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Resistance to Change in Clinical Practice: Pharmacy vs. Nurses
Guest Author: Kimberly Johnson
I have been an oncology nurse for the past 17 years. In that time, I have worked for 3 vastly different organizations: 8 years for-profit, 3 years non-profit, and 6 years government owned. As I look back and compare the 3 entities, there is one thing that stands out most: a resistance to change in clinical practice from government-owned facilities.
Where It Began
Currently, I work in a small outpatient oncology clinic within a hospital, which has 6 treatment chairs, a procedure room, and a dedicated oncology pharmacy.
Upon my arrival to the clinic and after introductions, not only would I become the newest individual, but the newest by 15 years or more. I was the youngest in practice by 10 years and the youngest in age, those things alone presented challenges from the beginning.
During my first day at work, I immediately recognized some poor practices and bad habits that foreshadowed the clinic’s immense resistance to change. These practices involved infection control, patient safety, and underutilized evidence-based practice.
Within the first month I set out to make what I thought would be, positive changes. I joined the infection control committee, I collaborated with patient safety, and worked closely with my co-workers.
The following scenarios are just a few of the many experiences I have witnessed firsthand of how intensely the resistance to change in clinical practice can be on nurses.
Resistance to Change in Practice
I quickly noticed that it was common practice to share a bedside table between staff and patients. The staff would use the table to place supplies during IV starts, accessing port-a-caths, and to hold lab specimens. The patient would use the table as their personal space to eat, work from their laptop, and play games with others. There was no cleaning of the table between either of those tasks. I made the recommendation to clean the table after each use with the proper cleaning solution as per guidelines of infection control.
The initial response, “We’ve always done it this way.”
Another issue addressed was regarding patient safety and evidence-based practice. Prior to the administration of chemotherapy, there was no double check system in place beyond the pharmacy. The pharmacist and the technician did their double check and that was as far as it went.
I questioned the lack of double–checking between two nurses prior to administration and the response was, “we don’t have time.” After this, I pushed even harder, and my recommendations continued to be ignored. This resistance to change, especially for something so necessary, astounded me.
The day soon came when 2 patients, on 2 different treatment days, but in the same month, received the right drug but the wrong dose. After the second error, double checks prior to chemotherapy were implemented.
Nurses at the Mercy of the Pharmacy
The most difficult issue with resistance to change in clinical practice that I have been dealing with over the past six years is the amount of control the pharmacy has over nurses.
Currently, the pharmacy tech dispenses the pre–meds, supportive meds, chemotherapy, and non-chemotherapy. Every drug I will ever need to administer, I obtain at the mercy of the pharmacy tech.
As nurses, we get to know our patients and their regimes, but the pharmacy does not. One instance I have experienced on several occasions is having a patient whose regimen is a duplet, and one of these drugs requires pre-meds and the other does not, so I am told by the pharmacy tech, “You can’t give the Tylenol and Benadryl yet, this drug doesn’t need premeds, so you have to give this one first,” which then sparks a frustrating debate between the two of us.
When conversations like this arise, it is disheartening to nurses because although drug administration is within the scope of our practice, we must receive approval from the pharmacy first. There have been many attempts to restructure this process within our clinic, yet it has never been successful.
This form of practice causes excessive wait times for patients and miscommunications between the nursing and pharmacy staff regarding what times the chemotherapy and non-chemotherapy drugs need to be administered — which further results in the patient having a negative experience during their treatment.
Despite the many attempts and concerns expressed in our clinic, the pharmacy team and the senior staff nurses are not willing to collaborate or discuss ideas for restructuring our outdated practices within the clinic. Their stance is too often defended by the statement, “this is how we’ve always done it.”
As a nurse who is passionate about her specialty, it is very disheartening to see such a strong resistance to change despite all the benefits it could bring to our patients and practice. By making simple changes, we could be decreasing wait times, increasing nursing and pharmacy efficiency, and enhancing overall patient satisfaction.
It is important that those of us who recognize the need for change stay persistent. With such resistance, change will not happen overnight, but without our advocacy, it will not happen at all.
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