Jeffery, Alvin D. MSN, RN-BC, CCRN, FNP-BC; Pickler, Rita H. PhD, RN, PPCNP-BC, FAAN
With reports of up to 98,000 patients dying in hospitals every year because of errors,1 efforts to increase safety in healthcare have gained attention.2 Nurses play key roles in error reduction as they comprise a significant portion of the healthcare workforce. They are the clinicians present at the patient’s bedside for the largest proportion of a patient’s hospital stay. Although significant work has been done to reduce errors by systems improvement,2 minimal work has been disseminated delineating the barriers that keep nurses from following accepted standards of practice. These barriers could lead to errors3 or prevent delivery of the highest quality care.
With the significant focus of safe care delivery being placed on systems issues, it is possible the individual nurse’s role in delivering safe care has lost adequate attention. Placing all improvement efforts solely on individuals has not proven to be effective.2 Individuals do work within systems, and the relationship of nurses to the healthcare system should not be neglected. Formal academic preparation and organizational orientation should provide the necessary tools for safe practice. However, barriers may arise that prevent the nurse from using previously acquired knowledge, skills, or behaviors. By identifying barriers and reducing or eliminating them, individual exemplary practice combined with functional systems may ensure the highest level of patient safety.
With approximately 41,000 preventable central line–associated bloodstream infections (CLABSIs) occurring in US hospitals each year4 and an associated cost range of $5,734 to $22,939 per infection,5 the importance of reducing and eliminating CLABSIs is well understood. In addition to the large impact of this problem, the guidelines and bundles delineating nursing care of these catheters are well defined and evidence based.6
Many researchers have documented the existence of a gap between knowledge and practice of both nursing as a profession and among individual nurses, but few researchers have attempted to determine what is actually responsible for this chasm. One study used a questionnaire to explore why nurses do not adhere to evidence-based guidelines for preventing ventilator-associated pneumonia7; the overall nonadherence rate was 22.3%, with the most common reason being unavailability of resources (37%). An investigation of barriers to another harm measure, pressure ulcers, cited “competing demands on nurses’ time, current documentation format, and available resources”8(p336) as the top 3 barriers while recognizing the nonmodifiable patient-related factors. In addition, the role of staffing in delivering safe care was described by Rogowski et al,9 where understaffing in a neonatal ICU resulted in an increased nosocomial infection risk for very low-birth-weight infants.
In regard to safe care delivery and error in general, Potter et al3 identified cognitive pressures among nurses as a potential source of safety threat, with an average of 3.4 interruptions per hour. Similarly, Ebright10 described the work of nursing as that of competing priorities that are influenced by cognitive and environmental factors.11 Ebright’s work led to the concept of “stacking” to describe how nurses prioritize 1 activity over another when both cannot be done simultaneously.12 Furthering this work, Gurses and Carayon13 found common performance obstacles among ICU nurses including (a) noisy work environment, (b) distractions from families, (c) hectic and crowded work environments, (d) delay in getting medications from pharmacy, (e) spending considerable amount of time teaching families, and (f) equipment not being available. Furthermore, Kalisch14 explored missed nursing care and found reasons for care omissions included many systems issues but also individual issues such as habit and denial.
Related work has been done by Tabari-Khomeiran and Parsa-Yektam,15 who studied competency development among working nurses using qualitative methods and found competent nurses appear to have a narrower knowledge-practice gap. Other researchers have examined cognitive flexibility/rigidity,16 competency,17,18 and decision making17 with little success in bridging the knowledge-practice gap. Finally, a literature review using a scoping methodology of 58 articles (including questionnaires, observations, and interviews) conducted by Debono et al19 described nurses’ workarounds in acute settings. The researchers discovered factors contributing to workaround included staffing, technology, equipment and medication unavailability, emergencies, customized care, cognitive load, unawareness of policies, perception that a policy is unnecessary, and clinician maturity. They also cited several articles describing the process of rationalizing actions if the patient did not experience untoward effects of the workaround.
The purpose of this pilot study was to identify barriers that nurses perceived in daily practice that interfere with adherence to standards of practice in caring for central venous catheters (CVCs). These barriers have both the potential to produce an error and may also keep the nurse from providing the highest quality of care. The research question was: What factors do nurses perceive contribute to deviation from accepted standards of practice in managing a CVC?
Conceptually, the study was informed by theories of knowledge acquisition and use, including those of Van Sell and Kalofissudis,20 Zimmerman and Schunk,21 and Kolb et al.22 Van Sell and Kalofissudis20 used a mathematical expression to convey the relationship between nursing science and nursing practice, with nursing practice improving with knowledge assimilation. Zimmerman and Schunk’s21 theory described how learners control their thoughts, feelings, and actions and explains how people improve their performance with systematic learning. Kolb and colleagues’22 theory described the significant role of experiences in adult learning. A preliminary unifying model to guide this investigation was developed by combining the core concepts of these theories (Figure 1). Didactic and experiential learning are funneled into a “holding chamber” of the brain. The acquired data undergo a multifaceted process of cognitive and metacognitive reasoning to create knowledge. Data not found to be important are released, with some data remaining in a process of conversion for extended periods. In an ideal situation, newly created knowledge is applied in practice, allowing the unique experiences encountered while using knowledge to formulate additional knowledge. However, the knowledge-practice gap3 provides evidence that this may not happen. There is a barrier between knowledge acquisition and use as represented in Figure 1 by the small gaps between the critical thinking/reflection oval and the application/use arrow. This gap is the conceptual representation of the origin of suboptimal care caused by perceived barriers to application of accepted standards of practice.
A qualitative descriptive phenomenological research method was used. Because the researchers explored the participants’ own perceptions of why they deviated from accepted norms, a phenomenological approach was most appropriate. The aim of the study was to describe the phenomenon under question based on the participants’ statements without the influence of supplementary texts or the researcher’s internal suppositions.
The study was conducted at an independent, not-for-profit children’s hospital in the Midwest. The hospital has approximately 2,500 nurses and offers a full range of inpatient and outpatient care, including intensive care for a wide range of children from infancy through adolescence. CVC standards of practice and care bundles have been in place for several years and are thoroughly integrated into education curricula and nursing culture. Competency in use of the bundle is verified in both classroom and clinical settings for all nurses. The CLABSI rates are tracked in all departments and reviewed at multiple levels in the organization.
The target population included all nurses who care for patients with CVCs. A sample size of 10 RNs was used, which is sufficient for a phenomenological pilot study.23 Inclusion criteria were as follows: (1) 2 years of nursing experience at the institution and (2) currently providing direct care for patients with CVCs. Exclusion criteria were employment in the 1st author’s department.
After obtaining institutional review board approval, participants were recruited using the organization’s e-mail system and by sending an e-mail flyer to educators and managers in the organization to print and post in their departments. Approximately 200 nurses responded, and 10 participants were selected. Purposive, nonprobability sampling was used; a heterogeneous sample was sought in order to gather a broad spectrum of data. Characteristics on which we sought diversity included years of experience, role (staff nurse, charge nurse, preceptor, educator, and manager), and unit/department of employment. The participants received compensation for their time and travel.
The 1st author conducted and audio recorded interviews, and a field journal was maintained for notes and bracketing. Each interview lasted less than 2 hours. Interviews were semistructured and included demographic data and a list of topics/questions to explore. The 1st author transcribed audio recordings (www.researchware.com) to facilitate immersion. Transcripts were reviewed for accuracy by replaying the audio recordings and reading the finished transcript concurrently.
Transcripts of audio recordings and field notes were analyzed using Colaizzi’s24 method for data analysis. These steps included (a) transcribing each interview, listening to the audio recording, and recording thoughts/feelings in a diary to aid with bracketing; (b) reviewing each transcript and extracting significant statements, which were then isolated for additional reflection and bracketing along with field notes; (c) formulating meanings; (d) organizing the formulated meanings into clusters of themes common to all participants; (e) integrating results into an exhaustive description of the phenomenon by preparing a summary of all emergent themes, cluster themes, formulated meanings, and significant statements; (f) describing the fundamental structure of the phenomenon; and (g) returning to the participants for their review and additional input.23,25
The experience level, patient population, and role of the sample participants are reported in Table 1. Participants described barriers present both in their environment (contextual) and within themselves (cognitive). Patient characteristics along with various organizational factors (ie, the materials, processes, and cultural aspects of the organization) comprised the major themes within contextual factors. Cognitive factors included themes of awareness/prioritization and unawareness, which included active and passive thinking processes that influence clinician decision making. Themes and subthemes are defined in Table 2. Figure 2 illustrates the fit of the themes and subthemes, including those that connect the major themes.
There were many cognitive (internal) barriers in adhering to standards, most involving decision making in which the nurse was forced to choose between 2 or more competing priorities.
I was kinda evaluating how, what was going to be like my risk-benefit … [omitted text] … I had to proceed with hooking up my new line [sigh] ‘cause we were in a pickle.
Sometimes these competing priorities involved multiple patient urgencies, whereas others considered non–value-added activities:
I’m not going to try to change a dressing on a patient sitting up when I know that the minute I move them again, it’s going to come loose again.
Other cognitive factors involved more passive decision making in which participants were noted to forget or be unaware of something occurring.
[Regarding donning a mask that is located outside the patient’s room for a sterile procedure] It’s not so much that you wouldn’t do it, it’s the “Oh, they’re out there” and you don’t think about it.
In addition, the acute care environment may not allow for sufficient time to thoroughly think about all aspects of a patient’s care:
You may not always take time to think about … [omitted text] … the global picture of what’s going to happen to this patient.
Many perceived barriers occurred in the environment (external to the nurse). Regardless of where the barrier presented itself, participants discussed their actions and perceived barriers within the context of a dynamic patient/family situation. The ever-changing needs of patients and families alter the context in which care is delivered, and barriers can be both attributed to or altered by this changing condition. The organizational factors included 3 themes: (a) organizational priorities, (b) staffing, and (c) supplies/equipment.
Organizational priorities became barriers when the participant did not feel supported in providing high-quality care to the patient/family:
If your focus is on cutting costs, being resourceful, or not wasting money, then you maybe are not so focused on being compliant or, or you know, high-quality care.
These priorities also included aspects of documentation, the ever-changing healthcare system and practices, and unit/department culture:
I feel like I chart more than I do (activities) sometimes.
We are so overloaded with information and competencies and changes, that it’s difficult … for staff to keep up with everything.
Once you’ve been in nursing for a while, your old ways of doing things start to conflict with the new.
There was nothing that was actually in orientation taught for how to do that.
You’ll get units that’ll (other nurses) say it’s their unit policy.
In addition, not having enough personnel available led to staffing problems, which added to the list of barriers:
I think a lot of barriers you might see where people take the shortcuts when you’re short-staffed with a bunch of ill-calls and can’t get them replaced. And they’re rushing you to do one thing after the other.
Finally, various supplies/equipment became barriers to optimal care when they were either unavailable or directly/indirectly interfered with provision of care, or multiple devices looked similar but were used differently.
I totally think people will cut corners if they (resources, supplies) are not available.
It’s not always easy to find policies and procedures.
Bigger rooms with bedside tables, so we could actually have space to do things.
[Regarding taking a patient for a procedure] Any patient that’s going to stay on their fluids has to have their line broken (disconnected) and then reconnected once they’re in the (CT) scanner.
I think a lot of times, we almost think of it [the CVC] as an art [arterial] line. I mean, it’s not, but it’s, we wouldn’t put a sterile field under an art line connection and draw, and I think that’s where our thought process probably comes in.
Connection of Major Themes
There were 3 subthemes identified as having overlap between the major themes. These included (a) balancing care, (b) adaptability, and (c) frequency of care. Balancing care was frequently used by participants to prioritize their actions based on the changing patient condition and served as a link between cognitive awareness and the surrounding patient/family context:
It was another pain medication where a kid’s screaming, parents are anxious, you know? Everyone’s upset, you want to give him pain medicine, you only brought, you only have 1 scrub (alcohol wipe) in the room. You scrub the line, and then you’re going to hook up the medication, and you dropped [the catheter]. Do I say, “Hold on, I gotta go outside to get another scrub?” or do you just trust the fact that it’s OK or good enough?
Adaptability served as a mediator between both cognitive factors and organizational factors. A few participants described far fewer barriers than others, and analysis of their lack of perceived barriers revealed several facilitators and a high degree of resiliency:
I’ll adapt; I adapted to this.
It just seems like as a nurse, you have a lot to deal with and know about.
Adaptability was influenced by life experience, the ability to speak up, and any fear of looking dumb (closely related to culture). One participant confided,
Sometimes we just don’t even say anything, which is not good … because of the repercussions.
The final overlapping theme, frequency of care, surfaced in both cognitive awareness and unawareness and may serve as either a facilitator or a barrier, depending on the skill being performed:
Awareness: I think if you use them (CVC) frequently, it is very easy to keep up with. If you don’t see them often, then I think it might be more difficult.
Unawareness: [Regarding hand washing] I don’t realize I’m doing it because I do it so much.
The results of this study reveal that nurses perceive many barriers to adherence to a standardized care practice, including those internal to themselves. There was a surprising lack of finger pointing at the institution in nurses’ stories about barriers to practice. Rather, much of what these nurses revealed had to do with their own limitations.
Many aspects of the research findings reported here were consistent with findings from studies reviewed in the background section of this article. These include time demands, documentation, and resource availability8 as well as staffing.9 Similar to the works by Potter et al3 and Ebright and colleagues,10-12 the findings of this study show nurses having to prioritize and balance the care they provide amid an ever-changing health system and patient/family situation. In addition, findings from our study included several components identified by Gurses and Carayon13 and Kalisch,14 as reviewed earlier. Finally, the concept of adaptability surfaced in our study, which may be similar to Tabari-Khomeiran and Parsa-Yektam’s15 description of competent nurses possessing a narrower knowledge-practice gap.
The reported findings complement the existing literature and add information from nurses who are actively practicing in acute and critical care settings. In addition, the findings demonstrate that direct care nurses are aware of the barriers to adherence of evidence-based protocols and that they use a variety of cognitive strategies to rationalize their nonadherence. These findings further emphasize the need for additional research involving experienced nurses and other care providers as sources of direct information about barriers to and facilitators of adherence to safe practice guidelines.
Research to improve healthcare systems and reduce medical errors is promising. However, the primary emphasis of most research about medical errors has been on systems improvement and not on individual factors that may affect errors.26 While a systems improvement approach is beneficial for describing many failures that lead to safety errors, the approach is limited in revealing the critical aspect of the professional caregivers’ thoughts and actions that occur when the caregiver is confronted with perceived barriers to practice. Institutional efforts to ensure fail-proof safety systems may lose sight of the role of the individual nurse or other professional in ensuring patient safety.
Improvement efforts should focus on the system, the individual, and the connection between the 2. Based on findings from this study, the researchers have proposed suggestions for practice, which are listed in Table 3. Both midlevel and senior leaders in the organization could begin focusing on some of these short-term solutions in an effort to overcome the challenges direct care providers face. For leaders who may wonder if nurses are even considering the potential consequences of not adhering to standards, the answer is yes, they are aware, but the clinical environment is full of competing priorities. From a more long-term perspective, as organizations increasingly move to electronic health records, senior leaders should be engaging with informatics teams to ensure these systems facilitate rather than hinder guideline adherence. In addition, intuitive process changes, hard-stops for routinely performed processes, and healthy work environments may all help create an organizational structure conducive to following evidence-based guidelines.
Future studies could focus on developing an instrument to measure the significance of each of these barriers within an organization. This focus would assist in identifying high-priority areas for improvement while also assessing the impact of any changes. For the time being, however, the authors encourage organizational leaders to ask questions such as “What prevents you from adhering to the guidelines?” or “What would make it easier to adhere to the guidelines?” Each organization will likely have different challenges, but seeking input from direct care providers is essential, and as this study demonstrated, asking simple questions to bedside clinicians yielded several responses that are amenable to direct intervention by organizational leaders.
Healthcare environments have become very complex, and to continue examining patient outcomes and care processes in global ways will fail to provide us with the information we need to improve. Rather, to further develop understanding of what really happens in our complex care systems, nurse leaders need to use more holistic and granular approaches to gather data from those at the point of care. Only by using the array of research methods at our disposal and by including in the research those who are delivering the care will we fully understand how to improve care practices and thus patient outcomes.
The findings of this study are limited by a single site, small sample size, and narrow focus. The findings are also limited by the inclusion of only nurses employed in a children’s hospital.