CLINICAL INCIDENTS SHARING PROGRAM

Introducing Clinical Incidents Sharing Programme for Nurses in Singapore Nursing

Abstract

The clinical incident sharing session programme implemented in Kwong Wai Shiu Nursing Home aims at achieving affordability, accessibility, and quality objectives in the care of elderly patients in Singapore. The process involves sufficient identification and reporting of critical incidences to minimise medical errors in the care process. Singapore has improved services provided to the aged in the past three decades through government and non-governmental support for nursing care. However, individual organisations have the responsibility of ensuring safe and quality support for the aged through medical error prevention. To address the challenge, Kwong Wai Shiu Nursing Home implements the clinical incident sharing session programme (CISSP), taking into account the various critical success factors, such as training and ongoing learning, effective communication and information sharing, leadership, a supportive culture, and adequate resources. The process is beneficial to the organisation through improved knowledge, skills, and competence among nurses to ensure critical thinking and clinical judgement in the service delivery process.

Keywords: clinical errors, clinical Incidents sharing, nursing home, sharing session

Introducing Clinical Incidents Sharing Programme for Nurses in Singapore Nursing

Introduction

Singapore faces the challenge of providing care to the elderly population. By 2013, the country had 19% of individuals aged 65 years and above. Demographic changes have created the burden of care, including the emergence of dual-income, reduction in extended families, and growth in age-associated degenerative diseases. Inadequately resourced families face difficulties in providing care and support to the aged at home. Frailty, functional dependence, and the risk of falls worsen the situation for loved ones (Low, 2017). Consequently, many families prefer taking their elderly members in nursing homes to receive critical and medical support in their older age or during illness. The growth in the support system has resulted in demand for quality services. The clinical incident sharing session programme (CISSP) is a system developed to improve the quality of services in the facilities by minimising medical errors. Although many other changes are necessary to improve nursing care in the country, the incident sharing session programme supports implementation of the CISSP to enhance accessibility, affordability, and quality.

History

The aging population has always posed a unique challenge for the healthcare system in Singapore. The country has witnessed major changes in its demographics, including dual-income and reduction in the role of extended families. Other changes include an increase in age-related degenerative disorders because of longer lives (Wong, Yap, & Pang, 2014). As a result, it becomes problematic for families to provide the primary care for the aged at home. Nursing homes have become increasingly relevant in Singapore to care for this population and provide families with critical support in caring for the dependent members. However, their acceptance in the country took time because they were regarded as last resort decisions by both professionals and patients. Besides, such programmes were considered with stereotypical views such as being “physically unattractive, often smelly, and populated with people who are frail and often demented” (Sitoh, 2003, p. 57). Besides, prejudice has been directed towards the facilities by the public. Health care professionals had a proclivity towards them, viewing nursing home patients as less critical while caring for such people being considered as insignificant. However, such opinions have changed with time, and nursing homes have become important in the healthcare system.

Nursing homes, as alternative organisations providing aged care at home, developed in the United States in the 1930s, and later, in other countries around the world. The last three decades have witnessed gradual changes in Singapore regarding the care of the elderly. The original model involved retired nurses who welcomed the ill and elderly in their homes for caregiving purposes. In Singapore, community-based charitable agencies provided the initial model of the services. They were sheltered accommodations that cared for the destitute and homeless aged immigrants. For instance, in 1935, St Theresa’s Home founded the Little Sisters of the Poor to provide services to such people, including food, shelter, and clothing (Wong, Yap, & Pang, 2014). In 1965, Teresa Hsu was a social worker who established one of the pioneering nursing homes known as the Aged Sick at Jalan Payoh Lai. During the 1970s, the country had only a limited number of Homes for the Aged. Recent statistics indicate that the nation has more than 6,400 nursing home beds (Sitoh, 2003). The changes have also enhanced nursing home care in Singapore.

The nursing home system in Singapore has improved tremendously. Voluntary welfare organisations (VWOs) operate around 75% of the nursing homes, while the private sector operates the remaining proportion (Sitoh, 2003). Besides the growth in the nursing home beds, a change in the focus of residential care for the elderly has also transformed. For example, in the 1970s, the residential aged home facilities cared for aged destitute by providing basic accommodation and care (Sitoh, 2003).  Gradually, residential aged care facilities took over the care for the elderly, focusing on medical and intensive support. Furthermore, the current nursing homes are motivated to provide a broader range of services for residential aged, creating “nodal points” within every community. The facilities should offer a wide range of eldercare services, including home nursing for the sick, home help/support, and residential care. The changes are aligned with the healthcare goal in the country to provide a seamless continuum of care to the aged Singaporeans.

The Singaporean government has invested more resources to improve nursing care. For example, in 2014, the Ministry of Health enacted the long-term care plan to improve the services offered to the elderly in the country. The government and public views the elderly as a burden to the economy, creating the need for service improvement to reduce the burden. The plan is future-oriented, aiming at improving the old-age support ratio to 2.1 by 2030. It will decrease the need for caregiving by members of the family to allow them to contribute to the economy. The care process will focus on institutionalised care (Chin & Phua, 2016). Later, in 2015, the government created the enhanced nursing home standards to provide better quality aged care (Chin & Phua, 2016). The health plan focused on the affordability, accessibility, and quality of support provided to the elderly. The government is committed to the achievement of the three objectives to reduce the burden of caring for the elderly.

Development of the Programme

The Clinical Incident Sharing Programme is aimed at reducing the prevalence of medical errors and improve the quality of care in nursing homes in Singapore. It will also reduce the cost of care by reducing the burden of medical errors. The improvement of patient safety requires changes in the culture of the care facility through ongoing quality enhancement. The system necessitates constant evidence-based learning among health care service providers. The management of nursing homes is cognizant of the pressure caused by the inadequacy of resources and the effect on the services of the frontline employees. The programme plays a significant role in reducing the challenges and improving services regardless of resource constraints (Stavropoulou, Doherty, & Tosey, 2015). The initiative is designed to receive information that can be translated into organisational and individualised learning. Shared sessions reduce medical errors and improve confidence among care providers to enhance the quality of care. The sessions provide the context to learn from previous medical errors to improve future services (Mosadeghrad, 2012). The nursing care facility implemented the evidence-based system to minimize errors in providing care for the elderly.

The Clinical Incident Sharing Programme implemented in Kwong Wai Shiu Nursing Home is based on a framework introduced by the American Nurses Association (ANA) using the Nursing Magnet Model (Upenieks & Abelew, 2006). The model had an application manual directing peer-reviews that concentrated on five components: (i) transformational leadership, (ii) knowledge enhancement, innovation and improvement, (iii) professional practice, (iv) structural empowerment, and (v) quality results (Grant, Colello, Riehle, & Dende, 2010). The model is international and adapted for use at Kwong Wai Shiu Nursing Home. The main aim of the model is to improve ongoing learning on collaborative efforts in reporting critical incidents to minimise medical errors and improve quality of care.

The implementation of the clinical incident sharing session programme occurs at Kwong Wai Shiu Nursing Home. The hospital was originally established in 1910 and currently operates as a nursing home and a community hospital. It is the largest single-site nursing home in Singapore, with 600 beds. The development of the facility is underway to expand the current infrastructure to accommodate over 1,100 beds (Goh, Khaw, Ow, & Devi, 2018). The management expects to achieve the expansion objective over the next two years. The healthcare facility, and the Singaporean healthcare system, in general, has invested more resources to advance the quality of care provided to patients. The quality is achievable through proper information creation and sharing within the facility and across the healthcare system in the country.

The increase in the residential burden in the nursing home requires major changes in practice to improve quality through effective services, such as minimising medical errors. The required transformation is motivated by the concerns raised by the senior management of the nursing home. Firstly, the facility requires an open and supportive culture based on general agreement among the caregivers that continued organisational learning is critical for quality outcomes and prevention of adverse effects (Abstoss et al., 2011).  Secondly, the facility requires a committee to spearhead the integration of the programme into practice through proper gathering, analysis, and evaluation of data regarding clinical incidents for timely reporting and remediation.  Thirdly, a platform is necessary to establish and share research findings regarding the types of feasible and effective interventions for safe patient outcomes (Bowen-Brady et al., 2019). The changes are critical to improve the quality of care at Kwong Wai Shiu Nursing Home amid the impending expansion plan.

The introduction and use of the CISSP is a relatively new area in the nursing home, especially in the Singaporean context. Therefore, its proof of effectiveness is drawn from available research evidence on its application in practice in similar settings. Information sharing in various medical contexts has proven effective in preventing negative clinical consequences, such as errors. The nursing home uses the CISSP as a planned programme to create standards for the assessment of the quality of care provided to residents. The process enables them to share information to discover the weaknesses and strengths of services and practice. Besides, it helps them to create policy changes and guidelines to improve care by minimising clinical errors while caring for the elderly and ill patients (Roberts & Cronin, 2017). The healthcare facility strives to enhance the quality of support they provide to vulnerable populations. The successful implementation of the system requires a clear definition to translate evidence to practice. Garner (2015) conducted a study that defined the clinical incident-sharing programme as a systematic process involved in the assessment, evaluation, and monitoring of practices within the health care facility by peers following established professional standards. The source provides support for the program and introduces the benefits of the program.

Benefits of the Programme

Various reasons are discussed in literature and practice for the implementation and use of the CISSP. The nursing home facility embarked on the implementation of the programme to support effective service provision to the residents. The system was designed to enable information sharing about the safety of patients. It would improve organisational learning, “a process of individual and shared thought and action in an organisational context” (Stavropoulou, Doherty, & Tosey, 2015, p. 826). In their systematic review of literature, the authors examined available evidence about the efficacy of the system as a means of supporting organisational learning to improve the quality of services.

The programme supports the translation of evidence into practice by care providers working in the Singaporean nursing homes. O’Brien and Arthur (2007) support the need for the programme because of the limitation in using available evidence in practice in the country. Although nurses have the necessary training in various aspects of care, they lack the necessary knowledge to critically approach incidences and achieve positive outcomes in their care processes. Thus, the system is necessary to instill critical thinking skills while providing care to patients in nursing homes in the country. Besides, it helps to meet the demands for nursing services among caregivers working independently in the nursing home settings. It will help them to use the available skills to improve the quality of care, such as through timely identification of medical errors and implementation of remediation strategies to achieve positive practice and patient outcomes. Generally, the programme is appropriate to create a culture of timely and effective translation of evidence into practice.

The effective implementation of the programme promotes transparency among nurses providing care at the facility. The system creates a platform for caregivers to share information and interact freely with their peers and management. Hence, the administration shares insights about the creation and implementation of the initiative to ensure proper application. Nurses are the primary information creators in any healthcare facility (Potgieter, 2012). Consequently, their input is critical in the design and integration of the plan into the nursing home facility. Therefore, success depends on the extent to which the management includes them in the necessary conversations regarding the adoption of the new process. The programme encourages critical transparency and accountability in the organisation to achieve the quality and safety improvement objectives. It also enables the management and nurses to effectively manage emerging conflicts in the facility (Norushe, Van Rooyen, & Strumpher, 2004). Therefore, it encourages the creation of a healthcare environment that supports team-work and transparency in patient care.

The system supports the development of a culture of safety in the nursing home. The main goal of the programme is to ensure effective incident sharing and rectification of limitations in the process to prevent adverse outcomes, such as medical errors. Consequently, the programme promotes cohesiveness and team-work in the provision of care to the residents. The management achieves the objective by creating an enabling environment for the deployment and use of the system. Regardless of the argument that such system implementation is still underway in Singapore, proper adoption into the nursing home practice will enable nurses to work in a safe environment and create an enabling culture to achieve patient safety objectives (Stavropoulou, Doherty, & Tosey, 2015). The programme also enables proper collaborative efforts among nurses to improve patient and practice outcomes. Vertical and horizontal collaboration within the expanding organisation is critical to creating an error-free environment as the nursing home receives additional patients. The sessions update them about emerging knowledge and medical information relating to the care of elderly patients. It also improves information sharing, communication, and interpersonal relations between care providers. Consequently, nurses become better at solving clinical problems affecting their patients.

The clinical incident sharing session programme supports the training of providers working in nursing home care. Mahajan (2010) suggests that incident reporting systems are educational tools for caregivers which is beneficial for ongoing quality improvement. The programme implementation and use require development of critical skills and expertise that motivate them to develop an ongoing learning culture. It eliminates constraints evident in continuous learning, such as time and resources, because it includes the training component as part of its regular use. The programme enables nurses to continually improve their skills and proficiency in providing care to patients in a safe environment. Learning becomes an important part of their care delivery practice. The sharing sessions enable nurses to identify limitations in their abilities and competencies in providing patient care, creating the room for improvement. The less-experienced caregivers have the opportunity to continue improving their learning in the workplace under the guidance of expert nurses. The programme closes the knowledge gap through ongoing knowledge development.

The improvement of the quality of care through the knowledge of nurses is beneficial to the nursing home through the use of the CISSP. Through the programme, they have the opportunity to improve their experience for better patient outcomes. The system is based on collaborative learning and sharing sessions that provide the opportunity for quality enhancement (Lincke-Salecker, 2004). It provides the much-needed opportunity for the caregivers to use their theoretical knowledge in practice. The programme will help them to improve their critical thinking and clinical judgement capabilities while working with patients with diverse needs. It will also support them to change their attitudes and behaviours towards the most vulnerable aged residents receiving care in the nursing home (Vincent, Neale, & Woloshynowych, 2001). The system will enable nurses to learn about the new and emerging challenges affecting the elderly to continue improving their care delivery practices. Healthcare providers have the opportunity to use acquired evidence-based strategies to determine the patient’s needs and create appropriate interventions in an error-free environment.

The clinical incident sharing session programme plays a critical role in eradicating the prejudiced and stereotypical view of a nursing home in the country. Sitoh (2003) noted the history of a negative perception of nursing homes among professionals and patients in Singapore. Such views are addressed effectively when systems are in place in nursing homes to improve the care of elderly persons in the country. The programme achieves the objective by enhancing the image of nursing homes and caregivers among the public. It helps to eliminate the negative images presented in the media of aged residents experiencing mistreatment in the country’s nursing homes. Generally, CISSP creates a new and improved perception of long-term care, which motivates families and the elderly to seek their services. The programme enhances care-giving through ongoing training to develop competent nurses

Critical Success Factors

Critical success factors are well explored in management literature relating to the implementation of organisational changes. However, they are seldom discussed in the adoption of new strategies in healthcare institutions, especially concerning multiple strategic transformations. Nonetheless, during such periods in healthcare facilities, the management can identify the most critical variables that impact on the change process. They require the knowledge to comprehend the areas they should focus on to ensure successful integration of the new approach to practice to improve quality outcomes (Kash, Spaulding, Johnson, & Gamm, 2014). Key success factors in healthcare change initiatives are as critical as in other organisational aspects because they determine the success of the project. The implementation of the CISSP in Kwong Wai Shiu Nursing Home requires the leaders to recognize and manage the success factors for quality improvement outcomes.

The implementation and successful integration of the CISSP depends on several critical success factors. Firstly, the improvement of quality using the system requires sufficient training for nursing care service providers. The management should develop the right skills and expertise to support the system. Kwong Wai Shiu Nursing Home has already adopted critical training for nurses to improve their service delivery tendencies and improve the quality and safety of care they offer to the nursing home residents. In 2018, the facility’s training department embarked on a project, “Thinking Nurse” to promote critical thinking skills among nurses. The aim of the programme was to empower nurses to develop a continuous learning mindset, which is at the core of the CISSP. The initiative ensured successful development of confidence and skills development in decision-making and critical thinking. It created a team of nurses ready to take relevant actions using their critical thinking skills and clinical judgment for the benefit of their patients. Therefore, training and skills development are among the required critical success factors for the integration of the CISSP into nursing home care.

The continuous learning is at the core of the implementation and use of CISSP in a nursing home in Singapore. Stavropoulou, Doherty, and Tosey (2015) aver that the programme supports ongoing learning in the healthcare setting. The programme supports learning and provides critical information on the way and why patients can experience harm in a medical institution, such as a nursing home. The success of the project emanates from concerted efforts by nurses to continue learning and improving care (Mahajan, 2010). The system that ensures patient safety allows nurses, providing care to nursing home residents, to access critical information and reporting systems that improve their daily learning process. They achieve creation of a safety culture in the institution that meets various needs, such as prevention of medical errors in the care delivery process. A learning culture is an enabler of the critical change and effective implementation of CISSP at the nursing home.

Professional competence is at the core of effective service delivery in healthcare settings. The improvement of nursing care to the aged in the institution will be achievable if the care providers develop the necessary capabilities to meet the increasing demands. Additional needs include a growing number of residents and the complexity of medical conditions experienced by elderly patients. Besides, the organisation requires trusted medical staff with the competence of health care delivery due to the delicate nature of the recipients of their services (Shieh, Wu, & Huang, 2010). Providers should have excellent communication skills, problem-solving abilities, adequate assessment abilities, and other professional qualifications that ensure their suitability in working in nursing homes. Hence, training on problem-solving and communication skills is necessary to promote positive interactions between trusted medical staff and patients. Overall, competence is a critical success factor for quality improvement through CISSP.

Culture and values determine the success of change initiatives in healthcare settings.  The leadership should ensure that the nursing home has a conducive environment that supports the new programme and achieves the quality improvement objectives (Kash, Spaulding, Johnson, & Gamm, 2014). For example, in Kwong Wai Shiu Nursing Home, the management should ensure that the staff understands the need for close relationships with the residents to support quality care. Creating such a culture supports the implementation of the new programme for ongoing quality improvement. The organisation should include close working relationships between the nurses and their leaders. The management will have a reduced burden when integrating the system in a working environment that has a positive culture and values.

Financial resources and accountability are other critical success factors that will enhance the effective implementation of the change initiative in the nursing home. Singapore enjoys improved government support for the care of the elderly in the country. Since 2013, the government, through the Ministry of Health, has shown concerted efforts to improve this area of health care services (Chin & Phua, 2016). The plans are future-oriented until 2030. Therefore, positive changes will receive adequate policy backing for successful implementation. Besides, the management of Kwong Wai Shiu Nursing Home supports service improvement by investing in the facility to accommodate additional residents. It has adequately resourced the nursing home to meet the increasing needs. Leadership support creates a well-resourced facility where quality improvement efforts can be integrated easily and successfully. It requires accountability from nurses and other members of staff in the use of the facilities to achieve quality objectives.

Information sharing capabilities and communication are also critical factors for the successful implementation of the programme. The effectiveness of the clinical incident sharing session programme emanates from the potential for the nursing home to capitalise on the ability to collect and share information seamlessly (Kash, Spaulding, Johnson, & Gamm, 2014). Nurses should have the competence to retrieve and use data to support clinical decisions. The capability enables the reporting of critical incidents to minimize medical errors in the nursing home. Information sharing includes elements of accountability and transparency in the facility, especially because of the advanced needs of aged patients. In such environments, patients might be unable to communicate their challenges relating to the type of care they receive. Thus, nurses should be accountable and transparent in communicating their services to patients and their families.

Conclusion

Although many types of changes can achieve quality improvement in nursing homes, a model based on adequate research evidence and tested framework, such as the CISSP, is one of the most effective approaches. The proposed programme is implemented at Kwong Wai Shiu Nursing Home. The system will ensure improved reporting and communication of incidences to minimise errors and improve the quality of care in the healthcare organisation. Nurses can apply critical thinking and clinical judgment in making decisions affecting the elderly patients receiving care in the facility. They can collaborate with peers, leaders, and families to implement evidence-based interventions. The programme will improve affordability, accessibility, and quality objectives within the aging care area of health care services in Singapore. Since such programmes are limited in the country, an extensive evaluation of efficacy and impact is necessary after implementation in the nursing home.

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