AACN News—January 2007—Opinions

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Vol. 24, No. 1, JANUARY 2007

Overrun by Rules (aka Rules Run Amok) Powered by Insight

An insight has the capacity to take something that you know in your head and make you feel it in your gut.
—Phil Dusenberry

Sometimes it’s another person’s insight that captures our imagination. For me it was a newsletter article by Kerry Patterson, co-author of the bestseller Crucial Conversations: Tools for Talking When Stakes Are High and co-founder of VitalSmarts. Cleverly titled “Crying Wolf: When ‘No’ Doesn’t Always Mean ‘No’,” the article captures Kerry’s reflections on his mother-in-law’s hospital stay for a broken hip.

Kerry named what he saw a “cry wolf” culture where rules and regulations, regardless of their importance, were often ignored or followed only when they did not get in the way. For example, team members who assiduously ignored equipment alarms because, as they explained it, the alarms are oversensitive. And others who paraded into her room after patting the antiseptic solution dispenser at the doorway yet never actually using its contents.

We have become so enamored with mindless regulation that we are painting ourselves into a dangerous corner. Rules with life-or-death consequences have become regarded in the same way as mundane rules developed as administrative quick-fixes to one-time episodes of thoughtlessness or oversight. Perhaps it is because we are blinded by the comfort of rules or we have chosen the path of least resistance. However, this paradox makes our work needlessly complex and worsens change fatigue. Ultimately, it introduces hazards to quality and safety that the rules intended to prevent.

Rules and Paradoxes
This insight led me to identify examples of the paradox from my own practice. There may be similar ones in your own.

“Standardized care is in a patient’s best interest. Yet care that is not individualized is less able to meet a person’s unique needs.” Both standardization and individualization are worthwhile goals to achieve. However, does standardization blind us to recognizing situations when it is inappropriate? The best practice standard to treat community-acquired pneumonia with antibiotics within four hours of arrival at the hospital is a worthwhile goal. But does that mean an absolutely literal four hours when striving to obtain an accurate diagnosis? For example, trying to determine if the pulmonary fluid is caused by pneumonia requiring antibiotics or exacerbated heart failure where repeated administration over time of unnecessary antibiotics is detrimental. Institutions and regulators will need to be cognizant of this fine line as they continue driving toward best practices, especially where they relate to reimbursement for care.

“Studies by Ann Rogers, Linda Scott and colleagues at the University of Pennsylvania indicate that nurse fatigue can lead to increased errors and heightened risk of failure to rescue. Yet nurses are often fatigued from working overtime, be it mandatory or voluntary.” The Penn nurse fatigue studies validate recommendations by the Institute of Medicine and others to at least limit nurses’ work hours to no more than 12 consecutive hours during a 24-hour period. Mandatory overtime is certainly inappropriate. But would a more appropriate goal be for administrators to sharply curtail, or eliminate entirely, all need for overtime? Ensuring adequate compensation for nurses would be one way to begin so nurses don’t need the option of voluntary overtime to make ends meet.

“Nurses are staunch advocates for patient safety. None of us wants to be responsible for an avoidable error or adverse outcome, yet we often circumvent the most basic of safety measures like handwashing and insisting on pre-procedure verification.” Unarguable evidence supports having rules in both instances. Yet despite the nearly universal existence of such rules, they are not universally followed because they have been devalued by an overabundance of rules. Kerry Patterson’s insight helped me to identify the proliferation of rules, often for their own sake. Rules are not always the solution and unnecessary rules may create dangers of their own.

No Doesn’t Always Mean No
I was further reminded that no doesn’t always mean no. Many rules are intended to have exceptions and the number of absolute rules should be quite small. After all, we do not practice in an exact science and even the strongest evidence may change with time. One way of approaching the problem is by reviewing our institutions’ rules according to three criteria: Does a rule conflict with other rules? Does a rule do good? Does it do harm?

So I ask you: How are rules and regulations developed where you work? Is the need thoughtfully considered and based on evidence? Or are they knee-jerk reactions to one-time episodes? What criteria are considered during periodic review of existing rules? Or is the need assumed, focusing instead on revising and updating? I would be interested in hearing about your experiences with rules, especially about successfully taming the rule monster. Please write to me at insights@aacn.org.

What do you see?

See something a new way and you’ll never see it the old way again. Each of my columns this year will feature a different graphic so we can share a different dimension of seeking insights. —MFT

Do you see a duck or a rabbit?
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