Fostering acceptance of computerized physician order entry: insights from an implementation study.

Computerized physician order entry (CPOE) allows physicians to enter orders in a computer rather than handwriting them. Computerized physician order entry is touted as a major improvement in patient safety, and although the literature suggests that such systems have the potential to improve patient outcomes, studies also suggest that CPOE may have significant drawbacks that accompany those benefits. Physicians have often been resistant to accept its implementation. This study investigates the implementation of CPOE at a 217-bed rural hospital in the southeastern United States. Drawing on a mixed-method approach, we identify correlates of change acceptance and propose a set of recommendations for health care managers to foster acceptance of CPOE. Findings from physician surveys (n = 19) indicate that older physicians are less accepting of CPOE, but high-quality change communication may overcome resistance even among older physicians. With insights derived from the organizational change literature, findings bring to the fore a set of practices that managers can use to foster acceptance of CPOE. The thrust of these practices is that managers should make physicians active participants in fine-tuning CPOE within the unique needs and constraints of the local hospital setting.

Interdisciplinary Rounds and Structured Communication Reduce Re-Admissions and Improve Some Patient Outcomes.

Hospital communication is more than access to information. Among staff, it is about achieving situation awareness-an understanding of a patient's current condition and likely trajectory. In the multidisciplinary context of providing care, structure, consistency, and repeatability of communication will enable a shared understanding of the patient and plan, leading to improved patient satisfaction and outcomes. This was tested using the Situation-Background-Assessment-Recommendation (SBAR) protocol, a re-admissions risk assessment and daily interdisciplinary rounds (IDR) in the medical/surgical units of a hospital. The impact of these interventions on patient satisfaction, Foley catheter removal compliance, and patient re-admission rates was assessed. Over the 3 year period, Foley compliance improved from 78% to 94%, and re-admissions decreased from 14.5% to 2.1%, both significant. Patient satisfaction trended positively, but was not significant. These results support the value of SBAR and IDR, and are advocated to improve situation awareness and maintain focus on key patient data.

Improving situation awareness and patient outcomes through interdisciplinary rounding and structured communication.

OBJECTIVE: To measure the impact of interdisciplinary rounds (IDRs) and the situation-background-assessment-recommendation (SBAR) communication protocol on staff situation awareness and patient outcomes. BACKGROUND: Communication frequency and consistency improve speed and clarity, especially between disciplines. Daily IDR using SBAR potentially facilitates the process. METHODS: Four patient review conditions were observed across 3 medical-surgical units of an acute care hospital: baseline, mobile (IDR only), paper-SBAR, and electronic-SBAR (IDR and SBAR). Observations occurred over a 9-month span. Review time (seconds), tools used, location, and field notes were recorded for 960 patient reviews. RESULTS: Patient review times were significantly shorter with IDR, decreasing from 102 to 69 seconds, but SBAR did not reduce times further. One patient satisfaction index did not change, whereas the other improved slightly. Length of stay did not change. CONCLUSION: The structure, consistency, and familiarity afforded by SBAR and IDR resulted in improved situation awareness and provided process, staff, and patient benefits.

Impact of SBAR on Nurse Shift Reports and Staff Rounding.

The Situation-Background-Assessment-Recommendation (SBAR) protocol was used to improve shift reports and interdisciplinary rounding. On a medical-surgical unit, observations were conducted before and after implementation. Both processes were significantly shorter and more consistent. SBAR enabled more focused and efficient communication.

Part of the job: the role of physical work conditions in the nurse turnover process.

BACKGROUND: Retention of nursing staff remains an important issue for health care managers. Turnover research has focused primarily on motivational and social factors as keys to retention, whereas the role of the physical work conditions has received considerably less attention. However, work design theory suggests that physical work conditions may be an important factor in fostering retention among nursing staff. PURPOSE: The aim of this study was to integrate work design theory with turnover process models to explore the influence of perceptions of physical work conditions on the development of turnover intentions among nursing staff. METHODS: Drawing on two samples of registered nurses working in cancer units in metropolitan hospitals in the southeastern United States, this study explores the impact of perceptions of physical work conditions on turnover intentions using ordinary least squares regression. Hypotheses are tested in Study 1 and replicated in Study 2. A measure of perceptions of physical work conditions is also developed and validated using exploratory (Study 1) and confirmatory (Study 2) factor analyses. FINDINGS: Perceptions of physical work conditions explain variance in turnover intentions above than that explained by motivational and social factors. Specifically, employee perceptions of noisy work conditions are found to significantly increase turnover intentions, whereas perceptions that work conditions facilitate tasks were found to significantly reduce turnover intentions. Perceptions of temperature and health hazard did not show significant effects. PRACTICE IMPLICATIONS: Results suggest that health care managers and scholars should re-examine the role of physical work conditions in the turnover process. Investments in upgrades that facilitate tasks may foster retention better than investments that simply improve employee comfort. Negative perceptions of work conditions may have no impact if they are considered a normal "part of the job," although negative perceptions of conditions that are viewed as under the organization's control may be important in creating a desire to leave.

Ward warriors: the complex nature of nurse mobility.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. In this article, the authors discuss the impact of complex system behavior on nurse workflow and its broader implications.

Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol.

OBJECTIVE: The Situation, Background, Assessment, Recommendation (SBAR) protocol was used to improve shift reports in 4 medical-surgical units. BACKGROUND: The SBAR protocol is increasingly advocated for use during shift reports, but data on the efficacy are limited. METHODS: Nurses were trained on SBAR in 4 medical-surgical units in a tertiary care hospital. Nurse tasks, tools, and locations were recorded during observation audits. RESULTS: The average time for shift reports did not decrease using SBAR. Nurses spent significantly more time on tasks specific to report. There was significantly more dialogue and less writing with SBAR. CONCLUSION: The introduction of SBAR made reports more focused, with more time spent discussing the patient and less on transcribing information. The SBAR protocol provides a concise and prioritized structure that enables consistent, comprehensive, and patient-centric reports.

Beyond communication: the role of standardized protocols in a changing health care environment.

BACKGROUND: Communication errors have grave consequences in health care settings. The situation-background-assessment-recommendation (SBAR) protocol has been theorized to improve communication by creating a common language between nurses and physicians in acute care situations. This practice is gaining acceptance across the health care field. However, as yet, there has been little investigation of the ways in which SBAR may have an impact on how health care professionals operate beyond the creation of a common language. PURPOSE: The purposes of the study were to explore the implementation of the SBAR protocol and investigate the potential impact of SBAR on the day-to-day experiences of nurses. METHODS: We performed a qualitative case study of 2 hospitals that were implementing the SBAR protocol. We collected data from 80 semistructured interviews with nurses, nurse manager, and physicians; observation of nursing and other hospital activities; and documents that pertained to the implementation of the SBAR protocol. Data were analyzed using a thematic approach. FINDINGS: Our analysis revealed 4 dimensions of impact that SBAR has beyond its use as a communication tool: schema formation, development of legitimacy, development of social capital, and reinforcement of dominant logics. PRACTICE IMPLICATIONS: The results indicate that SBAR may function as more than a tool to standardize communication among nurses and physicians. Rather, the findings indicate that SBAR may aid in schema development that allows rapid decision making by nurses, provide social capital and legitimacy for less-tenured nurses, and reinforce a move toward standardization in the nursing profession. Our findings further suggest that standardized protocols such as SBAR may be a cost-effective method for hospital managers and administrators to accelerate the socialization of nurses, particularly new hires.

Complexity and change in nurse workflows.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on management in social organizations such as hospitals. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. This is the 20th in a series of articles applying complex systems science to the traditional management concepts of planning, organizing, directing, coordinating, and controlling. In this article, the authors discuss how nurse workflow is characteristic of complex adaptive systems and the need for caution when selecting a performance improvement method.

Barriers to critical thinking: workflow interruptions and task switching among nurses.

Nurses are increasingly called upon to engage in critical thinking. However, current workflow inhibits this goal with frequent task switching and unpredictable demands. To assess workflow's cognitive impact, nurses were observed at 2 hospitals with different patient loads and acuity levels. Workflow on a medical/surgical and pediatric oncology unit was observed, recording tasks, tools, collaborators, and locations. Nineteen nurses were observed for a total of 85.2 hours. Tasks were short with a mean duration of 62.4 and 81.6 seconds on the 2 units. More than 50% of the recorded tasks were less than 30 seconds in length. An analysis of task sequence revealed few patterns and little pairwise repetition. Performance on specific tasks differed between the 2 units, but the character of the workflow was highly similar. The nonrepetitive flow and high amount of switching indicate nurses experience a heavy cognitive load with little uninterrupted time. This implies that nurses rarely have the conditions necessary for critical thinking.

Transforming nursing workflow, part 2: the impact of technology on nurse activities.

OBJECTIVE: To assess the impact of new technology on nurse workflow, nurses at 2 hospitals were observed before and after implementation of an electronic medication charting system. In part 1 (September 2010 issue), we discussed the chaotic nature of nurse activities and its implications on transforming workflow. BACKGROUND: Numerous studies have documented the impact of technology on performance and satisfaction, but technology's impact on the frequency, duration, and pattern of activities is less understood. These patterns are important to the development of new care models. METHODS: Observers shadowed nurses at 2 hospitals before and after the implementation of an electronic medication charting system. A total of 196 hours of observation was recorded at one site, and 185 hours at the other site. RESULTS: Analysis of variance revealed a number of significant differences in the time spent on a variety of activities, but the duration and frequency of nurse activities were not drastically altered by the additional technology. CONCLUSIONS: Computer use increased; however, the impact was evenly distributed among other activities. More importantly, time with patients and verbal communication remained unchanged as nurses seemed to incorporate the new requirements into their normal routine.

Transforming nursing workflow, part 1: the chaotic nature of nurse activities.

OBJECTIVE: To quantitatively measure workflow and computer use, the activities of 27 medical-surgical RNs were recorded through direct observation. BACKGROUND: Previous studies have shown how nurses spend their time but have not documented the pattern, duration, or frequency of activities. The absence of this information is problematic for leaders charged with improving performance and staff development. METHODS: Observers recorded nurse activities and location in real time using predefined lists. More than 98 hours of observations were recorded. RESULTS: Assessment, charting, and communicating were the most frequent activities, consuming 18.1%, 9.9%, and 11.8% of nurse time, respectively. The duration of 40% of the activities was less than 10 seconds. Timelines revealed that nurses constantly switch activities and locations in a seemingly random pattern. CONCLUSION: The results indicate that there is little "flow" in nurse workflow. The chaotic pace implies that nurses rarely complete an activity before switching to another. The opportunity to use critical thinking and engage in planning care is severely limited under these circumstances. The implications for cognition and role transformation are discussed. Part 2 of this research explores the impact of new technology on nurse activities and workflow.