Resident harm is every nurse’s nightmare. Four years ago, a nurse administered the wrong medication to a patient, which resulted in the patient’s death. RaDonda Vaught was recently criminally convicted of negligent homicide and neglect of an impaired adult. Although the defense argued that the error was a result of faulty processes the hospital was responsible for maintaining, the jury found that Vaught’s failure to follow safety protocols caused the patient’s death. When she encountered process inefficiencies, Vaught engaged in workarounds, and the situation cost an innocent person her life. Nurses and other healthcare professionals around the country are now sharing their experiences with flawed processes and how they must often use workarounds, like this nurse did, to perform their duties. Healthcare organizations, including skilled nursing facilities (SNFs) are responsible for implementing systems that ensure nightmares like this never occur; nurses are responsible for working within those systems to deliver care safely. This article will cover reasons that workarounds occur and discuss how to review processes and create a culture that prevents nurses from using them.
Nurse workarounds defined
Nurse workarounds are actions that nurses take to deliver care and accomplish the work assigned to them, despite those actions’ deviating from protocol and policy. Discussion and study of workarounds commonly focuses on technology used in hospitals to facilitate care delivery, such as scanners and medication delivery devices. Yet workarounds occur in SNFs, as well, and can also occur when technology is not involved. For example, a nurse who pops medication from a multi-dose card and pre-pours pills or places them in medication cups to be administered later, for one or more residents, does not intend to cause harm. Nurses do this so they can dispense medications quickly, saving precious time and allowing them to move on to the next task they must complete. But the intended time-saver exposes patients to the risk of harm. While an error probably will not occur every time a workaround is used, when one does occur, the harm is likely to be significant. The question SNF leaders should ask and then address is: what compels nurses to deviate from policy and protocols and rely on workarounds?
Causes of nurse workarounds
Usually when nurses seek a workaround, they are doing so because they have attempted to follow the SNF’s policy and protocols but encountered barriers that prevent or delay them from delivering care. At that point, the nurse finds a way to circumvent the barriers, which simultaneously deviates from the policy and protocols but enables them to complete work assigned to them.
Years of patient safety research have confirmed that the underlying causes prompting workarounds that can lead to patient harm are rooted in flawed processes, rather than the fault of any one individual. For example, assigning nurses non-clinical tasks without considering how it will impact nurse workflows is a flawed process. When the additional non-clinical tasks add to a hectic or heavy workload, it may be impossible to complete both non-clinical and clinical tasks without a workaround, despite risks to patient safety. This becomes especially problematic when management emphasizes the non-nursing tasks as a priority and shifts the nurses’ focus even further from clinical tasks.
A process that ignores acuity and other factors that influence the nurse’s ability to perform safely will also cause workarounds. Examples of this include nurse-to-resident ratios that do not afford sufficient time to meet each resident’s needs, or insufficient staffing of certified nurse aides, activities, social services, and others who perform important and necessary work to care for residents while allowing the nurse to focus on things only a nurse can do.
Any process that does not ensure the right equipment is readily available will also lead to nurses seeking workarounds. For example, if there are not enough glucose testing machines, nurses will use one machine for multiple residents, despite a policy stating that each resident will have his or her own machine to reduce the risk of bloodborne pathogens being spread.
Finally, if care delivery policies and protocols do not strive to eliminate interruptions in care delivery that require concerted effort, nurses will act accordingly. When staff accept that constant interruptions are just part of the job, it often results in a workaround. For example, if nurses are expected to answer the phone while also trying to complete a care procedure, they may skip some infection control steps to speed up the procedure so they can answer the ringing phone.
There are times when a nurse chooses to engage in reckless behavior. Recklessness is willingly acting in a way that disregards the risks or harm that may come to others because of one’s actions. Recklessness occurs when someone knew or should have known that the choice was likely to cause harm and did the behavior anyway. In contrast, negligence occurs when one violates a duty owed to someone else and that breach causes harm. While recklessness generally involves a choice, negligence often involves carelessness in one’s actions or inactions. The Vaught verdict highlights that both recklessness and negligence can constitute crimes. Vaught was acquitted on charges of recklessness but convicted on two lesser counts related to negligence. Even though it may be flawed processes that prompt a nurse to seek a workaround, one can be criminally negligent if those workarounds cause harm to a resident.
A Just and Safe Culture
Unfortunately, leadership usually monitors only whether work is completed and ignores the workarounds nurses had to use to do it or the quality-of-care delivery. Similarly, leadership sometimes neglects to investigate whether flawed processes are impeding task completion. Decisions leadership give to nurses often reinforce a message that how something is accomplished does not matter. For example, if a facility requires documentation be completed but does not allow sufficient time to do it, a nurse may understand this to mean that care delivery needs to be accelerated so that documentation is done regardless of the quality and safety of care. Although leadership does not intend to send this message and perpetuate workarounds, nonetheless, nurses are left with flawed processes, mixed messages, and the duty to provide care. If leadership does not provide staff with the time or resources to complete a task, a workaround is likely to occur.
There is another way leaders can operate, and it involves championing and adopting safety culture. Simply defined, safety culture is one that values safe care delivery. Ideally, safety culture is paired with just culture or the balance between an open, honest, and blame-free environment that also holds employees responsible for reckless behavior. To cultivate an environment that values safety and supports nurses so they can deliver care safely, SNF leaders can do the following:
- Adopt policies and protocols related to accidents and incident investigations that seek to determine the root causes of the problem and address them rather than immediately placing blame on one individual.
- Adopt human resource management policies that include behavioral expectations for all staff, including nurses, regarding safe care delivery and the avoidance of reckless behavior.
- Gain knowledge of how to use a systems approach to safety so that the processes designed and implemented enable nurses to practice safely and avoid workarounds.
- Listen to nurses when they report a problem or barriers to their workflows.
- After implementing new processes, follow-up with staff to ensure they are working properly.
- Conduct observations of nurses while they deliver care and ask questions when workarounds are done to learn why and what needs to be addressed.
The following resources are available to assist SNF leaders to cultivate a just and safe culture:
AAPACN’s Guides to Enhanced Resident Safety
AAPACN’s QAPI Certified Professional Education and Certification Program
Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network’s Patient Safety Primers Starter Pack and the Surveys on Patient Safety Culture
Institute for Healthcare Improvement’s (IHI) How Can You Identify and Confront Workarounds?
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