Are you Suffering from Toxic Policy Culture?

FYI-this is a bit of a long one, but keep read to get to the juiciest parts!

Hey nurses! I’m in your policies a lot and some are great.  Some, though, not so good (I know you feel me on this). Are policies the number 1 thing that keeps your patients safe? No. But, they can be an excellent tool for the number 1 thing that is keeping your patients safe (hint: it’s you, the nurses). In the cases I review, there are a few things that jump out, right off the bat, and alert me that your policies are contributing to less than optimal outcome. Some policies are just unnecessary and are total CYA nonsense. Others, the references are poor and out of date.  But beyond these technical elements, which I go over in my last article on policies, we need to address a bigger issue. We need to talk about the ways that our policies and our relationship to policies are contributing to our unit and nursing cultures.  Let me tell you, I’ve been on all the sides of policies.  A staff nurse trying to use them, an educator trying to teach to them, a leader and consultant trying to write them and an expert witness reviewing them and the extent that the policy met the standard of care or contributed to an unfortunate outcome. And what I’ve seen is that so many nurses and hospitals are suffering from what can only be called Toxic Policy Culture. I’ve listed four symptoms of TPC, but you might have others.

First off, let’s level set with policies.  They are for nurses and providers as a tool to help you make the right clinical decisions for the right reason.  Things they aren’t: 1) A one-size-fits all.  Your patient may not fit and it’s okay to do something different, if you have good rationale and are using your clinical judgement.  2) A requirement for patients.  These aren’t for patients and they have no obligation to follow our policies.  Policies must always be nurse or clinician facing, not patient-facing. You must get rid of policies that require patient compliance. 

TPC Symptom 1: Policy Doesn’t Match Practice i.e. Widespread Normalization of Deviance

I can tell when a single, usually far removed from the beside, person has written the policy.  They will be cumbersome, have contradictions, and can actually be a little unusable to the bedside clinicians. Nurses quickly learn that their policies aren’t a tool for them and don’t give them much thought. Practices that completely fly in the face of the hospital policies become widespread. Deviation becomes the norm and the unit gets lucky for awhile.  Until they don’t. 

Story time: I reviewed a policy that stated to notify a provider whenever there is a category 2 tracing.  I’m sure we can all think of instances when this would be inappropriate. It’s a little vague…like all category 2’s???  What if its a category 2 for 15 minutes, should you try intrauterine resuscitation first?  In this case, the nurses almost never called the provider for category 2 tracings, because they believed that category 2 didn’t mean much. This facility didn’t have nurses participate in the creation and the staff nurses said in deposition they didn’t really look or even think that much about policies…it was just some book that sat on the unit. The nurses had learned that they didn’t help that much. And that puts the hospital and nurses in an even stickier situation. Is the nurse a “bad” nurse for not following policy? Is the hospital negligent for not enforcing the policies? Had they had any nurses involved in the policy creation, they would have pointed out what a vague, crap policy this was.  I know, because they all did so in their depositions!

The point of policies and procedures is to help the staff do the right things for the right reasons. So when clinicians, the ones actually using them, are involved in their creation you get 3 things: policies that make sense, a unit of nurses who understand the policies, and care that matches the policies. They will catch things AND you have a built-in resource for the other nurses because the staff will know and understand the rationale and evidence behind your policies. The creation isn’t happening three levels above. Do your organization and patient a favor and include nurses in policy creation.

TPC Symptom  2- Crippling Overreliance on Policies

The flip side of this is that you have a culture where the policies have become hyperspecific and a unit culture where nurses so scared of getting in trouble, that they defer to the policy 100%. I hear this a lot. “Jen, will my hospital cover me if I don’t follow the policy?!?!”. This thinking is total TPC. They can’t act without using a policy and will follow it even when it makes absolutely no sense for their situation. But this was a culture that was intentionally created.  Either as a well-meaning, if misguided attempt to reduce liability, or more darkly, as a way of controlling staff.  It’s easier to be draconian and ensure nurses are in step. It’s easier to have 300 policies that attempt to cover every minutiae than to spend money on nurse education and development.  But the only way to have a healthy nursing culture, that really makes a difference in patient safety measures, is to support the nursing role. To help nurses connect to their professional identity as advocates.

 The goal is for the policy to be a tool for the nurses, not superior to, but in support of their clinical knowledge and judgement intact.  And if the care that is needed doesn’t seem to be what’s exactly in the policy, the expectation is that they discuss with the patient and providers and document why.  An example of this is a policy that says to check the blood pressure every 30 minutes while a patient is receiving pitocin.  But your patient asks for a little nap and when the 30 minutes comes around, she is snoring.  Should you wake her up?  If she’s had labile blood pressures or recent hypertensive crisis, yes.  If not, maybe no.  The nurse just writes a note why she skipped it, explaining that deviation from the policy.  Would it be reasonable to skip them for 5 hours? No.  Most nurses would agree with that. But you are allowed to use your clinical, critical judgement as long as it’s based on your assessment of this specific patient.

TPC Symptom 3- Preference become Policy

Sometimes, we have a Toxic Policy Culture that pushes policies that aren’t even real!! In TPC’s, we hear the word “let” a lot.  “I can’t let you out of bed” “The doctor isn’t letting me give you water” “We don’t let patients keep their placenta”.  Unless you are using the word ‘let’ in a sentence like “Let me make a photocopy of this beautiful birth plan so I can put an extra one on your door” then we can start to remove it from our clinical dialect. Again, policies are for the staff, to help them do the right things for the right reasons.  Patients do not have to follow our preferences or our policies.  They can decline whatever they don’t want.  I don’t mean to make this a battle or pit nurses against patients.  But as true patient advocates, let’s comb through our policies, common unit practices and preferences to see if we have elements that aren’t based in evidence and in fact de-center the patient. I recently found out some hospital have a policy that says if a patient is ROM’d they aren’t allowed out of bed and must use a bedpan.  This is TPC in the highest. 

TPC Symptom 4- Policies that violates patients rights or are racist or misogynistic garbage

I wish I was kidding.  I wish I was being hyperbolic or melodramatic or overblown.  There are policies, active today, that include all of these things.  We have to be vigilant against them in our institutions.  The best way I can illustrate this is by sharing examples of three policies I have recently seen.  

Policy A- A policy on “culture”. To say it’s racial profiling is being generous.  For example: Black women are more demonstrative of pain, seek prenatal care late and may wear alliums during labor. White women are “perceived” as being privileged and lead fast-paced, high-stress lifestyles.  Sorry folks, apparently white women have the corner on high stress levels. It goes on to say that Hispanic women defer to their husband, Asian women are quiet, and Native women speak tribal languages (this last one extra hurt my heart because we know tribal languages have been systematically erased through Indian boarding schools).  Really not sure of the purpose of this policy.  What would I, as a bedside nurse, even do with this? Unfortunately, the citation for these type of policies is an old version of AWHONN textbooks.  The organization has apologized and removed this harmful information, but the damage is far-reaching.

Policy B- A policy on intrapartum care.  Mostly an okay policy, but then we get to the part on preparing for delivery and it dictates that the perineum while be cleaned prior to delivery using the cleaner of the providers preference.  My first thought was “I’m not cleaning the providers perineum”.  Then we realize it’s the perineum that belongs to the patient! First, routine cleaning/prepping/sterilizing of the perineum is not supported by any evidence and indeed, research indicates best practice is to not. Second, this language is so wrong. It is deeply rooted in sexist ideas that the vagina or perineum are dirty. Be on the lookout for language or policies that are not evidence-based and that center anyone’s choice besides the patient. Words like ‘preference’, ‘allow’ and ‘let’ are good ones to watch out for.

Policy C- A policy on birth after cesarean.  There are variations on this policy all over the country.  But essentially, VBAC policies often seek to limit patient choices or act as a means of coercion.  This particular one states that certain hospitals within the system do not provide VBAC and that in the hospitals that do, a patient must have a success calculator score of above 60%.  These are toxic policies because it is impossible to not offer VBAC.  A patient can come in, refuse a cesarean, and Voila! you are doing a VBAC! Or a patient can have a precipitous birth.  Or deliver while the OR is tied up.  Trying to say you ‘don’t do VBAC’ is silly and not practical.  Second, limiting access to VBAC based on a VBAC score is not based in evidence and has no place in a healthy unit culture.  The only deciding factor, ever, is patient choice after a shared decision-making conversation. Otherwise, this is a violation of a patients rights.  

So there you have it! The biggest signs of Toxic Policy Culture and some ways to get started to shift to a healthier culture that centers patient autonomy and the nurses professional role as advocate. Let me know...have you seen these? What are your struggles trying to change problematic policies?