Working the System to Promote Timeliness in Hospital Care

1. 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

3. Timeliness When care is provided can be just as important as what care is provided. Institute for Healthcare Improvement

4. Nurses’ Role in Timeliness • Early detection of impending problems • Minimizing unnecessary delays between problem recognition and initiation of appropriate action

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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.”

11. Communicating Proactively with Physicians • Communicate their concerns with certitude • Explain the reasons for their concerns • Provide sound justification for the orders they wanted

12. “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.”

13. Being Persistent Exerting sustained effort to get a physician to listen to and act in response to their concerns about a patient

14. “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.”

15. 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

16. “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.”

17. “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.”

18. Taking Charge • Serving as a clinical resource for coworkers • Contributing to the socialization of new employees • Running interference for less experienced nurses

19. “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.”

20. 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)

21. 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)

22. 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)

23. 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)

24. 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

25. 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