Contents
What is policy? – Policy is not law – Can anyone write a policy? – Policy advantages and disadvantages – Elements of a well written policy – Compliance & enforcement – Where there is a policy to guide actions – Where there is an outdated policy – Where there is no policy – Conclusion
What is policy?
Policies are used in workplaces to guide decision making, set standards and to define processes or procedures. Policies often address ‘gaps’ in the law. Many health care related policies are implemented or updated after a serious adverse event or on a Coroner’s recommendations. The intention of these policies is to prevent further harm.
Policy is not law
There can be policy without law and law without policy. Laws can only be created or changed by local councils, state governments or the federal government.
Can anyone write a policy?
There is nothing to stop anyone from writing a policy. A policy can be as simple as, ‘It is management policy that all staff need to wash their hands after using the toilet‘. Although anyone can write a policy, implementing or changing a policy is taken very seriously as policy is used as reference material by tribunals and legal professionals to identify if standards have been breached (e.g. negligence).
∴ The bottom line: anyone can write a policy… implementing a policy is a different matter.
Policy Advantages
√ Policies provide guidance and set standards within a workplace (e.g. uniform policies, workplace health & safety).
√ Most policies are flexible and can be updated or changed to reflect current standards.
√ They are used in legal cases or coronial investigations to determine if acceptable standards of care have been met
(e.g. negligence or a preventable death).
√ Employers use them to assess and monitor standards within an organisation.
√ Employers and employees can use them as reference material there is conflict over a process.
Disadvantages
x Policy is not intended to replace common sense or critical thinking. Blindly following policy that causes harm
is just as dangerous as not following good policy.
x Policies can become outdated and may not reflect current standards. Policies need to be reviewed
regularly to ensure content is consistent with legal standards and evidence-based practice.
x They can be restrictive as they are usually a ‘one size fits all’ which may not apply to every situation.
For example, policy does not always respect an individual’s autonomy (i.e. the right to refuse) or
consider the unique needs of minority groups.
x People need to be aware there is a policy in place before they can follow it.
x Too many policies can make it hard to find one you are looking for, particularly when you need
the information quickly.
x Conflicting policies. Policies vary in states, regions and facilities.
x The larger the organisation the harder it becomes to change a policy. Whilst it is extremely important to
ensure policy changes are valid, well researched and evidence based, the process of change can take
so long that a policy can be behind best practice recommendations.
∴ The bottom line: clear, up to date, well written, well researched policies can be an advantage to any organisation. However, it is equally important to be aware of the significant disadvantages of restrictive, conflicting or outdated policies.
Elements of a well written policy
⇒ Clear goal or purpose
⇒ Valid reasons for creating the policy and reasons are explained
⇒ The intended audience is identified (e.g. all employees, health care professionals, etc.)
⇒ There is a date of commencement, author(s) and their qualifications are included in the policy
⇒ There is a proposed review date and recommended timeframe for ongoing reviews (e.g. annually, biannually)
⇒ The policy is written in plain unambiguous language with the intended audience in mind
⇒ Information in the policy has been well researched and is evidenced based. This includes assessing
and reviewing existing policies from other sources who have similar policies (e.g. other hospitals, large
organisations, government websites, etc.)
⇒ Sources are included in a bibliography or reference list
⇒ Stakeholders at all levels who will be affected by the policy should be provided with an opportunity
to give feedback on the final draft before it is implemented.
Compliance & enforcement
The larger and more complex the organisation, the more policies there are and, the harder and more resource intensive they become to manage and enforce.
Reasons for poor compliance include, inadequate tools to perform tasks, information overload or too many policies (Carthy, et al. 2011), conflicting priorities, workforce shortages, and poor time management.
Enforcement is problematic where policy changes constantly. The reverse applies where employers focus on ‘enforcing’ policy without objectively analysing or addressing the reasons why policy is not being followed.
∴ The bottom line: it can be easy to introduce a policy but they can be difficult to enforce.
Analysing policy effectiveness
If employees are consistently failing to follow a policy or policies an objective review process needs to occur. Asking ‘what, how, who, why, where‘ is a way to assess a policy and its importance in the scheme within an organisation. An objective assessment is essential – decisions should be based on facts, not assumptions.
- What is the policy topic?
- What are the consequences of not following the policy? (e.g. safety, budget, legal).
- What is the impact on employees when following the policy? (i.e. does it form part of ‘usual’ duties or is it an extra task).
- How easy is the policy to follow?
- Who is most affected when the policy is not followed? If there are multiple people or groups, try sorting them into a highest to lowest impact order.
- Why are employees not following the policy? (e.g. lack of awareness, limited resources, competing priorities, staff shortages).
- Where does this policy rank in the context of organisational safety?
∴ The bottom line: health and safety should always take precedence in any situation. The higher the impact on health or safety, the more important it becomes to address non-compliance with the policy.
Where there is policy to guide actions
The reason for not following policy should always be there is a high risk of harm if the policy is followed.
Any deviation from policy should be discussed with a senior nurse, manager, a specialist, or medical professional. Documenting the reasons for deviating from policy or accepted practice is essential.
∴ The bottom line: unless there is risk of harm, it is easier to follow a policy then it is to challenge one.
What to do if a policy is outdated
If you do not agree with a policy, find out why the policy was implemented – it might have been introduced following a death or injury in the organisation or facility.
Ultimately, everyone is responsible and accountable for their actions. This includes recognising when a policy or practice is out of date and taking steps to change it. All suggestions to change a policy should be done in writing, supported by evidence, and emailed to a manager and clinical educator. Changing policy in large organisations is not an easy or fast process. Even if the policy is not changed despite recommendations – there is still written evidence the attempt has been made.
∴ The bottom line: doing nothing guarantees nothing will change, doing something means something might change.
When there is no policy – do no harm
There will always be situations that are not covered by policy. The main outcome for any action or decision should be based on a ‘do no harm’ principle. Understanding why you are doing a task and assessing risks can make it easier to choose a course of action.
The following questions can assist with making decisions in these situations;
• Why are you doing the task?
• Is the task something you should be doing? (e.g. within skill level and training)
• What are the risks of harm in performing the task?
• What are the risks of harm through not performing the task?
Example – how to apply these questions these questions to any situation whether there is a policy in place or not.
Q. Why am I doing this task?
A. I have received an order from a Doctor to give an intramuscular (IM) injection of tetanus to a man who stepped on a rusty nail at work.
Q. Is this something I should be doing?
A. YES. I am and RN/EN and have been assessed as competent to give IM injections. Hospital policy states the injection must be checked with another nurse before I give it, so I will do this before giving the injection to the patient.
Q. Is there a risk of harm if I perform this task?
A. YES. There is always a risk of harm when I am injecting anything into a person. Risks include anaphylaxis, severe allergic reactions, localised site reactions, swelling, bleeding, pain etc.
Q. Is there a risk of harm if I do not perform this task?
A. YES. There is a greater risk of harm if he does not have the tetanus injection as a tetanus infection can result in death.
Assessment & application of task
The patient has no known drug allergies. As this is a small volume IM injection (0.5mL) the best place for me to give this is the deltoid. I have assessed this person’s left deltoid as this is his non-dominant arm and the muscle is well-developed so there should be no problems giving it there.
∴ The bottom line: often there is no ‘right’ or ‘wrong’ decision – the only choice is one intended to result in the least amount of harm.
Conclusion
‘Do no harm’ is a basic principle in nursing practice. Policies provide guidance and establish consistent standards. There will always be situations where there is no policy, outdated policies, or there is a ‘one size fits all’ policy that works in most cases but does not ‘fit’ every situation.
Unfortunately, policies vary considerably between states, settings and contexts. If you do not agree with a policy, you need to be objective and consider why you do not agree with it. Find out why the policy was implemented as the reasoning behind it might change your mind. If you still strongly believe the policy is outdated or there is a risk of harm, do your research and try to change it. Always address policy issues to your managers or organisation in writing. Any attempt at changing an outdated or impractical policy is far better than doing nothing at all.
Bibliography
Carthy, Jane, Suzannah Walker, Vashist Deelchand, Charles Vincent, and William Griffiths. 2011. “Breaking the rules: understanding non-compliance with policies and guidelines.” BMJ (343). doi:https://doi.org/10.1136/bmj.d5283.