Quality Improvement – Preventable Errors: Low Nursing Staff Morale Leads to Decreased Quality of Patient Care and Outcomes

Quality Improvement – Preventable Errors: Low Nursing Staff Morale Leads to Decreased Quality of Patient Care and Outcomes

Low Nursing Staff Morale Leads to Decreased Quality of Patient Care and Outcomes Introduction

This paper will summarize the fishbone diagram of a quality improvement plan by discussing the factors contributing to decreased nursing staff morale and leading to decreased quality of patient care and outcomes within the Veteran Affairs Pacific Islands Health Care System (VAPIHCS). This paper will describe the VAPIHCS’s definition of quality, the six dimensions of quality in health care that this definition supports, an explanation of why the identified problem is an issue, and why each issue is important to the quality of the organization.

VAPIHCS Definition of Quality in Health Care

The VAPIHCS is committed to providing veterans with timely access to health care. The MISSION Act of 2018 improved veterans access to care in VA facilities and the community (thus improving efficiency), expanded benefits for caregivers, and improved the VA’s ability to recruit and retain quality healthcare providers (U.S. Department of Veterans Affairs, 2020b). The MISSION Act Quality Standards comparison data illustrates VAPIHC performance at the measure level to aid consumers in understanding the quality of care available in their geographic region. The measures used are “indicators of inpatient, outpatient, and patient experience performance that align with three central tenants of VA care: Effective Care: Is based on scientific knowledge of what is likely to provide benefit to Veterans; Safe Care: Avoids harm from care that is intended to help Veterans; Veteran-Centered Care: Anticipates and responds to Veterans’ and their caregivers’ preferences and needs, and ensures that Veterans have input into clinical decisions” (U.S. Department of Veterans Affairs, 2020b).

The VAPIHCS definition of quality health care is also embedded in their mission, vision, and core values. Their mission is “to provide integrated and innovative health care services and benefits to eligible veterans and their beneficiaries.” The vision is “to be the preferred VA model for the 21st century, successfully anticipating and meeting the needs of its customers.” Both of which integrate the core values of “integrity, commitment, advocacy, respect, and excellence.” (VAPIHCS, 2019).

Six Dimensions of Healthcare Quality

The six dimensions of healthcare quality include; safety, effectiveness, patient-centeredness, timely care, efficiency, and equitability (AHRQ, 2020). Safety means the organization will ensure no harm happens to the patients, and the care delivered aims to restore them to their baseline (Harolds, 2019). Effectiveness means the care rendered is based on sound scientific knowledge to eliminate the instances of underuse or overuse. Patient-centered care refers to care that is individualized and responsive to the choices and the various needs of the patients, while timely care ensures a decrease in wait times of access to treatment as this may pose a risk for harm. Efficient care defines the prevention of waste of medical supplies, equipment, medical ideas, and effort in the delivery of care to the patients (Harolds, 2019). Equitability ensures the health care services offered to the patients are consistent despite their ethnic affiliation, gender, geographic position, or socioeconomic position. The Dimensions of Healthcare Quality that are clearly supported by the VAPIHCS’s healthcare definition of healthcare quality are; safety, effectiveness, patient-centeredness, and timely care. The dimensions of efficiency and equitability are implied but not explicitly stated. Therefore, VAPIHCS nursing staff are required to ensure the implementation of quality healthcare services. However, organizational challenges must be dealt with to achieve such objectives. Failure to ensure all six dimensions of health care quality may result in a noticeable decrease in morale and the empowerment of nursing staff.

Problem Statement

Leadership factors, team factors, patient characteristic factors, and nursing staff factors all contribute to the problem of low nursing staff morale, which leads to decreased quality of patient care and outcomes.

Factors Contributing to Low Nursing Staff Morale

Low nursing staff morale is an issue because it leads to a decrease in quality of nursing care which can negatively impact patient outcomes. Four major categories of causative factors have been identified; 1) Leadership Factors, 2) Team Factors, 3) Patient Factors, and 4) Nursing Staff Factors.

Leadership Factors

Leadership often does not consider or acknowledge feedback provided by nurses. To have a positive impact on health care delivery, input from nursing staff concerning the treatment and discharge plans is essential. Nursing feedback is crucial to make the required adjustments in areas of weakness or failed achievement of patient goals.

Nurses are excluded by leadership from activities that involve decision-making. This makes them feel less valuable. Devaluation of nurses creates inequity and tension in the workplace between nursing staff, team members, and leadership.

Nursing staff do not feel recognized in their workplace for their accomplishments, especially by their direct leadership. An essential indicator for workplace satisfaction is ensuring that nursing staff remains motivated to provide timely care and positive patient outcomes. This can be achieved through verbal acknowledgement giving during morning huddles or during morning report. Recognizing nursing staff makes for a more positive work environment and encourages nursing staff to want to come to work as they feel valued.

Team Factors

Team members do not communicate information punctually for time-sensitive matters such as discharge planning. This results in patients not receiving adequate care, prolonged hospitalization, increased cost of care, and increased risk for hospital acquired infections. Another concern is that there is unequal expectations of team members, causing some team members to carry more of the weight. Lastly, nursing staff refrain from sharing their concerns during monthly team meetings due to a lack of trust. Holding on to those concerns creates animosity and further challenges which impacts delivery of quality health care.

Patient Factors

The VAPIHCS provides both inpatient and outpatient mental health care to veterans. Patients with mental illness are challenging to take care of due to their high risk for aggression towards self or others. Patients with cognitive disorders such as Alzheimer’s disease or dementia are often inappropriately admitted to inpatient mental health units due to their aggressive behavior. Patients who are homeless will often manipulate the team into staying longer by by being particular about their placement. This creates a challenge for discharging the patient because groups homes do not want to take an aggressive or homeless patient.

Nursing Staff Factors

Nurses do not feel empowered within their departments irrespective of any strength displayed, which leads to a sense of apathy and an increase in calling out sick. Nurses are mandated to work overtime causing physical and emotional exhaustion, which prevents nursing staff from providing the necessary care. When physically and emotionally exhausted, the nursing staff will not be able to perform their duties with their best efforts. Moreover, emotional exhaustion will affect their ability to make clinically appropriate decisions, as it will be too challenging (White, Butterworth & Wells, 2017). It is important for nursing staff to request a mental health day to rest so that upon return to work, he or she will be able to be alert and present in assuming duties. Professional strength and avoidance of tiredness among nurses will indicate the increased ability for functional teamwork (Reis, Paiva & Sousa, 2018). This leads to increased patient safety, as nurses will be better engaged with the patients.  Nurse burnout is on the rise at VAPIHCS, hence patient outcomes are lowered. Addressing these issues will boost the nursing staff morale which will lead to enhanced quality of health care delivery within VAPIHCS.

Relationship of Problems and Issues to the Quality of the Organization

The empowerment of nursing staff is an indicator of workplace satisfaction and a supportive nursing work environment. Attainment of the right type of care for the Veteran’s health status as VAPIHCS’s quality of care is experienced. Nursing staff motivation and mobilization are facilitated through empowerment, enabling positive patient outcomes. Improved communication among nursing staff, providers, and nursing leaders encourage teamwork provision of care. Treatment goals and discharge planning should be done as a team for the purpose of communication. Discussing the patients underlying disease process as a team allows for better team members to ask questions and to get a better clear understanding of how to provide the patient with patient-centered care. This is in alignment with VAPIHCS’s quality of care.. Nurses provide individualized care to patients enabling them to feel a sense of respect, safety, and confidence (Mormer & Stevans, 2019). These needs are essential for ensuring high-quality patient outcomes.

Conclusion

Patients have the right to receive timely and safe nursing care in relation to the VAPIHCS quality of care standards. Effective communication between leadership and staff will increase moral and decrease staff burnout. The absence of nurse burnout will lead to increased patient satisfaction and favorable outcomes with the quality of care provided.

References

Association for Healthcare Research and Quality (AHRQ). (2020). Six Domains of Health Care Quality. Retrieved from https://www.ahrq.gov/talkingquality/measures/six-domains.html

Harolds, J. A. (2019). Quality and safety in healthcare, Part XLVII: resilience and burnout. Clinical nuclear medicine, 44(5), 394-396.

Mormer, E. & Stevans, J. (2019). Clinical Quality Improvement and Quality Improvement Research. ASHAWIRE, 4(1), 27-37.

Reis, C. T., Paiva, S. G., & Sousa, P. (2018). The patient safety culture: a systematic review by characteristics of hospital survey on patient safety culture dimensions. International Journal for Quality in Health Care, 30(9), 660-677.

White, M., Butterworth, T. & Wells, J.S. (2017). Healthcare Quality Improvement & Work Engagement: Concluding Results From a National, Longitudinal, Cross-Sectional Study of the’ Productive Ward-Releasing Time to Care’ Program. BMC Health Services Research, 17(1), 510. https://doi.org/10.1186/s12913-017-2446-2

U.S. Department of Veterans Affairs (2020a). MISSION Act Strengthens VA Care. Retrieved from https://missionact.va.gov/

U.S. Department of Veterans Affairs (2020b). MISSION Act Quality Standards. Retrieved from https://www.accesstocare.va.gov/Healthcare/MissionActQualityStandards

VA Pacific Island Health Care System (VAPIHCS). (2019). Mission, Vision, and Core Values.

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