NURS 8301 Week 7 Stalled Adoption Post Example

Week 7 Discussion: Initial Post

Two Nurses and a Checklist Nobody Else Picked Up: Reading a Stalled Readiness Change Through Rogers' Diffusion of Innovations

In the composite outpatient surgery department I have been writing about, two of the nurses who make preoperative calls made the new readiness checklist a habit within a week. It is a one-page script for the readiness call that confirms fasting, medications, escort and testing every time. A month later, nobody else was using it. The other six nurses went back to their own way of making calls, which usually means confirming the arrival time and asking whether the patient has questions. I want to treat that stall as data rather than as a failure of the other nurses.

Rogers (2003) argued that people take up a new practice faster or slower depending on five things they perceive about it: whether it beats what they do now, whether it fits their work, how hard it is, whether they can try it in small doses and whether its results can be seen. Our checklist does well on some of them. It is compatible with the existing call, not complex and easy to try on one patient. It does badly on the two that matter most here. Its relative advantage is invisible to the people carrying its cost. The checklist adds about four minutes to each call, and the nurse making the call pays that cost on a busy afternoon. The benefit, a patient who arrives ready and a case that proceeds, happens the next morning in the operating room, where the calling nurse is not. Its observability is poor for the same reason: nobody on the calling team sees the cancellations that did not happen.

Greenhalgh et al. (2004) add that adoption in organizations depends not only on the innovation's attributes but on the system's readiness, the presence of champions and the way information about results flows back to adopters. In our department, results do not flow back. The cancellation log goes to the surgical services director monthly, not to the nurses who make calls. A Cochrane review of audit and feedback found that feedback on performance generally produces small to moderate improvements in professional practice, with larger effects in some conditions, such as when baseline performance is low (Ivers et al., 2012), which suggests the missing loop is worth building.

So my reading is that the checklist stalled because its benefit lands where its cost is not seen, and the fix is to make the benefit visible to the people paying for it. Five leadership moves follow, each assigned to a role:

1. Nurse manager: post the weekly count of avoidable cancellations on the preoperative board, with a note when a checklist call caught a problem such as a missed anticoagulant hold.

2. The two early adopters: describe at the Monday huddle one call from the past week where the checklist changed what happened, since stories from peers carry weight that data alone do not.

3. Surgical services director: send the monthly cancellation log with reason codes to the preoperative team, not only to leadership.

4. Anesthesia director: thank the team when a case proceeds because a problem was caught the day before, closing the loop between the operating room and the calling team.

5. Scheduler: adjust the call assignment so the four extra minutes per call fit within the afternoon, rather than being absorbed by whoever is calling.

Question for the thread: is there a change on your unit whose benefit shows up somewhere the people doing the work never see?

Reply to Yolanda

Yolanda, you suggested making the checklist mandatory with an audit. That might raise use quickly, but it treats the stall as a compliance problem when the diagnosis points to a feedback problem. Rogers (2003) notes that innovations adopted under authority can be discontinued once pressure eases. I would try the feedback moves first and audit only if they fail, so we learn whether visible benefit is enough.

Reply to Graham

Graham, your point about time is important, and it is why I assigned the fifth move to the scheduler. Greenhalgh et al. (2004) describe resources for implementation as one of the system conditions for adoption. If the checklist adds four minutes to each of twenty calls, that is over an hour a day, and asking nurses to absorb it without adjusting workload would make the stall likely again.

References

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581-629. https://doi.org/10.1111/j.0887-378X.2004.00325.x

Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., O'Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6), Article CD000259. https://doi.org/10.1002/14651858.CD000259.pub3

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.