Photo © Associated Press
A couple of months ago, we posted a query on Facebook asking visitors to the page if they had ever used workarounds—the improvised shortcuts that may not be the standard practice or the policy, but may allow for more efficient work processes. We were amazed at the uniformity of the responses. No one saw a problem with workarounds, and most responded along the lines of “I love my workarounds—couldn’t do my job without them” and “I’ll never tell—keep hands off my workarounds.”
Nothing new.
Workarounds have probably been around since Florence Nightingale’s day—I can imagine one of her nurses at Scutari hiding lamp oil so she’d have enough to make rounds at night. In my early nursing days, we hid sheets so we’d have some in case we needed an extra bed change for a patient. When I worked in the ER of a busy city hospital, we kept a pretty large supply of IV fluids and medications on hand in a closet. It became a well-known secret that the ER had its own stockpile—in fact, there were occasions when the pharmacy would come to us for meds!
Today, the workarounds I hear about tend to revolve around dealing with the electronic health record and scanning medication bar codes.
Some cautions.
In this month’s article, “Workarounds Are Routinely Used by Nurses—But Are They Ethical?”, ethicist Nancy Berlinger presents some cautions in her exploration of these time-savers. She notes that most workarounds likely occur because nurses want to provide better, more efficient care but system flaws prompt them from devising alternative paths to do so. The workaround works, and so becomes part of this nurse’s workflow. It may or may not be shared with other colleagues, so not all patients benefit. Berlinger also notes:
“… quick fixes that keep the system moving often violate rules (putting clinicians in a difficult situation) and may occur outside of institutional processes designed to improve safety and quality (putting patients at risk).”
Perpetuating system dysfunction.
Moreover, hidden workarounds perpetuate a dysfunctional system—bringing workarounds out in the open allows for the possibility of revisiting system processes. For example, the need to hide linen points to a possible supply shortage—a quick fix is to order more linen. Scanning medication bar codes all at once instead of at the bedside with each patient may indicate the need for more portable computers or computers at the bedside, or for additional staff during peak medication administration times.
Berlinger suggests that administrators who want to improve hospital systems and enhance care delivery should perhaps ask, “What’s your best workaround?” The responses may be enlightening.
(The article will be free to read until October 27.)
And when the answer is, “Our management consultant has determined that no more bar code scanners are needed for X nurses or Y beds, so make it work,” or, “The scanners are under warranty only if we send them to ABC for repairs, and we can’t get them back any faster, so we’ll still hold you responsible for scanning 95% of the time,” or, “There is no more linen, so do the best you can,” then nurses will continue to do what we’ve always done — the best we can work out to give safe care.
We’ve always dealt c linen shortages — I can remember having state-of-the-art blood gas kits in the ICU but “No washcloths until Monday.” And oddly, nurses gave meds safely without barcode scanners for years by following the Rights and could do again with more experience using them and less blind reliance on technology (staff in bedside use, management in often punitive oversight) … if there were more RN staff with more time to think about more than completing task checklists. But then … see above: “No more linen.” There will be no more staff, will there?
And so, workarounds.