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. W hen care is provided can be just as important as what care is provided.
Linda Hughes, PhD, RN
Research Associate Professor
University of North Carolina-Chapel Hill
Funded by T32 NR07091
When care is provided can be just as important as what care is provided.
Institute for Healthcare Improvement
suggesting that . . .
suggesting that . . . .
(Hutchinson, 1990; Kramer & Schmalenberg, 2003)
(Bower & Mallik, 1998; Prowse & Lyne, 2000)
Describe how experienced critical care nurses resolve situations when action is warranted due to changes in patient status but physician authorization is lacking
“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.”
“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.”
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.”
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.”
“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.”
Employee actions that result in effective job performance despite a faulty procedure, inaccurate job description, or role expectation that is dysfunctional
(Staw & Boettger, 1990)
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)
Voluntary and constructive behaviors initiated by individual employees to effect organizationally functional change with respect to how work is executed
(Morrison & Phelps, 1999)
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)