Workarounds: The Hidden Pathway to Excellence

doi:10.1016/j.mnl.2010.05.009

Nurse Leader

Volume 8, Issue 4, August 2010, Pages 29-32

https://doi.org/10.1016/j.mnl.2010.05.009 Get rights and content

Nurses are regularly celebrated as creative, resourceful professionals who are able to make things work when few others can. The ability to create and implement workarounds to speed up processes is a common practice that has not been studied in depth. In spite of the perceived value of workarounds, one wonders if there is a dark side to workarounds. Workarounds may, in fact, be an obstacle to progress, an obstacle to achieving practice excellence, and may present a false sense of effectiveness. Further study is needed to determine whether workarounds are creativity gone awry.

Section snippets

Literature review

The notion of workarounds has gained increasing attention with the advancement of documentation and clinical monitoring technology in healthcare.¹ Prior to 1999, the citations for workarounds in healthcare literature were in reference to a physical location such as working around a patient or an object. Workarounds have been discussed in several articles that describe use of technology in healthcare and include efforts to provide a humanistic service rather than a technological approach,

Concept analysis

Walker and Avant's work¹⁴ was used to guide this concept analysis for workarounds. To gain a broader understanding of workarounds, further analysis of the concept reveals new information. Examples of defining attributes, contrary cases, antecedents, and consequences are presented in Figure 1.

The Merriam-Webster Online¹⁵ dictionary defines workarounds as “a plan or method to circumvent a problem (as in computer software) without eliminating it.” Clancy¹⁶ describes workarounds as the work of

Antecedents

The antecedents or incidents that occur before the occurrence of the concept can include a block in workflow, additional work demands, poorly designed systems, or organizational policies that are incompatible with safety and system limitations. For example, the inability to move a computer on wheels with the barcode scanner to a patient's bedside or chair is a situation that might precede a workaround. Having organizational policies that are incompatible with safety is an antecedent to

Consequences

The consequences of workarounds can be either positive or negative events. Interestingly, Halbesleben et al.¹ noted that studies suggest that workarounds have negative consequences (medical errors), but there has been little empirical validation of harm that has resulted. Other consequences include rendering safety systems meaningless and raising awareness of ineffective processes. One positive consequence to workarounds is that they draw attention to things that need to be fixed.⁸

Three

A new definition

Based on the review of literature and analysis of healthcare practices, a more robust and descriptive definition of healthcare workarounds is proposed: Workaround is a creative, redesigned process that facilitates care to patients by providing opportunities for nurses, designers, regulators, and administrators to interact and produce novel patterns or knowledge.

Opportunities

The opportunities within workarounds are considerable and can be addressed in several ways—ignored, discouraged, or addressed. Most commonly, workarounds are ignored or discouraged. They are perceived as something that just happens and, in many situations, have become normative. A third option exists, namely to recognize and address workarounds. Workarounds present an opportunity to analyze and learn from the situation to create more effective processes on the excellence journey. The following

Workarounds and the electronic health record

Many situations occur every day that have embedded workarounds in them. Not surprisingly, the movement from the industrial to digital age has resulted in workarounds with the implementation of the electronic health record (EHR). In hospitals where nurses are using health information technologies that do not match their workflow, they are creating workarounds to complete tasks. Workarounds occur because the designed process does not work as the designer intended. Through interactions with

Conclusion

Workarounds are excellence opportunities waiting to happen. They are opportunities to integrate creative ideas or to correct course along the excellence journey. When an organization sustains workarounds by benign neglect, inefficiencies and errors can result, thereby avoiding the examination of processes that are indeed problematic. When an organization actively seeks out workarounds as opportunities for improvement, a culture of co-creation, involvement, and respect for ideas is

References (17)

AA Vogelsmeier et al.
Technology implementation and workarounds in the nursing home
JAMIA
(2008)
R Koppel et al.
Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety
JAMIA
(2008)
K Vestal
Nursing and the art of the workaround
Nurse Leader
(2008)
JR Halbesleben et al.
Work-arounds in healthcare settings: literature review and research agenda
Health Care Manage Rev
(2008)
S Espin et al.
Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room
Qual Saf Health Care
(2006)
KE Walsh et al.
Medication errors related to computerized order entry for children
Pediatrics
(2006)
MC Boudreau et al.
Enacting integrated information technology: a human agency perspective
Organ Sci
(2005)
JS Bozman
Workaround
Computerworld
(1993)

There are more references available in the full text version of this article.

Cited by (28)

Technology Isn't the Half of It: Integrating Electronic Health Records and Infusion Pumps in a Large Hospital
2019, Joint Commission Journal on Quality and Patient Safety
Citation Excerpt :
Current literature suggests that variations in workflows can be both beneficial and harmful to patient safety. Some studies suggest that variations in practice can be behaviors that circumvent safety blocks,23 disguise individual deficiencies,24 and undermine standard practices,25 but flexible behaviors often provide adaptations to inefficiencies and opportunities for innovation and improvement.26 As such, although increased standardization at CSMC due to IVCI may improve patient care in the short run, over time it may lead to an eventual lack of adaptation and prevent practice evolution and innovation.
Although adoption of “smart” infusion pumps has improved intravenous medication administration safety, pump integration with electronic health records (EHRs) remains rare. Early-adopter hospitals have recently implemented intravenous clinical integration (IVCI) to allow bidirectional communication between their EHRs and infusion pumps. However, the challenges and strategies involved in IVCI implementation have not been described.
A qualitative description of one hospital’s IVCI implementation was conducted. The research team interviewed 33 pharmacists, technologists, clinicians, nurse managers, educators, and organizational leaders; observed nurses on five units using EHR–integrated pumps; and attended nurse training. Interview notes and transcripts were analyzed to describe IVCI implementation, highlighting its effects on clinicians and the organization.
Motivations for implementation included a culture of innovation, simultaneous pump and EHR upgrades, and belief that IVCI would improve patient safety. Proactive planning included a simultaneous go-live across selected units, financial investment, multidisciplinary planning teams, and clinical training. Challenges included lack of direct communication between EHR and pump vendors, nonstandardized unit-specific drug libraries, and unit- and nurse-specific variation in workflows for administering infusions. Mitigation strategies included serving as messenger between vendors, conducting hospitalwide efforts to standardize drug libraries and workflows, and standardizing organizational policies. Lessons learned included that IVCI adoption was as much a nursing workflow and organizational policy intervention as a technological implementation.
Integrating infusion pumps and EHRs involves much more than installing new technologies. Hospitals considering IVCI should prepare to undertake significant simultaneous changes to organizational policies and clinician workflows.
Inpatient Clinical Information Systems
2017, Key Advances in Clinical Informatics: Transforming Health Care through Health Information Technology
Electronic health records (EHRs) are increasingly being deployed as digital inpatient information systems of clinical and administrative data. The interplay of social and technical factors is important when considering effective implementation and adoption strategies in busy, complex hospital environments. These systems offer considerable potential to enhance the safety, quality, and efficiency of hospital healthcare provision, but realizing these benefits is heavily dependent on system optimization. The optimization of inpatient information systems is best conceptualized as an ongoing journey. Developments such as the move to cloud-based EHRs, the opening up of application program interfaces, the opportunity to connect with other digitized hospital infrastructure such as smart infusion pumps and beds, patient access to EHRs, and developments in approaches to and capacity for interrogating standalone and linked EHR-based datasets in real time present major new opportunities to improve outcomes. These developments will however also bring important new ethical, organizational, and privacy related challenges that society will need to address.
Leadership Excellence: Weaving Multiple Initiatives and Frameworks to Advance Culture Change
2013, Nurse Leader
Citation Excerpt :
We learned that we decrease the complexity and can improve the reliability and outcomes from routine process such as admissions, handoffs, and discharges by focusing on processes and checklists that have evolved out of the movement to utilize LEAN methods.5 Knowing that healthcare is full of waste and that work-arounds often become the standard,9 we looked for workarounds and viewed them as positive deviance—opportunities to keep our minds open to the new ways of doing things.10 We used the principle of standard work, described as “the best way we know how to do something,” to change the way we did change-of-shift reports.
Health care innovations across practice and academia: A theoretical framework
2019, Nursing Outlook
Citation Excerpt :
Workarounds are most frequently discussed in relation to information technology and medication administration (Barrett & Stephens, 2017; Patterson, 2018; van der Veen et al., 2018). A tool has been developed to measure nursing workarounds (Halbesleben, Rathert, & Bennett, 2013); however, despite the creative, resourceful, and innovative aspects of workarounds, these behaviors may be questioned as unethical (Berlinger, 2017; Lalley & Malloch, 2010) because it is not yet a supported, legitimized, and rewarded part of the nursing role. Nurses are uniquely positioned to see opportunities for innovation because they are at the center of patient care and interact with many health care professionals as well as perform administrative functions.
An innovation scholarly interest group used the Jobs to Be Done Theory from the business literature to provide insight into the solution-focused progress that nurses are trying to make in challenging situations.
This article presents a theoretical framework for understanding the progress nurses are trying to make through health care innovations across both practice and academic environments.
This was a qualitative descriptive study using directed content analysis. We used the Jobs to Be Done Theory to guide the development of the semistructured questionnaire and the interpretation of findings.
A theoretical framework of nursing innovations was derived to summarize and visually display the pathways and linkages of challenges, innovations, and impact domains of nursing innovations. Situations and opportunities arise within the context of interconnectedness and can lead to health care innovations in care delivery, patient care interventions, role transitions, research and translational methods, communication and collaboration, technology and data, teaching methods, and processes to improve care.
This theoretical framework offers insight into the dynamic interactions of academic-practice partnerships for innovation. Workplace situations are interconnected and can result in needed innovations designed to impact care delivery.
Ethnographic investigation of oral care in the intensive care unit
2016, American Journal of Critical Care
Citation Excerpt :
Therefore, standardized documentation of oral care could be amended to include the behavioral and technical components of this care. In line with recommendations of previous studies46-49 that reported limited procedural preparation for oral care, professional development could include formal instruction in methods to mitigate limited oral access, such as advanced patient communication skills,50 and work-arounds that include modification of tools or procedures.51,52 To further enrich the evidence base for application of oral care, ICU researchers could investigate prevalence and predictors of barriers to oral care, oral pain, theories of aversive oral behaviors, and patients’ recollections.
Oral care plays a clear and important role in the prevention of ventilator-associated pneumonia. However, few studies have explored the actual work of oral care by nurses in the intensive care unit.
To explore intensive care nurses’ knowledge of and experiences with the delivery of oral care to reveal less visible aspects of this work.
In an institutional ethnography, go-along and semistructured interview methods were used to explore the oral care practices and perspectives of 12 bedside nurses and 12 interprofessional (intensivist, allied health, and management) participants in an intensive care unit at a large urban teaching hospital in Ontario, Canada.
Nurses described how obstacles frequently inhibited the delivery of oral care. Technical barriers included oral crowding with tubes and aversive responses by patients, such as biting. Contextual impediments to oral care included time constraints, lack of training, and limited opportunities for interprofessional collaboration. A key discovery was the presence of an informal unit-based nursing curriculum, whereby nurses acquired strategies to overcome barriers to oral care. Although the nurses did extensive problem solving in providing oral care, the interprofessional participants had limited knowledge of how oral care was accomplished.
These data suggest the complexity of performing oral care in intensive care is underestimated and perhaps undervalued. Future research is needed to address technical and contextual barriers to optimize current guideline expectations for the provision of regular and effective oral care.
Why Talking Is Not Cheap: Adverse Events and Informal Communication
2024, Healthcare (Switzerland)

View all citing articles on Scopus

¹: Cathy Lalley, MHI, BSN, RN, is a doctoral student in the Arizona State University College of Nursing and Health Innovation.

²: Kathy Malloch, PhD, MBA, RN, FAAN, is president of KMLS, LLC, in Glendale, Arizona, a clinical professor in the ASU College of Nursing, and clinical consultant for API Healthcare, Inc.

View full text

Workarounds: The Hidden Pathway to Excellence

Section snippets

Literature review

Concept analysis

Antecedents

Consequences

A new definition

Opportunities

Workarounds and the electronic health record

Conclusion

JAMIA

JAMIA

Nurse Leader

Work-arounds in healthcare settings: literature review and research agenda

Health Care Manage Rev

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room

Qual Saf Health Care

Medication errors related to computerized order entry for children

Pediatrics

Enacting integrated information technology: a human agency perspective

Organ Sci

Workaround

Computerworld