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Root Cause Analysis of a Safety Problem

Michelle Duesberry-Woody
Bon Secours Memorial College of Nursing

NUR 3206
Tomeka Dowling

On my honor, I have neither given nor received aid on this

assignment or test, and I pledge that I am in compliance
with the BSMCON Honor System.

Root Cause Analysis of a Safety Problem

There is ample evidence to support lower patient to nurse ratios. Each
unit, area, or group needs to be able to staff adequately in order for patients
to be safely cared for by a nurse that is not overwhelmed by their patient
load. When a unit is well staffed a patient can get the holistic care that most

nurses seek to provide. In order to have better staffing ratios there needs to
be plenty of experienced nurses available for staffing. This is an area that
health care facilities around the country continue to struggle against. Why
are there simply not enough nurses?
There are many reasons why there is a shortage of qualified nurses to
fill the many positions that are open. One of the reasons that there are not
enough nurses is because there are some areas that could use improvement
in the education of nurses. Many times a new nurse does not have a grasp
of what floor nursing really can be. Under the safety of an instructor, a
student nurse is safe and protected with no real patient load. As a new
nurse there can be a very large gap between that safe protected
environment and the time after orientation to a unit. According to Amer
(2013) A standard six-month transition to practice residency with a
preceptor is one solution toward improving patient safety and healthcare
outcomes during these challenging times (Amer, 2013, p.44). Many new
nurses experience a sort of shell shock after a few months orientation. After
years of training and education, they leave the field feeling disillusioned.
Nurses also leave their place of work due to a shortage of equipment.
A professional baseball player would not be asked to play baseball without
things like a ball, a bat, and a uniform. An electrician would not try to wire a
house without wire, wire cutters, and other essential equipment. Each day
nurses are asked to do more with less equipment. How can a nurse regulate
a patient who is hypovolemic without an IV pump? A patient who is


hypertensive needs vitals every fifteen minutes, but there are no

programmable vitals machines to be found. On many floors in the country
individuals who have never worked at the bedside make decisions for those
who do. Accountants have more say about the kinds of items that are
available on the floor for nurses to use than the nurses who use them.
Many nurses also feel that their work environment is difficult at best
and hostile at worst. There is growing evidence in nursing literature
regarding the positive impact of healthy work environments on staff
satisfaction, retention, improved patient outcomes, and organizational
performance (Sherman and Pross, 2010). A lack of respect from peers and
colleagues makes work difficult. Nurses often feel as though their opinions
are disregarded by the physicians that they work with. It is also difficult to
obtain assistance from other nurses who have heavy patient loads just like
theirs. A nurse should be able to work in an environment that promotes safe
care, evidence-based practice, and collaboration.
Another reason that there are not enough experienced nurses is poor
nurse retention.

According to the National Council of State Boards of

Nursing there is evidence in literature that states that in the first year of
practice there can be a 35% to 60% turnover rate (Spector and Echternacht,
2009). This high turnover continues after the first year. According to the U.
S. Department of Health and Human Services group the Health Resources
and Services Administration approximately 15% of all licensed RNs were not


working in their field in 2010 (HRSA, 2010). When a nurse leaves his or her
floor, it creates a staffing difficulty for the nurses that remain.
There are far too many reasons that there are not enough experienced
nurses available to care for the many patients in the U. S. Unfortunately the
shortage of nurses appears to be getting worse not better. The healthcare
system needs to find ways to encourage nurses in their field. Nursing is a
profession that deserves respect for the difficult job that is done every day. If
nurses had: enough staff for a reasonable patient load, the equipment to
care for them, an adequate orientation to learn their job, and positive work
environment then maybe the workforce would have enough experienced



Poor nurse retention

Transition to practice
Orientation too short


lack of equipment
Lack of
lack of support
lack of peer respect



Amer, K. S. (2013). Risks and threats to safe quality care in hospital settings.
Quality and Safety for Transformational Nursing. Retrieved from
Sherman, R., & Pross, E. (2010, January). Growing Future Nurse Leaders to
Build and Sustain Healthy Work Environments at the Unit Level
[article]. Online Journal of Issues in Nursing, 15(1). Retrieved from
Spector, N., & Echternacht, M. (2009). A Regulatory Model for
TransitioningNewly Licensed Nurses to Practice [journal article]. Journal
of Nursing Regulation, 1(2). Retrieved from
U.S. Department of Health and Human Services, Health Resources and Services
Administration (2010). The Registered Nurse Population: Initial Findings
from the 2008 National Sample Survey of Registered Nurses.