ISSUE 3, 2023
Volume 97, Number 3
EDITOR IN CHIEF: Serena Bumpus, DNP, RN, NEA-BC MANAGING EDITOR: Lisa Maxwell
COPY EDITORS: Gabi Nintunze, Natalie Hill
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BOARD OF DIRECTORS
OFFICERS:
Joyce Batcheller DNP, RN, NEA-BC, FAONL, FAAN, President jbatcheller7@yahoo.com
Amy McCarthy, DNP, RNC-MNN, NE-BC, President-elect amccarthyrn@gmail.com
Gloria Lorea, DNP, RN, NEA-BC, Treasurer glorialoeradnp@gmail.com
Missam Merchant, MBA, BSN, RN, CENP, CCRN-K, PCCN, CV-BC, GERO-BC, MEDSURG-BC, NE-BC, Secretary sam.merchant2017@gmail.com
DIRECTORS:
Jose Alejandro, PhD, RN, NEA-BC, MBA, CNE, FACHE, FAAN - Dallas josealexrn@gmail.com
Patricia “Pat” Francis-Johnson DNP, RN, CDP – Lubbock patricia.francis@ttuhsc.edu
Edtrina Moss, PhD, RN-BC edtrina@comcast.net
Brandon “Kit” Bredimus, DNP, RN, CEN, CPEN, CNML, NE-BC, CENP, NEA-BC kit.bredimus@midlandhealth.org
Mary Vitullo, MBA, MSN, RN-BC, PCCN, NE-BC, CLSBB vitullo.mary@yahoo.com
CHIEF EXECUTIVE OFFICER: Serena Bumpus, DNP, RN, NEA-BC sbumpus@texasnurses.org
Dist. 1: Jackeline Biddle Richard, DNP, JD, RN, CNE, jackie.richard1@icloud.com
Dist. 3: Christopher Rougeux, MSN, RN, crougeux99@gmail.com; District office: Jamie R. Rivera, JamieRivera@texashealth.org
Dist. 4: Alaina Tellson, PhD, RN, CLNC, NPD-BC, NE-BC alaina@tellson.net; tnad4.nursingnetwork.com; District Secretary Lori Batchelor, batchelorb@prodigy.net
Dist. 5: Chelsea Vaughan, RN, chelseareneevaughan@gmail.com, tna5.org
Dist. 7: Connie Barker, APRN. PhD. FNP-C, crbarker1@yahoo.com, tnadistrict7@gmail.com
Dist. 8: Nelson Tuazon, DNP, DBA, RN, NEA-BC, FNAP, FACHE, FAAN, nelsonactuazon@gmail.com
Dist. 9: Marco Ollervides, MSN, RN, marco.ollervides@memorialhermann.org District office: Melanie Truong, RN, Executive Secretary, tna9@tnadistrict9.com, tnadistrict9.com
Dist. 17: Mari Cuellar, NEA-BC, MSN, RN, mari.cuellar@christushealth.org
Dist. 18: Rebecca Clark, DNP, RN, CNE, MEDSURG-BC, rebecca.clark@ttuhsc.edu
Dist. 19: Dixie R. Rose, RN, dixiegtc@gmail.com
Dist. 35: Karen Koerber-Timmons, PhD, RN, CLNC, CNE, NEA-BC, CCRN, RN-BC mkkoerbertimmons@gmail.com
At-Large: Contact TNA, 800-862-2022, ext. 129, brichey@texasnurses.org
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WHAT WOULD IT TAKE for all patient care settings to achieve the goal of zero preventable deaths and injuries? What would we need to change in academia to support this direction? How do we create healthy work environments and systems to support this overarching goal? What can we do to invigorate and integrate the principles of a just culture?
According to the World Health Organization, the risk of being harmed while receiving healthcare is one in 300, whereas the risk of being harmed during air travel is one in one million. Patient harm is the fourteenth leading cause of global morbidity and mortality. One in 10 patients is harmed in the US while receiving care in a hospital, and 50 percent of the adverse events that cause this harm are preventable. (World Health Organization, 2022)
Several factors that contribute to staffing challenges in all practice settings have been exacerbated by the COVID-19 pandemic. Examples include nurse turnover, time to fill positions and a greater gap between the experience level of nurses and the acuity of the patients.
As a result, many organizations see an increase in errors and believe medical errors are still underreported. The criminalization of medical errors and the resultant impact on transparency and reporting of errors is a major concern. This concern has been heightened since RaDonda Vaught, a Tennessee nurse, was charged with reckless homicide after administering a paralytic medication instead of a prescribed sedative.
In March 2022, she was found guilty of negligent homicide and gross neglect of an impaired adult. While cases like this are not frequent, the Tennessee case is not an isolated event in the U.S. Many nurses may have been personally impacted in untoward ways because of this case. They may feel vulnerable because they are working in overly complex systems with an increased acuity of patients and continue to have staffing shortages, experience moral distress or injury, and are dealing with more violence in the workplace. Nurses across the country supported the Tennessee nurse as they personalized the experience and worried if they could find themselves in a comparable situation. What would your organization do if you committed a similar error? Do you work in an environment that supports a just culture?
A just culture is focused on openness, transparency and learning from adverse events rather than assigning blame. Most medical errors are the result of faulty systems such as technological, environmental, cultural, and workflow difficulties. To provide care, staff frequently create workarounds to address the challenges and increase efficiency. For example, overriding a medication dispensing cabinet warning may be a direct consequence of defective systems, rather than an act of willfully reckless clinicians. In the RaDonda Vaught case, the nurse performed several overrides that included drug warnings. We might think this was wrong until we learn nurses reported they do this same kind of practice every day.
In a just culture, the organization supports learning from mistakes to encour-
continued on page 6
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age error disclosure and reporting of adverse events. An organization may see an increase in reporting of near misses/ good catches and adverse events when they start on this journey. The increased reporting is a positive sign that staff feel safe reporting errors and should be embraced. Rather than feeling threatened, we should feel grateful.
Inclusion of the clinician(s) involved in the error, and the patient and family sharing their perspectives can add to the learnings post event. Clinicians who participate in these discussions and help develop action plans have expressed this process helped them heal. The goal of all of this is to help prevent the error from happening again.
Recognize that investments are needed beyond education and training. Just culture principles are relevant in all settings-academia, ambulatory settings, patient homes, and hospitals. Start with self-reflection on how much you understand what a just culture is and what you could do to influence these principles wherever you practice.
For example, how can you be involved in your organization’s commitment to patient safety? Have you committed to supporting key safety practices related to hand off communication, huddles, purposeful rounding, constructive feedback, and celebration of near misses/ good catches?
Other ideas include engaging the team in post- event learning, root cause analysis or simulated patient safety error scenario planning to enhance everyone’s understanding of a Just Culture. Proactively identify and discuss system issues that need to be addressed to prevent serious errors. Openly discuss an error to demonstrate that transparency is valued. Support colleagues who may make a serious mistake resulting in harm to a patient. Be willing to speak up or “stop the line” if you see someone who is about to make a mistake. Be involved in your organization’s staffing committee. Help to determine how staffing and patient errors may be correlated and what strategies may be needed to avoid such errors. Be knowledgeable about how nursing peer review works in Texas and be willing to serve if needed. The Texas nursing peer review process was designed to support a just culture in our healthcare organizations.
These are just a few ideas, and you are welcome to use them and share them with others. I am including resources and encourage each of you to develop your own plan and join me in supporting just cultures in all practice settings. i
SOURCES
Global Patient Safety Action Plan 2021-2030 (August 2021)
www.who.int/teams/integrated-health-services/ patient-safety/policy/global-patient-safety-action-plan www.nursingworld.org/~4afe07/globalassets/ practiceandpolicy/health-and-safety/just_culture.pdf
To Err Is Human, Just Culture, Practice, and Liability in the Face of Nursing Error. Lancaster, Rachelle J. et al. Nurse Leader, Volume 20, Issue 5, 517 - 521
The Texas Prescription Monitoring Program (PMP) is an essential tool for reducing prescription drug misuse and overdose. Checking the PMP for every patient, every time, can limit the risks associated with patients receiving prescriptions from multiple providers and prevent deadly drug interactions.
As of March 1, 2020, prescribers and pharmacists are required to check a patient’s Schedule II–V controlled substance history in the PMP before prescribing or dispensing opioids, benzodiazepines, barbiturates, or carisoprodol, with limited exceptions. This mandate was adopted by the 85th Texas Legislature with House Bill 2561.
The Texas State Board of Pharmacy recently determined some integrated EHR systems only show a patient’s NarxCare™ score when a patient’s record is accessed, rather than the full report.
Viewing a patient’s score alone does not comply with the state mandated lookup requirement. Providers must manually initiate a report request by clicking “View/Show Report” to access the patient’s full controlled substance history to comply with the law.
Additional information on the PMP policy is available at the following website: pharmacy.texas.gov/news/ pmp-integration-compliance.asp.
For further support, please visit txpmp.org/training to complete the no-cost continuing education course titled “Complying with the Statewide Mandate and Using the PMP to Provide PatientCentered Care.” This expert-led course is eligible for continuing medical education and Ethics credits and is available at any time.
Sign on before your sign off.
For more information and resources, visit txpmp.org. Sign on before you sign off.
KUDOS
2023 AANP State Award for Excellence
Nurse Practitioner: Dr. Robin Hardwicke
Advocate: Ilaria Reyes
• David Wyatt, PhD, RN, NEA-BC, CNOR
– UT Southwestern Medical Center
The following organizations received ANCC’s Magnet redesignation:
• Baylor Scott & White Medical Center-Hillcrest, Waco, Texas
• Houston Methodist West Hospital , Houston, Texas
Marlene Porter, PhD, RN, NPD-BC, CEN, CCRN-K, has been named the new Nurse Scientist for Baylor Scott & White Health, Temple Region.
Kristin Benton , DNP, RN was named Executive Director of the Texas Board of Nursing.
American Academy of Nursing announces the 2023 Class of New Fellows:
• Sherry Adkins , MSN, RN, ANP-C, CNS – The University of Texas MD Anderson Cancer Center
• Emily Barr, PhD, CPNP-PC, CNM, RN –UTHealth Houston Cizik School of Nursing
• Allison Edwards , DrPH, MS, RN, CNE –UTHealth Houston Cizik School of Nursing
• Bradley Goettl , DNP, APRN, AGACNPBC, FNP-C, ENP-C, CEN, CPEN, CFRN, EMT-P – UT Southwestern Medical Center
• Megan Lippe, PhD, RN – UT Health San Antonio School of Nursing
• Robin Page, PhD, APRN, CNM, FACNM
– Texas A&M University
• Jessica Shank Coviello, DNP, APRNANP-BC – UTHealth Houston Cizik School of Nursing
• Becky Spencer, PhD, APRN, PMHNP-BC, IBCLC, FILCA – Texas Woman’s University
• Cindy Weston , DNP, APRN, CNS-CC, FNP-BC, CHSE – Texas A&M University College of Nursing
Congratulations to the following hospitals for receiving the prestigious Pathway to Excellence designation:
• Texas Health Harris Methodist Hospital Alliance in Fort Worth, Texas
• Redesignation: Midland Memorial Hospita l in Midland, Texas
Dina Perez-Graham , MSN, RN has been named senior vice president, chief nurse executive of University Health.
Sharon Wright, DNP, APRN, FNP-C, has been elected to Boerne City Council District 2.
Sherry Camacho has been named the new Chief Nursing Officer of Methodist Hospital in San Antonio.
TNA District 1 president, Jackeline Biddle Richard , DNP, JD, RN, CNE, Society of Latinx Nurses – has been appointed to the National Commission to Address Racism in Nursing.
Dr. Brenda L. Cleary passed away at the age of 71 on Monday, June 5, 2023 in Cary, NC. i
Laura Kincheloe, Ed.D., MSN, RN, NE-BC, has joined TNA staff as the new Director of Nursing Practice.
Texas Board of Nursing
Texas Health Steps Advisory Committee
DSHS Preparedness Coordinating Council
C/SNA Nurse Staffing Advisory Group
Texas Public Health Coalition
National Forum Conference
ANA Membership Assembly
Texas Society of Association Executives
Workplace Violence Against Nurses Taskforce
2023 DSHS Public Health Nursing Conference
AMSN Legislative Committee
CFA Quarterly Action Coalition
State Nurses Associations & Environmental Health
UT Houston Policy Class
Nursing Associations Committee
CLAIR BETH JORDAN, MSN, RN served as Executive Director of the Texas Nurses Association (TNA) and Texas Nurses Foundation (TNF) from 1978 until 2012. In that role, TNA accomplished significant, and in some cases first-in-the-nation, legislation, such as establishing the right to safe harbor and creating the Texas Peer Assistance Program (TPAPN) for nurses. During that time, TNA created the Texas Nurse Friendly program, which was then transferred to ANCC and became the Pathway to Excellence program. There are many similar examples; Clair’s positive impact on nurses nationwide cannot be overstated. (See Texas Nursing Issue 4 of 2022 for more on Clair.)
After her death in 2022, to both honor Clair’s legacy and to ensure her groundbreaking work could continue, a group of former TNA leaders proposed establishing an endowment fund to be used by TNF to make this possible. A fundraising campaign was launched in the spring of 2023 with the first milestone goal of raising $100,000 by January 31, 2024. As of July 2023, more than $75,000 has been raised. This money may be used for supporting nursing and health care researchers, sponsoring think tanks or similar activities.
We invite you to become part of this legacy through donation. Your dollars will go directly to programs that improve the lives and work of Texas nurses.
Proceeds from charitable gifts are administered by TNF to support activities that promote health care by enhanc -
ing the art and science of nursing. The Texas Nurses Foundation funds a variety of activities including grants for nurses, Texas Team, nursing-related research and the largest TNF program, the Texas Peer Assistance Program for Nurses (TPAPN). Gifts to the Texas Nurses Foundation, a 501(c)(3) organization, are fully tax deductible as allowed by law. i
HELP US REACH OUR GOAL
Use the QR code below to donate.
The virtual summit will take place from 1 to 3 p.m. CT.
Encourage your students to attend this informative afternoon designed to engage students in discussions about healthcare policies and their impact.
November 10, 2023 Read
Connect with fellow students, professionals, elected officials, and advocates as we explore key policy issues shaping the nursing landscape. Enhance your advocacy skills and gain insights into the future of nursing.
Together, let's amplify our voices, drive policy reforms, and create a brighter and healthier future for all!
A JUST CULTURE, as defined by David Marx, is a system of shared accountability in which organizations are responsible for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner. A High Reliability Organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. In healthcare, we strive to become highly reliable and to avoid catastrophic outcomes in our complex care environments. On that journey to high reliability, having a just culture is an essential component. Without a just culture, an organization will never succeed in becoming highly reliable.
In healthcare, ‘preoccupation with failure’ requires all levels of an organization, both clinical and non-clinical team members, to have a questioning attitude and to feel empowered to speak up when safety is at stake.
To gain a deeper understanding of the essentialness of a just culture in HROs, one needs to look no further than the first principle of high reliability: preoccupation with failure. In healthcare, ‘preoccupation with failure’ requires all levels of an organization, both clinical and non-clinical team members, to have a questioning attitude and to feel empowered to speak up when safety is at stake. When I mention safety, I am not only referring to the safety of our patients. This also applies to the safety
of the members of the healthcare team. Failures impact everyone.
Having a questioning attitude means that healthcare team members are mindful of the hazards of their environ -
ment and are hypervigilant in seeking out failures. We are all experts in our work environment, regardless of which environment that may be. Things that are out of the ordinary should not be
Having a just culture provides the psychological safety that members of the healthcare team need to have confidence in a questioning attitude. Psychological safety also provides the empowerment to speak up when safety is at stake.
ered to speak up. A system’s weakness or failure point can only be improved if it is identified and appropriately acted upon. As a patient safety specialist, I’m often asked what makes me lose sleep at night. I lose sleep over all the potential failures that have yet to be called out or those that have become normalized, especially since either could have the potential for a catastrophic outcome. Knowing that a preoccupation with failure requires a questioning attitude and empowerment to speak up, let’s return to the component I deemed essential: a just culture. Having a just culture provides the psychological safety that members of the healthcare team need to have confidence in a questioning attitude. Psychological safety also provides the empowerment to speak up when safety is at stake. It is the psychological safety provided by a just culture that enables the preoccupation with failure.
Where does healthcare often get stuck? Just culture. Having a focus on individual accountability is easy, but shifting focus to organizational-level systems is really hard. We must embed a just culture in our organizations if we seek to become highly reliable. Responding in a fair and just manner is what enables psychological safety. Psychological safety allows team members to open up and share with complete transparency all of the potential and real failures of their work environment.
We are all human, and there is likely not one healthcare team member out there that hasn’t made an inadvertent human error. Our system’s processes, procedures, training, and environment all influence
our behavioral choices. We should console and support team members that make inadvertent mistakes and address them at the system-level failure point. We are also all capable of at-risk behavior. If you’ve taken a shortcut or workaround, perhaps to gain perceived efficiency, that behavior has increased the risk of error. A just culture takes a shared accountability approach for atrisk behavior. An individual is coached to change the perception of risk or change the consequences of said risk. The organization’s accountability must extend past individual coaching. The organization must also engage the individual in problem-solving, removing barriers to compliance, and examining the system for opportunities for improvement. Examples of system-level improvements are increasing situational awareness, addressing issues that have led to workarounds, improving communication techniques, and eliminating barriers to smooth process flow.
Healthcare team members vow to heal and not harm. Reckless behavior, a conscious disregard of a substantial and unjustifiable risk with a willful disregard for safety procedures, is rarely the cause of error in healthcare. In these rare instances, disciplinary action is required for remediation. An organization must also be accountable for any re-education that may be needed in addition to the disciplinary action itself.
overlooked. Instead, there should be a continual evaluation of the atypical as a potential or real safety issue.
When a near-miss, or a safety issue is found, team members must feel empow-
A just culture takes a shared accountability approach for at-risk behavior. An individual is coached to change the perception of risk or change the consequences of said risk... The organization must also engage the individual in problem-solving, removing barriers to compliance, and examining the system for opportunities for improvement.
Dr. Todd Conklin says it best: “You can learn and improve, or you can blame and punish, but you can’t do both.” So if we can’t do both, we must embed a just culture in our organizations. Our patients deserve no less than highly reliable care and we as nurses deserve no less than to practice in a highly reliable work environment. i
Conklin, T. (2019). The 5 principles of human performance: A contemporary update of the building blocks of human performance for the new view of safety. Santa Fe, NM: Pre-Accident Investigation Media. Leonard M.W., Frankel A. The path to safe and reliable healthcare. Patient Educ Couns . 2010 Sep;80(3):288–292. Epub 2010 Aug 4
Perrow, C. (1984), Normal Accidents: Living With High Risk Technologies , Basic Books, New York . Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University.
Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in the age of uncertainty (2nd ed.). Jossey-Bass.
ON NOVEMBER 29, 1999, the Institute of Medicine (IOM) released a report called To Err is Human: Building a Safer Health System. This landmark report highlighted the issue of patient safety and put it high on the nation’s health care agenda. The report revealed that as many as 98,000 patients died from preventable medical errors in U.S. hospitals each year (IOM, 2000). Today, almost 24 years later, healthcare organizations continue to struggle with preventable errors in their systems. There is still a “blame and shame” culture in many organizations and practitioners fear the consequences of mistakes. As a result, there is a lack of adequate reporting making it difficult for organizations to correct behavioral and systemic issues that may be involved. To make matters worse, there have now been highly publicized cases of healthcare personnel facing criminal charges when a mistake results in a serious patient outcome.
Harris Health System, located in Harris County, Houston, Texas, is the nation’s fourth largest public healthcare system and serves as the county’s safety net organization. They established a major tenet of a culture of safety—just culture—to be used throughout their organization. As an alternative to the traditional ‘blame and shame’ system in healthcare that punishes people for making mistakes, the just culture model creates an environment that encourages individuals to report mistakes. Why? So that the reasons underlying errors can be better understood and prevented in the future.
By Maureen Padilla, DNP, RN, NEA-BCThere is still a “blame and shame” culture in many organizations and practitioners fear the consequences of mistakes. As a result, there is a lack of adequate reporting making it difficult for organizations to correct behavioral and systemic issues that may be involved.
Between 2009 and 2014, the nursing department at Harris Health launched a plan for implementation of a just culture. There was communication sent out to staff explaining the tenets of a just culture and why it was important. Unfortunately, the plan was not embraced by senior leaders of the organization and stalled as an organizational goal. However, nursing leaders moved forward with integrating a just culture framework into their Nursing Peer Review process, modifying a model developed by the North Carolina Board of Nursing.
In 2015, with a new Chief Medical Officer (CMO) and Chief Nurse Executive (CNE) in place, the organization began searching for strategies to improve the safety culture, move towards zero harm, and become a High Reliability Organization (HRO). The CNE shared the nursing peer review process with the CMO as well as other articles describing a just culture.
The CMO proposed three quality focus areas for the next fiscal year: strengthening the time-out process, strengthening the patient identification process, and establishing a just culture. The CNE was asked to co-chair a steering committee for just culture with a physician leader.
The steering committee was established with representatives from departments of nursing, human resources, quality, risk management, physicians, corporate compliance and communications. The group realized that they needed to be educated on the principles of just culture before trying to implement a program across the organization. After some research, the committee settled on utilizing the training and framework set forth by Outcome Engenuity, LLC, established by David Marx, CEO. The CNE and Director of Employee Relations attended a threeday training course presented by Outcome Engenuity. This training was then modified and shared with the steering committee members. Once these members had received the training, the committee utilized a tool developed by the Minnesota Alliance for Patient Safety (MAPS), to set forth the phases and timing of implementing a just culture within our organization. A charter was written to outline the committee membership, goals and objectives, outcome measures, and a transition plan for sustainability once the committee work was complete. The charter and plan were presented to the executive team and the Board of Trustees for approval. After some concerns that a just culture presents a “free pass” to many, the word accountable was added and our program, Just and Accountable Culture, was established.
The challenge of educating 9000+ staff members was resolved by the following:
Steering committee members presented an overview of the program at all hospital and clinic staff meetings and townhalls.
A website was developed for the program where staff could find more information and articles.
A mascot (JAC), selected by the steering committee was created as a life size poster, and was placed in different parts of the organization. Employees were encouraged to take selfies with the mascot and send them in to the Just and Accountable website.
We gained support and buy-in from our physician partners through the following:
Physician representatives from each hospital and our ambulatory care facilities were part of the steering committee membership.
The program was shared in Grand Round meetings
In the interest of longevity, leaders were trained throughout the organization in all departments, with training established for both hospitals and clinics, and facilitated by the CNE and Director of Human Resources.
Continuing education for new employees and leaders was ensured through leadership training for all new leader orientation. A video for new employee orientation was developed which outlined the organization’s commitment to establishing a just culture. It shared the concepts of a just culture and the part the employee has in making appropriate behavioral choices at work.
The organizational disciplinary policy was updated to include utilizing the just culture algorithm and framework.
The organization had a minor stall in fully integrating the just and accountable program during the COVID-19 pandemic. However, we are back on track. The HR department has worked endlessly to improve the new employee and leader training programs. They adjusted policies and disciplinary documents to include the just culture philosophy. All employees and staff are trained on just culture and review our organizational commitment video annually.
Our risk department utilizes the just culture framework in all root cause analyses. There are no “automatic” punishments for errors, but rather a process to determine if there is a systemic problem to correct or a human behavior to coach to better performance. The goal is to uncover the source of an error and determine how to improve the process to decrease the likelihood of another error. i
Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press.
After some concerns that a just culture presents a “free pass” to many, the word accountable was added and our program, Just and Accountable Culture, was established.
In an attempt to increase nurse accountability, the Texas Board of Nursing (TBON) created the requirement for a peer review committee in organizations with eight or more nurses along with a process for addressing nursing practice breakdowns. The peer review committee empowers healthcare organizations to address systems issues and remediate a nurse’s practice for minor errors.
MEDICAL ERRORS have been a cause for concern in healthcare organizations for years. In 1999 it was estimated that one million people were injured and 120,000 deaths occurred due to medical errors in the United States alone. Shortly after this discovery, the Institute of Medicine (IOM) called upon healthcare organizations to recognize systemic problems and how they contribute to errors. Organizations were encouraged to look at events more comprehensively to identify the true cause of an error and take appropriate corrective action.1 In 2018, medical errors were considered the third leading cause of death, with 250,000 deaths per year resulting from these errors.2
They continue to be cited as one of the leading causes of death in the U.S.
Because nurses encompass the greatest number of practitioners, nurses are often blamed for mistakes made in the workplace. In an attempt to increase nurse accountability, the Texas Board of Nursing (BON) created the requirement for a peer review committee in organizations with eight or more nurses along with a process for addressing nursing practice breakdowns. The peer review committee empowers healthcare organizations to address systems issues and remediate a nurse’s practice for minor errors.
In 1987, Texas became the first state to pass Nursing Peer Review (NPR)
requirements and the minor incident rule.3,4 These requirements called for organizations that employ eight or more nurses to establish a peer review committee to evaluate a nurse’s practice and determine if a nurse’s conduct is subject to reporting to the Board of Nursing (BON). The BON does not have the authority to regulate healthcare organizations, nor does it determine how organizations should operationalize these requirements. Texas continues to be the only state with NPR and a minor incident rule.
A minor incident occurs when a nurse may be in violation of the Nurse Practice Act (NPA) or Board rule, but that violation does not mean the nurse poses a continued practice risk to the public. 4 Not all minor incidents should be reported to the BON. Organizations should have the mechanisms in place to identify errors and take the necessary actions to fix the error or remediate the nurse’s practice patterns. The BON encourages minor incidents to be reported through the NPR Committee (NPRC) unless another requirement is specified in the NPA.
Two types of Nursing Peer Review exist: Incident Based Nursing Peer Review (IBNPR) and Safe Harbor Nursing Peer Review (SHNPR). IBNPR is the evaluation of nursing services, the qualifications of a nurse, the quality of patient care rendered by nurses, the merits of a
complaint concerning a nurse or nursing care, and determination or recommendation regarding a complaint.3 The role of an NPRC committee is to look at the nurse’s conduct in either a single event or multiple events , such as five minor incidents within the same rolling calendar year or a pattern of behaviors. The committee can then review the nursing practice of a Licensed Vocational Nurse (LVN), Registered Nurse (RN), or Advanced Practice Registered Nurse (APRN). The NPRC is responsible for reviewing external factors beyond the nurse’s control that may have contributed to the practice breakdown. They then determine if the nurse’s conduct requires reporting to the Board or if it can be remediated within the nurse’s employment setting.
Both the Texas BON and nurse leaders have a responsibility to protect the public through enforcement of the Nurse Practice Act. Nurse leaders are obligated to understand the complexities of regulatory requirements, particularly in tracking and reporting minor incidents and nursing practice breakdowns. Nurse leaders also have a responsibility to ensure that the process supports the reporting of errors without fear.
Traditionally, an organization’s response to practice errors, especially those resulting in harm, are blame, shame, discipline, and punishment.6 Errors that do not cause harm are usually ignored or dismissed with very little intervention. However, errors that result in injury or death are known to have severe consequences.6 When nurses receive disciplinary action for unintended errors, they are less likely to report their actions or the actions of their peers.7
Disciplinary action should be tied to the behavioral choices of the individual and potential risk their choices present instead of focusing on the actual outcome of the error.8 This approach moves from a punitive approach to one of learning how to prevent the error from occurring again.9 Organizations that foster a just approach aim to increase the accountability of appropriate reporting of nursing practice breakdowns as well as to provide clarity around the differences between human error, at-risk
behavior, and reckless behavior.10 They focus more on individual behavioral choices rather than error occurrences or negative outcomes.8 This approach encourages individuals to discuss and report errors without fear of disciplinary action.
The intent behind the Texas minor incident rule and NPR requirements is to support a just culture in healthcare organizations. Many healthcare organizations in multiple states with statewide patient safety initiatives have introduced just culture to increase error reporting, identify system issues, and hold organizations accountable to the expectations in order to provide support to the nursing staff and improve patient safety across the continuum of care.
Texas does not have a statewide patient safety initiative and the BON does not regulate how organizations operationalize the way they review and track minor incidents or conduct NPR. Therefore, no consistency can be found in the process statewide.
Texas regulations require organizations to have structures in place to monitor a nurse’s practice breakdowns and the ability to review them in an NPRC. How-
ever, accountability and adherence of organizations to these expectations are unknown. A just culture was designed to process information in a way that doesn’t target one person as the blamed but to look more comprehensively into the problem that caused the practice breakdown to occur. A just culture recognizes the behavioral choices of an individual and the potential risk those choices present rather than the actual outcome of their actions.10
In light of the current staffing crisis, it is critical that nurse leaders are fostering and supporting a just culture in their organizations. High quality care is top of mind for nurses, and many are scared to make a mistake for fear of losing their job or worse, their license. Our health systems are fraught with challenges that cause errors to occur daily. The question is, do our organizations foster a just culture and do they use the peer review process in a way that fosters a just culture?
TNA offers monthly workshops to help healthcare organizations put a strong and supportive nursing peer review program and process in place. TNA will also
customize workshops for your organization. Please check our website for the next monthly workshop or feel free to reach out and inquire further about a workshop specific to your organization. Now, more than ever it is critically important to foster a culture that encourages nurses to speak up for safety and when errors occur. The preoccupation with failure and fixing system issues is the very premise on which nursing peer review was designed. Nurses are often not the ones to blame but the system is. i
1 Tocco, S, & Blum, A, (2013). Just culture promotess a partnersship for patient safety. America Nurse Today, 8(5), 16-17.
2 AHRQ, (2016). High Reliability. Retrieved from Patient Safety Network: https://psnet.ahrq.gov/primers/ primer/31/high-reliability
3 Texas Register, (2009). Texas Administrative Code Rule 217.19 Incident-based nursing peer review and whistleblower protections . Retrieved from Texas Register: https://texreg.sos.state.tx.us/ public/readtac$ext.TacPage?sl=R&app=9&p_ dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_ tac=&ti=22&pt=11&ch=217&rl=19
4 Texas Register, (2009). Texas Administrative Code Rule 217.17 Minor Incidents . Retrieved from Texas Register: https://texreg.sos.state.tx.us/ public/readtac$ext.TacPage?sl=R&app=9&p_ dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_ tac=&ti=22&pt=11&ch=217&rl=16
5 Meyer, M, (2010). Nursing Law and Order. Retrieved from Why don’t all states have peer review for nurses?: http://advocatefornurses.typepad.com/ my2cents/2010/09/why-dont-all-states-have-peerreview-for-nurses-like-the-great-state-of-texas.html
6 Burhans, L D, Chastain, K, & George, J L, (2012). Just culture and nursing regulation: Learning to improve patient safety. Journal of Nursing Regulation , 2(4), 43-49.
7 Martin, B, Reneau, K, & Jarosz, L, (2018). Patient safety culture and barriers to adverse event reporting: A national survey of nurse executives. Journal of Nursing Regulation , 9(2), 9-17.
8 North Carolina State Board of Nursing, (2012). Just culture in nursing regulation . Retrieved from North Carolina State Board of Nursing: https://www.ncbon. com/vdownloads/cet/cet-booklet.pdf
9 Penn, C E, (2014). Integrating just culture into nursing student error policy. Journal of Nursing Education 53(9), S107-S111.
10 Marx, D, (2007). Patient safety and the “Just Culture”. Retrieved from http://www.wapatientsafety. org/downloads/0610-D-Marx.pdf
Order
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If you, a coworker, or a family member need help with a substance use or mental health issue, call the Texas Peer Assistance Program for Nurses. TPAPN case managers provide guidance, support, and monitoring to help nurses recover and maintain their licenses. And TPAPN peer advocates provide an empathetic listening ear. You and those you care about are not alone!
www.tpapn.org
THE AMERICAN NURSES ASSOCIATION defines just culture as a “…process where mistakes or errors do not result in automatic punishment, but rather a process to uncover the source of the error….and that the culture of the workplace is one that encourages quality and safety over immediate punishment and blame” (American Nurses Association, 2010).
In healthcare, just culture is a hot topic. But what does this truly mean, and what resources are out there for healthcare systems and nurses to utilize to help ensure that the workplace is participating in the just culture concept?
At the Texas Peer Assistance Program for Nurses (TPAPN), we have a motto that stems from a just philosophy: “Helping Nurses, Safeguarding Patients.” Both concepts are key in creating a system that looks at continuous improvements from a more holistic approach, rather than a one-sided viewpoint. We are just one of such programs across the nation that are considered an alternative to discipline.
As nurses, we know that patient safety is a priority. Yet nurses are regularly faced with challenging situations that can create moral distress or ethical dilemmas. These situations can, over time, lead to an increase in work-related errors due to compounding pressures felt by the nurse.
TPAPN strives to help support nurses in creating a balance between accountability, self-care, wellness and safe practice. At TPAPN, we recognize the importance of the healthcare system advocating for safer practices to help prevent patient safety
issues. We also recognize the concerns related to higher risk for mental health and substance use issues among staff. TPAPN can provide not just an alternative to discipline, but support before errors occur when nurses experience mental health crises or substance use disorders.
The concept, communication, and advocacy of being ‘just’ must begin upon new hire orientation and be so engrained in the system culture that nurses know where to turn when concerns or problems arise and feel confident and safe in doing so. Many programs and tools are available for implementation within your facilities, in the interest of taking a more collaborative approach to help promote these ideals. Some possible actions include:
Actively utilizing and promoting employee assistance programs.
Instituting well-being programs that help promote balance, health and prevent burn out.
Establishing peer review committees.
Collaborating with Alternative to Discipline Programs like TPAPN. Encouraging reporting of events or errors with open-door policies.
Improve education and training programs.
Make use of hospital-based Peer Support Programs.
Address concerns at the system-level with Process Improvement Committees that have direct care nurses present at the table.
Ensuring leadership support with these and other nurse support programs.
Nurses can and must advocate for improvements to systems and structures within healthcare facilities. The concept of a just culture is important for the nurses that are in the workforce today and those that will be in the future. To continue to have a sustainable work force, nurses must feel valued, heard, and empowered to take on the role of increasing patient safety through decreasing errors. Errors arise for a variety of reasons. By creating a safe reporting environment, we can all work together to increase improved outcomes for our patients and simultaneously increase the well-being of our nursing workforce.
If you or any nurse you know is suffering from mental health concerns or a substance use disorder, please feel free to contact us at http://tpapn.org. We are here to support Texas nurses and help decrease stigma associated with substance use and mental healthWe are here to help support Texas Nurses. i
American Nurses Association (2010). Just Culture [Position Statement]. chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nursingworld. org/~4afe07/ globalassets/practiceandpolicy/health-and-safety/just_culture.pdf
The concept, communication, and advocacy of being ‘just’ must begin upon new hire orientation and be so engrained in the system culture that nurses know where to turn when concerns or problems arise and feel confident and safe in doing so.
To continue to have a sustainable work force, nurses must feel valued, heard, and empowered to take on the role of increasing patient safety through decreasing errors.
By Jack Frazee, J.D., TNA Director of Governmental Affairs
THE 88TH REGULAR SESSION of the Texas Legislature was historic for nursing policy. After years of battling the COVID-19 pandemic, nurses explained to their representatives and senators that Texas faced a crisis in staffing and workplace violence, Supported by data showing a statewide shortage of more than 30,000 nurses and intolerable rates of physical and verbal abuse against nurses throughout the state.
Fortunately, nurses found a receptive audience in their elected officials and in response to these significant challenges, the Texas Legislature passed the largest investment in nursing education in state history (HB 1 and SB 25) and a comprehensive framework for addressing workplace violence (SB 240) along with an increased felony penalty for assaulting nurses on hospital property (SB 840).
These investments and policy changes will provide nurses with relief from the state’s staffing crisis and workplace violence, but passing the bills is only the first step.
As a result of HB 1 and SB 25, we will see the Texas Higher Education Coordinating Board offer nursing students $25M in scholarships, provide nursing faculty $7M in loan repayment, award $6M in nursing innovation grants, and invest $46.8M to increase nursing schools’ capacity to graduate students throughout the state. TNA will provide information about these funding programs as they become available for the 2024-2025 academic year.
As a result of SB 240 and SB 840, nurses will gain new decisionmaking authority in the effort to prevent and punish violence against healthcare professionals.
SB 240 applies to nurses working in home and community support services agencies, hospitals, nursing facilities, ambulatory surgical centers, and freestanding emergency medical care facilities. It requires each facility to create a committee with at least one nurse, one member of security staff, and (in some circumstances) one physician.
The committee must then draft a policy and plan of action that addresses the security needs of the facility. The committee is able to receive input from staff throughout the facility and ultimately reports its recommendations to the facility’s governing body.
The law also provides antiretaliation protections for nurses so
they are empowered to report physical or verbal abuse when it occurs without fear of being disciplined or terminated. This law is complimented by the state’s Workplace Violence Prevention Grant Program, which helps fund innovative approaches to preventing workplace violence.
SB 840 increased the penalty for assaulting hospital personnel from a misdemeanor to a felony. The coverage of the law is broad and includes nurses, physicians, physicians’ assistants, maintenance or janitorial staff, receptionists, and other individuals who are employed by or work in a hospital. The law is named the Jacqueline “Jackie” Pokuaa and Katie “Annette” Flowers Act in memory of the nurse and social worker shot and killed by a violent criminal at Methodist Dallas Medical Center in 2022.
Nurses also advocated for significant expansions in access to care for children and mothers. School nurses will now be able to access and administer breathing medications and opioid antagonists to students suffering from respiratory attacks or opioid overdoses more easily (SB 294 and SB 629), and mothers on Medicaid will now have increased post-partum coverage from two to twelve months (HB 12).
Nurses also asked for changes in the Board of Nursing. SB 1343 expanded the Board of Nursing from 13 to 15 members, adding one new APRN member and one new public representative. The new law also requires expert review by an APRN of any standard of care violation alleged to have been committed by another APRN and requires the expert to report their findings to the Board.
Altogether, the session marked a statewide commitment to reinvest in nursing. These commitments come as welcome news for a profession that is healing and needs support.
These policy changes came with official statements from the Texas Legislature articulating the public’s appreciation for the sacrifices nurses made over the course of the pandemic. Among the many resolutions filed celebrating nurses, was Senate Resolution No. 237 by Kolkhorst which states, “Nurses bravely fought the COVID-19 pandemic and protected the health of Texans at great risk and often expense to their personal safety… [we] commend all Texas nurses on their invaluable service to the Lone Star State…” i
The Texas Nurses Association recently undertook a months-long strategic planning process with input from the Board of Directors, district presidents and staff. Below are the four pillars of the strategic plan, areas of focus in each, and goals for the future.
OBJECTIVE
Demonstrate organizational excellence through stewardship of human, fiscal, organizational, community, and environmental resources.
• Assess internal infrastructure and professional governance model to strengthen the organization’s ability to be nimble and responsive to emerging needs.
• Strengthen organizational finances through the diversification of revenue streams and deficit reduction by 30%.
FOCUS AREAS Fiscal Responsibility | Governance | Non-dues Revenue | Human Resources | Operational Resources/Efficiencies
OBJECTIVE
Grow membership by acquiring, engaging, and retaining members.
GOALS GOALS
• Develop a comprehensive plan to increase membership by 5% annually through collaborative initiatives, development of programs, and innovative recruitment and retention of members.
• Increase the visibility of TNA among members and external stakeholders.
FOCUS AREAS Value Proposition | Partnership Development | New Member Categories | Member Journey | Communication Efforts | Member Benefits
Texas Nurses Association Strategic Plan 2023-2028
OBJECTIVE
Advance the quality and safety of patient care through policy initiatives that optimize professional nursing practice, advance positive nursing practice environments, and promote full use of the knowledge and skills of nurses.
• Develop new partnerships and lead opportunities to strengthen the voice of nursing in all healthcare policy related decisions.
• Increase engagement of the profession to influence and shape health policy in Texas.
• Develop programs and services to advance the knowledge of the nurse’s role in advocacy.
FOCUS AREAS Legislative Initiatives | Coalitions | Member Engagement | Agency Relations
OBJECTIVE
Optimize TNA’s ability to lead the advancement of the profession through engagement with nurses and others.
• Partner with external stakeholders to ensure nurses are practicing in an environment that supports an inclusive and just culture and promotes a healthy and safe work environment.
• Develop innovative and evidence-based programs and services that address all levels of experience within the profession.
• Engage the public through education and community outreach.
• Increase the recognition of nurses by leveraging partnerships with external stakeholders.
FOCUS AREAS Education | Events | Publications | Recognition | Products and Programs
At Texas Nurses Association, one of our priorities is helping nurses protect their practice. It’s why we advocated for laws like Nursing Peer Review. It’s also why we’ve had a longtime partnership with Nurses Service Organization (NSO).
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