Nurse burnout: Planning intentional quality and safety

By Suzanne Waddill-Goad and Holly Jo Langster | 05/02/2016

Chapter from
Nurse Burnout: Overcoming Stress in Nursing, an STTI book.

This chapter from Nurse Burnout: Overcoming Stress in Nursing explores intentionality in relation to patient risk, reliability science, quality, and safety.

What is intentionality?
Our first experiences with intentionality are typically in school. Although our parents intentionally feed us, care for us, and play with us for bonding purposes, there is very little agenda-driven interaction to guide the encounters. When we get to school, things are different. Most likely, this is one of the first places we learn about the consequences of feeling stress.
NurseBurnout_Cover_SFWThere might be a test to pass at the end of the week, and we have to learn primary colors, count to 10, and be completely bathroom independent in order to advance from preschool to kindergarten. Epstein (2007) speaks about the importance of intentional teaching, which does not happen by chance. It is planful (full of plans), thoughtful, and purposeful. Intentional teachers use their knowledge, judgment, and expertise to organize learning experiences for children. When an unexpected situation arises (as it always does), these teachers can recognize a teaching opportunity and are able to take advantage of it, too.
Being an intentional teacher requires a wide range of knowledge and a recognition that learning occurs sometimes from adult-guided experiences and other times from child-guided experiences (Epstein, 2007). Epstein (2007) lists the characteristics of an intentional teacher as: having high expectations, planning and managing, valuing a learning-oriented classroom, offering engaging activities, posing thoughtful questions, and providing feedback. Choosing a career in nursing and the healthcare industry allows practitioners to experience each of these characteristics as learners in the field and then subsequently as care providers.
As adults, most of our learning comes from life experiences. Any formal education we receive is often hand-selected to meet the intentional plan we have for our lives. The word intentional is much like the word purposeful. In the best-selling book, The Purpose Driven Life, Rick Warren notes that what we pay attention to in our lives flourishes. If we nurture sadness by refusing to leave the house or rejoin society after the death of a spouse, we might spiral into a deep depression. If, on the other hand, we nurture friendships that offer support after the death of a spouse, we build stronger relationships and process grief more effectively (Warren, 2002).
Success in life’s various elements, whether career, family, faith, physical, or emotional health, is rarely incidental. Success most often comes from intentional planning and attention to detail. Nurses must have intentional focus when it comes to providing care for patients. Nurses naturally and intentionally strive for high quality and optimal safety to help patients achieve the best outcomes. To be intentional is to be purposeful, focused, and determined. Nurses who are unable to focus and prioritize will struggle with higher levels of stress throughout their careers.
Much like learning an instrument, you must practice a little bit every day to retain enough information to be able to advance the selected skill (Warren, 2002). Nursing is a career with many opportunities for practice, learning, and growth. You can change specialties, learn new skills, practice in a variety of work environments, and receive formal advanced education. Being bored is not an excuse for burnout in nursing; opportunity to advance in the profession of nursing is abundant for nurses who are willing to stretch themselves.
Hospitals and healthcare organizations that achieve national notoriety for stellar outcomes in quality and safety are organizations that place intentional focus on those elements, as evidenced by their efficient systems and organizational design.
In an interview with Saint Joseph Hospital West in Lake Saint Louis, Missouri, the chief nursing officer (CNO) was asked, “How does your organization achieve a ‘Truven Top 100 Hospital’ ranking so consistently?”
She simply replied, “We did not even know we were on the radar for recognition. We simply work to ensure quality and safety are the best that they can possibly be” (Pestle, 2014).
This is an excellent example of intentional focus for the right reason. St. Joseph Hospital West was not only successful in meeting the objective it set out to achieve (excellent quality and safety), but it earned the hospital national recognition. Intentionality can be powerful.


  • Be intentional about learning new knowledge and skills.
  • Learn to realistically prioritize short-term work to be done each day and longer-term career goals.
  • Focus.

Patient safety and transparency and managing practice risk
Many organizations strive to attain a culture of safety. The World Health Organization (2015) provides patient safety organization (PSO) campaign resources such as safe surgery, the safe childbirth checklist, clean your hands campaign, and so on. The Joint Commission seeks to identify how safe an organization is by asking specifically what the facility does to promote patient safety. State hospital associations have devised patient safety organizational programs that are open to hospital participation.
Nurses need to be aware of the variety of national and regional quality and safety programs. Healthcare organizations are expected to make the environment as safe as possible. Because nurses are the vast majority of healthcare providers in most organizations, nurses must clearly understand and apply quality and safety concepts. Applying these to our work environment is done through policy, standardized protocols, and efficient work processes; these create a structure to make the care we provide more reliable.
The era of focus on safety in healthcare began in 1999 with the Institute of Medicine (IOM) report titled, “To Err Is Human.” Intimate details about operations and the business of healthcare not putting patient safety first or as a top priority were included. Per the 1999 report, medical errors caused between 44,000 and 98,000 deaths in hospitals each year. Deaths from medical errors are those defined as “could have been prevented” (Kohn, Corrigan, & Donaldson, 2000, p. 1). With the national release of this information, healthcare providers have been vigilant to promote—with clear intention—the prevention of medical errors.
Intentional plans and checklists
In an exposé comparing healthcare to aviation, John Nance (a former pilot and attorney) describes why hospitals should fly. The ultimate flight plan must include intentional systems designed to prevent error (Nance, 2008). A patient-safety orientation and quality care delivery must be precise elements in safe practice. In aviation, Nance described how checklist protocols are applied to standard work processes. The same philosophy could be applied to the variation existing in current healthcare systems. Step-by-step process protocols decrease the need to memorize or recall every step of a process in an emergent situation. Having to remember a great deal of information at a moment’s notice can in itself be very stressful, and checklists can relieve that stress.

Although PSOs are often organizations coveted by non PSO-hospitals across the nation, nurses in those facilities can identify with significant pressure for near-perfect performance. The implication that an organization has achieved a foolproof system (to prevent errors) can lead nurses to fear reporting errors that do occur. Nurses must remain vigilant because rarely is any process completely foolproof. The potential for human error cannot be completely eliminated. Being honest about error reporting helps prevent future errors.


  • Never rely on memory alone.
  • Use “tip sheets” and checklists when possible.
  • Patient safety is everyone’s job: Be honest and transparent.
  • Be intentional about the care you provide; it should be safe and of high quality.

These key strategies are basics to achieving a hospital embedded with a culture of patient safety. “Back to basics” is often a saying used when something goes awry. To solve problems in healthcare, it is imperative to start with the beginning of a process and look at each step along the way for relevance and accuracy. Historically, changes have been applied to current practices or processes without taking the time to break down what currently exists, what needs to change, and what is the best approach to achieving the desired result.

Patient safety organizations frequently utilize the skills of consultants or employees trained in Six Sigma, Lean, or a combination of process- improvement strategies. These specialized skills are an ideal match for organizations who want to improve their safety culture. Participation in process improvement initiatives is a good way for nurses to learn additional problem-solving methodologies.

The nurse’s role in safer and higher-quality systems
How do nurses and organizations ensure high quality and safe patient care? Technology can be utilized for building safer systems. Most healthcare facilities now have an electronic health record (EHR). Checklists and standardized protocols can be embedded into the EHR for more consistent decision-making and to reduce practice variation.

One standardized example is that surgical centers and operating suites have nearly universally implemented the safety steps of a “time-out” checklist (approximately a decade ago). Before a procedure begins, a series of questions are discussed among the surgical team. The information is generally entered into the medical record, which only allows the user to proceed if all safety checks and balances have been completed. This standardization has prevented many medical errors, which include wrong-site surgeries, incorrect procedures or anesthesia, and incorrect patient-procedure matches. Following this type of checklist can be simple and it is important; following it step-by-step every time ensures a more predictable and safer outcome.

Each person who chooses a career in healthcare must understand his or her role in patient safety; no position should be exempt. Many organizations conduct daily safety meetings, either in person or via technology. This approach communicates the importance of patient safety and leader responsibility; it also ensures accountability as departments or disciplines are required to report their status. Because healthcare organizations are not silos, each department/discipline influences or has the ability to affect the functions of others.

Safety is everyone’s job. If we notice breaks in protocol, such as a lack of hand washing, not labeling specimens in the presence of a patient, or an incomplete timeout, healthcare providers need to be able to speak up. Each person needs to understand the importance and his or her responsibility and needs to feel empowered. For example, a surgeon seen wearing a surgical mask in the hallway outside of the surgery department should be reminded to remove the mask. If a co-worker does not wash his or her hands per protocol, it should be brought to the person’s attention. Cultures that support safety also support civility, where all staff are seen as equal team members regardless of rank, position, or tenure.

Create a culture of transparency
A culture of safety in healthcare is evolving. Most institutions are experiencing significant change, and the culture is moving toward improved quality and higher system reliability. Transparency for doing the right things right is becoming the norm—not changing systems or practice solely due to regulatory requirements or intervention. In an organization that’s truly encompassing patient safety, everyone knows that everyone else is and will be responsible for achieving a unified goal—safety.
Patient safety is also a primary focus of the U.S. government relative to healthcare. As a result, systems such as the Veterans Administration have made necessary changes to access and care. A national news release in April 2014 (Bronstein & Griffin) revealed at least 40 veterans have recently died while waiting for appointments. Alleged secret lists of patients waiting to be seen were not entered into the computerized scheduling system. Subsequently, the patients never received provider appointments. In addition, no official records existed to indicate a delay in care. Clearly, equal responsibility for patient safety was not infused nor adopted throughout the organization. Transparency was not valued; all realms of the organization, including the operators and receptionists, were not empowered or held accountable to ensure quality and safety were paramount.
Manage the handoff
An additional area of practice risk is the patient “handoff” process. It is a very important element of patient care designed to deliver intimate details of a patient’s situation and care requirements and to allow communication between caregivers. Patient care may transition from one provider to another in a variety of situations. Typical handoffs include receptionists, clerical personnel, nurses, medical providers, diagnostic personnel such as laboratory and radiology, and consultative personnel such as a dietitian or a specialist of another discipline. Handoffs may occur either inside an organization or outside to other clinics or facilities. It is incredibly important that handoffs be standardized, be pertinent to individual patient needs, and include safety and quality concerns relevant to their care.


  • Be transparent.
  • Follow organizational policy.
  • Use unique patient identifiers and include the patient in handoffs.
  • Share information the next provider needs to know.

Bedside reporting
Nursing “report” is a type of handoff or communication process that has historically been in place between nurses. When viewing old movies with hospital scenes, medical records are often seen hanging on the footboard of the hospital bed; this promoted bedside conversations about care and report from nurse to nurse. Since that time, a variety of options for more confidential nurse reporting has evolved, whether in person, by audiotape, or in writing. More recently, report has changed location (moved to the bedside) and includes the patient.
Publications outlining the specific benefits of bedside reporting have been prevalent since the early 1980s. In 1995, Minick published a qualitative study identifying bedside report as a means for critical care nurses to identify potential problems earlier in the care of the patient. Bedside report also resulted in what Minick (1995) deemed “making a connection” with the patient when patients are included in the process.
Implementing bedside reports in an organization that has utilized alternative methods can be quite challenging. It requires a different type of thinking from nurses and new skills in communication. Nurses who have not experienced this style of open communication with patients and/or family members may be unsure of themselves, uneasy with the honest dialogue, and fearful of potential questions. There is no definitive conclusion as to why resistance to bedside reporting exists, but it does (Agency for Healthcare Research and Quality [AHRQ], 2015).
Challenges for nurses to overcome when using bedside report include how to deal with sensitive information in front of a patient, potential violations of confidentiality and privacy, fearing change, and not wanting to disturb the patient (AHRQ, 2015). Changing the process for nurse reporting can be complex. It is very important for nurses and nursing leadership to be jointly involved in planning the change process. The end product must ensure delivery of pertinent information and allow time for quality conversations. Measurement milestones to follow up and evaluate the new process are necessary in order to achieve a successful change in reporting practices.
The literature is rife with studies of organizations implementing bedside report, the challenges of doing so, the processes used, and the benefits reaped. The Agency for Healthcare Research and Quality (AHRQ) published an implementation handbook for bedside report in conjunction with the U.S. Department of Health and Human Services (2015). The step-by-step guide gives clear direction for organizations to begin the implementation process and provides case studies from hospitals that have achieved successful implementation. It also summarizes the benefits of bedside shift report including improved patient satisfaction and less time required to complete the shift report. You can read more about the Nurse Bedside Shift Report at
systems/hospital/engagingfamilies/strategy3/ index.html
Anderson and Mangino (2006) reported improved relationship-building among nurses and improved patient satisfaction; most patients want to know more about their health status and the plan for their care. Caruso (2007) found nurses doing bedside report were frustrated with the repetition of history in front of the patient. Caruso (2007) suggested use of Lewin’s change theory when presenting and promoting the concept of bedside report. A new reporting template using only pertinent and current information (with follow-up via mentoring and accountability) worked well for a remodeled bedside report. As a result of the study, nurses continued their improvement work and designed a pre-report that reviewed the patient’s history followed by a bedside report for verification of care requirements, as well as the plan for the shift or day. The revised model provided efficiency for nurses and patients.
Many hospitals that try to implement bedside report find frustration among nurses. Because it is a radical change, it is easy to revert to what is more commonly known: nursing station report. Generally, nurses fear failure and especially failure in front of a patient. But is it really fear of the organizational change or the consequences? Whatever the reason, bedside report is best for patient outcomes (Sigma Theta Tau International [STTI], 2012). Both patients and families have reported it improves their understanding of the hospital process and considers needs the patient will have after hospitalization.
The Joint Commission made the second national patient safety goal (NPSG) of 2006 this: improve the effectiveness of communication among caregivers (The Joint Commission, 2007). The 13th goal of 2006 was: encourage the active involvement of the patients and their families in the patient’s own care (Patient Safety Net, 2015). Although The Joint Commission has not specifically listed bedside report as a national patient safety goal, the objectives can be easily met by using the method of bedside report for improved communication. You can read the latest version of The Joint Commission’s publication, “America’s Hospitals: Improving Quality and Safety: The Joint Commission’s Annual Report 2015,” at
Reliability science and the prevention of harm
Sheridan-Leos (2014) discussed the premise of reliability science as a platform to ultimately improve quality and safety. Historically, reliability science has been commonly used in high-risk industries. The principles are designed to compensate for limitations in human performance, with a movement toward zero defects. Defects in healthcare can be defined as medical mistakes, lapses in service, and other measurable metrics demonstrating quality, safe systems, and operational success. The goals of patient safety intersect with reliability science because they are both intended to prevent harm. Healthcare must develop a laser focus on anticipation of what might go wrong and subsequently design stopgaps to eliminate errors from occurring. The anticipation of error prevention uses systems thinking and change theory; while both concepts are somewhat familiar to nurses, this may be a paradigm shift for some in the ability to see interdependent relationships in complicated processes rather than linear cause and effect (Sheridan-Leos, 2014).
Nurses are vital participants in preventing errors and defects. They are at the “sharp point,” or at the point of service (with the customer). Being at the bedside caring for incredibly sick people in trying circumstances is not without risk. However, examples of nursing work processes designed to prevent error include independent verification; individual double-checks; a review of medication side effects; mediation reconciliation; consultation with colleagues regarding policy or procedure standards, and so on. Nurses and organizations that embrace safety science have an opportunity to decrease or eliminate associated organizational stressors resulting from mistakes. Organizational stress often leads to personal stress, which launches the reiterative cycle of stress, fatigue, and burnout.
One of the hallmark characteristics of reliability, as described by Sheridan-Leos (2014)—in the modified definition of Berwick and Nolan’s (2003) application of reliability to healthcare—is the measurable capacity of healthcare processes, procedures, or services to perform the intended functions in the required time. Most medical care must be delivered in a timely fashion. Delays in care should be considered a defect. Delays also have the potential to disrupt care delivery and optimal healing as well as the potential to affect outcomes.
Nursing has typically been silent when errors occur in practice. There is an overwhelming fear of litigation and public humiliation of both organizations and individuals who make errors. Honesty takes work. Children do not have to be taught how to lie; they have to be taught how not to lie. Natural instincts facilitate protection; protecting ourselves and others is human nature. Living with knowledge that an error occurred is just as stressful as reporting an error and fearing the consequence. Stress, fatigue, and burnout frequently occur more quickly for nurses in organizations where honesty and transparency are not supported, appreciated, or encouraged.
Case 1: In 2011, the media reported a story about a nurse in Seattle, Washington, named Kimberly Hiatt who made a serious medication error (Aleccia, 2011). Nurse Hiatt recognized the error and immediately reported it to the nurse in charge. The child who received the inaccurate dosage of medication had been a frequent patient at the healthcare facility due to a heart defect. The patient did eventually die, but it was never clear if the medication error contributed directly or indirectly to a further decline of the patient’s heart function.
As sad as this death was, another unnecessary death occurred subsequent to the investigation. Hiatt had been an employee and worked in her specialty for 24 years and had never knowingly made a critical medication error. After this error, she was thoroughly investigated, terminated from her position at her hospital, and fined by the Washington State Board of Nursing. In addition, the Board of Nursing required her to complete 80 hours of medication administration coursework, and as an additional sanction, she received a 4-year probationary period that required regular reporting. Unfortunately, the shame of the error, the fear of never working again as a nurse, and the guilt of the harm she may have inflicted led her to commit suicide. Hiatt’s suicide was just one week after the State Board’s ruling.
Case 2: In Ohio, also in 2011, pharmacist Eric Cropp was sentenced to 6 months in jail for the death of a 6-year-old cancer patient. In Cropp’s case, he was obligated to supervise a pharmacy technician who inadvertently used the wrong percent of saline while mixing a medication in solution. Unfortunately, Cropp is now a convicted felon and lost his license to practice pharmacy (Lebowitz & Mzhen, LLC, 2011). Healthcare is serious business; inadvertent mistakes can result in unintended death or harm.
Case 3: A temporary nurse was working in an intensive care unit (ICU) and assigned to a critically ill patient. The nurse was new and unfamiliar with the unit and also with many of the hospital’s unique protocols. In the absence of an intravenous (IV) pump, standard practice was to use a tube feeding pump to infuse the medication (incidentally, this was in the late 1980s—long before the global focus on patient safety). Against her better judgment, the nurse hung a 250cc bag of dopamine to be used to augment the patient’s blood pressure. Unbeknownst to the nurse, shortly after initiation, the tubing became dislodged inside the pump. Later, as the nurse was performing an assessment of the patient, she noticed the arterial line wave form had become very large and accentuated on the monitor, as well as a change in patient condition—the patient had become very restless. As the nurse proceeded to investigate the cause for a change in condition, she looked up and noted that the entire bag of IV medication had run in (through the patient’s central line) in a “free-flow” fashion. She was mortified! Next, she immediately notified the nurse in charge and the medical provider. Fortunately, the patient did not suffer any long-term ill effects and was treated with other supportive medications until the dopamine’s effects were diminished. However, as for the nurse—she had a very difficult time with the fact that she had made such a potentially grave error. She took a break and went to a private area. There, she had a complete breakdown. She then requested to leave her shift for the rest of the day. The leaders obliged. She had never made a medication error before to her knowledge. The next 15 hours were agonizing for the nurse replaying the scenario in her head, asking herself what she could have done differently, and so on. This story had a happy ending—the medical director of the ICU asked the hospital and the nursing agency for the nurse’s contact information. He made a call to the nurse to console her and asked her to come back to work later that day (the call was on the day following the error). He assured her that she could do it and that this mistake should not deter her confidence in her ability to practice nursing in the future! The nurse did go in to the hospital that day to find a very supportive group of clinical colleagues waiting for her return—they allowed her to help them care for patients that day and not be assigned a patient or patients of her own. This compassionate and caring approach made all the difference in her own “recovery” by allowing time to process and finally accept the error. Fortunately, she was able to continue her practice working in this and other ICUs. She has never forgotten the error, and overall, it has made her a better nurse—more present and aware.

No professional curricula adequately prepares future healthcare practitioners with all of the competencies necessary to deliver quality healthcare (Morris, Otto, & Golemboski, 2013). Nurses must take special care to remain vigilant to prevent errors. Strategies for safe practice must include following organizational policy, delivering patient-centered care on an interdisciplinary team, knowing the standards of practice, utilizing available technology, staying current with medical and nursing evidence (practicing evidence-based nursing), being present and aware, and caring for one’s own well-being. Providers in healthcare are diligently working to bridge the gaps in the care continuum for improved quality of care. The comprehensive care continuum now includes what happens before an episodic office visit or hospital encounter and those activities that take place inside a hospital, clinic, provider office, and the home environment of patients to ensure care is consistent and meets the patient’s needs.

Organizational transparency is necessary to forge optimal safety, quality, and legal reform. Public reporting has removed the veil of secrecy organizations have enjoyed; no longer is there an impenetrable shield when errors occur. Smart organizations have begun to open their private world to the public by bringing together patients, family, healthcare providers, and community members as collective advocates for system change. The objective is to allow participation in setting organizational policy and decision-making by those whom healthcare is designed to serve.


  • Learn about reliability science.
  • Apply the principles of reliability science to improve quality and safety in the work environment.
  • Attend to your own well-being to be able to provide safe care.
  • Design or redesign care systems to be safer and more patient-focused.

Promoting accountability
Promoting accountability is a difficult and somewhat ambiguous task. As people, we often link the words accountable and guilty; if you are accountable, you are the one to blame. Nurses are generally altruistic people who honor the truth. Telling the truth means reporting errors and catching near misses. Unfortunately, nurses cannot eliminate human error and are subject to error potential with even the most well-designed processes and systems. Making any kind of mistake causes stress. Depending on the gravity of the error, the stress can be extreme, as evidenced by the earlier professional practice examples in this chapter.
Lyons, Adams, Woloshynowych, and Vincent (2004) reviewed a variety of levels of human errors in healthcare, from the most unintentional of absent-minded errors to the intentional maleficent causes of harm. Fortunately, intentional harm is uncommon in healthcare. Typically, human reliability assessment and process improvement efforts within an organization can prevent unintentional errors from recurring.
Dr. Lucian Leape from the Harvard School of Public Health first briefed the U.S. congressional subcommittee on the management of human error in healthcare on October 12, 1999 (Marx, 2001). Leape reported that only 2% to 3% of major medical errors are reported through hospital reporting structures. He stressed the urgency of finding ways for healthcare organizations to prevent errors, eliminate punitive error-reporting responses, and use the errors to improve the chances that they would not be repeated.
Marx (2001) described disciplinary system theory as a way to define categories of error based on historical court cases, jury decisions, and penal codes. Errors are then categorized as one of “four evils”:
  • Human error—The one committing the error should have done something other than what he did.
  • Negligent conduct—Failure to exercise expected care and should have been aware.
  • Reckless conduct—Conscious disregard of substantial and unjustifiable risk.
  • Knowing violations—Knowingly violated a rule or procedure.

Similarly, categories of error are used in the decision-making process titled Just Culture. The visual model shown in Figure 9.1 outlines the types of error, considerations resulting from investigation of the error, and appropriate follow-up behavior.

Figure 2: Cycle of ImprovementClick image for larger view.

Just Culture is a process by which organizations can evaluate errors and determine appropriate responses. The organizational enticement to such a process is that by using the well-designed tools, leaders can encourage more reporting, learn from mistakes without blame, and appropriately identify those who behave recklessly and need to be removed from the organization. Brunt (2010) described how using Just Culture pushes organizations to make six major changes:

  • Move from looking at errors as individual failures to realizing they are often caused by system failures.
  • Move from a punitive environment to a just culture.
  • Move from secrecy to transparency.
  • Move from provider-centered care to patient-centered care.
  • Move from models of care that rely on independence to models of care that encourage interdependent, collaborative, and interprofessional teamwork.
  • Move from top-down accountability to universal and reciprocal accountability.

The visual model shown in Figure 9.2 is supported by learning systems, justice, and accountability. It outlines a cycle of improvement based on values and expectations, which drive system design and behavioral choices, which result in good or bad outcomes.

Figure 9.2
Click image for larger view.

Reportable quality measures
Using reportable quality measures to drive successful change is something healthcare organizations should strive for. Providers across the nation are being held responsible for reportable quality metrics such as clinical core measures, state-initiated quality indicators, and national patient satisfaction percentile rankings. Additional measurement schemes relative to patient experience and outcomes (patient satisfaction with care, hospital readmission rates, procedural complications, and infection rates for organizations by cause) complicate payment and reimbursement systems.
Decisions have become complicated for patients when selecting healthcare providers. Organizations that are able to convey their quality, safety, and excellent patient experiences will have clientele. Those with poor results will struggle in the marketplace. Organizations that can teach nurses how their individual practice affects fiscal health will be successful. Nurses must learn and understand reportable and reimbursement-dependent indicators. Organizations of the future must build team- oriented cultures with creative talent and use proactive plans to drive quality outcomes. You can learn more about core measures at these two websites:

Healthcare organizations must eliminate blaming and eliminate sayings such as, “if the physician would only…” or “if the nurse had…” or “it was the cardio-pulmonary staff’s fault for not….” Studies show open-ended and honest discussion about errors not only improves communication among the members of the healthcare team but also improves patient care and doesn’t lead to increased litigation (Stewart et al., 2006). Organizational stress, fatigue, and burnout are less likely to occur in transparent organizations, where all levels of healthcare providers know what to expect from each other and from the organization.

Leading innovation and improvement
Nurses must take the lead to guide healthcare to a better future. Nurses provide the preponderance of care in most if not all types of healthcare organizations. Nurses spend the most time with patients and families. Nurses have significant influence with patients and families in care planning, accepting, and translating treatment recommendations, and understanding the intricacies of their healthcare encounters.

Nursing leadership plays a significant role in the outcomes of patients. Nurse leaders control the resources—the people, places, and things that provide care. The role of a nursing leader, at whatever level, is to set the tone. Nursing leaders must lead by example. Leaders might be in formal positions to set policy and design or collaborate in creating a philosophy for practice or in determining how a shift might operate; they may also have more informal influence as evidenced by everyday dealings with colleagues.

Clinical nurses need to take every opportunity to present themselves as leading the care team: taking charge of care coordination, rounding with other clinical and non-clinical disciplines, thinking of better ways to do things, and monitoring all patient-education initiatives. While medical providers determine the plan of treatment or appropriate procedures for a medical condition, nurses are the communication conduit among team members and the patient for understanding the “what” and the “why.”

Participating in evidence-based practice councils and shared governance committees allows nurses to be a part of the important decision-making. Nurses can build the confidence needed to lead innovation and care improvement from these types of activities. Nurses need to be active in the profession and knowledgeable about their chosen specialty. The best patient advocates are informed.


  • Volunteer for learning opportunities—stretch yourself.
  • Participate in organization-sponsored knowledge-building programs.
  • Become an expert.

A healthy nursing culture is critical for both nursing satisfaction and patient experience. In 2013, Sheryl Sandberg (Facebook’s COO) went on a crusade to educate women in leadership roles. The vast majority of nurses are women. Sandberg described learned detrimental behaviors by women in corporate culture: They tend to sit in the second row of a meeting room, lack confidence, and are quiet and do not interrupt “testosterone driven” conversations. Women favor being pleasers, kind hearts, and servants (Sandberg, 2013). The same could be said for nurses, and it is time for change.

Nurse leaders must be well educated, experientially prepared, and use their expertise by having a voice. It is time to “sit up and lean in,” as Sandberg describes, to become part of the decision-making body. Nurses represent the largest group of employees in healthcare. Nurses do have influence. Nurses can guide organizations to achieve desired outcomes. It is time for nurses to stand up, take charge, and be a positive force in the healthcare industry.

Nurses must also share their good work. Best practices are routinely discovered in nursing units within organizations every day. Many nurses provide exceptional care and do extraordinary things. Informal research is conducted by daily experimentation to achieve solutions to common problems. Nurses want to practice with high standards. Differing models of care are explored, knowledge is shared between novices and experts, and leadership is abundant. Knowledge is power, and communication is the only way to unleash it.

Most nurses are required to obtain pertinent continuing education to relicense or recertify. However, studying what is new in the literature related to healthcare economics, policy, or innovative methods of care provision can be difficult. The amount of information can be overwhelming. Streamlining subjects or sharing information among colleagues can be effective methods to stay current. Communication among care providers is very important for patient care and for good practice.

Patients are also encouraged to speak up and be involved in their care for their own safety. You can read more about The Joint Commission’s Speak Up campaign at these websites:


  • What kind of communicator are you as a nurse? Do you speak up when it’s important and helpful to do so?
  • Do your colleagues think you’re a valuable participant?
  • Are you able to understand the preferences of different generations, cultures, and religions?
  • Are you able to understand the finite nuances of disease?
  • Can you apply the latest knowledge and research to patient situations?

Creating a better workplace
Research shows employee satisfaction can be linked to customer satisfaction or, in healthcare, to the patient experience. Improvements can be low or no cost. The patient experience is a critical component to the assessment of quality. Folkman (2013) listed seven ways one company found to increase employee satisfaction without giving raises:
  • Consistent core values exhibited by the leadership that do not disappear during times of stress
  • Long-term focus promoting a positive and bright future
  • Local leadership accepting feedback and driving change
  • Continuous communication in good and bad times
  • Collaboration with others to maximize resources and teamwork
  • Abundant opportunities for development
  • Speedy and agile decision-making

Nurses are the backbone of any healthcare operation; the influence they possess must not be wasted. Nurses must be active participants in improvement activities and take full advantage of the perks associated with employment, such as tuition reimbursement, certification pay differentials, and educational offerings. Being a good employee requires give and take. More than a decade has passed since the first report by the IOM regarding the status of safety in healthcare. We can do better. Being an involved employee in an environment devoted to quality and safety provides a buffer from organizational stressors.

Staying connected to purpose buffers stressful conditions. In Pistorius’s 2013 book Ghost Boy, he described a nurse who loved her job. She performed her duties with passion and commitment every day. As a result, she saw life in the boy who was truly alive inside his prison of a body. The patient, named Martin, had a mysterious illness causing him to be comatose. He lost all bodily functions, including speech. However, one day his mind woke up but he couldn’t let anybody know. Virna, his nurse, took time to relate to the boy as if he were awake. She didn’t know if he was actually “in there” or not. In doing so, she found life in a boy and gave him a great gift (Pistorius, 2013). Virna was not stressed by the patient’s condition or the environment, but instead provided him with care, compassion, and human kindness.


  • Why did you become a nurse? Passion and purpose provide amazing individual and professional rewards.
  • Stay involved and contribute by sharing what you know.
  • Always give your best.

Influencing state and national policy
Nurses are ideal advocates for healthcare change. Their knowledge and expertise of what is best for patients cannot be matched. Nurses must remain abreast of current issues to be informed and vote on amendments and healthcare laws with conviction. Be a promoter of health and the prevention of illness. Use nursing and non-nursing related venues as a platform to share expertise. Consider volunteering to speak about nursing and healthcare in the community. Be knowledgeable about the impact of changing healthcare law. The political arena offers a number of opportunities for nurses to get involved in driving change: testifying, lobbying, and/or running for public office.
Nurses occasionally find themselves in situations of distress. These situations commonly challenge their patience, integrity, and values. It can be morally distressing to seek justice or what you believe to be the best care for a patient without having the plan supported or agreed upon by the patient, the family, or in some cases even the medical provider. Worldwide challenges remain, such as, impoverished people and/or communities with no means of obtaining or growing their own food are not likely to have healthy food choices. Religious communities with strict conviction about immunizations may require specialized provisions to help fend off viruses and/or disease.
Many social issues still exist in nursing and healthcare both inside and outside of the United States. Often, these types of challenges are shared with nurses and can be a source of stress. Conflicts arise in healthcare as they do in any other industry on a regular basis, but in healthcare and nursing, the conflict may have a direct impact on someone’s life. Thus, a stronger focus on quality and safety must be included in all plans for the future of nursing and healthcare.
What is nurtured is what will flourish. O’Reilly (2009) pronounced that healthcare was slightly improving 10 years after the IOM report on errors. The progress has been slow, and experts in the industry would give the effort toward safety and quality a grade ranging from a B– to a C+ (O’Reilly, 2009; Wachter, 2010). We can do much better. We can manage patient risk, improve safety, and become more reliable in what we do. Ask yourself these questions: 
  • What are you nurturing in your practice?
  • What are your organization’s leaders nurturing?
  • What is your community nurturing?
  • What can you do in your practice to make a difference?

The next chapter discusses strategies to reduce stress and fatigue in an effort to banish burnout and to promote a healthy work-life balance.

Book and chapter author:
Suzanne Waddill-Goad, DNP, MBA, RN, CEN, is president and principal consultant of Suzanne M. Waddill-Goad & Company.

Chapter author:
Holly Jo Langster, DNP, FNP-C, HCA, CENP, is nursing project manager for Baptist Health Medical Center in North Little Rock, Arkansas, USA.

Information on purchasing Nurse Burnout: Overcoming Stress in Nursing.

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  • Just Culture
  • accountability
  • reliability science
  • bedside reporting
  • handoff
  • practice risk
  • transparency
  • patient safety
  • intentionality
  • Holly Jo Langster
  • Suzanne Waddill-Goad
  • stress
  • burnout
  • Nurse Burnout
  • mental health
  • education
  • RNL
  • Nurse burnout: Planning intentional quality and safety