Post on 03-Jan-2016
description
Working the System to Promote Timeliness in Hospital Care
Linda Hughes, PhD, RN
Research Associate Professor
University of North Carolina-Chapel Hill
Funded by T32 NR07091
Timeliness
When care is provided can be just as
important as what care is provided.
Institute for Healthcare Improvement
Nurses’ Role in Timeliness
Early detection of impending problems
Minimizing unnecessary delays between problem recognition and initiation of appropriate action
Early Detection: Staffing
Adequate staffing has been linked to lower mortality, less failure to rescue, and fewer avoidable adverse events
suggesting that . . . Sufficient staffing is essential for close
patient surveillance and early detection of problems
Early Detection: Experience
Nurses’ experience has been linked to lower mortality and fewer adverse events during hospitalization
suggesting that . . . . Experience contributes to early detection
and accurate interpretation of patient cues indicating clinical deterioration
Minimizing Unnecessary Treatment Delays
Nurses practice under restrictions that limit the actions they can independently initiate in response to patient needs
(Hutchinson, 1990; Kramer & Schmalenberg, 2003)
Such restrictions can contribute to potentially harmful treatment delays
(Bower & Mallik, 1998; Prowse & Lyne, 2000)
Study Purpose
Describe how experienced critical care
nurses resolve situations when action is
warranted due to changes in patient status
but physician authorization is lacking
Study Sample
Licensed to practice as a registered nurse
Not less than 2 years experience in nursing
Employed in a direct patient care role on the same critical care unit for at least two years
Working the System
“you have to know how to jump through the hoops in order to get what you need for your patient and how to do it and with whom you need to do it with. You just have to know how to work the system for the best of the patient.”
Communicating Proactively with Physicians
Communicate their concerns with
certitude
Explain the reasons for their concerns
Provide sound justification for the orders
they wanted
“Doctors respect nurses who will tell them the
facts straight up about what’s going on. They’ll
listen to you more if you tell them what you
want instead of asking them what they think.
You tell them what’s going on with the patient,
what you think the patient might need, and
usually they’ll give you the order.”
Being Persistent
Exerting sustained effort to get a
physician to listen to and act in response
to their concerns about a patient
“I had a patient with calf pain and I called [the doctor] who ordered something for pain. [The patient got worse so] I called again and he told me to quit bothering him. So I called the supervisor who called another doctor and 2 hours later the patient was in surgery. As a new nurse, I would have doubted my clinical judgment and let it go. But over time, you learn not to let things go.”
Temporarily Ignoring the Rules
Overlooking the requirement for prior
physician authorization in situations
where compliance with the rules is thought
to be incompatible with the temporal
demands of the clinical situation
“I’ll order an ABG [arterial blood gases] for somebody in respiratory distress and that way you have all your facts. Because when you call a doctor, one of the things they’re going to order is an ABG and at least if you have that done, then the doctor can make a decision right then and there about what to do next.”
“I was working nights and I had a patient whose glucose was like 39 on the Accucheck and she didn’t have any orders to give her anything. And before I even called the physician, I gave an amp of D50 [50% dextrose] and then I called, you know, told him what I did and he was fine with it. It took a while to get a hold of him so if I had been waiting who knows how low her sugar would have been.”
Taking Charge
Serving as a clinical resource for coworkers
Contributing to the socialization of new
employees
Running interference for less experienced
nurses
“we have a nurse who has been on our unit for 23 years. She knows the system. She will find out about a problem, someone will bring it to her or she may have overheard something and said “what’s going on?” And if it’s a nurse who doesn’t feel comfortable calling a doctor whether that’s due to inexperience or just not wanting to butt heads with a certain physician, she’ll go to this nurse who will take care of it.”
Task Revision
Employee actions that result in effective job
performance despite a faulty procedure,
inaccurate job description, or role expectation
that is dysfunctional
(Staw & Boettger, 1990)
Proactive Behaviors
The use of a self-starting approach that
transforms one’s work role by
incorporating behaviors that extend
beyond formal job requirements yet make
a positive contribution to the attainment
of organizational goals
(Crant, 1995, Fay & Frese, 2000)
Flexible Role Orientation
Voluntary and constructive behaviors
initiated by individual employees to effect
organizationally functional change with
respect to how work is executed
(Morrison & Phelps, 1999)
Positive DeviancePro-social Rule Breaking
Violation of an organizational policy,
regulation, or prohibition, based on the
desire to do one’s job better or to do what
one believes to be appropriate in a given
situation (Morrison, 2006)
Conclusions
The organizational approach to point-of-
care decision making in hospitals often is
ill-suited to the situational demands of the
work
These nurses sometimes could not do their
job if they just did their job
Implications
Provides insight into the processes
leading to “failure to rescue”
Nurses’ discretionary work behaviors
may mediate the relationships among
staffing, experience, and better
outcomes among hospitalized patients