Workarounds in the Workplace a Second Look

ETHICS COLUMN 2.0 ANCC Contact Hours Workarounds in the Workplace A Second Look Jennifer B. Seaman ▼ Judith A. Erlen Nursing workarounds have garnered increased attention from the protocol established by the organization over the past 15 years, corresponding with an increased ( Debono et al., 2013 ). While these behaviors are ob- focus on patient safety and evidence-based practice and served across the spectrum of professions and work- a rise in the use of health information technologies (HITs). place environments, this article focuses on issues that Workarounds have typically been viewed as deviations from occur because of workarounds performed by nurses in best practice that put patients at risk for poor outcomes. the course of patient care. Published work chiefl y por- trays nursing workarounds as negative behaviors and However, this narrow view fails to take into consideration examples of poor nursing practice that need to be elimi- the multifactorial origins of workarounds. The authors ex- nated, as they increase the risk for poor patient out- plore the ways in which evidence-based protocols and HIT, comes. Healthcare providers who engage in worka- designed to improve patient safety and quality, can have rounds are described as “noncompliant” and “risking an unintended consequence of increasing the likelihood of patient safety” ( Debono et al., 2013 ). However, these nurses engaging in workarounds. The article also examines characterizations fail to consider that workarounds are workarounds considering the ethical obligations of both frequently undertaken to ensure patient safety and well- nurses and administrative leaders to optimize patient safety being and provide effi cient care, as demonstrated in and quality. Michael’s case. To view all workarounds as inappropri- ate is an oversimplifi cation of the phenomenon; casting Michael is a registered nurse with a baccalaureate de- those who engage in them in a negative light is ethically gree who began working 3 years ago at a hospital that problematic. Because there is an increased focus on was part of a large health system. Last month, he was nursing workarounds in clinical practice, a more nu- transferred to another hospital within the health sys- anced exploration of this topic is needed. tem to take a job in a specialty ICU. The health system Workarounds have existed throughout modern nurs- has an integrated, enterprise-wide health information ing but have gained more attention in the last 5 years. system, so that all hospitals within the health system An example of an early, low-tech workaround is the share the same basic electronic ordering, charting, “homemade” warm compress composed of hot towels and medication administration systems. In many wrapped and taped in an underbed pad that was used ways, this made the transition easier, because he was familiar with the various technological applications. temporarily while waiting for the K-pad unit to arrive However, one problem he encountered was that he from central supply. Since that time, the use of worka- was unable to print laboratory specimen labels with rounds has expanded to meet the needs of a complex, his user-ID and password, although he was able to ex- changing clinical environment. Debono et al. (2013) un- ecute all the other functions like order entry, clinical dertook a scoping review of the published literature on charting, and medication administration. As a worka- nursing workarounds in the fi elds of nursing, healthcare, round, Michael has another nurse or his preceptor safety science, and sociology. Although only 251 articles enter her user-ID and password to print out the labels. on the topic were published in the years 1961 to 1999 However, Michael expresses discomfort with this so- (about seven per year), there were 517 articles on work- lution, because it is another nurse’s name that is at- arounds published between 2008 and 2012, correspond- tached to the blood draw or specimen collection in the electronic record. Despite multiple calls to the IT ing to a rate of about 130 per year. What factors led to help center, the problem remains unsolved. Michael would prefer not to use this workaround but is not sure what other options he has available at present. Jennifer B. Seaman, PhD, RN , Post-Doctoral Fellow (T32 HL007820), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. he incident described earlier is commonly re- Judith A. Erlen, PhD, RN, FAAN , Professor and Chair, Department of ferred to as a workaround. A workaround is de- Health and Community Systems, University of Pittsburgh, Pittsburgh, PA. fi ned as an action that is performed by an indi- The authors and planners have disclosed that there are no confl icts of vidual to circumvent a block in workfl ow and interest, fi nancial or otherwise. Tthereby achieve a desired goal; yet, the action deviates DOI: 10.1097/NOR.0000000000000161 © 2015 by National Association of Orthopaedic Nurses Orthopaedic Nursing • July/August 2015 • Volume 34 • Number 4 235 Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. OONJ799_LRNJ799_LR 223535 110/07/150/07/15 55:08:08 PPMM this exponential increase in interest? This heightened application of technology in healthcare gained momen- interest is possibly the result of multiple forces in the tum and expanded into the clinical care dimension. social, technological, and healthcare environments. Highly error-prone clinical care tasks, such as the order- Exploring these simultaneous and pivotal changes that ing, dispensing, and administration of medications, have had an impact on the care delivery environment were obvious targets for systems-level applications of will aid in better understanding nursing workarounds technological solutions. The result was the development and their ethical implications. of large integrated systems, including computerized provider order entry (CPOE), automated medication dispensing, electronic medication administration re- Patient Safety and Evidence-Based cords, and barcode medication administration (BCMA) Practice applications. Similar systems for laboratory specimens The increased interest in nursing workarounds is closely were implemented, with CPOE and automated label related to the rise of the patient safely and quality “move- printing, specimen processing, and results posting. ment” and the advent of evidence-based practice (EBP) Once these systems were in place, they were expected standards. Monitoring of patient outcomes in the 1990s to eliminate (or nearly eliminate) the possibility of med- revealed that many patient injuries and deaths were pre- ication errors. Computerized provider order entry offers ventable. Perhaps the most widely recognized call for ac- real-time alerts to the provider, signaling an allergy, du- tion was the 1999 Institute of Medicine (IOM, 2000) report, plicate order, drug–drug interaction, or an out-of-range To Err Is Human: Building a Safer Health System (2000). dose ( Classen, Avery, & Bates, 2007 ). Computerized pro- Although early work in the fi eld of quality improvement vider order entry also puts to rest the perennial problem focused on increasing the knowledge and critical thinking of interpreting illegible orders. Electronic pharmacist skills of the individual clinician to reduce the number of verifi cation and automated dispensing further ensure unintentional errors, the IOM report recognized the role of that the correct medication, dosage, and form are deliv- system-level factors. This report called for systems-level ered to the nurse. Barcode medication administration interventions to reduce unintentional errors and poor clin- theoretically closes the loop by ensuring that the 5-Rights ical practice and thereby improve patient outcomes. of medication administration are achieved. However, Simultaneously the body of nursing knowledge con- many clinicians report that they have just traded one set tinued to expand and technological tools for rapid in- of problems (risk for human error) for another (burden formation dissemination became widely available. The of ineffi cient and unreliable technology). In fact, a re- available data on a clinical topic could be gathered, cent study by Westphal, Lancaster, and Park (2014) re- analyzed, and synthesized to determine which inter- vealed that along with infection control activities, medi- ventions resulted in the best patient outcomes. This cation administration tasks were the clinical activities technological capability, combined with the motivation most commonly associated with workarounds. to utilize research to improve patient outcomes, led to the development of the EBP model ( Melnyk & Fineout- Problems of Complexity and Overholt, 2005). Once a “best practice” was identifi ed, it was operationalized in a protocol that was imple- Technology mented across a practice environment. Evidence-based Protocols coupled with technology-based systems such protocols were seen as the ideal vehicles with which to as BCMA or CPOE were designed to embed the ele- standardize practice and address the patient safety and ments of best practice into workfl ow and are now the quality concerns at the systems level. Subsequently, ev- dominant model in promoting healthcare quality. This idence-based protocols were widely disseminated approach to improving patient safety and quality, how- across practice environments and the principles of evi- ever, has several limitations. For example, these proto- dence-based healthcare as a model

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