Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views

Abstract

Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules. Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews. Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines. Conclusions: While the creation of a ''safety culture'' requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.

Factors affecting health care workers’ adoption of a website with infection control guidelines

“…Target group [26] + The website is useful for nurses (n = 12), [27] + The website is useful for patients (n = 14) [28] + The website is useful for patients' relatives (n = 6) [29] + The website is useful for physicians (n = 6) Enabling (work-related) (53 statements) Workload [30] + The website lowers work pressure for infection control professionals, as they will receive fewer questions from health care workers (n = 3) [31] − High work pressure impedes consulting the website during working hours (n = 9) Tacit knowledge [32] + The website enables health care workers with lack of knowledge of MRSA guidelines to retrieve relevant information (n = 4) [33] − Personal, practical, and experiential wisdom about MRSA guidelines leads health care workers to not need the website (n = 10)…”

“…Therefore, these occupational groups deemed the website to be useful only for nursing staff and patients, but not for themselves. This finding is not surprising, as technology adoption in health care has always been associated with resistance among HCWs with more strategic tasks [32,33]. Nursing staff might be more willing to conform, as their views of professionalism are bound up with adherence to rules and guidelines, and they are therefore more inclined to adopt web-based guidelines than are physicians and infection control staff.…”

Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards

“…Fourth, in accordance with the Delphi principle, there may be a cohort of persons who disagree with alcohol gel as a means of hand decontamination and may choose to ignore occasional hospital guidelines. Doctors have been shown to be more averse to following standardised written rules than nurses within the operating theatre 24 and may preferentially follow independent practice rather than formal written protocols.…”

The Iron Cage and the Gaze: Interpreting Medical Control in the English Health System

“…As health services have become subject to market competition, such comparison have become useful for patients as consumers. Public reporting facilitates control of sur-geons since surgery might be seen as more easily measurable than some other clinical services (Katz, 1998;McDonald, Waring, Harrison, Walshe, & Boaden, 2005). However, the impact of control over doctors which is exercised by patients (acting as consumers) and managers (acting as regulators of medical profession) is not fully understood (Gabe et al, 2012;Shekelle et al, 2008).…”