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Understanding the Relationship Between Quality, Safety, and Ethics

CATHERINE ROBICHAUX

LEARNING OBJECTIVES AND OUTCOMES

As a registered nurse, you know that the language of quality and safety permeates health care today. As the providers who spend the most time with patients, nurses are critical to ensuring their safety through identifying, interrupting, and correcting potential errors that can result in adverse events (Henneman, Gawlinski, & Giuliano, 2012; Henneman et al., 2014). In fact, nurses have been involved in defining and assessing quality health care, the umbrella under which patient safety resides, since long before the current proliferation of quality/safety programs and initiatives (Robichaux & Sauerland, 2012).

This chapter provides a brief history of the nursing profession’s concern with quality care, patient safety, and ethics. In addition, the relationship of ethics principles, virtue ethics, and care ethics and examples of how they are manifested in the Institute of Medicine’s (IOM, 2001) quality domains are presented. Implications of the ethical principles, virtue ethics, and care ethics approaches for patient/family care, and nursing practice and leadership are discussed. To practice ethically and deliver safe, quality care, nurses must work in an ethical, supportive environment that reflects the same principles and qualities.

As you read the opening to the following Case Scenario, ask yourself:

          Which factors might contribute to a patient safety event?

          How could you prevent this potential patient safety event?

          Would you report this patient safety event? To whom?

CASE SCENARIO

Question to Consider Before Reading On

1.   How do you describe quality and safety in your current nursing practice?

QUALITY AND SAFETY

While both are essential, the difference between patient safety and quality has been debated for some time. Safety has to do with a lack of harm, while quality means efficient, effective, purposeful care that gets the job done at the right time for the right cost. Quality nursing care also means meeting and exceeding the expectations of the client. Safety focuses on avoiding bad events while quality focuses on doing things well (Hospital Safety Score, 2015).

The Institute of Medicine describes six domains (safe, effective, efficient, timely, equitable, and patient centered) that constitute overall, quality health care. These six attributes were identified in the 2001 publication, Crossing the Quality Chasm: A New Health System for the 21st. Century (IOM, 2001), a follow-up to To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000). The latter document reported that, at the time, medical errors were estimated to cause 44,000 to 98,000 deaths annually and result in $17 to $29 billion dollars in excess medical expenses. Despite myriad international, national, and private endeavors to improve patient safety over the past 15 years, recent estimates indicate that 2 to 4 million serious adverse events still occur in the United States each year, with approximately 400,000 resulting in premature deaths (James, 2013).

Definitions of terms associated with patient safety and quality care also differ somewhat among agencies such as the National Quality Forum (NQF), the World Health Organization (WHO), and the Agency for Healthcare Research and Quality (AHRQ). NQF (2009) describes “error” as: “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (commission). This definition also includes failure of an unplanned action that should have been completed (omission).” AHRQ (2012) identifies both “close calls” and “near misses” as: “an event or situation that did not produce patient injury, but only because of chance. This good fortune might reflect robustness of the patient (e.g., a patient with penicillin allergy receives penicillin, but has no reaction) or a fortuitous, timely intervention (e.g., a nurse happens to realize that a physician wrote an order in the wrong chart).” Similarly, the WHO (2009) defines “near miss” as a serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted, as presented in the opening Case Scenario.

NURSING, QUALITY CARE, AND ETHICS: A BRIEF HISTORY

Florence Nightingale (1863) was a pioneer of quality care. Her persistent advocacy of quality care included systematic data collection and statistical analyses. Nightingale was responsible for perhaps the most significant hospital quality improvement project ever undertaken and, as demonstrated in her meticulous documentation, of the processes and outcomes of care. Using innovative, color-coded bar graphs and pie charts, her analysis of mortality data among British troops at Scutari Hospital in what is now Istanbul accomplished significant reductions in deaths through organizational and hygienic practices. Sheingold and Hahn (2014) observe that Florence Nightingale’s three key contributions to the development of quality care evaluation and improvement are:

          The measurement of quality improvement in all of health care, which is the foundation upon which current international benchmarks for excellence are identified today

          The importance of proper documentation and presentation of measurement results

          The value of generating buy-in from others to support health care quality intervention (p. 21)

Nightingale also maintained that nurses should make independent judgments as opposed to unquestionably following the demands of physicians, thus providing the groundwork for modern nursing practice.

Aydelotte and Tener (1961) conducted one of the first studies exploring the relationship between the quality of the care provided by nurses and patient recovery or “welfare.” It was hypothesized that the quality of nursing care would improve by increasing the number of nursing staff and offering an education program focused on elements of quality care. Patient outcome measures assessed were number of hospital days, postoperative days, fever, and number of doses of narcotics, sedatives, and pain medications administered. Aydelotte and Tener’s findings indicated no significant improvement in patient recovery, perhaps due to insufficient reliability and validity of the instruments used (Griffith, 1995). The study served as a template for future investigations exploring the relationship of nurse staffing to patient outcomes (Aiken et al., 2012). Aydelotte identified the connection between quality care and ethics in her description of nursing: “Nursing encompasses an art, a humanistic orientation, a feeling of value of the individual, and an intuitive sense of ethics, and of the appropriateness of the actions taken” (Scrubs Magazine, 2015).

Phaneuf and Wandelt (1974) noted that “any profession that does not monitor itself becomes a technology” (p. 328) and encouraged nurses to develop and use methods of quality assessment that would assist in the improvement of nursing practice. Reflecting Provision 8 of the American Nurses Association (ANA) Code of Ethics (2015a), Phaneuf and Wandelt observed that “the availability of and access to health care for all are seen as human rights” and “the quality, quantity, and costs of care have become interrelated social and professional issues” (p. 329). The authors developed or shared in the development of several nursing quality care measures that remain in use today. These include the Slater Nursing Competencies Rating Scale (Wandelt & Stewart, 1975), the Quality Patient Care Scale (Wandelt & Ager, 1974), and the Nursing Audit (Phaneuf, 1972).

In 1975, Lang proposed a quality assurance model that included an assessment of values, observing “it is impossible to discuss quality without examining values of the professional” and “most of our conflicts arise from a difference of opinion regarding values” (p. 180). She also noted that the staff nurse is a major determiner of quality. Integrating societal and professional values in addition to the most current scientific knowledge, Lang’s work and model predate the IOM’s definition of quality by almost two decades and continues to be used today.

The ANA developed the Patient and Quality Safety Initiative (ANA, 1995), to evaluate linkages between nurse staffing and the quality of care through a series of pilot studies across the United States. An initial set of 10 nursing sensitive indicators were identified for use in evaluating patient care quality and implementation guidelines were published (ANA, 1996, 1999). The National Database of Nursing Care Quality Indicators (NDNQI) was established by ANA in 1998 to continue to collect data to evaluate and improve patient care. Originally managed at the University of Kansas School of Nursing under contract to ANA, the database was sold to Press Ganey, a patient experience improvement firm with a similar commitment to quality, patient-centered care in 2014. At present, more than 2,000 U.S. hospitals and 98% of Magnet^® facilities participate in the NDNQI program to measure nursing quality, improve nurse satisfaction, strengthen the work environment, and improve current pay for performance policies (Press-Ganey, 2015).

The quality mandate is evident in foundational nursing documents such as Nursing’s Social Policy Statement (ANA, 2010a), Code of Ethics (ANA, 2015a) and Scope Standards of Practice (ANA, 2015b). Standard 11 of the latter addresses the quality of practice and states, among other competencies, that the registered nurse uses indicators to monitor the quality, safety, and effectiveness of nursing practice. Graduate-level and advanced practice nurses are expected to use the results of quality improvement to initiate changes in nursing practice and the health care delivery system. Several chapters in the present book illustrate integration and application of relevant competencies developed by the Quality and Safety Education for Nurses (QSEN) initiative. This project aimed to provide nurses “with the knowledge, skills, and attitudes (KSAs) necessary to improve the quality and safety of the health care systems in which they work” (QSEN, 2015).

Question to Consider Before Reading On

1.   How are you and other nurses involved in evaluating the quality of care?

As discussed in earlier chapters in this text, nurses have an extensive history of identifying and responding to ethical issues and taking seriously their moral responsibilities as health care providers. From the earliest nursing text by Eva Luckes (1886), through the 11th revision of the Code of Ethics (ANA, 2015a), nurses have sought to articulate how their roles and actions have been grounded in ethical principles. The essential, interdependent relationship between ethics and quality initiatives designed to measure, evaluate, and improve nursing practice is reflected in Provision 3 of the Code of Ethics, which states “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 9). Quality and patient safety are addressed specifically in provisions 3 and 6 and in many statements throughout the document (Box 13.1).

Question to Consider Before Reading On

Statement 3.4 in Box 13.1 identifies the nurse’s role in establishing a “culture of safety.”

1.   How would you describe the culture of safety in your institution?

Box 13.1

Quality Health Care, Patient Safety and Ethics: Relevant Provisions and Statements from the Code of Ethics (2015)

Source: ANA (2015a).

ETHICS PRINCIPLES, VIRTUE ETHICS, CARE ETHICS, AND QUALITY/SAFETY

As presented in Chapter 1, the principles of autonomy, beneficence, nonmaleficence, and justice form the foundation of Western health care ethics. Quality care and patient safety are grounded in these principles and reflected in the IOM domains (Table 13.1). The principles also have implications for nursing practice and leadership in regard to intra/interprofessional collaboration and development of an ethical environment conducive to the provision of quality, safe nursing care. These implications were discussed in earlier chapters and are addressed further in this chapter.

Unlike principle-based ethics, virtue ethics does not emphasize specific rules of behavior but recognizes the significance of moral character and the role of emotions and experiences in providing safe, quality care. In addition, “Virtue is the tenet that a nurse has an obligation to maintain one’s own integrity as well as the integrity of the profession” (see Chapter 1, p. 17). While ethical principles focus on “What should I do?” in a particular situation, virtue ethics asks, “What kind of nurse should I be?” (Armstrong, 2006; Robichaux & Sauerland, 2012). As Dans (1993) states, perhaps the greatest guarantee for safe, quality health care for the patient lies in the character of the provider both at the practice and leadership levels. Relevant virtues include honesty, compassion, prudence, and courage, among others.

An ethic of care has relevance for discussions of overall health care quality as it recognizes the inherent relational nature of nursing practice and, in particular, the IOM domain of patient/family-centered care (Chapter 6). Much research has been conducted to measure, evaluate, and improve the quality of care by means of objective measurements that focus on the IOM domains. In each domain, tools have been developed to measure and improve the performance of health care professionals and assess indicators such as number of readmissions, reoperations, and prevalence of pressure ulcers. Questionnaires are also used to evaluate patient outcomes and satisfaction as indicators of quality care. While objective measurements are vital to improvement in quality/safety, they may neglect one of the most important aspects of health care, the patient–provider relationship (Kuis, Hesselink, & Goosensenn, 2014). Milton (2011) has suggested that emphasis on quality and safety in the performance of tasks may diminish the nurse–patient caring relationship. She questions whether the “monitoring for potential error is the new standard for nursing practice rather than participating in the nurse–patient relationship with responsibility and accountability” (p. 110). Milton maintains that inattention to situational context with a focus on “doing things right” rather than “doing the right thing” (p. 110) has the potential to harm both the nursing profession and the recipients of care.

An ethic of care acknowledges nursing responsibility and accountability yet recognizes that care is not delivered to vulnerable others as a product. Clinical guidelines and standardized protocols are insufficient for facilitating the care that each unique patient needs, much like ethics principles alone are inadequate for ethical nursing practice. Supporting principles with elements of virtue ethics and care ethics may enable nurses to provide safe, quality care while integrating the essential humanistic and relational characteristics that consistently make nursing the most trusted profession. This integrated approach may contribute to developing an ethical environment in which nurses can practice quality care.

In the following section, the significance of each ethics principle in the provision of quality, safe care to the patient/family and in nursing practice and leadership is discussed. Aspects of virtue ethics and care ethics relevant to each principle are addressed. Table 13.1 presents a summary of the implications of ethics principles, virtue ethics, and care ethics to the IOM quality domains and patient safety. Table 13.2 presents a summary of the implications of each principle and those of virtue ethics and care ethics to practice and leadership.

Table 13.2

Implications of Ethics Principles, Virtue Ethics, and Care Ethics to Practice and Leadership

Source: Robichaux and Sauerland (2012).

AUTONOMY

Patient/Family Care

Individual autonomy is highly valued in Western culture. In bioethics, respect for autonomy is associated with supporting patients in making decisions about which treatments or interventions they will or will not receive. The IOM domain and QSEN competency of patient-centered care reflect this ethical principle and provide an expanded understanding intended to correct entrenched tendencies of health care to be too disease focused or system or provider centric. Patient-centered care (PCC) or, to use the more inclusive term, patient/family-centered care (PFCC, Chapter 6), has been shown to result in improved health outcomes, including survival, greater patient satisfaction and well-being, improved communication between patients and health care professionals, and reductions in health care resource needs and costs (Berghout, van Exel, Leensvaart, & Cramm, 2015; Rathert, Wyrwich, & Boren, 2013). Elements of virtue ethics and care ethics also contribute to a relational understanding of autonomy that may enhance the overall quality of patient care.

Associating respect for autonomy solely with autonomous decision making and independence in choosing may neglect the idea that people are located within personal relationships, environments, and cultural systems. Simply offering and allowing patient/family choices about health care options or interventions and then standing back will isolate them in their decision-making and would be contrary to PFCC and the Code of Ethics (Box 13.1). A relational understanding of autonomy encourages us to consider these factors and recognize our interdependence in collaborative decision making (Ells, Hunt, & Chambers-Evans, 2011; Entwistle, Carter, Cribb, & McCaffney, 2010). Respectful, caring communication elicits and considers patient/family perspectives and promotes understanding of them as persons with guiding values, including those that are cultural and spiritual in nature (Epstein & Peters, 2009; Robichaux & Sauerland, 2012). As Houghton (Chapter 3) observes, nurses must be aware that many other factors such as race, level of education, and trust in the provider influence decision making.

While self-determination without undue provider influence may be associated with patients’ perceptions of quality care, it is enhanced by provider prudence. Understood as practical wisdom, prudence is the ability to make decisions, often in the face of uncertainties (Marcum, 2011). Larrabee (1996) described one of the first models of health care quality as viewing patients and families as equal partners, and included the virtue of prudence, described as “good judgment in setting realistic goals . . . and skill in using resources to achieve those goals” (p. 356). Nurses and other providers can provide information regarding the availability, suitability, and cost of care. Prudence acknowledges, however, that patients/families may need help in understanding what they believe and want in complex medical situations, including the use of technological interventions.

Respect for autonomy embodies the virtues of honesty and trust and thus includes the duty to report and disclose errors and near misses to patients and appropriate authorities (Egan, 2014). Despite an emphasis on transparency in developing a patient safety culture, research indicates that fear of retaliation and subsequent underreporting persists. This is especially true in regard to near misses or close calls. Additional factors identified for lack of error/near-miss disclosure and underreporting include personal sense of responsibility, cumbersome documentation, and lack of feedback on reports (Lederman, Dreyfus, Matchan, Knott, & Milton, 2013; Ulrich & Kear, 2014). Individual accountability or responsibility for nursing actions and decisions is addressed throughout the Code of Ethics (ANA, 2015a) but perhaps best exemplified in the statement: “To be accountable, nurses follow a code of ethical conduct that includes such moral principles as fidelity, loyalty, veracity, beneficence and respect for the dignity, worth and self-determination of patients. . . .” [emphasis added] (p. 15). This accountability is more fully realized in a just, patient safety culture.

Questions to Consider Before Reading On

1.   Can you describe a patient/family situation(s) in which you believe the principle of autonomy was compromised and/or supported?

2.   What is the process for identifying and reporting errors/near misses in your facility?

Nursing Practice and Leadership

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