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Nurses must contend with many competing demands during a typical shift (delivering care to patients, educating families, communicating with other members of the healthcare team, to name just a few), often causing them to seek ways to compress everything they must do into a short time frame.
In these situations, it can be tempting to engage in “workarounds”, subverting policies, procedures, and even standards of care to pick up precious minutes. The goal is a worthy one — more time with patients. But workarounds are potentially dangerous to patients and nurses, with some leading to serious consequences such as harm to patients and subsequent legal actions against nurses — and the organizations that employ them.
Nurse leaders and healthcare administrators can protect nurses, themselves, and their organizations from legal jeopardy by understanding the nature of workarounds and creating an environment that minimizes them.
Causes of workarounds
Debono and colleagues provide this useful definition of workarounds: “Observed or described behaviors that may differ from organizationally prescribed or intended procedures in which workers ‘circumvent’ or temporarily ‘fix’ an evident or perceived workflow hindrance to meet a goal or to achieve it more readily.” In essence, a workaround occurs when a nurse takes action that deviates from established policies and procedures to accomplish the work they need to do — delivering patient care.
Nurses may engage in workarounds when they encounter barriers to their ability to deliver care. Time is a frequently cited barrier, but many causes lie behind this one word. In a scoping review, Debono and colleagues categorized factors contributing to workarounds as organizational (such as insufficient staffing, productivity pressures), work process (such as new technology not matching workflow), patient-related (such as the need to ensure patients receive timely care, or policies not in the best interest of the patient), individual clinician (such as fatigue), and social and professional (such as poor communication between clinicians). A key factor to remember is that in most cases, nurses engage in the behavior because they feel it is important to overcome obstacles and deliver needed care to patients.
Workarounds can be viewed on a continuum. For example, they can be innovative when, perhaps, a more efficient workflow is identified. On the other hand, they can be harmful, resulting in patient morbidity and mortality. (Deutsch notes that in addition to immediate danger to patients, workarounds make it less likely that an underlying problem will be identified and addressed.) Certainly, some workarounds pose less potential harm to patients than others, but in general, workarounds are something to be avoided because of patient safety risks.
Nursing and other organizational leaders can take several steps to reduce workarounds:
Engage in dialogue. Leaders and staff should collaborate when implementing new technology or practices to ensure they fit into nurses’ workflow. A systematic review found that workarounds most frequently occurred when new technology was implemented and when medications were administered.
Leaders also should regularly ask staff about problems in workflows and to share any workarounds they have engaged in. It can be helpful to observe care directly, since nurses may not be conscious of workarounds they use. Be aware of situations particularly vulnerable to workarounds, such as when a new process is implemented. In addition to considering the reason for the workaround, those that do not put patients in harm’s way should be evaluated to see if they could result in positive practice changes.
Promote a culture of safety. Leaders need to communicate to staff that the primary goal of the organization is to deliver safe, quality patient care. While that may be stating the obvious, too often nurses perceive that the goal is to complete all the work in the allotted time; this message is reinforced when organizations don’t provide needed support such as adequate staffing.
Another component of a safety culture is a just culture, where there is open communication and a blame-free environment. Errors should be investigated with the goal of identifying root causes, rather than assigning blame. Steven Spear, a senior fellow at the Institute for Healthcare Improvement, suggests that when an error occurs because of a workaround, helpful questions include: What went wrong? What got in my way? Why did it get in my way? What can I — what can we — do differently going forward that will address the causal factors and remove the bad experience?
Hold staff accountable. A just culture does not preclude holding staff accountable for their actions. Nurses who engage in reckless behaviors should be counseled and disciplined. A behavior is considered reckless when the person consciously engages in it while knowing that there is substantial and unjustifiable risk. Leaders can work with human resources departments to establish procedures to follow in these situations.
Provide needed resources. Nurses will engage in workarounds when they don’t have the resources they need to care for patients. These resources include adequate staff, equipment, and supplies. For example, a study found that understaffing during the COVID-19 pandemic led to greater use of safety workarounds.
Provide education. Education about the potential dangers of workarounds should include reasons for it and the importance of speaking up when the nurse feels a workaround is necessary. It also can be helpful to discuss normalization of deviance. When someone chooses to use a workaround and no negative consequences occur, there is the tendency to repeat the workaround and drift away from the standard of behavior, resulting in deviance that can result in harm.
Ensure a user-friendly electronic health record (EHR). Cumbersome EHRs are a frequent source of workarounds, which can lead to patient harm, including medication errors. For example, a study found that 46 percent to 64 percent of nurses used workarounds related to EHRs. Including staff when selecting an EHR and soliciting their input on a regular basis to detect ways the EHR can be made more user-friendly can help reduce workarounds.
Protecting patients, nurses, and organizations
While sometimes helpful in illuminating ways processes can be improved, workarounds more often result in an increased risk of patient harm. This harm can lead to legal action for caregivers, leaders, and organizations. By minimizing workarounds, nursing leaders can help keep patients safe and reduce the risk of liability.
By: Cynthia Saver, MS, RN, is president of CLS Development, Inc., in Columbia, Md.
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