Presentation to 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 of mindfulness in patient safety.

1. Organizational Context and
Patient Safety:
Is There a Role for Mindfulness
Heather M. Gilmartin, PhD, NP
Post-doctoral Nurse Fellow
Denver-Seattle Center of Innovation
Department of Veterans Affairs
October 9, 2015
1

2. 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
2

3. 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
3

4. Context is everything.
Bate P. Context is everything. London, England: Health Foundation;2014.
4

5. Context is everything.
Bate P. Context is everything. London, England: Health Foundation;2014.
5

6. 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.
6

7. 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)
7

8. 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)
8

9. 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
9

10. Organizational
Context
Adherence to
Central Line
Bundle
Client
X
XX
Leadership
Psych
Safety
Climate
MD RC
HA RC
RN RC
Estimator: WLSMV
Chi-sq (1,315) = 1,986.30
P <.0000
RMSEA = .04
CFI = .97
0.24
(p=.00) -0.07 (NS)
0.87
0.81
0.96 -0.67
-0.76
-0.65
-0.37
CLABSI
Weighted
Mean
EVS RC
RC: Relational Coordination
10

11. 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 models
o 120 ICUs per year - 2008-2011
11

12. Patient Weighted
Case Severity Index
(ICU level)
Organizational
Context
CL Bundle
Intervention
CLABSI Outcomes
Hand Hygiene
2% CHG
Max Barrier
Optimal Site
Organizational
Climate
Organizational
Culture
Work
Environment
Structural
Characteristics
AES Culture
Survey
AES Job
Satisfaction
AES OAI Facility
Complexity Level
30-day Standard
Mortality Ratio
AES: All Employee Survey
CHG: Chlorhexidine Gluconate
The Quality Health Outcomes Model Applied to
Infection Prevention in the VA
12

13. 13

14. Culture
Work
Environment
Patient
Healthcare
Provider
Climate
Patient
Safety
14

15. Mindfulness
Awareness or Heartfulness
15

16. 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.
16

17. 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
17

18. Mindfulness is attending to the
ordinary, the obvious, and the present.
Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839
18

19. Mindfulness is the opposite of
multitasking.
Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839
19

20. 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
20

21. Somatic and Psychological
Disorders
Work/Caregiving Related
Issues
21
• 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.

22. Mindfulness-Based Stress
Reduction Program
• 8-week intensive introduction to mindfulness practice
o 2.5 hour class 1x/week
o 30-45 minutes of meditation per day
o 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 themselves
22
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.

23. Mindfulness Techniques
• Meditation
o Sitting
o Walking
o Eating
o Everyday activities
o Loving kindness
• Mindful movement (yoga)
• Attitudinal Foundations
o Non-judging
o Patience
o Trust
o Non-striving
o Beginner’s mind
o Acceptance
o Letting go
23
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.

24. 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 patients
24
Sharma, 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.

25. 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.
Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839
25

26. Challenges: Method and Process
• Lack of a standardized approach to the method and its
interventions
• Lack of a universally accepted definition
o 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
26
Mars, T.S., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal
of Osteopathic Medicine, 13, 56-66.

27. 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 Inventory
o Mindfulness Attention and Awareness Scale
o The Kentucky Inventory of Mindfulness Skills
o The Cognitive and Affective Mindfulness Scale
o The Mindfulness Questionnaire
o Toronto Mindfulness Scale
o The Philadelphia Mindfulness Scale
o Five Facet Mindfulness Questionnaire
27
Mars, T.S., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal
of Osteopathic Medicine, 13, 56-66.

28. 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
28
Mars, T.S., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal
of Osteopathic Medicine, 13, 56-66.

29. Culture
Work
Environment
Patient
Healthcare
Provider
Climate
Patient
Safety
29

30. 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 mindfulness
o Awareness back to the present
o Allow for a moment of clarity, insight, and reflection
o Move hand hygiene from passive compliance to act of self-care
and self-compassion
• We provided an mindful guide to hand hygiene
30

31. 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.
31http://www.cdc.gov/handwashing/when-how-handwashing.html

32. 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.
32

33. Does a mindful guide to hand
hygiene improve the self-reported
experience of hand hygiene for
healthcare providers versus standard
hand hygiene instructions?
33

34. 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.
34

35. 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
35

36. Acknowledgments
• Thank you:
o Dr. Pat Stone, Columbia University
o Dr. Karen Sousa, University of Colorado
o Dr. Cathy Battaglia, University of Colorado &
Denver VA
o Dr. Sarah Krein, University of Michigan &
Ann Arbor VA
o Dr. Sanjay Saint, University of Michigan &
Ann Arbor VA
36

37. Contact Information
Heather M. Gilmartin
Post-doctoral Nurse Fellow
U.S. Department of Veterans Affairs
Denver/Seattle Center of Innovation
1055 Clermont St.
Denver, CO 80220
Heather.gilmartin@va.gov
720-857-5097
37

38. Thanks to the VA for
thinking outside the box
for our Veterans and their
caregivers.
Go Blue!!!
Thank You
38

39. References
Bate, P. (2014). Context is everything. In J. R. Bamber (Ed.), Perspectives on context: A selection of essays considering the role of context in successful
quality improvement (pp. 1-30). London, England: Health Foundation.
Damschroder, L. J., Banaszak-Holl, J., Kowalski, C. P., Forman, J., Saint, S., & Krein, S. L. (2009). The role of the "champion" in infection prevention: Results
from a multisite qualitative study. Quality & Safety in Health Care, 18(6), 434-440. doi: 10.1136/qshc.2009.034199
Epstein, R.M. (1999). Mindful practice. JAMA, 282(9), 833-839. doi: http://dx.doi.org/10.1001/jama.282.9.833
Goldin, P.R., & Gross, J.J. (2010). The effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion, 10, 83-
91.
Goodman, M.J., & Schorling, J.B. (2012). A mindfulness course decreases burnout and improves well-bing among healthcare providers. International Journal
of Psychiatry in Medicine, 43(2), 119-128.
Hulsheger, U.R., Feinholdt, A., & Niubold, A. (2015). A low-dose mindfulness intervention and recovery from work: Effects on psychological detachment, sleep
quality, and sleep duration. Journal of Occupational and Organizational Psychology, 88, 464-489.
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.
Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E., Pbert, L., . . . Santorelli, S.F. (1992). Effectiveness of a meditation-based stress
reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149(7), 936-943. doi: http://dx.doi.org/10.1176/ajp.149.7.936
Krasner, M.S., Epstein, R.M., Beckman, H., Suchman, A.L., Chapman, B., Mooney, C.J., & Quill, T.E. (2009). Association of an educational program in mindful
communication with burnout, empathy, and attitudes among primary care physicians. JAMA, 302(12), 1284-1293.
Krein, S., Kowalski, C., Damschroder, L., Forman, J., Kaufman, S.R., & Saint, S. (2008). Preventing ventilator-associated pneumonia in the United States: A
multicenter mixed-methods study. Infect Control Hosp Epidemiol, 29(10), 933-940.
Krein, S.L., Damschroder, L.J., Kowalski, C.P., Forman, J., Hofer, T.P., & Saint, S. (2010). The influence of organizational context on quality improvement and
patient safety efforts in infection prevention: A multi-center qualitative study. Social Science & Medicine, 71(9), 1692-1701. doi:
http://dx.doi.org/10.1016/j.socscimed.2010.07.041
39

40. ReferencesLudwig, D.S., & Kabat-Zinn, J. (2008). Mindfulness in medicine. JAMA, 300(11), 1350-1352.
Mackenzie, C.S., Poulin, P.a., & Seidman-Carlson, R. (2006). A brief mindfulness-based stress reduction intervention for nurses and nurses-aides. Applied
Nursing Research, 19, 105-109.
Mars, T.S., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal of Osteopathic
Medicine, 13, 56-66.
Mitchell, P.H., Ferketich, S. , & Jennings, B.M. (1998). Quality health outcomes model. Image - the Journal of Nursing Scholarship, 30(1), 43-46. doi:
http://dx.doi.org/10.1111/j.1547-5069.1998.tb01234.x
Potter, P., Deshields, T., Berger, J.A., Clarke, M., Olsen, S., & Chen, L. F. (2013). Evaluation of a compassion fatigue resiliency program for oncology nurses.
Oncology Nursing Forum, 40(2), 180-187.
Saint, S., Kowalski, C., Kaufman, S.R., Hofer, T. P., Kauffman, C.A., Olmstead, R.N., . . . Krein, S. (2008). Preventing hospital-acquired urinary tract infection in
the United States: A national study. Clinical Infectious Diseases, 46(2), 243-250.
Saint, S., Kowalski, C. P., Banaszak-Holl, J., Forman, J., Damschroder, L., & Krein, S. L. (2010). The importance of leadership in preventing healthcare-
associated infection: Results of a multisite qualitative study. Infection Control & Hospital Epidemiology, 31(9), 901-907. doi: http://dx.doi.org/10.1086/655459
Shanafelt, T.D. (2009). Enhancing meaning in work. A prescription for preventing physician burnout and promoting patient-centered care. JAMA, 302(12),
1338-1340.
Shapiro, S.L., Astin, J.A., Bishop, S.R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: Results from a randomized
trial. International Journal of Stress Management, 12(2), 164-176. doi: http://dx.doi.org/10.1037/1072-5245.12.2.164
Shapiro, S.L., Schwartz, G.E., & Bonner, G. (1998). Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral
Medicine, 21(6), 581-599.
Sharma, 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.
Shekelle, P.G., Pronovost, P.J., Wachter, R.M., Taylor, S.L., Dy, S., Foy, R., . . . Rubenstein, L. (2010). Assessing the evidence for context-sensitive
effectiveness and safety of patient safety practices: Developing criteria. Rockville, MD: Agency for Healthcare Research and Quality.
Stone, P., Pogorzelska-Maziarz, M., Herzig, C.T., Weiner, L.M., Furuya, E.Y., Dick, A., & Larson, E. (2014). State of infection prevention in US hospitals
enrolled in the National Health and Safety Network. American Journal of Infection Control, 42(2), 94-99. doi: http://dx.doi.org/10.1016/j.ajic.2013.10.003 40