Elsevier

Collegian

Volume 26, Issue 1, February 2019, Pages 151-157
Collegian

Managing gaps in the continuity of nursing care to enhance patient safety

https://doi.org/10.1016/j.colegn.2018.06.006Get rights and content

Abstract

Background

Gaps in the continuity of patient care increase the risk of preventable adverse events. This paper reports findings from the first Australian study to explore the role and expertise of nurses in identifying and managing gaps.

Aim

To describe the processes nurses used to (i) identify potentially harmful gaps in the continuity of patient care and (ii) manage the gaps identified as a key aspect of safe care.

Method

The study used a qualitative exploratory descriptive approach. Data were collected from a purposeful sample of seventy one registered nurses from emergency department, critical care, perioperative, rehabilitation and transitional care, and neurosciences settings in Australia and analysed using content and thematic analysis strategies.

Results

The identification and management of gaps were based on nurses’ knowledge and experience of: where gaps occur; the types of gaps that occur; the things that happen, go wrong and are overlooked; the clinical environment; available equipment; and correct processes and procedures. The gaps identified included failure to recognise and respond to the deteriorating patient, inattention to the ‘simple things’, the practice of cutting corners, and lapses in critical thinking. Three deliberative processes were used to manage the gaps identified: nursing surveillance, teamwork and communication. These, in turn, were augmented by the non-deliberative processes of serendipity and ‘chance’.

Conclusion

The study deepens understanding of how nurses contribute to creating safety through the use of effective nursing strategies for identifying and managing gaps in hospital settings.

Introduction

Nurses are widely recognised as being inseparably linked to patient safety and an indispensable ‘front line’ defence that protects patients from the harmful effects of healthcare errors and preventable adverse events (Page, 2004). Gaps, defined for the purposes of this study as ‘discontinuities’ or breakdowns in the continuity of patient care, are prevalent in health care and increase the risk of preventable adverse events (Cook, Render, & Woods, 2000). Gaps often occur with a change of shift or health care provider or when a patient transfers to another unit or organisation, however, gaps may also emerge within the processes of patient care and with single practitioners (Cook et al., 2000). In hospital settings, gaps are spawned by the complex nature of patient care and the intricate network of individuals, professions, departments and shifts of work that provide care over a twenty four hour period (Krogstad, Hofoss, & Hjortdahl, 2002).

Health care providers, including nurses, are generally successful at identifying and managing gaps and re-establishing the continuity of patient care (Cook et al., 2000). Hence, it is argued that safety might be increased by understanding and reinforcing the ability of health care providers to successfully manage gaps in patient care. It is acknowledged that several studies have focussed on gaps that contribute to adverse events (i.e. gaps in clinical handover, teamwork, communication, and failure-to-rescue) (Johnson & Barach, 2009; Manser, 2009; Taenzer, Pyke, & McGrath, 2011; Weller, Boyd, & Cumin, 2014). However, there is a paucity of published research that specifically explores and describes the types of gaps that nurses encounter in clinical contexts and how they identify and manage gaps to keep patients safe. A key aim of this study is to redress this oversight.

Section snippets

Background

Over the past decade, efforts to address the pressing global challenge of preventable patient harm have conventionally focussed on ascertaining the root causes of adverse events to determine ‘what went wrong’ and implementing system changes to reduce the risk of further adverse outcomes. This approach, labelled Safety-I, has contributed to valuable learnings and improvements in patient safety (Braithwaite, Wears, & Hollnagel, 2015). Concerns have been raised, however, about the utility of ‘find

Study design

The study was undertaken using a qualitative exploratory descriptive (QED) research method informed by the works of Patton (2002) and Sandelowski (2000). The study was approved by the Human Research and Ethics Committee at [Deakin University] and one metropolitan health service at which participant recruitment and interviewing occurred.

Setting

The participants in this study were nurses employed in emergency, critical care, perioperative, neuroscience, and rehabilitation and transitional care units in

Gaps

Clustering of the analysed data into themes within each of the research questions generated rich descriptions of what participants considered a ‘gap’ to be as well as the processes used to identify and manage the gaps in their everyday practice. These findings are each considered under separate subheadings below. The numbers in brackets indicate the de-identified numerically coded transcript and page number from which the quote is taken.

Discussion

Commensurate with the views of Cook et al. (2000), the study found that the identification and management of gaps is based on nurses’ knowledge, understanding and experience of: where gaps occur; the types of gaps that occur; the things that happen, go wrong and are overlooked; the clinical environment; available equipment; and correct processes and procedures (Fig. 1). The study has also captured ‘resilience’ in its different forms as described by Westrum (2006). Westrum’s taxonomy encompasses

Limitations

A key strength of this study is the contribution it makes to a deeper understanding of ‘safety successes’ in nursing. A limitation of the study is that it had as its focus nurses only thus the views of doctors and other co-workers who benefitted from the nurse interventions were not captured. A comparative inquiry into the perceptions and experiences of other members of the heath care team about the nature and impact of the nurse interventions would strengthen the conclusions of this study.

Conclusion

Patient safety initiatives have conventionally focussed on adverse events, ascertaining their root causes via structured processes such as root cause analysis and determining what went ‘wrong’. This study has demonstrated that valuable lessons can be learned from the investigation of how nurses identify and manage gaps and ‘get it right’. The study provides a rich description of effective nursing surveillance and successful everyday nursing performance in hospital settings. The elements of

Acknowledgments

The research was supported by an Australian Postgraduate Award and a Research Scholarship from the Australian College of Nursing. Maxine Duke contributed to the supervision of the PhD study which this manuscript reports. Angela Jones and Megan-Jane Johnstone have no competing interests or conflicts of interest to declare.

Conflict of interest

No conflict of interest has been declared by the authors.

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