Hello,

"Wouldn't the predominant method staff RNs use for processing (Conservator) support creating a clearly defined structure of best practices? " The answer to this question is NO.

There are other things/aspects/features/characteristics at play. It is a question [but the only one] of power and power play and power status.

"King et al. (2010, p. 292), building on Bauman and May (2001) and Czarniawska (1997), have an appropriate statement that applies here: “Their [organization’s] status derives from the expectations of others, including the state, individual members of the organization itself, and other stakeholders and audiences who monitor and hold them accountable for their actions.” "The more people depend on you, the more 'powerful' you are [please note that 'powerful is in quotations]

"Organizations and departments of healthcare institutions use different resources and tactics available to them in order to secure the desired resources. It must be noted that most of the resources and the different strategies that are employed to secure them, some are within the unwritten rules, some are not. Therefore, tensions rise between different actors." Here, what is important are the unwritten rules.

"The hospital increased in complexity, structure and size due to a very fast development of this institution (as well as due to medical advances also). There were major and fast changes. Kingston (1983, p. 1163) provides some historical references regarding the changes in the duties of an administrator: “the hospital administrator in the U.S. has moved from being little more than a clerk at the turn of the century to a business manager (1920s-1940s) to coordinator (1950s-1960s) to corporate chief and management team leader (1970s- ).” This was the case in most Western countries."

"In his research, Litwak (1961) points out that there are two different system implemented (medical vs. administrative) (decentralized vs. centralized); however, the reason why those different systems work is that a pre-allocated distribution of authority is presented, imposed, and accepted by the employees (i.e., their roles, responsibilities, and duties are clearly predetermined). In different words, all know where they stand and what their duties are. To this, “there was little conflict between the two systems because management and workers had agreed in advance that interaction between one set of roles was to be handled by local discretion, but between another set of roles by centralized authority. Since the roles were clearly differentiated, it was possible to do this with minimal friction.”"

"One of Thompson’s (2000) roadblocks to change is ‘too much regulation’. This may be imposed by one or two or all of the pillars present in the hospital institution. However, bad regulation or not enough regulation, or the items that need to be regulated are having the same effect. Most of the regulations are imposed by the administration, contingent on what the professional staff wants/desires . It is the administrator’s duty to make sure that the system works properly. Furthermore, it is not only a question of ‘proposed’ regulation, but also a matter of implementation. Those that implement it, most of the time are part of the hospital’s professional staff. Their input must be noted and taken in consideration. "

I would add more... Some guidance towards the direction would help :)

Kind regards,

Alex

Thank you so much for your in-depth reply! What I am noting in professional nursing practice is that the reaction to complexity means that they miss basic parts of their professional roles; such as their legal responsibility/accountability to offer initial and ongoing direction to others they lead on the team, and also to miss the actual care tasks due to fragmentation of their work.  They miss knowing their patients to the extent that the right therapy is completed for the right patient at the right time and frequency.  We are not talking here about regulations placed on them unwillingly from a clueless administration. These are nurse practice act responsibilities as well as healing and patient safety imperatives. Therefore Thompson's (2000) point about actual professional implementation suggests that the profession has agreed-upon guidelines that could act as barriers.  However, these guidelines/best practices are imposed to protect public safety, but  are not infrequently omitted in reality, which leads to missed care. Litwak's points are well taken,  but management often believes that the RNs use their professional authority even when they do not. Role frictions then emerge.  

I have noted in my practice that helping staff RNs visualize an overall structure to their work and experiencing/learning best practices allows them to alter their practice (thus change, because the results are preferable to the former work flow.)  I have worked with about 175 healthcare organizations over 25 years so I suspect my thoughts are based more on my experienced reality than theory. My question was more about how staff RNs process information.  My  dissertation was on critical thinking and clinical judgment.  I am always interested in why and how nurses can grow and change; to help them think more effectively.  The practical clinical results have been positive when I expose them to best practice structure:  nurse sensitive indicators improve such as fewer HAPUs, reduced length of stay, fewer infections, fewer errors, fewer falls, better patient/family satisfaction, better staff satisfaction.

So I do believe a structure that allows staff RNs to re-think their responsibilities, accountability, and to "schedule" best practices, does help them practice differently. 

I really appreciate your time and the thoughts expressed. 

Ruth

Hi Dr. Ruth,

I am a current nursing student at uni. Thank you very much for you inspiring sharing here and some critical points have been made for helping us to be more aware of improving our real-time practice.

For "They miss knowing their patients to the extent that the right therapy is completed for the right patient at the right time and frequency.", it reminded me the time of having practicum at hospitals that the staffs there might try to neglect some basic responsibilities or guidelines in ward practice, like the 3-checks-5-rights in AOM. As a nursing student, being on the way to the track, we always emphasize on fulfilling every roles and tasks in taking care of patient. And I think maybe because of the "experiences" and "convenience", staff nurses will soon adapt to a 'better" way to conduct their works. Sometimes, they just underestimate the risks behind. So I appreciate you a lot about giving the idea of having a good practice structure to help them to be more fit to their roles. And obviously, the predominant methods could be the strong practice with expert-based that most of the things we are learning/ have learned are from those originally, serving as a template.

Looking forward to you further research and sharing.

Best Regards,

Nadeshiko

thank  you so much Nadeshiko for your perspective on this as a student!

Ruth