By: Francella Smoker, Ph.D., RN
Published: 1 August 2018

Now more than ever change is constant, especially in the healthcare marketplace. For change to be effective and strong, capable leaders are needed to create direction, remain focused on objectives, and lead others. Doctoral and master’s prepared nurse educators, coupled with years of clinical practice experience, can positively impact on rebooting processes and systems within facilities. Nurse educators are often the leaders capable of breaking down barriers, redefining processes, improving system workflow, challenging traditional thinking, and upgrading thinking to evidence-based practice. In this position, the nurse educator develops and maintains educational programs, as well as evaluates and documents outcomes of programs. Additionally, the nurse educator applies current concepts and findings from research and studies to practice. Further, the nurse educator’s broad understanding of instructional methods, materials, and theories enable him/her to be versatile, flexible, and able to make people feel significant, use discretion, exercise choice, and foster competence. Working with patients, families, nursing staff, and nursing students require interpersonal skills; which is why the nurse educator must be approachable, and empathetic to other’s needs. The educator should portray a friendly, warm, and receptive behavior conducive to learning, displaying self-confidence, and respect which allows people to feel comfortable, confident, and secure in learning situations.

This paper examines situations in a hypothetical surgical unit and how nurse educators can break down barriers and pave the way to implement programs which focus on the needs of patients, staff, and the organization; and, facilitate changes for redefining processes and improving systems for a better workflow.

Hospital Alpha

Imagine being employed for hospital Alpha where the vision and philosophy of the organization are dedicated to conducting quality and useful evaluations with the belief that evaluations are most successful when conducted by teams of organization members who have different experiences and responsibilities to the program or service being evaluated. The goal of the evaluation program for nurses is for staff nurses to develop into the role of clinical teachers and express confidence in teaching and evaluation skills. As such, dedicated nurse educators are an integral part of educating and training staff nurses, newly hired nurses, student nurses, licensed practical nurses, and certified nurse assistants. Evidence-based practice is the norm and resources, such as a full library to conduct research, is available and supervised by a librarian.

Staff members are versed in utilizing resources in the library to promote and integrate current clinical research evidence to practice. In addition, updated nursing and technician books, manuals, computers, and videos of surgery recorded for training purposes are available to staff upon request. Hospital Alpha also has a simulation lab with trained experts who conduct face-to-face clinical training based on data gathered from problematic areas in clinical environments. High-risk patient care issues are handled in a professional, non-threatening, non-punitive manner and the attitude used to deal with mistakes is one of correction and learning. At the end of orientation in Hospital Alpha, newly hired employees feel empowered and motivated to be a team member and are excited at the prospect of coming to work. The nurse educator in this hospital made a positive impact on implementing programs which focus on the needs of patients, staff, and the organization.

Hospital Bravo

Now imagine being employed at hospital Bravo where the culture is one of reprisal and punishment. Nurse educators are tasked to perform many jobs in order to save money; thus, education and training are neglected. A small library is available but is rarely utilized by clinical staff members. RNs and other staff members have limited resources when support is needed for patient care and staff related issues. Incorporating evidence-based practice into routine patient care is unfamiliar to staff members; thus, nurses live by the phrase ‘If it ain’t broke don’t fix it’. High-risk patient care issues are handled in a punitive manner and the attitude used to deal with mistakes is fostered out of fear and punishment. At the end of orientation in hospital Bravo, new members feel undervalued, apathetic, and think about finding a position elsewhere or leaving the nursing profession altogether.

Developing an Environment of Learning

The days of focusing on only nursing care are gone. Today, nurses are challenged to consider the method of care they use, how it will impact the health of the patient, the cost of providing care, and the outcome for both the patient and organization. Nurses are expected to consider factors across various clinical activities. Nurse educators are at the forefront of this change and encourage lifelong learning as a part of being a healthcare professional. In developing an environment of learning, the nurse educator utilizes a variety of learning tools and strategies to teach others the importance of learning and growing. Nurse educators are crucial in setting the foundation for research-based practice. Expert nurse educators can provide the essential support to assist nurses through the different phases of research, applying best evidence to practice and to be lifelong learners.

Quality Improvement at Hospital Alpha

Continuing the hypothetical scenario at hospital Alpha, after reading peered-reviewed nursing journal an RN in the surgical unit decides to investigate if a custom surgical pack would accomplish the objectives of saving time, improve efficiency, and lower cost. The RN realizes that costs such as waste disposal and facility overhead are difficult to measure and often ignored because it is challenging to quantify savings in these areas; however, the cost of supplies used during a surgical procedure can be quantified by logistics invoices. The current practice in the surgical unit is to pick frequently used disposable items separately for common surgical procedures that require the same item every case. In this scenario, the RN, in collaboration with the nurse educator, puts together a quality improvement team and conducts a research project to investigate if having a custom surgical pact would accomplish the objectives of saving time, improving efficiency, and lowering costs.

Quality Improvement at Hospital Bravo

Imagine that upper leadership at hospital Bravo launches a new Patient Safety Reporting system (PSR). PSR is an effective system of monitoring near misses and actual events to improve processes and system functions. A patient safety reporting system creates a just culture that looks at errors and mistakes in an objective manner to find contributing factors, and after reviewing the factors determines accountability in relation to the actions. The staff is told of this new PSR system however the majority of staff members continue to report incidents via the old paper charting system, or they do not report incidents due to fear of reprisals. Continuing to use the old paper system for reporting incidents is ineffective because of the incident may not be addressed. One of the reasons for this gap is that hospital Bravo supports a culture of reprisals and punishments. If there was a dedicated nurse educator, he/she could emphasize the importance of the new system and ensure that nurses are properly trained and fully understand the consequences to the organization, the team, and themselves of not using the system as it was intended. Without a nurse educator who is able to close the gap between what the upper management expects and what the staff understands, information becomes lost resulting in a disjointedness from what is expected and what actually happens.

Upper Management at Hospital Bravo

The upper management at Hospital Bravo experienced a robust unit when they did a walkthrough of the surgical unit; however, the reality of working in this unit is opposite of what upper leadership saw. The reality on this surgical unit is that of short staffing, dysfunctional teamwork, lack of training and education, poorly designed systems, and staff members who feel they must take shortcuts which are not in compliance with standards and policies. Consequently, a near miss, an actual event, or a sentinel event is waiting to happen. Why does the hospital upper leadership see a different picture than the workers? Because upper leadership does not always understand how information is been disseminated to grassroots levels in their organization. Information collected from safety programs, infection control programs, and other sources is not always passed down to staff members who could utilize the information to make a difference in the unit.

Orientation Hospital Alpha and Hospital Bravo

An experienced RN was hired by hospital Bravo and it was assumed by the operating room manager and staff nurses in the surgical unit that because the newly hired nurse was experienced, the nurse did not need an orientation. The newly hired nurse was placed to provide direct patient care within one week of being hired and without being given an orientation to the unit. The newly hired nurse inserts a Foley catheter on a pre-operative surgical patient under anesthesia and the patient suffered an injury resulting in the patient’s surgery being canceled. Management punishes the nurse and the staff holds the nurse in contempt. As such, the nurse becomes disgruntled and works in constant fear of this culture. Considering failures in communication in the surgical arena account for up to 70 percent of adverse events, best practices in creating a culture steeped in corrections and training, rather than one entrenched in punishment and reprisals, will result in effective teams. Creating an effective team is important especially in the operating room environment where patient care is a team activity.

In hospital Alpha, similar to the scenario in hospital Bravo, an experienced RN was hired; however, the newly hired RN is provided an experienced nurse preceptor with in-depth knowledge of the orientation process. The nurse preceptor is supervised by the nurse educator in monitoring the newly hired nurse’s progress. The criteria used to measure successful progress toward meeting the outcome of orientation was discussed with the newly hired nurse prior to beginning orientation. At the end of the orientation period the newly hired nurse, after reviewing and practicing competency assessments feels prepared to begin providing patient care.

If the newly hired experienced RN did make an error inserting the Foley catheter, a dedicated nurse educator at hospital Alpha would go through a step-by-step process to determine contributory factors of the incident. The nurse educator may resolve to utilize Reason’s Algorithm in determining ways to minimize this incident from occurring in the future. James Reason’s algorithm suggests that perioperative leaders should apply this model when investigating incidents to determine whether disciplinary action is warranted.  Six basic steps are used and the importance of focusing on the error, and not the outcome, is stressed. Yet another method the nurse educator might utilize is one such as TeamSTEPPS, an evidence-based teamwork system designed to improve the quality, safety, and efficiency of healthcare. According to the TeamSTEPPS model, the contributory factors which led to an unfavorable incident could be prevented if principles of leadership, situation monitoring, mutual support, and communication were in effect. With these cornerstones implemented to protect patients from actual and sentinel events, patient safety will increase and medical errors will decrease. The hospital would save money when cases are not canceled and patients would receive desired outcomes from scheduled surgical cases. Lawsuits and other shortcomings that would result in a net loss would be avoided, and profit margins would rise as the reputation of the organization spreads.

Analysis of Hospital Alpha and Hospital Bravo

In comparing and contrasting these two hospital environments it is clear to see the many benefits a dedicated nurse educator can offer that is difficult to find. Nurse educators are at the forefront of answering the call for improved outcomes and cost-effective care. Improving patient outcomes, while providing cost-effective care, is one benefit nurse educators can provide. The nurse educator, by virtue of their clinical experience and formal educational preparation, is empowered with the versatility to function in a broad scope of practices enabling them to serve as a catalyst for closing gaps in communication, and utilization of evidence-based practices to promote quality care and staff educational opportunities. Organizations that value their staff and high-quality patient care, value education, and training. Organizations that promote a culture of correction, training, and evaluation will effect changes at the grassroots level leading to sustaining high-quality staff who can provide outcomes patients can count on.

On the other hand, as was evident at hospital Bravo, the absence of a nurse educator and the limited value placed on education and training has a far-reaching negative impact on staff and the care provided to patients. If nurses have limited time and lack of resources to assist in applying best practices, then traditional nursing intervention may lead to harm in providing patient care. If nurses must work in an environment with limited resources, where safety and best practices are not the norms and taking shortcuts prevails, then organizations should not reasonably expect nurses to produce top quality care for patients. In other words, organizations cannot expect to reap success if they sow failure.


Nurse educators have key roles to play as gatekeepers to ensure the public remains safe as healthcare institutions continue their quest for higher quality, better patient care, and safety. The nurse educator, by virtue of their clinical experience and formal educational preparation, is empowered with the versatility to function and adapt in many roles. This enables the nurse educator to serve as a catalyst for closing gaps in communication, in the utilization of evidence-based practice to promote quality care for patients, and in achieving optimal educational opportunities for staff development and student nurses.


Veterans Benefits Information. (2016, Dec 30). DoD PSP Treasure chest: January edition. Retrieved from

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