organizational contex and patient safety: is there a role for mindfulness?

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Organizational Context and Patient Safety:

Is There a Role for Mindfulness

Heather M. Gilmartin, PhD, NPPost-doctoral Nurse Fellow

Denver-Seattle Center of InnovationDepartment of Veterans Affairs

October 9, 2015

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Disclaimer & Conflicts of Interest

Disclaimer: The contents of this presentation do not represent the views of the Department of Veterans Affairs or the United States Government.

Conflicts of Interest:None

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Goals• Review and define the concept of

organizational context • Present research on context and the

relationship to healthcare-associated infections

• Review the practice of mindfulness• Discuss a role for mindfulness in patient

safety

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Context is everything.Bate P. Context is everything. London, England: Health Foundation;2014.

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Context is everything.Bate P. Context is everything. London, England: Health Foundation;2014.

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Does a proven patient safety program vary in its’

effectiveness in different contexts?

If so, how and why?

Shekelle PG, Pronovost PJ, Wachter RM, et al. Assessing the evidence for context-sensitive effectiveness and safety of patient safety practices: Developing criteria. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Prepared under Contract No. HHSA-290-2009-10001C.

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Translating Infection Prevention Evidence to Enhance Patient Safety

Sarah L. Krein, PhD, RN et al. (2004-2008)• Examined how complex organizational and

contextual factors either facilitated or hindered the adoption and effective implementation of evidence-based practices

• Results:o Prevalence rates for prevention practices:

• Central line-associated bloodstream infections (CLABSI) (Krein et al., 2007)• Catheter-related urinary tract infections (Saint et al.,2008)• Ventilator-associated pneumonia infections (Krein, et al., 2008)

o Benefit of “champions” and financial incentives (Damschroder et al., 2009)o Role of collaborative programs (Krein et al., 2008)o Priority of interventions in organization (Saint et al., 2008)o Debate about evidence supporting interventions (Saint et al., 2008)o Role of leadership (Saint et al., 2010)o Role of organizational context (Krein et al, 2010)

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The Quality Health Outcomes Model

Client

Context

Intervention Outcome

Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality health outcomes model. Image - the Journal of Nursing Scholarship, 30(1), 43-46. (with permission)

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Organizational Context and HAIs:Testing the Quality Health Outcomes Model

Heather Gilmartin, PhD, NP, CIC et al. (2014)

• Data Source:o Prevention of Nosocomial Infection and Cost-Effectiveness Refined

(PNICER) Study (Stone et al., 2014)• Objective:

o Test a middle-range theoretical model to explain the relationships between:• Adherence to central line bundle interventions• Organizational context• CLABSI outcomes

• Methods:o Secondary data analysis o Exploratory/confirmatory factor analysis o Structural equation modeling o 614 U.S. hospitals in 2011

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Organizational

Context

Adherence to Central

Line Bundle

Client

X

XX

Leadership

Psych Safety

Climate

MD RCHA RC

RN RC

Estimator: WLSMVChi-sq (1,315) = 1,986.30P <.0000RMSEA = .04CFI = .97

0.24(p=.00) -0.07 (NS)

0.87

0.810.96 -0.67

-0.76-0.65

-0.37

CLABSI Weighted

Mean

EVS RC

RC: Relational Coordination

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The Role of Organizational Context on Adherence to HAI Bundle Practices and HAI

Outcomes Post-doctoral Project

• Data Source:o VHA All-employee Survey and Inpatient Evaluation Center data

• Objectives:o Explore the relationships between:

• Aspects of organizational context • Adherence to central line bundle interventions • CLABSI outcomes

o Adjusted for patient severity• Methods:

o Secondary data analysis o Exploratory/confirmatory factor analysis o Mediation modelso 120 ICUs per year - 2008-2011

o Patient Severity - Weighted Case Severity IndexMethods:• Secondary data analysis• Exploratory/confirmatory

• AE• S

•

• I

• N• S

• T

• R

• U

• 120-135 VA ICUs – 2008-2011

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AES: All Employee SurveyCHG: Chlorhexidine Gluconate

The Quality Health Outcomes Model Applied to Infection Prevention in the VA

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Culture

Work Environme

nt

PatientHealthcare Provider

ClimatePatient Safety

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MindfulnessAwareness or Heartfulness

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Paying attention in a particular way, on purpose, in the present moment, and non-judgmentally.

Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Random House; 1991.

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A mindful practitioner attends, in a nonjudgmental way, to his or her own physical and mental

processes during ordinary everyday tasks to act with clarity

and insight.

Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839

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Mindfulness is attending to the ordinary, the obvious, and the

present.


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Mindfulness is the opposite of multitasking.


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An aim of mindfulness practice is to take greater responsibility for

one’s life choices.

Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300(11):1350-1352

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Somatic and Psychological Disorders

Work/Caregiving Related Issues

• Pain• Depression• Anxiety• Addiction• Insomnia• PTSD

• Burnout• Stress• Compassion fatigue• Recovery from work

Mindfulness as an Intervention

Irving, J.A., Dobkin, P.L., & Park, J. (2009). Cultivating mindfulness in health care professionals: A review of empirical studies of mindfulness-based stress reduction. Complementary Therapies in Clinical Practice, 15, 61-66.

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Mindfulness-Based Stress Reduction Program

• 8-week intensive introduction to mindfulness practiceo 2.5 hour class 1x/week o 30-45 minutes of meditation per dayo 7-hour retreat(day of silence) after week 6

• Began at U Mass Medical Center in 1979 • >700 hospitals have programs for patients and

staff • Instructors receive extensive training and must

be committed practitioners themselvesKabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Random House; 1991.

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Mindfulness Techniques• Meditation

o Sittingo Walkingo Eatingo Everyday activitieso Loving kindness

• Mindful movement (yoga)

• Attitudinal Foundationso Non-judging o Patienceo Trust o Non-strivingo Beginner’s mindo Acceptanceo Letting go

Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Random House; 1991.

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Stress and Burnout in Healthcare Professionals

• Burnout:o Over 40% of nurses report general occupational burnout o 28% of physicians endorse 2 out of 3 aspects of burnout o Up to 60% of psychologists admit to having practiced at times

when they viewed themselves as distressed to the point of clinical ineffectiveness

• Physical Health Problems:• Fatigue, insomnia, heart disease, depression, obesity,

hypertension, infection, carcinogenesis, diabetes, and premature aging

• Stress:• Significantly reduces clinicians’ attention and concentration • Detracts from decision-making skills• Diminishes the ability to communicate effectively, to convey

empathy, and to establish meaningful relationships with patientsSharma, M., & Rush, S.E. (2014). Mindfulness-based stress reduction as a stress management intervention for healthy individuals: A systematic review. Journal of Evidence-based Complementary & Alternative Medicine, 19(4), 271-286.

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Mindful critical self-reflection enables physicians to listen

attentively to patients’ distress, recognize their own errors, refine

their technical skills, make evidence-based decisions, and

clarify their value so they can act with compassion, technical competence, presence, and

insight.


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Challenges: Method and Process

• Lack of a standardized approach to the method and its interventions

• Lack of a universally accepted definitiono Example: John Kabat-Zinn versus Ellen Langer

• Lack of consensus on approach to measurement:o Technique o General method o Psychological process that can produce outcomes o Outcome all on its own

• Mindfulness may be best represented as a latent variable

Mars, T.S., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal of Osteopathic Medicine, 13, 56-66.

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Measuring Mindfulness• Self-report scales that assess the general tendency to

be mindful in daily life• Psychometric validation• Instruments assess different content due to issues with

conceptualization of the concept:o Frieburg Mindfulness Inventoryo Mindfulness Attention and Awareness Scaleo The Kentucky Inventory of Mindfulness Skillso The Cognitive and Affective Mindfulness Scaleo The Mindfulness Questionnaireo Toronto Mindfulness Scaleo The Philadelphia Mindfulness Scaleo Five Facet Mindfulness Questionnaire


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Measuring the Impact of Mindfulness

• Maslach Burnout Inventory• Professional Quality of Life (ProQOL) IV• Impact of Event Scale – Revised (IES-R)• Nursing Job Satisfaction Scale• Short Form 12 Health Survey (SF-12)• Jefferson Scale of Physician Empathy• Profile of Mood States• Recovery Experience Questionnaire• Pittsburgh Sleep Quality Index


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Culture

Work Environme

nt

PatientHealthcare Provider

ClimatePatient Safety

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Applying mindfulness at the bedside: A mind-hand connection

(Gilmartin & Saint, In Review)

• Frenzied environment of clinical practice • Hand hygiene as a prompt for a moment of

mindfulnesso Awareness back to the presento Allow for a moment of clarity, insight, and reflectiono Move hand hygiene from passive compliance to act of

self-care and self-compassion• We provided an mindful guide to hand hygiene

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Clean Hands Save Lives • Wet your hands with clean, running water (warm

or cold), turn off the tap, and apply soap.• Lather your hands by rubbing them together

with the soap. Be sure to lather the backs of your hands, between your fingers, and under your nails.

• Scrub your hands for at least 20 seconds. Need a timer? Hum the "Happy Birthday" song from beginning to end twice.

• Rinse your hands well under clean, running water.

• Dry your hands using a clean towel or air dry them.http://www.cdc.gov/handwashing/when-how-handwashing.html

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Mindful Hand Hygiene• Pause, take a breath, notice that you are turning on the

faucet and regard the feeling of water flowing from your wrists to your fingers.

• Be present in the moment and experience the sensation of rubbing soap into your wrists, hands, and fingers, then washing it all down the drain.

• Focus your attention on your thoughts and emotions. Stay present and accept whatever arises, just as it is, without reacting.

• Set an intention, be it listening with intent, choosing your words mindfully, or to act with compassion in your next encounter.

• Smile, to acknowledge this act of kindness to yourself and to your patient.

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Does a mindful guide to hand hygiene improve the self-

reported experience of hand hygiene for healthcare

providers versus standard hand hygiene instructions?

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Surgical Scrub Guide• Start the water taps and get a comfortably warm and

adequate flow of water. • During washing, use your elbows to release the soap

and turn the taps off, because your hands must remain decontaminated.

• Scrubbing begins at the fingernails, and a nail file and brush from a sterile pack can be used. Scrubbing then occurs in three washing cycles: o Hands and arms extending to two inches above the elbow; o Hands and half way up the forearms; and o Hands only

• Your hands should always be held above the level of your elbows at all times in order to prevent dirty water from dripping from the upper arm onto lower sterile areas.

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Conclusion• Mindfulness is an inherently human quality• Mindfulness can be developed with training• Mindfulness is being applied to self-treat a variety

of conditions with reported positive effects• There are challenges in measuring mindfulness

o What is mindfulness?o How is mindfulness expressed?o How is it measured?• How does mindfulness operate to produce positive outcomes?

• There is a role for mindfulness in patient safety

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Acknowledgments• Thank you:

o Dr. Pat Stone, Columbia University o Dr. Karen Sousa, University of Coloradoo Dr. Cathy Battaglia, University of Colorado &

Denver VAo Dr. Sarah Krein, University of Michigan &

Ann Arbor VAo Dr. Sanjay Saint, University of Michigan &

Ann Arbor VA

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Contact InformationHeather M. Gilmartin

Post-doctoral Nurse FellowU.S. Department of Veterans AffairsDenver/Seattle Center of Innovation

1055 Clermont St.Denver, CO 80220

[email protected]

mailto:[email protected]

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Thanks to the VA for thinking outside the box for our Veterans and their caregivers.

Go Blue!!!

Thank You

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