using systems thinking in healthcare aand …...using systems thinking 36 february 2018 † nursing...

Using systems thinkingto envision quality and safety in healthcare

By Ann M. Stalter, PhD, MEd, RN, and Altagracia Mota, EdD, MSN, RN, OCN

Avision for safe quality care has been

acknowledged since the days of

Florence Nightingale, who recognized

the link between nursing practice and

outcomes.1 In 1998, nurses identified the

significance of practice errors on poor

patient outcomes, and the National Database of

Nursing Quality Indicators® was established by the

American Nurses Association to monitor how

patient outcomes were related to unit-level nursing

care.1 The Institute of Medicine report, To Err is Human, highlighted human error as causing nearly

98,000 deaths and over 1 million injuries in U.S.

hospitals.2 The report offered opportunities for

improving healthcare through total system

transformation. The Robert Wood Johnson

Foundation answered the call with Quality and

Safety Education for Nurses (QSEN) to develop

minimum standards for safe nursing practice.3

Once standards were established, national nursing

education credentialing bodies responded by

requiring that QSEN competencies and systems

thinking be integrated into program curricula.4,5

32 February 2018 • Nursing Management www.nursingmanagement.com

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

www.nursingmanagement.com Nursing Management • February 2018 33


Using systems thinking


After over a decade of delib-

erate transformation attempts,

system-related errors were still

being identified as a primary

cause of death in the United

States, translating to over

400,000 preventable deaths.6 So,

why haven’t QSEN and efforts

to develop systems thinking

resulted in improved safety out-

comes? Anecdotal evidence sug-

gests that QSEN competencies

and systems thinking aren’t well

integrated into practice settings. This article seeks to increase

awareness of administrative and

educator roles in empowering

clinical nurses to understand the

impact of their actions on patient

and organizational outcomes

using QSEN competencies and a

systems thinking approach.

Defining roles

All nurses are leaders, educators,

and care providers. Nursing

position descriptions formalize

nursing roles according to work

settings. In this article, nurse

leaders can be organizational

directors or unit-level managers.

Educators are defined by clinical

instruction, often referred to as

nursing professional development

specialists. Clinical nurses are

those who provide care within

practice settings such as acute, long-

term, home, or ambulatory care.

What are the QSEN

competencies?

The six QSEN competencies—

patient-centered care, teamwork

and collaboration, evidence-based

practice (EBP), quality improve-

ment, safety, and informatics—

have recommended, specific

knowledge, skills, and attitudes

that all nurses should exhibit for

safe practice. Having these skills

will assist nurses to continuously

improve the quality and safety of

the healthcare systems in which

they work. Utilizing QSEN as a

guide, nurses are able to redesign

the content and context of how

they deliver nursing care to

ensure high-quality, safe care.7

The competencies, developed at

the prelicensure and graduate

level, have been integrated into

most nursing program curricula.

However, more effort is needed

to bridge these competencies to

practice settings.

What’s systems thinking?

Systems thinking isn’t new to

nursing. Most nursing theories

contain systems thinking “where

the whole is more than the sum of

the parts.”8 A person’s interaction

with his or her environment com-

prises a whole-person system,

which is healthy based on a bal-

ance of inputs, throughputs, and

outputs; nurses fits into the

schema at the whole-person level.9

The dynamic state of the whole-

person system can ultimately

influence global health. (See Figure 1.) An analogy of a pebble drop-

ping into a pool of water exempli-

fies how one nurse’s actions can

influence the greater whole.10

Nurses can use systems think-

ing to view how caregiving deci-

sions and actions have an overall

impact on organizational health

outcomes. Systems thinking is

a process of self-awareness in

which the nurse knows bound-

aries specific to clinical reason-

ing, personal effort, reliance

on authority, and awareness of

interdependencies.11 Nurses can

choose to mobilize change for

the good of the whole system,

based on experience and fore-

sight. Nurses who display strong

leadership behaviors can lead

changes in practice and adher-

ence to performance standards.12

Systems thinkers are those who

have an acute awareness of the

current system, an appreciation

for behind-the-scenes patterns

and structures, a willingness to

Figure 1: Concentric circles bridging the whole-person system to public and global health

Whole personwithin a system

Public domain

Regional healthtrends

National healthdata

World or globalhealth



challenge systems and boundaries

despite existing hierarchies, and

an understanding of how system

relationships are linked to system

improvements.12

Influence on practice

QSEN is on the brink of adopt-

ing a new systems-based practice

competency for which nurses

need to have basic knowledge

about the healthcare system to

create optimum health benefits

for patients/families, peers,

and organizations.13 Systems

thinking competencies reinforce

nurses’ roles in safety and qual-

ity improvement.13 At minimum,

nurses employing systems think-

ing and systems-based practice

should be able to understand

interrelationships among nurs-

ing, the nursing work unit, and

organizational goals. They’re

encouraged to solve problems

encountered at the point of care

and appreciate their roles in iden-

tifying work unit inefficiencies

and operational failures.14 Nurses

must be able to take action to

address potential or ongoing

quality and safety concerns. They

need to be active participants in

monitoring, admitting to, report-

ing, investigating, and resolving

near misses, errors, and systems

breakdowns involving com-

munication, supplies, medica-

tion, equipment, finances, and

technology.

Strategies to increase awareness

How can nurse leaders and edu-

cators empower clinical nurses to

understand the impact of their

actions on patient and organiza-

tional outcomes using QSEN com-

petencies and systems thinking?

More important, how can clinical

nurses envision the ripples or

waves they make across the

healthcare system as being influen-

tial in positive patient outcomes?

The following evidence-based

strategies envision an improved

practice reality and expand on

published ideas recommended for

nursing professional development

and leadership.15

Patient-centered careNurse leaders working at the unit

or system level can use a variety

of strategies to increase aware-

ness of QSEN competencies and

systems thinking among clinical

nurses. These strategies include

promoting relationship-based

care by providing caring, heal-

ing environments; removing bar-

riers that inhibit clinical nurses’

abilities to be healthy, alert, and

present with their patients; and

promoting inclusion of patient

involvement in health and treat-

ment plan discussions.16-18 Nurse

leaders can utilize managerial

expertise to allocate human,

financial, and clinical resources

based on unit needs and in align-

ment with the organization’s mis-

sion and vision.19,20 We need to

promote and sustain patient–

centered models of collaborative

practice, such as interdisciplinary

rounds, huddles, and/or primary

nursing models. These structures

provide nurses with complete

autonomy in managing patient

care and modifying practice to

accommodate patient needs.19

To influence patient-centered

care, nurse educators can encour-

age self-health principles, cham-

pion patient-centered models,

and instruct on ways to alleviate

pain and suffering during staff

education programs.21 Nurse edu-

cators can teach staff members

how to individualize patient care

plans and empower patients to

participate in treatment modali-

ties.22 Also, they can incorporate

QSEN competencies into orienta-

tion assessments and evaluation

tools.23,24

Teamwork and collaborationClosed-loop communication,

identified leadership (at the

senior and clinical level), and

trust among team members

have been identified as being

essential to effective teamwork.25

In today’s healthcare system,

patient care teams are challenged

by expectations of specialized

skill sets, value-based demands

on performance, and complex

environments with challenging

workloads. Such challenges may

impact team functioning and

relationships. Incivility among

team members in these situations

has also been documented.25

Nurse leaders can address these

challenges through role modeling

teamwork and collaboration, and

by fostering open communica-

tion, mutual respect, and shared

decision making.20 Our support

of teamwork building tools,

such as TeamSTEPPS or I-PASS,

may provide guidance to teams.

TeamSTEPPS is used to minimize

risks associated with handoffs

among providers and across the

care continuum, promote inter-

disciplinary communication of

safety concerns, and build collab-

orative relationships.26,27 I-PASS,

a refined mnemonic for illness

severity, patient summary, action

list, situation awareness and con-

tingency plans, and synthesis by

receiver, is used to standardize

handoffs and prevent errors.26

At the organizational level,

nurse leaders can establish col-

laborative relationships with




public health, academic partners,

and professional organizations.20

We can advance the establish-

ment of dedicated education

units, in which the partnership

between academic institutions

and healthcare organizations pro-

vides an enhanced learning and

clinical environment for nurs-

ing students.28 This model offers

educational support through a

preceptor model experience; stu-

dents can apply theory to practice

while being immersed in the clin-

ical environment and partnered

with RNs.29

To promote effective teamwork

and collaboration, nurse educa-

tors can support the need for

interprofessional immersion in

clinical education.30 Interprofes-

sional education is a growing

expectation of many professional

organizations.31,32 Educators

can design interprofessional

continuing-education programs

that incorporate tools, such as

TeamSTEPPS, with high-fidelity,

interdisciplinary clinical simu-

lations.26 They can promote an

interdisciplinary patient-centered

culture by using educational

programs to reinforce the role of

team members in delivering safe

and effective care.33 Educators

can also partner with leaders to

establish interprofessional dedi-

cated education units as part of

the inpatient infrastructure.34

EBPEBP is the current driving force

behind high-quality care deliv-

ery. Current evidence is inte-

grated with individualized

patient care needs and clinical

expertise to design practice.35

However, practice changes can

lead to change fatigue, and

nurse leaders and educators may

struggle with addressing this

side effect of EBP. Promoting

change from the bottom up helps

address change fatigue.35 Clinical

nurses do better with change

when they’re the ones initiating

it. Putting processes in place and

educating nurses on EBP will

facilitate their active participa-

tion in practice changes.

Nurse leaders can integrate

EBP by building an organiza-

tional culture that supports best

practice and provides opportuni-

ties to enhance clinical nurses’

EBP competencies.35 In that

process, nurse leaders share

unit goals and organizational

outcomes aimed at delivering

EBP.20 We can role model EBP by

fostering a healthy work environ-

ment and minimizing change

fatigue.36,37

To integrate EBP, nurse educa-

tors can infuse the Alliance for

Continuing Education in Health

Professions National Learning

Competency Area 1, which is the

“use of evidenced-based adult and

organizational learning principles

to improve employee perfor-

mance into continuing education

programming.”38 Nurse educators

can advocate for the adoption

of EBP throughout the nursing

unit and organization by educat-

ing nurses on EBP skills, such as

critical appraisal and translation

of research findings into prac-

tice.39,40 If nurse educators serve

as experts at the national level in

formulating practice guidelines,

they can incorporate best evi-

dence with clinical expertise and

patient/family preferences in the

delivery of optimum care.3,41

Quality improvementTo enhance quality improvement,

nurse leaders can employ error

prevention strategies by continu-

ally monitoring outcomes and

completing root cause analysis

when errors occur, including

clinical nurse input.42 During

rounding and/or in staff meet-

ings, nurse leaders can share

error prevention data to improve

patient outcomes and promote

an interprofessional approach to

quality improvement and system

processes.3,43

Nurse educators can use data

to evaluate and impact the effec-

tiveness of continuing-education

activities and programs. They

can educate nursing staff on

various quality/process improve-

ment models in the utilization of

outcomes data to improve care

delivery. Educators can provide

clinical nurses and students

with opportunities to share EBP

projects on the unit. They can

also share unit-based EBP and

quality improvement projects

in staff meetings and during

continuing-education programs,

and/or by creating meaningful

dashboards.44

SafetyNurse leaders can adopt high-

reliability goals, such as stan-

dardized processes; safety

checks; empowered decision

making (authority migration);

open, transparent communica-

tion; and collaborative, interpro-

fessional teamwork.45 We can

also address the potential for

errors by discouraging and put-

ting policies/processes in place

that minimize disruptions dur-

ing high-risk situations, such as

blood transfusions, surgical or

invasive procedures, needle use,

and medication administration/

reconciliation, and by advocat-

ing for the use of technologies



that monitor and control for

errors, such as two-identifier

systems for bar coding, I.V. med-

ication pumps, and wander

alarms.46-48 Nurse leaders can

implement 15-minute safety

(adverse event) huddles as a

way to reduce errors.49 If errors

occur, lead root cause analyses

using the “Five Why’s” strategy

to determine causes and mitigat-

ing factors.50 Leaders set the

stage for clinical excellence by

implementing a just culture

that’s intolerant of recklessness

but works to resolve system-

based errors in a collaborative,

nonpunitive manner.51,52 To pre-

vent practice errors, nurse lead-

ers can facilitate clinical nurses

in establishing personal goals

aimed at patient safety and

error mitigation.53

To promote safety, nurse edu-

cators can provide continuing-

education programs geared

toward educating clinical nurses

about high-risk potential for

errors.46,47 They can also pro-

vide onboarding and ongoing

education on safety measures

to ensure proper patient identi-

fication.48 At the organizational

level, they can offer expertise

during participation in root

cause analysis using a clinical

event investigation approach to

determine causes and mitigating

factors of errors.50 They can facili-

tate the implementation of inter-

professional education regarding

open disclosures, collaborative

review, and error and near-miss

management.54 Educators can

also help clinical nurses by pro-

moting self-reflection and peer

review of clinical practice.53,55

InformaticsNurse leaders can advocate for

the incorporation of evidence-

based technologies and informat-

ics. Enriched technologies may

include electronically accessible

clinical decision-making algo-

rithms, clinical practice guide-

lines, and access to web-based

resources.56 Nurse educators can

provide continuing education on

modern technologies that sustain

safe patient care and clinical

judgments.57 They can also

support the roll-out of these

technologies, serving as experts

or liaisons between technology

specialists and clinical staff.

Systems thinkingTo implement systems think-

ing, nurse leaders can promote

professional configurations, such

as interprofessional collabora-

tions, academic-clinical practice

partnerships, and shared gov-

ernance.34,58,59 We can champion

organizational structures of

empowerment in which nurses

have the opportunity, resources,

and information to provide

high-quality care; serve as a

liaison or be a voice between the

organization and clinical staff;

promote staff understanding of

local actions that impact organi-

zational goals; and demonstrate

how organizational goals drive

local actions, impacting system-

wide accountability for efficient,

safe, quality care.60-62 Lastly,

nurse leaders can advance sys-

tems thinking through infra-

structure redesign by integrating

QSEN concepts into orientation,

job descriptions, evaluations, or

promotion criteria.

Nurse educators can imple-

ment evidence-based interven-

tions that produce expected

results for nurses and the organi-

zation, such as incorporating

interprofessional education and

education on hospital-acquired

infection guidelines. They can

educate staff on how to approach

quality care delivery as the first

step toward positive patient and

organizational outcomes. Educa-

tors can emphasize the nurse’s

role in utilizing available organi-

zational resources and processes

to provide safe, efficient patient-

centered care. They can approach

Nurse leaders working at the unit or system level can use a variety of strategies to increase awareness of QSEN

competencies and systems thinking among clinical nurses.




the practice of continuing educa-

tion from a systems thinking

perspective, recognizing that

the healthcare team is part of a

complex system, and incorporate

individual, group, and gover-

nance leadership competencies

into onboarding and continuing-

education programs.38,63,64

A primary role

Providing high-quality, evidence-

based, patient-centered care is a

primary role of clinical nurses.

Both nurse leaders and educa-

tors serve as facilitators to clini-

cal nurses as they collaborate

to improve care. This article

provides a variety of evidence-

based strategies for all nurses,

at all levels, to consider when

using QSEN competencies and

systems thinking to improve

outcomes. NM

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Ann M. Stalter is an associate professor at the Wright State University College of Nurs-ing and Health in Dayton, Ohio. Altagracia Mota is a manager for clinical learning at Montefiore Medical Center, Montefiore Learning Network in Bronx, N.Y.

The authors have disclosed no financial relationships related to this article.

DOI-10.1097/01.NUMA.0000529925.66375.d0


using systems thinking in healthcare aand …...using systems thinking 36 february 2018 † nursing...

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