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