Are you still putting oxygen on patients with chest pain even though their pulse oximetry is 97% on room air? Or, are you still reluctant to put oxygen on patients with chronic obstructive pulmonary disease who are dyspneic and hypoxic? Are you still running normal saline in wide open on trauma patients with a systolic blood pressure less than 100 mmHg? Are you still assessing gastric tube placement with auscultation and a whoosh of air? Are you still irrigating lacerations with sterile normal saline before suturing? If you answered “yes” to any of these questions, it's time to ask yourself, “Why?” There is good evidence that all are outmoded, outdated, and, in some cases, potentially dangerous practices. Yet, many health care providers persist in these practices or are forced to do so by organizational policies or provider orders.
The difference between knowledge and action can be a wide chasm indeed. The term “clinical inertia” is used in the literature to describe the “underuse of therapy that is effective and efficacious in preventing serious endpoint clinical outcomes” (Allen, Curtiss, & Fairman, 2009, p. 690). The term is usually used in relationship to the management of chronic conditions such as diabetes and cardiovascular disease. However, inertia is also involved in the situations described in the first paragraph—we tend to continue doing what we've always done despite evidence that a change is indicated.
In contrast, has your facility adopted any of the Institute for Healthcare Improvement's recommendations for the prevention of central line–related blood stream infections, catheter-related urinary tract infections, pressure ulcers, and ventilator-associated pneumonia? (Institute for Healthcare Improvement, 2014). The answer here is more likely in the affirmative with regard to changing clinical practice. Why? Probably because these topics have become areas of focus for health care organizations and in many cases have significant reimbursement (i.e., financial) implications. This type of financial incentive catches the attention of health care leaders like nothing else. However, you may remember, or still be experiencing, resistance to those changes on the part of clinical practitioners. As a result, organization-wide efforts with visible support from top leadership are usually required to effectively implement these best practice recommendations. The ultimate success of the change initiative almost always rests on a multidisciplinary effort and the emergence or designation of a champion or champions.
Champions rally around a cause and keep it in the consciousness of practitioners until it becomes a hardwired practice change. Gawande (2013) discusses the history of slow versus fast changes in health care (e.g., asepsis vs. anesthesia) in his The New Yorker editorial “Slow Ideas.” Although there are many factors at play in implementing change, the role of a champion is evident, especially for ideas that do not have readily visible results. Gawande describes the slow process and eventual successes of a nurse champion who works in rural India trying to change basic birth practices. Emergency nurses are not known for patience, but change requires just that, along with a healthy dose of persistence. Championing change is a natural role for advanced practice registered nurses. In fact, “change agent” should be the first thing listed in a clinical nurse specialist's job description because so much of the role involves introducing new and better ways of doing things. Embracing the role of change agent is not easy, but it is essential. It requires a persistent presence to coach people in new practices and work behind the scenes to ensure that the system enables success by making it easy to do the right thing. It also requires role modeling the desired practices. As Gandhi advised, “Be the change that you wish to see in the world.” To that we add, “Be the champion.”
—Jean A. Proehl, RN, MN, CEN,
Emergency Clinical Nurse Specialist
Proehl PRN, LLC
—K. Sue Hoyt, PhD, RN, FNP-BC, CEN,
FAEN, FAANP, FAAN
Emergency Nurse Practitioner
St. Mary Medical Center
Long Beach, CA
Allen J. D., Curtiss F. R., Fairman K. A. (2009). Nonadherance, clinical inertia, or therapeutic inertia? Journal of Managed Care Pharmacy, 15, 690–695.