examples of nursing workaround

Resident Safety and Nurse Workarounds

Resident harm is every nurse’s nightmare. Four years ago, a nurse administered the wrong medication to a patient, which resulted in the patient’s death. RaDonda Vaught was recently criminally convicted of negligent homicide and neglect of an impaired adult. Although the defense argued that the error was a result of faulty processes the hospital was responsible for maintaining, the jury found that Vaught’s failure to follow safety protocols caused the patient’s death. When she encountered process inefficiencies, Vaught engaged in workarounds, and the situation cost an innocent person her life. Nurses and other healthcare professionals around the country are now sharing their experiences with flawed processes and how they must often use workarounds, like this nurse did, to perform their duties. Healthcare organizations, including skilled nursing facilities (SNFs) are responsible for implementing systems that ensure nightmares like this never occur; nurses are responsible for working within those systems to deliver care safely. This article will cover reasons that workarounds occur and discuss how to review processes and create a culture that prevents nurses from using them.

Nurse workarounds defined

Nurse workarounds are actions that nurses take to deliver care and accomplish the work assigned to them, despite those actions’ deviating from protocol and policy. Discussion and study of workarounds commonly focuses on technology used in hospitals to facilitate care delivery, such as scanners and medication delivery devices. Yet workarounds occur in SNFs, as well, and can also occur when technology is not involved. For example, a nurse who pops medication from a multi-dose card and pre-pours pills or places them in medication cups to be administered later, for one or more residents, does not intend to cause harm. Nurses do this so they can dispense medications quickly, saving precious time and allowing them to move on to the next task they must complete. But the intended time-saver exposes patients to the risk of harm. While an error probably will not occur every time a workaround is used, when one does occur, the harm is likely to be significant. The question SNF leaders should ask and then address is: what compels nurses to deviate from policy and protocols and rely on workarounds?

Causes of nurse workarounds

Usually when nurses seek a workaround, they are doing so because they have attempted to follow the SNF’s policy and protocols but encountered barriers that prevent or delay them from delivering care. At that point, the nurse finds a way to circumvent the barriers, which simultaneously deviates from the policy and protocols but enables them to complete work assigned to them.

Years of patient safety research have confirmed that the underlying causes prompting workarounds that can lead to patient harm are rooted in flawed processes, rather than the fault of any one individual. For example, assigning nurses non-clinical tasks without considering how it will impact nurse workflows is a flawed process. When the additional non-clinical tasks add to a hectic or heavy workload, it may be impossible to complete both non-clinical and clinical tasks without a workaround, despite risks to patient safety. This becomes especially problematic when management emphasizes the non-nursing tasks as a priority and shifts the nurses’ focus even further from clinical tasks.

A process that ignores acuity and other factors that influence the nurse’s ability to perform safely will also cause workarounds. Examples of this include nurse-to-resident ratios that do not afford sufficient time to meet each resident’s needs, or insufficient staffing of certified nurse aides, activities, social services, and others who perform important and necessary work to care for residents while allowing the nurse to focus on things only a nurse can do.

Any process that does not ensure the right equipment is readily available will also lead to nurses seeking workarounds. For example, if there are not enough glucose testing machines, nurses will use one machine for multiple residents, despite a policy stating that each resident will have his or her own machine to reduce the risk of bloodborne pathogens being spread.

Finally, if care delivery policies and protocols do not strive to eliminate interruptions in care delivery that require concerted effort, nurses will act accordingly. When staff accept that constant interruptions are just part of the job, it often results in a workaround. For example, if nurses are expected to answer the phone while also trying to complete a care procedure, they may skip some infection control steps to speed up the procedure so they can answer the ringing phone.

There are times when a nurse chooses to engage in reckless behavior. Recklessness is willingly acting in a way that disregards the risks or harm that may come to others because of one’s actions. Recklessness occurs when someone knew or should have known that the choice was likely to cause harm and did the behavior anyway. In contrast, negligence occurs when one violates a duty owed to someone else and that breach causes harm. While recklessness generally involves a choice, negligence often involves carelessness in one’s actions or inactions. The Vaught verdict highlights that both recklessness and negligence can constitute crimes. Vaught was acquitted on charges of recklessness but convicted on two lesser counts related to negligence. Even though it may be flawed processes that prompt a nurse to seek a workaround, one can be criminally negligent if those workarounds cause harm to a resident.

A Just and Safe Culture

Unfortunately, leadership usually monitors only whether work is completed and ignores the workarounds nurses had to use to do it or the quality-of-care delivery. Similarly, leadership sometimes neglects to investigate whether flawed processes are impeding task completion. Decisions leadership give to nurses often reinforce a message that how something is accomplished does not matter. For example, if a facility requires documentation be completed but does not allow sufficient time to do it, a nurse may understand this to mean that care delivery needs to be accelerated so that documentation is done regardless of the quality and safety of care. Although leadership does not intend to send this message and perpetuate workarounds, nonetheless, nurses are left with flawed processes, mixed messages, and the duty to provide care. If leadership does not provide staff with the time or resources to complete a task, a workaround is likely to occur.

There is another way leaders can operate, and it involves championing and adopting safety culture. Simply defined, safety culture is one that values safe care delivery. Ideally, safety culture is paired with just culture or the balance between an open, honest, and blame-free environment that also holds employees responsible for reckless behavior. To cultivate an environment that values safety and supports nurses so they can deliver care safely, SNF leaders can do the following:

• Adopt policies and protocols related to accidents and incident investigations that seek to determine the root causes of the problem and address them rather than immediately placing blame on one individual.
• Adopt human resource management policies that include behavioral expectations for all staff, including nurses, regarding safe care delivery and the avoidance of reckless behavior.
• Gain knowledge of how to use a systems approach to safety so that the processes designed and implemented enable nurses to practice safely and avoid workarounds.
• Listen to nurses when they report a problem or barriers to their workflows.
• After implementing new processes, follow-up with staff to ensure they are working properly.
• Conduct observations of nurses while they deliver care and ask questions when workarounds are done to learn why and what needs to be addressed.

The following resources are available to assist SNF leaders to cultivate a just and safe culture:

AAPACN’s Guides to Enhanced Resident Safety

AAPACN’s QAPI Certified Professional Education and Certification Program

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network’s Patient Safety Primers Starter Pack and the Surveys on Patient Safety Culture

Institute for Healthcare Improvement’s (IHI) How Can You Identify and Confront Workarounds?

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Nursing workarounds and what they mean for the future of healthcare

September 28, 2016    |    digital health , entrepreneur , innovation , intrapreneur , know my patient , linen cart , mHealth , nightingale apps , Nurses , Nursing , nursing apps , workaround

Nursing workarounds and what they mean for the future of healthcare. 

Last evening, I spoke to a group of approximately 60 graduate nursing students at Northeastern University in Boston MA.  I spoke on the topic of nurse entrepreneurship and intrapraneurship. The faculty members, Dr. Laura Mylott and Dr. Janet Rico wanted to show their students the different opportunities there are for nurses in the health care arena. Nurse entrepreneurship or intrapreneurship are two career options that we often don’t discuss in our formalized nursing education classes. However, I will tell you that they are very real career options and in many ways will be the only way in which we solve some of the day-to-day problems nurses are faced with at the bedside. The reason why nurses are the only individuals set up to solve these problems is because no one else knows they exist. No one is going to come knocking on the door with a solution to solve problems they don’t know exist.

Workarounds.

  I asked the class, “ What is a workaround?” . It could have been that no one wanted to speak up but I didn’t get a volunteer to answer the question. So, I turned it around. “Ok. What is a problem you deal with every day and how to you get around it?” I had one student volunteer to tell the group that he works nights. At night, STAT labs are entered at midnight however the system goes down for 30 minutes every night at this time. It affects the timing in which labels are printed and subsequently when they can be drawn, resulted, and acted upon. So, instead of waiting and wasting time, he figured out a way to manually force print the labels. This is the workaround.

I then asked, “Ok, so you can get the labels but what is the impact of this effort?” He said, “time wasted”. That is exactly right. I then asked, “What does that mean (e.g. time wasted)?” The response from another student: “It means less time spent with the patient.” Exactly. It also means that you are forced to speed up other efforts to make up for the lost time. After that, the class was clear on workarounds. Whether getting linen from another unit because the cart was empty or using a syringe to pull out the air bubbles in the IV tubing to stop the ‘air in the line’ problem, they all had something that they fight with daily in an effort to get the patient the care he or she deserves.

  Innovation.

Developing workarounds to existing problems at the individual level is the first step in understanding innovation. Innovation is a new product, service, or method created to benefit others. In many instances these workarounds affect all nurses. However, at the time in which they are being experienced, a short term solution is essential. We, as a profession, seem to struggle to bubble these workarounds up toward a long term solution.

  For example, let’s go back to the linen cart. Every day that I worked as a bedside nurse, I strived to change the bed linens for each patient. However, despite the number of beds on the unit not changing, I always ran into the issue of an empty linen cart (whether for the pillow case, bed sheet, towel). I would then run to another unit and grab what I needed from another cart and proceed with my day. This took a few minutes to do each time and I always thought it was just me. Well, after using this example in recent talks, I have come to find out that I was not alone and actually everyone can relate to this problem.

As nurses, our short term solution is to run to another linen cart and solve the immediate need. It usually stops there. We have so many other things to manage over the course of the day that fighting the battle of a fully stocked linen cart doesn’t make it to the top of the list. Additionally, we don’t think of bringing it to someone who can help us solve it or champion the effort and move it forward with the support of others. Now, that example isn’t one that directly places patients at risk. However, it is an example of a problem that could be solved with some organizational support, data, communication, and revised processes across departments.

Nurses as intrapraneurs and entrepreneurs.

To tackle the linen cart example and solve it, would be an intrapreneurial act. Intrapreneurship is creating innovation within the walls of an established organization. Many organizations now have Chief Innovation Officers or Directors of Innovation to create new solutions. Any nurse could participate in these efforts and should explore these departments if they want to bring forward positive change that can impact not just themselves, but every other affected nurse, patient, family, doctor etc. This is where we can make change in healthcare that will help us for the future.

Entrepreneurship is the other place for innovation where nurses can get on board. Entrepreneurship is when an identified problem is solved through innovation (e.g., new product, service, method) and a business is created around it. Instead of within the health care organization, entrepreneurs create new businesses and organizations to address problems that affect large populations of people.

I created Know My Patient TM  to address the pervasive issue of nurses relying on that report sheet that lives in their pockets and is used as a reference guide to support what nurses need to know about their patients on the go. However, that sheet is also a data collector now at the bedside and it is the most sophisticated of its kind in comparison to the alternatives. The alternatives are writing on paper towels, alcohol swabs, post it notes, tape on pants and even one’s own hands or glove. This happens every day.  This is a workaround to a problem that hadn’t been solved… There is no reason why we cannot leverage the mobile technology that exists to replace the reliance on this workaround. The smart phone came along and changed how individuals access and use information. I saw the way nurses used the smart phone to their benefit instead of as a barrier and their actions sparked my action to take this on. I decided to go the entrepreneurial path and form a company, Nightingale Apps LLC, to help solve this problem that affects every nurse.

As nurses, we are trained to protect and promote the lives of our patients. At times, this also means that nurses are saving lives which is quite powerful. By taking the nursing process (e.g., assessing, planning, intervening and evaluating) and applying to existing problems, we as a profession can shift from individual workarounds to system-wide innovations that benefit the greater good of nurses, patients, families, health care professionals, and the industry at large.

Hi I’m Dr. Kelley and the founder of Nightingale Apps !

Dr. Kelley has 23 years of nursing experience. She spent the last 20 years working in the field of nursing informatics. Read more

Caring for Oneself while Caring for Others

I was eager to become a nurse and help other people. My mother has... Read more

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Nurse workarounds in the electronic health record: An integrative review

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Dan Fraczkowski, Jeffrey Matson, Karen Dunn Lopez, Nurse workarounds in the electronic health record: An integrative review, Journal of the American Medical Informatics Association , Volume 27, Issue 7, July 2020, Pages 1149–1165, https://doi.org/10.1093/jamia/ocaa050

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The study sought to synthesize published literature on direct care nurses’ use of workarounds related to the electronic health record.

We conducted an integrative review of qualitative and quantitative peer-reviewed research through a structured search of Academic Search Complete, EBSCO Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Engineering Village, Ovid Medline, Scopus, and Web of Science. We systematically applied exclusion rules at the title, abstract, and full article stages and extracted and synthesized their research methods, workaround classifications, and probable causes from articles meeting inclusion criteria.

Our search yielded 5221 results. After removing duplicates and applying rules, 33 results met inclusion criteria. A total of 22 articles used qualitative approaches, 10 used mixed methods, and 1 used quantitative methods. While researchers may classify workarounds differently, they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Each study identified probable causes, which included technology, task, organizational, patient, environmental, and usability factors.

Extensive study of nurse workarounds in acute settings highlights the gap in ambulatory care research. Despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team. The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system. Research is needed to explore the gaps in our understanding of and identify strategies to reduce workaround behaviors.

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A Systematic Review of Nursing Practice Workarounds

• PMID: 36179314
• DOI: 10.1097/DCC.0000000000000549

Background: Nursing practice workarounds (NPWs) are a significant problem for health care organizations. Identified NPWs serve as a catalyst for innovation to improve efficiency, patient safety, and system design. To date, a systematic review of NPW literature has not been performed.

Objectives: The aim of this systematic review was to synthesize evidence of NPW definitions, context, and prevention strategies, utilizing previous research to develop a framework that examines the current state of this phenomenon and implications for clinical practice, while highlighting the need for future research.

Methods: A systematic review of the literature was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Academic Search, Ovid MEDLINE, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar databases were reviewed for eligible studies from 2013 to 2020. Results were further screened and sorted by relevance and scored for quality.

Results: Thirteen studies were included. Studies lacked the use of theory, and NPW definitions were varied. Nursing workarounds occurred most frequently when implementing new technology (46%) and when administering medications (31%). Contributing factors were workplace stressors and obstructions in workflow environment. Workaround prevention strategies include open communication and a proactive approach addressing conditions, situations, and processes. Overall study quality was low.

Discussion: This systematic review provides valuable information for critical care nurses and administrators regarding NPW. Implications for practice include the need for proactive and open communication between nurses and administrators when new technology and/or patient care processes require NPW. Administrative considerations include process and environmental improvement strategies to remove perceived workflow barriers. Future research to examine causes and consequences of NPW is needed to identify interventions for NPW prevention. Specific nursing considerations include workload, staffing and time constraints, and impacts of work-related stress levels. Critical care nursing processes should be examined for common NPW challenges. Interventions developed to address these challenges should then be tested to further advance evidence-based critical care nursing care.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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Nurse workarounds in the electronic health record: an integrative review.

Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050.

The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design .

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