Are we (over) ruled?
Many of our rulebooks are a result of regulatory and accreditation expectations, scope of practice limitations, corrective actions from sentinel events, and more. Our rule-based healthcare culture is inevitable in a highly regulated industry and, from a pure safety perspective, necessary. The case for safety, regulations, and standards is undeniable. High reliability doesn't come from everyone doing their own thing—this is basic.
The case for codes of conduct is there, too. In a way, it seems disappointing that we have to define right and wrong behaviors; however, clearly aligning behavioral expectations with values is culture building. Also, when it comes to conduct in most organizations, a rule usually has to exist to be broken in order to coach, counsel, warn, and, unfortunately, terminate employees.
This all works when our policies are in line with organizational values and patient-centeredness. However, some states' nursing practice restrictions aren't designed with patients in mind. For example, modifying a patient's diet, involving physical therapy in a patient's care, drawing a troponin for a patient with chest pain, or letting a patient out for fresh air may not be permitted without an order. I'm sure you can think of other restrictive policies or regulations.
Where it gets fuzzy is when we overprescribe procedures and tie our staff in knots to solve problems or meet patient needs. Even though staff members want and need structure, we have to be balanced and not let policies get in the way. Should we punish staff members for doing what they see as the right thing if a policy is “broken”? If safety or legality is compromised, yes; maybe not in other scenarios. This approach is clearly dependent on organizational culture and leadership.
We've also scripted the patient experience—what you should say and do, and how often—but we know that one shoe doesn't fit all when it comes to human beings. Can we give staff leeway under the umbrella of meeting the purpose of expectations within organizational culture and established guidelines? We should support making exceptions if acting safely with good intent. Who we are must be reflected in what we do and how we treat people, whether staff members, patients, or families. And when we make a mistake, we have to own it with empathy and action.
There's empirical evidence that improved staff engagement and trust are directly related to a better patient experience. This is a focus on which we can all agree—our staff will be spot-on for patients if there's a compelling vision, a healthy work environment, tools and resources to do the job, clear expectations, aligned values, and a voice in work rules and practice.
Following our personal and organizational values is the golden rule. Self-inflicted constraints and lack of true engagement frustrate everyone, and values can get lost in the fray. Don't let that happen. Be the leader who stands for doing the right thing, always.