1. Hay, James EdD, MSN, RN, CRRN
  2. Collin, Susan MSN, RN, NE-BC
  3. Koruth, Suzy MSN, RN, CNL

Article Content

The most significant challenge for new nursing graduates is effective communication with other nurses and members of the healthcare team.1 Nurses are often the lead members of a healthcare team to initiate communication, yet, classroom education insufficiently prepares nurse graduates to manage the aspects of communication within the multidisciplinary patient care team. The existing hierarchical power structure in healthcare institutions creates specific silos of care, with each discipline working within its professional focus on the patient.2-4 Education targeting collaborative efforts of interdisciplinary teams, the interrelated structure of healthcare systems, and understanding team members in their professional scope of practice is absent in many academic institutions.5

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

With this in mind, a nurse leader must identify and utilize all available resources, including the support of staff members, to achieve safe patient care. An exciting combination of nursing theory, philosophy of nursing practice, the expert knowledge of clinical nurse leaders (CNL), and clinical crew resource management (CCRM) training has brought the nursing staff members on a medical-surgical unit to a change in practice. After a few short months, there has been clear evidence of positive staff and patient care outcomes. This article will share the results of an eclectic approach to the utilization of available resources on a medical-surgical nursing unit that led to the improvement of patient safety and outcomes.


The needle and thread

On 7A, a 23-bed medical-surgical unit at a large eastern Veteran's Administration Medical Center, the combination of a national communication program and a new CNL role created the impetus for nurse-driven changes to improve patient safety and outcomes. Early in 2012, two critical resources were mobilized to improve these practices. The first was the development of a CNL role on the nursing unit. This role incorporates a master's-prepared nurse to focus on the clinical operations of the unit. The CNL bridges the gap in communication and coordinates patient care. The second resource was the national communications program, CCRM, which trains clinical nursing staff members in aviation-based strategies to enhance teamwork, communication, and the quality of clinical decision making at the point of care.


As a baseline to initiate the change process, the 7A nursing staff members recognized their clinical strengths and weaknesses, as well as the need for a theory-based foundation to begin change in communication. Challenges experienced by the nursing staff included the coordination of patient care activities on the busy medical-surgical unit. Monitoring the veterans' physiologic status on 7A required frequent updates, which resulted in the division and delegation of a dynamic workload. This reinforced the need for explicit communication within the nursing staff. In addition to the CCRM training, 7A became one of the first nursing units in the facility to introduce the concepts of Jean Watson's Theory of Human Caring as a foundation for a nursing professional practice model.6 The implementation of a safety briefing, following CCRM training, supported by the CNL and a theoretical foundation, led to enhanced communication and improved patient outcomes.


The theory-based foundation that the staff members of 7A created for changing their communication culture was the 4 Cs. (See Figure 1.) Integration of the 4 Cs created a dynamic mixture that led to the change in 7A's safety culture, nursing practice, and patient outcomes. The nurse manager and CNL worked with unit nurse staff members to create the concept for a safety project, which is how the safety briefing was created. The safety briefing effectively tied together all elements of the 4 Cs: Caring theory, compassion, the CNL role, and the CCRM program.

Figure 1:. The 4Cs o... - Click to enlarge in new windowFigure 1:. The 4Cs of 7A

Caring theory

The unit's nurse manager and CNL identified a nursing model to establish a framework for future changes in the care process. Jean Watson's Theory of Human Caring expresses the ethical and theoretical perspectives of the nursing process in providing care at the clinical level.6 Clinical nurses do more than simply provide a service. It's common for them to connect both emotionally and spiritually with their patients. This link is considerably greater when caring for veterans because there's also a debt of gratitude attached to the nursing care. Caring theory provided a global theory and structure to initiate changes in the culture of 7A.



Compassion is a core philosophical approach noted in the Ideal Community unit mission statement. The concept of an ideal community was developed early in the establishment of the 7A nursing culture and facilitates the honor of caring for our nation's veterans. One of the first steps in creating an ideal community of nursing staff members was to collaboratively establish the community promises-a collection of collaborative norms associated with professional behavior. Community promises guide the style of communication among the members of 7A to reinforce standardization and positive effects. Compassion is the most important part of the community promises for the foundation of teamwork between the nurses and the veterans receiving care on 7A. Nurses demonstrate compassion not only for the veterans and their families, but also for each member of the team and any visitors to 7A's ideal community.



The CNL role served many purposes in the initial implementation of the 4 Cs. This clinical nurse translates expert knowledge into practice through direct patient care, coordination of care, and as a staff resource.7 On 7A, the CNL supports team situational awareness by critically assessing the safety priorities of the unit. A major goal of the CNL is to create a cultural emphasis on safety and communication in patient care. The incorporation of the CNL into nursing practice provides the bridge in communication between leadership and frontline staff. The CNL also improves the leadership's contribution to decision making and supports the unit's nursing staff members during daily patient care activities.



In February 2012, the CCRM program trained 7A staff members in strategies, originally found in aviation-based crew resource management (CRM), to improve safety, communication, teamwork, and outcomes. CCRM learning sessions are 4 hours long and were scheduled with variable start times to accommodate the staff members on different shifts. Three interactive, didactic learning sessions provided CCRM training for at least 80% of the nursing staff members.


The CCRM didactic learning sessions are divided into five modules. Each module includes critical CRM concepts and strategies for improving effective communication that the participants can begin using immediately. In the first module, participants join an interactive discussion on developing systems to manage human error in patient care. The participants examine healthcare case studies and identify specific behaviors to prevent, trap, or mitigate the consequences of error.


During the second module, participants examine the dual roles of nursing staff members on a healthcare team. Leadership behaviors that facilitate open communication are explored with the participants. Followership roles (nurses supporting the mission of the team) are also reinforced in the second module. Strategies for respectful and assertive communication during patient care are practiced in small group exercises. The application of aviation-based tools equip the participants to break through the resistance to open communication often found in a hierarchical system.


The third module of the learning session focuses on the concept of situational awareness. Situational awareness in healthcare is the ability to discriminate key items for decision making from extraneous patient information, attach significance to the information, and begin to execute a plan of care.4 Situational awareness is severely reduced by the many distractions found on the unit, such as pagers or alarms, which require the immediate attention of the nurses. Maintaining an elevated level of situational awareness requires team effort, individual vigilance, and communication.4


The content of the fourth module outlines the use of briefings and debriefings as a mechanism for standardized communication for the nurses to create a shared mental model for planning patient care activities. Briefings organize care by dividing the workload in a manner that ensures efficiency and safety. Debriefings, after an unanticipated event on the unit, for example, can be used to improve future nursing care.4


In the fifth module, the participants also review successful implementation of strategies to elevate situational awareness by reducing distractions during a critical task. The participants are encouraged to identify patient care activities in their work environment in which distractions reduce patient safety. After the fifth module, the participants practice the new communication tools in a simulation session later in the week.


Threading it through

After the initial CCRM learning sessions, monthly coaching calls with CCRM faculty provide additional support for the nurses to develop and implement a safety project. 7A nurses developed a SAFETY briefing led by the CNL. The SAFETY briefing is a 5-minute meeting held to develop team situational awareness for all staff members on 7A and to create a shared plan for coordination of care. SAFETY is an acronym for skin, acuity, falls/Foleys, evaluate, teamwork, and "YAY!"-celebration of the team. (See Table 1.)

Table 1: SAFETY brie... - Click to enlarge in new windowTable 1: SAFETY brief

Initially, the CNL met with the overnight nurses to ascertain overnight changes and issues with the veterans on 7A's medical-surgical unit. At 7:30 a.m., the CNL reviews the key elements with day staff, including RNs, LPNs, unlicensed assistive personnel (UAP), and the administrative support assistant for the unit. The CNL continues to focus on patient safety as she reviews the nursing outcomes report, coordinates the plan for patient care, and checks the resources available to accomplish the mission. The CNL collaborates with the UAP to do focused hourly rounds to prevent skin breakdown and falls for high-risk patients. The CNL models the community promises and demonstrates the key element of compassion.


Throughout the day, the nurses must be aware of the overall picture regarding the veterans' physical conditions to recognize if anyone is deteriorating or becoming unstable with arrhythmias. Acuity is reported from the night tour as are the challenges faced by the nurses managing any physiologic changes in unstable veterans on the unit. The CNL provides additional monitoring and detection of subtle signs indicating further change. The CNL also supports the staff members in identifying veterans at high risk for suffering an adverse event such as a fall. The staff members then work together by adjusting their workload to manage the veterans requiring focused attention for safety issues.


The list of safety priorities is continually evaluated by the CNL in collaboration with the nurses and the nurse manager. To support the concept of teamwork on 7A, thoughts of encouragement and positive quotes, accompanied many times with chocolate, are shared with the staff. This commitment to the unit working as a team has now extended into actions that go beyond the expected patient care tasks. During the implementation of the SAFETY briefing, 7A was struggling with vacancies in 26% of the nursing staff positions. Nursing staff member morale remained high as they embraced the element of compassion in support of each other. Nurses were heard saying, "We won't leave anyone on their own to work." This application of mutual support and caring impacted the quality of the care provided to the veterans and their families.


After the CNL conducts the morning SAFETY brief, she reviews the daily skin report with the nurse manager. At this time, there's a discussion to help set priorities for the nursing care over the next 8 hours. The CNL and the nurse manager may also discuss concerns with staff member's task load or issues of a nature unrelated to clinical operations. By this time, the dayshift nursing team is out of report and beginning the patient care for the day. The CNL continues to weave the fabric of patient safety and communication with the plans for providing care that were established by the nursing staff.


During the shift, the CNL will monitor staff members for signs of fatigue or distraction that may contribute to an error. The goal of the CNL is to collaborate with the charge nurse to ensure that not only patient safety is met but the nurses' safety is met, too. The SAFETY brief continues into afternoon and night tours, with the charge nurses conducting the review and monitoring the team. A daily safety checklist is completed throughout the day. This handwritten tool lists patient care concerns and is shared between the CNL and charges nurses. The checklist prevents any missing information during shift handoffs and contributes to the situational awareness of the nursing team leader. At the end of the third shift, the safety checklist is returned to the nurse manager for review.


Sewing it together

Metrics, founded on indicators of quality nursing care, are being monitored for changes corresponding to the implementation of the 4 Cs on 7A: hospital-acquired pressure ulcers (HAPUs), catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), and falls sustained by veterans.


A clinical questionnaire (CQ), a modified version of the safety-attitude questionnaire, measured specific domains regarding the culture of safety, teamwork, stress recognition, and staff morale on 7A.8 In order to specify unit feedback from the CQ and maintain privacy of respondents, a minimum of 10 questionnaires were completed. All nursing staff members were encouraged to provide their feedback; the questionnaires remained voluntary and anonymous. CQs were administered at baseline, during the initial CCRM learning session, and 6 months after the CCRM training.


In addition, anecdotal comments from veterans, families, and other members of the healthcare team were recorded to determine consistent patterns related to the impact of the SAFETY briefing and the nursing care provided on 7A.



Compared with results from October 2011, there was a greater than 25% reduction in percentage of veterans with HAPUs. In the first 60 days of implementation, only two HAPUs were developed on 7A. Both cases were defined as "unavoidable" due to the critical condition of the veterans. A decrease occurred in fiscal year 2011 to 2012, from five CAUTIs per 100 device days to zero in 1,000 device days. This change reflects a decrease in resource utilization related to improvements in team situational awareness and the SAFETY briefing. No incidents of CLABSIs are reported for greater than 4 months. Falls on 7A have been contained to only six, in greater than 4 months, with no injuries sustained by the veterans. The remaining danger of falls is reinforced to staff members through the SAFETY briefing and a targeted review of available tools to protect the veterans.


Through the efforts of all staff members, a residual effect of an overall increased awareness of safety through communication processes leads staff members to expand their efforts to reduce injuries through management of safe patient transfers. The success of the project has led to institutional support of the development of new SAFETY briefs on other inpatient units in the facility.


CQs indicated significant improvements, noted by the 7A nursing staff members related to the use of CRM-based safety tools such as briefings, debriefings, and assertive communication strategies. Additional information provided by the nursing staff members regarding debriefings indicates that a recent change occurred in the unit's safety culture encouraging the discussion of errors as an opportunity to learn. Slight improvements also occurred in the recognition of the effects of stress in the work environment and the impression of elevated morale in the nursing staff. Notably, nursing staff members' impression of morale continues to be weighted by the high vacancy of open clinical nurse positions on 7A and the facility.


Inpatient comment reports indicate veterans and families are observing engagement and the elements of caring in the nursing staff. Indicative of the recent comments from the report, one veteran remarked, "Best experience, I ever had at a hospital." Another patient commented, "Nurses are most compassionate with my needs." A third veteran met with the nurse manager, during skin assessment rounds, to express her readiness to return for more surgery and checking to see "if her room was available and ready." On another occasion, the nurse manager was touring the unit with a nursing applicant when a patient spontaneously expressed her level of satisfaction with 7A. She also forewarned the applicant that hand washing was critical. Based on comments reported to 7A nursing staff members, veterans view the hospital as a safe haven instead of a place to fear.


Trimming the excess

Although the use of briefings and CCRM training programs supported by process improvement projects is gaining wide acceptance, the utilization of new clinical roles is new. CNLs are just becoming an accepted role that adds not only expert knowledge but also operational oversight to a busy nursing unit. However, the CNL can't be on the unit 24 hours a day, 7 days a week. Sustainment of situational awareness and a SAFETY briefing must continue through the use of other clinical champions and charge nurses. Without the buy-in of all staff members, progress in team communication sustained during the week and on dayshift may deteriorate.


It remains a logistical dilemma to bring CCRM training to all members of the multidisciplinary team in an academic facility experiencing rapid staff turnover and a vacancy rate of nearly a quarter of the desired nursing staff. Imbedding the 4 Cs into the culture of nursing throughout this facility and others will require a concentrated effort by leadership, buy-in from all staff, and multiple educational venues, including a program to train the nursing staff to become local experts who facilitate CCRM in other clinical areas within the facility. It's predicted that the improvements in safety culture and teamwork will also improve unit attrition of valuable nursing staff and support hiring goals.10


Many facilities are beginning to employ briefing strategies, such as morning huddles. The briefings have been mandated and become a requirement without stakeholder buy-in. To truly sustain change in practice on 7A, there must be a purposeful focus, with an underlying core value of compassion held by the team, utilizing the CRM concepts, Caring theory, and the expert knowledge of a CNL. Otherwise the briefing will degrade into another routine.


Unveiling the result

Nurse leaders benefit from the wise investment of educational resources to improve the quality of communication within their teams. Team success depends on the trust and respect that occurs in effective communication. Conversely, the safety culture of an entire organization suffers from the degradation of communication, respect, and trust.9 To support the strategic healthcare mission, nurse leaders must implement a multifaceted approach to establish communication strategies.


The 4 Cs is an eclectic model outlining the combination of resources used to improve patient safety and team communication. The successful template for communication provided in high-reliability industries, such as aviation, sets the example for team training programs.10 The combined efforts of the CNL and the entire nursing staff guided by the theoretical underpinnings of Caring theory and a philosophical approach, including compassion in all patient care, predict success for nursing teams. Utilizing a foundational base of nursing theory and philosophical approach to nursing care along with expert knowledge and unit-based CCRM training contributed to improvements in safety culture, patient outcomes, and staff morale on 7A, and may do the same for other units within the organization and outside it.




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