1. Warner, Sandra L. BSN, RN

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Making mistakes is part of human nature. However, in healthcare, mistakes can cost lives. Errors in direct patient care, billing errors, misplaced and mismatched medical records, and computer programs gone awry can all lead to serious consequences. In fact, on any given day, it is likely that more than one provider is worrying about a career-ending error.


From the first semester in nursing school, nurses are taught to avoid risk and fear mistakes-especially medication errors. Nurses are told that if they do not know how to do something, they should never guess or experiment. However, in other areas of the healthcare system such as information technology and nursing informatics, thinking outside the box and experimentation are encouraged and commonplace. Although traditional leaders frown on behavior that could put an organization at risk, transformational leaders realize that plenty of areas within healthcare may benefit from creativity-even critical care-despite the threat to the status quo. Failures, sometimes in the form of error, must then be viewed as part of the learning and creativity process. When errors lead to better processes, improved practice, or increased knowledge, the risk is often worth the potential, or realized, reward.


This is not to suggest that clinical nurses begin experimenting on patients; creativity should never jeopardize patient care, violate practice standards, or take the place of evidence-based practice. It does, however, mean allowing critical care nurses to develop new and potentially better ways to complete tasks-knowing full well that along with successes, they will experience many disappointments.


Transforming care

Developed by the late professor Bernard M. Bass, PhD, more than 25 years ago, transformational leadership is widely practiced and is particularly suitable for nurse leaders challenged with nurse burnout, high turnover, and balancing the interests of staff, patients, and physicians. Transformational leaders inspire positive change that supports the organization's vision and goals and encourage healthcare professionals to take ownership of their work.1


Transformational leaders, by virtue of their ability to inspire change and promote high performance, can have an extremely positive influence on the culture of a workplace and those who work within it. Research shows that when organizational culture is positive and supportive of employees and their values, employees experience increased job satisfaction and less workplace incivility.2,3 Staff members also become more engaged, working with an enhanced sense of self-efficacy.4


The challenge for nurse leaders is to begin to see nursing and medical errors as opportunities to learn and grow. Likewise, the astute transformational leader can also identify when errors indicate an opportunity to align practice with high-quality care. For example, several recent medication errors on an oncology unit are linked to improper operation of I.V. infusion delivery devices. Rather than blame staff, the transformational nurse manager arranges for the entire staff to receive training on the devices.


So how should leaders manage error and effectively deal with the employees who make them without stifling learning and creativity? The transformational leader works hard to reduce risk to the system as a whole by helping the employee, and the system, recover from identified error. Part of this effort includes building and reinforcing a just culture workplace.


Supporting a just culture

In a workplace structured after the just culture concept, nurses are responsible for exhibiting consistent, dependable, and reliable behaviors in the workplace. Although all nurses are accountable for their own actions and choices, they work as a team to minimize and manage "at-risk behaviors" in an effort to catch errors before they occur.5 Every nurse plays a part in reducing the stigma of error.


Leadership's role is to recognize that mistakes are inevitable in changing and complex work environments, and that unreported mistakes cannot be fixed. Thus, a workplace culture where employees feel safe reporting an error creates opportunities to examine best practices and devise ways to prevent an error from happening again. The transformational leader recognizes that no honest mistake is worth destroying an individual's self-esteem, and instead seeks to identify the process failure that may have led to the error and coach the individual to better processes and accountability.


Transformational leadership skills help maintain or establish a workplace culture that is favorable for personal growth, job satisfaction, and safety. A just culture workplace emphasizes values, inspires trust, encourages ethical conduct, and recognizes that errors are an opportunity for learning and innovation. Organizations with a just culture are supportive of employees when errors are made and avoid reactionary responses or punishment and blame, thus encouraging accurate reporting of near-miss incidents and errors. Blaming or punishing the individual who caused an error does little to decrease errors in an organization, and prevents leaders from initiating improvements in the workplace.6,7


It is also important to remember that mistakes are rarely made on purpose. Effective, compassionate coaching following an error not only helps reduce the likelihood of recurrence, but also helps the employee deal with a sense of remorse or failure.8


Differentiating error and risky behavior

Risky or reckless behavior should be handled a bit differently than error. At-risk behavior is a behavioral choice-a choice to not conform or submit to safety regulations or nursing protocols. Reckless behavior is conscious disregard for clear risks to a patient's safety and well-being. For example, the nurse who stops reading medication labels because she "knows" the pill colors is at risk for administering the wrong medication or dosage to the wrong patient. Similarly, the nurse who comes to work intoxicated is behaving recklessly. These events may result in error, but not the productive kind.


When errors occur because of risky behavior, determine the underlying reason for the lapse in appropriate conduct, then address it on both a systemwide and individual level. For example, nurses may postpone documenting an I.V. medication administration until later in the shift because access to computer terminals is limited in the morning during physician rounds. This potential for error can be addressed by systems improvements, such as increasing nurses' access to computer terminals in the morning. Individually, nurses may need additional coaching to reinforce the importance of prompt documentation and following safety protocols.


Reckless behavior should never be tolerated. In a just culture, all nurses are accountable for their behaviors.


Empowering nurses to take ownership

Empowerment occurs when leaders invite participation, creativity, and initiative by challenging employees with new tasks, opportunities for growth, and problems to solve, even though this process inevitably involves error. It is incumbent upon the transformational leader to create a just workplace culture that inspires and motivates others to strive for excellence while holding individuals accountable for their behavior. Welcome innovation and reward initiative; anticipate victory, but understand that it is often through "failure" that true growth and learning occurs.




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8. Porter-O'Grady T, Malloch K. Quantum Leadership: A Resource for Health Care Innovation. 3rd ed. Boston, MA: Jones & Bartlett Publishers; 2011. [Context Link]