The Impact of Individual and Contextual Factors on Nursing Care and the Implementation of AHCPR Practice Guidelines

Abstract

Clinical practice guidelines are meant to assist practitioners in making decisions about appropriate care (Field and Lohr 1992). They are also an attempt to exercise control over practice variation and, by eliminating ineffective services, to reduce the cost of health care (Garber and Wagner 1991). The concept of practice guidelines has received renewed attention with the establishment of the Agency for Health Care Policy and Research (AHCPR) whose guidelines cross disciplinary lines and are expected to affect nursing care as well as medical care (Jacox, Ferrell, Heidrich, et al. 1992). Although nursing is the largest single component of inpatient cost (McKibbin et al. 1985; U.S. Department of Health and Human Services 1987; Walker 1983) and, like medical care, is subject to practice variation (Hinshaw, Verran, and Chance 1977; Fetter, Thompson, Ryan, et al. 1987; Skydell and Arndt 1988), research and policy discussions traditionally focus on the effect of guidelines on medical practice. Downloaded from 62 analyzing the potential impact on nursing care of the guidelines proposed by the AHCPR.An underlying assumption of practice guidelines is that clinical practice can be altered by rational information about outcomes and patient preferences (Eddy 1988). However, it has been pointed out that the link between information and actual medical or nursing care may be moderated by other factors (Waitzken and Hubbell 1992;Coyle and Sokop 1990;Kirchhoff 1982). This article looks at such influences on nursing care, arguing that nursing care not only is a function of the patient's illness but is influenced as well by the nurse's cognition and by the organizational context.The health management literature has paid little attention to the effect of individual or contextual factors on nursing care. The nursing literature adds insights but is not consistent in the factors it admits as influences. For example, theoretical models of nursing, which are concerned with what nursing &dquo;ought to be&dquo; (Stevens 1984), sometimes acknowledge that nurses' perceptions play a role in patient assessment (King 1981;Neuman 1982;Orem 1985) but discount influences from the work setting (Orem 1985;Orlando 1961). Practitioner literature, on the other hand, often recognizes the work setting as an important influence on nursing care (Aydelotte 1972;Hodges, Sanford, and Elzinga 1986;Van Slyck 1987), yet discounts nurses' perceptions, describing patient assessment as an objective analysis of patient need (Aydelotte 1972;Halloran 1988; Yura and Walsh 1988). The intent of this article is first to review the research on the impact of individual and contextual factors on nursing care, and second to analyze their impact on the implementation of AHCPR practice guidelines.The article is organized into three sections. The first draws on diverse fields, including nursing, psychology, sociology, health policy, and management, to describe individual and organizational factors that affect decisions about nursing care. The second section turns to an analysis ...

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