The Role of Culture, Social Learning & Mindfulness in Enhancing Safety

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Frank Whitehead
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What is one part of the intervention that Hofstede's Multimodal Approach to Reduce Catheter removal?
What does a hierarchical order need no further what?

1 The Role of Culture, Social Learning & Mindfulness in Enhancing Safety Sanjay Saint, MD, MPH George Dock Professor of Internal Medicine University of Michigan & Ann Arbor VA Medical Center Special Correspondent, The New England Journal of Medicine NYSPFP - September 2014

2 What is Culture? Outline Cultural Differences Conformity & Social Learning Medical Mindfulness A Closing Thought

3 Each of us has his or her own distinct personality. But overlaid on top of that are tendencies and assumptions and reflexes handed down to us by the history of the community we grew up in, and those differences are extraordinarily specific.

4 What is Culture? Geert Hofstede (Dutch Psychologist): "Culture is the collective programming of the mind which distinguishes the members of one category of people from another."

5 Hofstede s Dimensions of National Cultures 1. Power Distance Index (PDI) 2. Individualism versus Collectivism 3. Masculinity versus femininity 4. Uncertainty avoidance 5. Long-term versus short-term orientation 6. Indulgence versus restraint (

6 Power Distance Index (PDI) The extent to which the less powerful members of society accept and expect that power is distributed unequally People in societies exhibiting a large degree of power distance accept a hierarchical order in which everybody has a place and which needs no further justification. In societies with low power distance, people strive to equalise the distribution of power (The Hofstede Centre)

7 Hofstede s Country Scores: Power Distance Power Distance Index Russia 93 India & West Africa 77 Brazil 69 France 68 USA 40 New Zealand 22 Denmark 18 (

8 October 2004 Critical Care Medicine 2004 Quasi-experimental study at Johns Hopkins Hospital in Baltimore, Maryland

9 Multimodal Approach to Reduce Catheter-related Bloodstream Infection Nurses empowered to stop the doctor from inserting the catheter if necessary (32% of the time) 1 part of a 5-part intervention (education, early catheter removal, checklist, and insertion cart) Reduced BSI in the intervention group (Berenholtz et al. Crit Care Med 2004) Formed the basis of the Keystone Project in Michigan (Pronovost et al. N Eng J Med 2006)

10 Hofstede s Country Scores: Power Distance Power Distance Index Russia 93 India & West Africa 77 Brazil 69 France 68 USA 40 New Zealand 22 Denmark 18 (

11 Relevance to the United States

12 Hospital Outcomes Program of Excellence (HOPE) ( Systems redesign grant to Ann Arbor VAMC Behavioral lab for interventions to improve quality of care, and enhance nurse-doctor communication CAUTI prevention one of many initiatives: nurseinitiated reminder

13 The key intervention was having the bedside nurse take ownership of the issue.

14 Circle of Concern

15 Individualism versus Collectivism ( The high side ( Individualistic ): prefer a loosely-knit social framework in which individuals are expected to take care of themselves and their immediate families only Collectivistic : prefer a tightly-knit social framework in which individuals can expect society to look after them

16 Individualism (versus Collectivism) Individualism Index USA 91 Great Britain 89 Germany 67 Japan 46 Greece 35 East Africa 27 Venezuela 12 (

17 Individualism (versus Collectivism) Individualism Index USA 91 Great Britain 89 Germany 67 Japan 46 Greece 35 East Africa 27 Venezuela 12 (

18 Implications.Antimicrobial Stewardship In countries with a high individualism index: In countries with a low individualism index:

19 Relevance to the United States

20 Number of Clostridium difficile diagnoses, U.S. Hospitals, 1993 to 2011(HCUP data) Prevalence of Clostridium difficile infection has steadily increased in the US

21 Rates of CDI Among Hospitalized Patients Aged 65 Years: National Hospital Discharge Survey, U.S.A to 2009 (MMWR 2 September 2011) From 1996 to 2009, C. diff rates for hospitalized persons aged 65 years increased 200%...

22 Conformity & Social Learning Conformity & social learning are universal Conformity: tendency to prefer behavior that is common in the local population despite previous preferences for other options Social learning: when the beliefs and behavior of a group are internalized by an individual This cultural transmission of behavior is a second inheritance system

23 The Culture at Our Hospital Has Now Changed Foley catheters go in and stay in for appropriate reasons Bedside nurses track if a patient has a Foley and why on every shift Doctors are now frequently asked by the nurses: Can we remove the catheter?

24 A Dilemma Much of what we do in healthcare especially in the hospital is reflexive If a patient is hypoxemic: we give oxygen Low BP: IV fluids Positive blood cultures: antibiotics Frequency, urgency, and dysuria: dx UTI

25 A Dilemma These rote responses are usually helpful However, this reflex-like approach can lead to problems Pt sick enough to be admitted from the ED: Foley catheter Asymptomatic catheterized patient has a dirty urine: antibiotics

26 Applying Mindfulness to Bedside Nursing: Catheter-Associated Urinary Tract Infection (Kiyoshi-Teo et al. Infect Cont Hosp Epid 2013) Taking a 5-second pause before Inserting an indwelling catheter Emptying the drainage bag or transporting the patient Asking Is it absolutely necessary to use an indwelling catheter in this patient? Can I use an alternative? Am I using proper technique? Do I need to ask for help? Can the catheter be removed today?

27 A Closing Thought Karl Weick: Knowledge develops through 3 stages:

28 Profound Simplicity.

29 A Closing Thought To be successful, however, we must:

30 Thank you!

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Choosing Human Resources Development Interventions JP Singh Singh argues that top management should examine the managerial culture of the group and the organization before introducing change through human

The Role of Culture, Social Learning & Mindfulness in Enhancing Safety

What is one part of the intervention that Hofstede's Multimodal Approach to Reduce Catheter removal?

What does a hierarchical order need no further what?