Advancing Nurse Autonomy

Jeffrey D. Wayne, MD, and Debra A. Da Rosa, PhD
Department of Surgery
Northwestern University
Feinberg School of Medicine

Introduction

As of July 1, 2003, all 7,800 residency programs in the United States were compelled to comply with Accreditation Council for Graduate Medical Education's new duty hour standards (www.acgme.org). These standards stipulate that all residents must be limited to a maximum of 80 duty hours per week, including in-house call, averaged over four weeks. Additionally, residents must be given one day out of seven free from all clinical and educational responsibilities, including carrying a pager. Duty periods can no longer last for more than 24 hours and residents cannot be scheduled for in-house call more than once every three nights. Numerous strategies have been devised and implemented to accommodate these new regulations.¹ Examples include the Stretch Model, the Night Float Model, the Apprentice Model, and the Mastery or Case-Based Model.² However, no matter which model or hybrid of these models is selected, within each residency, there will be an approximate 20 percent reduction in resident man hours available for patient care, including responding to routine pages.

At the same time, numerous studies within the past decade have documented a direct correlation between job satisfaction amongst registered nurses and their degree of autonomy. For example, Finn et al demonstrated in a quantitative pilot study of 178 nurses at a large teaching hospital that autonomy was the most important job component for work satisfaction, ranking ahead of professional status, interaction, and task requirements.³ Another study by Upenkis indicated that implementation of nursing practice models enhances job satisfaction, increases personal power and accountability, and improves climatic change.⁴

Herein we describe strategies for reducing the need to page residents and increasing nurse autonomy. We include details of a recently completed nursing autonomy initiative set up at Northwestern Memorial Hospital (NMH), an urban teaching hospital in Chicago, IL. The initiative was undertaken as a joint venture between the Department of Surgery and hospital administration and the goals of the initiative were manifold, including: reducing the need for routine pages to our house staff (which had just been effectively cut by 20 percent), fostering a better work environment within the hospital by decreasing the codependency among our nurses and house staff, and increasing the job satisfaction of our surgical nurses.

Formation of a Working Group and Collection of Data

The first step taken by the department was to convene a working committee consisting of surgeons, nurse managers from all of the surgical inpatient units, nurse practitioners currently working with the surgical divisions, representatives from hospital administration, nurse educators, and a pharmacist from one of the inpatient nursing units. The surgical intensive care unit was excluded from this process, as some protocol-based care was already in place in this setting, and as ready access to resident and attending physicians was felt to already be available for this unit. A preliminary meeting was held to discuss the concept of increasing nursing autonomy and implementing protocol-based care and there was a positive response from both nursing and physician staff. It was decided at this first meeting that the attending surgeons would poll the surgical house staff either formally or informally to identify the most frequently cited reasons for why the doctors are paged. Similarly, the nursing representatives would query the surgical floor nurses to discern the most frequent reasons for paging resident physicians. Inquiries would also be made to both groups as to which problems they felt would be most appropriate for protocol-based care.

While a validated survey would have served as an effective tool to study both resident and nurse satisfaction prior to and after the implementation of this program; in the interest of time, an informal poll was carried out prior to the next available resident educational conference and at the next nursing "in-service" session. Results of these polls and surveys were reviewed by the group at our next meeting.

Protocol Development

The group agreed to focus on seven clinical issues and three procedural tasks that were deemed most appropriate for intervention (See Table 1). Items that were identified by both physicians and nursing were: glucose management, heparin administration, routine PRN requests (such as Tylenol, ice chips, throat lozenges, saline nasal spray, and artificial tears), urinary catheter re-insertion after failed voiding trail, inability of ancillary services to obtain blood or place intravenous catheters, and inability to wean oxygen without specific orders. Procedures identified as being currently performed only by the resident staff but could easily be performed by our nursing staff after educational intervention were nasogastric tube placement, central line removal, and drain removal. Issues and procedures which were felt to be inappropriate for protocol-based care were: routine fever work-up, low urine output, electrolyte replacement, pain management, and chest tube removal. Individual members of the group were assigned to each of these issues and procedures and were asked to research these topics in terms of finding out if protocols exist either in our hospital in specialized nursing units such as the cardiac care unit or the surgical intensive care unit or in other hospitals specifically within the metropolitan Chicago area. Also reviewed were current hospital policies and nursing guidelines to see if the development of such protocols, decision trees, and algorithms would work within the framework of the existing hospital bylaws. In addition, as a parallel initiative was being carried out on the general medicine floors of our hospital, a dialogue was opened with the nurse managers of the general medical floors to see if there were any protocols being developed that would be appropriate for use on the surgical floors, so as not to duplicate our efforts.

Table 1. Actions taken by Nursing Autonomy Committee

Issue	Action	Comments
Anticoagulation of patients with heparin	Heparin drip protocol	Weight-based program based on protocol already being used in the Cardiac Care Unit
Failure of patient to void after urinary catheter removal	Urinary catheter decision tree	Formalized practices already in place; Calls for use of bladder scan and re-insertion of catheter without physician notification
Inability to obtain phlebotomy specimen	Phlebotomy decision tree	Calls for assistance by "expert" nurse on floor and off unit resource prior to physician notification
Inability to obtain IV access	IV insertion decision tree	Use of expert nurse, hand-held ultrasound prior to physician notification
Clogged gastric or jejunal feeding tube	Enteric feeding tube occlusion decision tree
Specific orders required to wean oxygen	Oxygen weaning protocol	Adopted respiratory care policy already in practice in ICU
Frequent calls for elevated glucose levels	Diabetes management team	Developed in conjunction with Division of Endocrinology; Sliding scale insulin orders incompatible with hospital nursing policy
Frequent calls for routine PRN orders	"Menu" selection of such items when hospital adopts computerized order entry

Procedure	Action	Comment
Drain removal	Drain removal protocol
Central line removal	Central line removal protocol
Chest tube removal	Chest tube removal protocol	**Nurse Practitioners Only

Abandoned Issues	Reason
Fever work-up	House staff felt the need to examine these patients
Low urine output protocol	Too diverse a patient population for protocol-based care
Electrolyte replacement	Felt to be inappropriate for transplant patients and those with renal insufficiency
Pain management	Felt to require extensive education. Inappropriate for protocol- based care.

Results at NMH

In the end, two protocols, four decision trees, and three procedures were developed by our group, and sent to hospital administration for approval (Table 1). After reviewing current protocols available in the Surgical Intensive Care Unit, we were able to easily modify an existing oxygen weaning protocol, which was already approved by our hospital's Department of Respiratory Care. We worked closely with our Division of Vascular Surgery to create protocols for heparin administration for both the low-risk and high-risk surgical patient. Implementation of this protocol again was facilitated as a post-procedure heparin administration protocol was already in place in the Cardiac Care Unit. Specific procedure protocols developed included central line removal (which includes both indwelling intravenous central catheters and peripherally placed central venous catheters), drain removal, and chest tube removal. It was felt by both house staff and the nurses alike that only nurse practitioners, with additional training, should remove chest tubes. Decision trees, that are formal algorithms available for individual nurses to follow, cover intravenous catheter insertion, phlebotomy, urinary catheter removal, and declogging of feeding tubes. It was decided that the best way to handle the issue of frequent pages for "routine" PRN orders was to allow physicians to directly order any or all of these items from a drop-down menu when our hospital adopts an electronic order entry system within the upcoming year. Finally, as current nursing policy within our hospital does not allow for the routine administration of "sliding-scale" insulin to floor patients, we were forced to explore other avenues to address this particular issue. In conjunction with our Division of Endocrinology, a plan was formalized for a Diabetes Management Team, to be staffed by attendings, fellows, and nurse practitioners. Given the increased cross-cover responsibilities of the surgical residents, especially at night and on the weekends, it was felt that having an endocrinologist manage insulin administration would not only provide better patient care, but also allow provide for education of the surgical house staff as to the most up-to-date management of diabetic patients.

Implementation

Implementation of our initiatives has been a slow but steady process. All of the changes had to be approved by either the hospital's Patient Care Committee or Pharmaceutical and Therapeutics Committee (in the case of the heparin drip protocol). The decision tree initiative has been embraced by our nursing staff. Implemented more slowly are the procedure protocols, as individual nurses must be educated and credentialed in these procedures. Adoption of our protocols has been facilitated by our current monthly house staff and nursing discussion forum. The forum has served as an ideal arena for minor issues, that have arisen during the implementation of the aforementioned protocols, to be discussed and for solutions to be created in the most expedient manner possible. For instance, a suggestion to page all nurses on the floor when there is a drain or central line to be removed was generated at one such meeting, and has allowed more nurses to become comfortable with such procedures. Educational seminars are also planned for both the nurses and the residents to better educate them on the clinical evidence behind the creation of our algorithms.

Alternative Strategies

Other residency program administrators implemented alternative methods for achieving the same goals. One program director planned a half-day retreat with selected faculty, residents, and nurses. The goal of the retreat is to brainstorm elements surrounding the problem and collectively derive solutions so each attendee has vested interest. Some in-service training will also occur. Another program director described "quiet hours" whereby nurses would not page residents for anything other than life-threatening issues. Lastly, one program director reported significantly reducing pages by gleaning agreement from the nurses to post their non-emergent questions/issues on a bulletin board with the promise that a resident would collect and answer the questions at stipulated times throughout the day and night.

Conclusions

Implementation of the ACGME's new duty hours standards has served to stress attending physicians, residents, and nurses alike who are now forced to care for patients under new service models. No longer can it be assumed that interns and junior residents will be wandering the surgical floors, immediately available to deal with routine and/or critical issues. By undertaking a broad-based initiative to decrease the number of pages made to physicians, we hope to provide for optimal patient care by allowing available in-house physicians to concentrate on the care of the sickest patients. An expected by-product of this initiative will be increased job satisfaction of our registered nurses, who will be given greater autonomy to fully participate in the care of their patients. We invite other institutions to share their experience with implementing other strategies and to discuss successes or failures they have had with protocol driven care.

References

1. DaRosa DA, Bell RH Jr, Dunnington, GL: Residency program models, programs and evaluation: results of a think tank consortium on resident work hours. Surgery. 2003 Jan;133(1):13-23.

2. Bell RH: Models of residency rotations. American College of Surgeons Web site. Internet (http://www.facs.org/education/rap/bell.html), July 3, 2003.

3. Finn CP: Autonomy: an important component for nurses' job satisfaction. Int J Nurs Stud. 2001 Jun;38(3):349-57.

4. Upenieks V: The relationship of nursing practice models and job satisfaction outcomes. J Nurs Adm. 2000 Jun;30(6):330-5.