How everyday functioning in acute care really works: the case of nurses’ workarounds

Deborah Debono and Jeffrey Braithwaite

Australian Institute of Health Innovation

Presentation to the Resilient Health Care Net Summer Meeting

Middelfart, DenmarkAugust 26 to 28, 2013

The Resilient Health Care Net – Summer Meeting, August 26-28, 2013

The Resilience of Everyday Clinical WorkTentative programme

Sunday August 2515:00 – 17:00 Tutorial – topic to be announced.

Monday August 2607:00 – 08:30 Breakfast

Session 1: The range of everyday clinical work08:30 – 09:00 Features of resilience in maternity services – a case study on adaptations of micro

systems to influences from meso and macro system levels. (Plessen, C. v., Wiig, S.,Aase, K.)

09:00 – 09:30 The 2011 Stanley Cup riot: A lesson in resilience. (Hunte, G. S.)

09:30 – 10:00 Hospital discharge of the elderly – using the ETTO principle to explain performance variability. (Laugaland, K., Åsa, K.)

10:00 – 10:30 Coffee break

10:30 – 12:00 The range of everyday clinical work – Extended thematic discussion / panel

12:00 – 13:30 Lunch

Session 2: Tradeoffs, workarounds, coping, dampening13:30 – 14:00 Individual – Collective Tradeoffs in Healthcare and their Implications for Resilience.

(Wears, R. L., Hunte, G. S.)

14:00 – 14:30 How everyday functioning in acute care really works: the case of nurses’ workarounds. (Debono, D., Braithwaite, J.)

14:30 – 15:00 Tensions and trade-offs in patient handover emergency care. (Sujan, M. A.)

15:00 – 15:30 Coffee break

15:30 – 17:00 Tradeoffs, workarounds, coping, dampening – Extended thematic discussion / panel

19:00 – Dinner at Hindsgavl

Tuesday August 2707:00 – 08:30 Breakfast

Session 3: Resilience in other words08:30 – 09:00 A system migration, a social cognition, or a naturalistic decision: understanding the

use of rules in anaesthetic practice. (Phipps, D. L., Parker,D., Beatty, P. C. W.)

09:00 – 09:30 Resilience and Phronesis. (Hunte, G., Sheps, S., Wears, B.)

09:30 – 10:00 Three attributes of everyday functioning: social organisation, cultural features and network characteristics. (Braithwaite, J., Plumb, J.)

10:00 – 10:30 Coffee break

Australian Institute of Health Innovation’s mission

Our mission is to enhance local, institutional and international health system decision-

making through evidence; and use systems sciences and translational approaches to provide innovative,

evidence-based solutions to specified health care delivery problems.

http://www.med.unsw.edu.au/medweb.nsf/page/ihi

Australian Institute of Health Innovation• Professor Jeffrey Braithwaite

Professor and Foundation Director, AIHI; Director, Centre for Clinical Governance Research

• Professor Enrico CoieraProfessor of Health Informatics, Centre for Health Informatics, AIHI, UNSW

• Professor Ken HillmanProfessor of Intensive Care, Simpson Centre for Health Services Research, AIHI, UNSW

• Professor Johanna WestbrookProfessor of Health Informatics Centre for Health Systems and Safety Research, AIHI, UNSW

Background - the Centre

The Centre for Clinical Governance Research undertakes strategic

research, evaluations and research-based projects of national and

international standing with a core interest to investigate health sector issues of policy, culture, systems, governance

and leadership.

http://www.med.unsw.edu.au/medweb.nsf/page/ClinGov_About

World

Australia Denmark

The dominant Safety 1 view

Health care occurs in a CAS

Requiring navigation of:• complex, challenging

environments• heavy workloads• interruptions• competing requirements• time critical pressures• emotional demands

But health care occurs in a CAS

This is normal• Exceptions are not exceptional …

but routine

[Tucker and Edmondson 2002]

And …• The ‘systematisers’, ‘anti-variationalists’,

‘quality improvement advocates’ and ‘patient safety solutionists’ are in a Safety 1 paradigm

• With a view that: with a little more effort, a few more resources, a more refined set of recommendations from a knowledgeable inquiry, some new tools, an updated IT system, and better policy, we will ameliorate harm

[Hollnagel, Braithwaite and Wears 2013]

But…• This assumes an orderly, linear,

predicable world• Not found in the real world of

health care

[Hollnagel, Braithwaite and Wears 2013]

Question

How do clinicians navigate workflows and manage the complexity and ubiquitous workflow hindrances to deliver safe and effective care?

Answer

One way is to work around them

Workarounds: definition

“Workarounds are observed or described behaviours that may differ from organisationally prescribed or intended procedures. They circumvent or temporarily ‘fix’ an evident or perceived workflow hindrance in order to meet a goal or to achieve it more readily”

[Debono, Greenfield, Travaglia, Long, Black, Johnson, Braithwaite, 2013]

Workarounds: what they look like

Workaround the shortage of gum boots to shower patients

Workaround the shortage of intravenous therapy solution stands

Workarounds: what they look like

Workaround the shortage of gum boots to shower patients

Workaround the shortage of intravenous therapy solution stands

Workaround in a hospital ward to solve the problem of the smoke alarm that kept going off because of nebulisers in a patient's room

Workarounds: other terms

• Shortcuts (-)• Situational violations (-)• Deviations (-)• Innovations (+)• Ready-made fixes (+)• Problem solving (+)

Workarounds and resilience

Workarounds often examples of ‘first order problem solving’– adapting work to cope with basic

system inefficienciesBut this can impair the capacity to engage in ‘second order problem solving’– change the system so the problem

does not reappear

Studying workaroundsStudies of workarounds provide an opportunity to examine:• individual and collective everyday

functioning of frontline clinicians• how informal practices flourish• what nurses do when they deploy

workarounds to contribute to resilient health care

Objective

To examine the empirical evidence on the implementation, propagation, rationalisation, conceptualisation and impact of nurses’ workarounds in acute care settings

Method: a scoping review

)

[Debono, Greenfield, Travaglia, Long, Black, Johnson and Braithwaite, 2013]

Findings

Nurses’ workarounds are:• collectively and individually enacted• a response to a range of workflow

barriers including policy, technology or operational “failures”

• perceived to contribute to (+) or to compromise (-) patient care

Findings

Nurses’ workarounds hide:• how care is otherwise thought to be

delivered (WAI vs WAD)• how policies are actually enacted• problems and glitches to care delivery• sometimes, opportunities for

improvement

Findings

The development and proliferation of nurses’ workarounds are influenced by:• workflow issues including policy,

technology or operational failures• patient, clinician, organisational factors• cultural norms• notions of professional competency

Findings

Few studies measure the negative impact of workarounds on patient care

Even fewer studies measure the positive impact of workarounds on patient care

Discussion

• In everyday practice nurses use workarounds all the time

• Workarounds may facilitate delivery of care and/or destabilise safety mechanisms

Examples of +ive effects of workarounds

• Care tailored to a patient’s specific needs

• Batching care so the patient gets a good night’s sleep

• Giving medications early so patients won’t wait four hours

• May lead to better rules, practices

Examples of -ive effects of workarounds

• Fix individual problems but mask underlying systems problems

• Increasing complexity and the potential for new errors

• Make staff vulnerable to retribution• Challenges what should be taught to

new clinicians

Discussion

Workarounds are often not reported or discussed and so may create an illusion that sanctioned or formal processes are seamless and more effective than they actually are

Conclusion

• Workarounds neatly encapsulate distinctions between WAI (the blunt end) and WAD (the sharp end)

• Relying on resilience (and the workarounds that create it) may be too much of a good thing

[Wears and Vincent, 2013]

Conclusion

• Workarounds can have features of resilience and brittleness

• They often provide rich insights into everyday activities that make care succeed

[Wears and Vincent, 2013]

Reference

● Debono, DS., Greenfield, D., Travaglia, JF., Long, JC., Black, D., Johnson, J., Braithwaite, J. Nurses' workarounds in acute healthcare settings: a scoping review. BMC Health Services Research, 13:175 (http://www.biomedcentral.com/1472-6963/13/175)

Contact details

Jeffrey Braithwaite, PhD

Foundation Director

Australian Institute of Health Innovation

Director

Centre for Clinical Governance Research

Professor, Faculty of Medicine

University of New South Wales

SYDNEY NSW 2052

AUSTRALIA

Email: j.braithwaite@unsw.edu.au

Wiki: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite

Web: http://www.aihi.unsw.edu.au