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.”
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.
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.)