medication to a lot of different patients, and many of them get more than one kind of medication. There’s a lot to keep track of.
You really need to focus.
But then, of course, there are the inevitable distractions. Doctors, nurses, health technicians, patients and others interrupt your train of thought to ask you a question, seek your advice, or request your assistance.
“In 2010 the United States Pharmacopeia sited distractions as a contributing factor in 45 percent of medication errors.”
— Gary Sculli, National Center for Patient Safety
“The reality is that interruptions and distractions are commonplace on any busy multi-bed nursing unit,” explained Gary Sculli, a program manager at VA’s National Center for Patient Safety in Ann Arbor, Mich. “High task loads and multiple distractions combine to make our nurses susceptible to reduced awareness.
“Medication administration, for example, is a critical task — one that requires concentration,” he continued. “When nurses experience interruptions, diversions and distractions during such tasks, vulnerabilities are created and the risk of patient harm increases. Our nurses need to know how to manage, reduce and, when possible, eliminate distractions that increase risk and undermine patient safety.”
To teach front-line nurses how to do this, VA’s National Center for Patient Safety is introducing a new training program throughout VA called Nursing Crew Resource Management, or NCRM.
Minimizing distractions is just one aspect of the training, however.
“Let’s be honest,” Sculli said. “Nurses can tell you, in a heartbeat, what the impediments are to safe care. Hierarchical leadership styles. Poor communication between nurses and doctors. Lack of psychological safety when trying to communicate important information to medical decision-makers. Workloads that can’t help but lead to fatigue and, in some cases, task saturation.”
Sculli, who spent seven years as an airline pilot before joining VA, said NCRM training addresses all these issues.
“NCRM is based on training that began in the airline industry 30 years ago,” he explained. “The airlines implemented this training to address operational mishaps and significant loss of life that resulted not from mechanical failures, but human failures related to teamwork, communication, decision-making, and leadership.”
Sculli said NCRM, in a nutshell, provides the tools that can be used on nursing units to build teamwork, improve performance, and manage human error. The training consists of six modules.
Module One explores the systems approach to analyzing error, as well as the attributes that define a culture of safety.
Module Two describes the undesired effect of authoritative and dictatorial leadership styles on patient care. The art of assertive ‘followership’ is defined, a critical behavior for front-line nurses.
“A key point in Module Two is the avoidance of ‘hint and hope’ communication,” Sculli noted. “It’s a phenomenon that often leads to adverse events when a nurse, feeling intimidated, fails to directly and concisely share safety-critical information with a medical decision-maker. It happens more than you think, and it’s avoidable.”
Module Three defines ‘situational awareness,’ or big picture thinking, and explains how nurses process information to make clinical decisions. Threats that reduce situational awareness are identified and countermeasures are discussed.
Module Four demonstrates how briefings can be used on the nursing unit to enhance teamwork, communication, and situational awareness. Methods on how to brief members of the nursing team, as well as patients, are demonstrated.
Module Five discusses the impact of fatigue on clinical performance and outlines countermeasures to combat its effect. This module also defines rule-based behaviors nurses can use to reduce distractions during critical tasks such as administering medications.
“What’s a quick, easy way to make sure no one disturbs the nurse who’s dispensing medication?” Sculli asked. “Simply have that nurse wear a ‘Do Not Disturb’ vest, and train his or her-coworkers to respect it. It’s a simple solution, and the results are impressive.”
Lastly, Module Six exposes nurse teams to clinical scenarios through the use of a high-tech, simulated human patient.
“Front-line nurses deliver the majority of hands-on care and spend the most time with hospitalized patients,” Sculli said. “It’s a noble profession, but an incredibly high-stress and demanding one. We need to support our nurses. We need to give them all the tools at our disposal to help them do their jobs well. I think NCRM is a big step in that direction.”