A frustrating problem for nurses can be getting Best Practice information.
Nurses can no longer continue practices that are not shown by research to help patients, and may be shown to harm patients. But in a typical complex healthcare setting, many barriers exist to change.
Nursing myths persist, and sacred cows are not always put out to pasture. In the end, nurses have to hold themselves responsible for their professional practice.
Let’s say, for example, your patient has a central line. You’re unsure when to change the central line dressing. So you ask Ashlee, who says, “24 hours after it’s inserted if it’s soiled, then every seven days.”
At lunchtime you relay what you just learned to your friend, when nurse Laurie overhears and corrects you emphatically “No. We change central line dressings every Sunday. On day shift.” Who is right?
Turns out Ashlee is correct, and the policy changed over one year ago!
Or maybe you were told in Orientation that the dwell/wet time for disinfecting accucheck machines is four minutes, only to see a notice on the accucheck machine on the floor that says three minutes, and then to observe your preceptor doing it for only two minutes.
One problem is the sheer volume of changes to be communicated. Practice guidelines change frequently, Centers for Medicare and Medicaid Services (CMS), and Joint Commission (JC) take off on a new focus, products change, the computer changes and how/where/what to document changes weekly. A nurse has four days off and the first thing he asks on his day back is “What changed while I was off?”
Many hospitals live in crisis mode, reacting to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey surveys, infection breakouts, nursing shortages, survey deficiencies, corrective action plans, and more.
Ebola happens and the fiscal budget is due. Fires flare up and must be put out. They never get to a proactive place, where change is planned and communicated ahead of time.
Here’s a current example. A 2014 Joint Commission National Patient Safety Goal is Clinical Alarm Safety. As of July 2014, hospitals were to differentiate critical alarms from non-critical alarms. Policies must be in place by 2016. Many hospitals have not yet begun this huge project, and will rush to be compliant in 2016. So in early or mid 2016, you may be assigned to attend a last minute, mandatory inservice about who can or cannot change alarm settings and by what criteria, etc.
You leave the inservice confused because the bugs are far from worked out, all the right people were not at the table when process changes were decided, questions could not be answered consistently, what you are being taught has not yet made it into policy, etc. etc. (Do let me know how this goes at your hospital).
Miscommunication happens. Something is announced in shift huddles or staff meetings housewide. Each manger states it a little bit differently, with a different focus. Each person hears it a bit differently or not at all. A manager or educator may feel he or she communicated something clearly, only to find that wasn’t the case. Scripting of important information helps with this, along with a blast system (email, flyers, huddles, online).
There are silos in hospitals, across which communication does not flow readily, like Lab and Nursing. As a result, both could be working on the blood transfusion policy, and both could be making changes that affect the other without realizing it.
Reba, the Charge Nurse who works weekends only on night shift Med-Surg, still hasn’t heard that nasogastric tube (NGT) placement must be confirmed radiographically, and not by injection of air followed by auscultation. So the night nurses on her watch are taught an old method. They are like small tribes on a desert island who haven’t gotten the message in a bottle yet.
Individual Choice or My Way is Best
Some people have been informed of new practice, but choose to continue old practice because of their own strongly held beliefs. Currently our hospital is changing over from bathing with soap and water using basins, to using bath wipes only, as an Infection prevention measure.
This is a very hard change for some caregivers who don’t want to give up bathing with water, using basins, because, well, let’s face it, we all love how good it feels to give a thorough bath with water! Some CNAs especially, who give excellent care, take pride and derive most of their job satisfaction from giving good bed baths.
But not following policy results in mixed practice, confusion for patients, and different standards of care.
Ryan insists on using separate IVPB tubing for each antibiotic, making it impossible for the following nurse to conserve tubing and avoid breaking the system unnecessarily (in patients who also have a maintenance IV). The reason? Not thinking it through critically. Easier to change every antibiotic tubing than to look up/learn antibiotic incompatibilities.
Nurse Melissa doesn’t care what the evidence shows, she does not want flexible visiting policies and increased family participation on her unit.
Dr. Heart had a bad outcome once, with a patient being rushed back to cath lab, and forever more his practice changed, based on that one experience. So all his patients remain on heparin gtt and bed rest longer than the standard after an angioplasty.
Span of Control
Many Nurse Managers have more than one nursing unit, 100-200 plus direct report employees working around the clock, up to 20% turnover in staff, travelers, agency staff, part-time and per diem staff who they rarely see. Communicating frequent change processes effectively to that many people is a challenge. Sometimes they have to triage what to push out, hoping that what they pick turns out to be the most important.
When Preceptors, Shift Leaders, and Charge Nurses are wrong
Double Penalty. Authority Bias. This is damaging because they are all authority figures. Most preceptors, shift leaders and charge nurses are informed and conscientious, but some give wrong information. Maybe it’s pride (some can’t say I don’t know), maybe it’s carelessness (not keeping up), or maybe they just don’t know what they don’t know.
Maybe they underestimate their influence and don’t realize that their words are weighted by virtue of their position.
Another version of this is dismissing a new nurse’s input. Maybe the new nurse learned best practice in school, and is respectfully clarifying what she learned. This scenario goes badly when the preceptor doesn’t thank them and check it out, and instead replies “Well, this is how I’m showing you how to do it.”
Practice by Personality
Sometimes it’s not a formal leader, but the most vocal, opinionated, self-declared expert on the floor who rules! I call it Practice by Personality.
Tiffany frequently declares that “Joint Commission/CMS says we have to do it this way! ” Tiffany also has no problem interpreting state law and the Board of Nursing to tell everyone what is or isn’t within “scope of practice,” depending on if she does or does not support the proposed change.
Tiffany has never researched the Nurse Practice Act, or CMS regs, but she is a great team player, makes great cakes for potlucks, and is well liked. Never underestimate the influence of informal leaders.
If all else fails, it can always be said “We’ve ALWAYS done it that way.” This is best delivered with a raised eyebrow and withering look.
Cows are not just sacred in India. There are plenty of them in Med-Surg, ICU, and all nursing areas.
Who to Ask
First rule is find out who NOT to ask. Tiffany is at the top of your list. After you have been at your facility a short time, you will be able to identify most of the Do Not Ask nurses. A person who is wrong once, apologizes and re-informs people with the correct information is one thing. The person who is wrong repeatedly and doesn’t seem to be concerned is another.
I would rather ask someone who is thoughtful in response, looks things up, and is concerned with rationale than the person who is dogmatic, loud and insistent.
A good resource is your Nurse Educator who will research and get you the best answer. As a Nurse Educator myself, with an interest in CMS/JC regs, I enjoy nothing more than digging for the right answer to help YOU and uphold professional nursing practice. I also love talking to and learning from new nurses, because they are open minded, generally not biased, eager to learn, and grounded in evidence-based practice.
Policy and Procedure
Policies are your best friend and protection. Policy is your best source, because it is written, and it’s a formal document authorized by your facility stating how things should be done. Policies are accessible and not subject to word of mouth misinterpretation. Always rely on the electronic version as the paper copy in your hand may be an older version.
If you do not know your facility’s policy and procedures, you are in a risky spot. I would ask, if not policy, then on what do you base your practice? You don’t want to base your nursing practice on someone else’s opinion.
Subscribe to nursing journals in your speciality. Look things up. Offer to inservice others on latest evidence-based practice. Lippincott Nursing Center is an excellent online resource, and if you have access, Lippincott procedures are all evidence based, and updated regularly.
Have a questioning mind, and a curious spirit.
Be that credible nursing colleague to others.
What nursing myths have you come across in your facility? Leave me a comment, I’d love to hear from you!
Until next time friend,