Title: Nurses' workarounds in acute healthcare settings: a scoping review

Transcription

1 Author's response to reviews Title: Nurses' workarounds in acute healthcare settings: a scoping review Authors: Deborah S Debono (d.debono@unsw.edu.au) David Greenfield (d.greenfield@unsw.edu.au) Joanne F Travaglia (j.travaglia@unsw.edu.au) Janet C Long (janet.long@student.unsw.edu.au) Deborah Black (deborah.black@sydney.edu.au) Julie Johnson (j.johnson@unsw.edu.au) Jeffrey Braithwaite (j.braithwaite@unsw.edu.au) Version: 4 Date: 19 April 2013 Author's response to reviews: see over

2 "Nurses' workarounds in acute healthcare settings: a scoping review" Dear Associate Editor, On behalf of my co-authors and myself please accept our revised paper entitled Nurses workarounds in acute healthcare settings: a scoping review (MS ), which we resubmit for consideration for publication in BMC Health Services Research. We have reviewed and revised the paper in line with the editor and reviewers comments. We provide the revised manuscript in which we have highlighted revisions by underlining them. We also provide a Table of our responses to the editor and reviewers comments. We have uploaded a revised Figure 1 that incorporates revisions suggested by the reviewers. We confirm that the manuscript comprises original, unpublished material which is not under consideration elsewhere. for considering our revised submission. Yours sincerely Deborah Debono 1

3 Tables of responses to Reviewers comments Associate Editor s comments The reviewers believe this paper is an important contribution, and I concur. They request some clarification and additional details, particularly Dr. Semple. The suggestions of all the reviewers will contribute to an even stronger paper. Please revise accordingly and explain the changes you have made in response to each of the reviewers' comments. Abstract needs background section which needs context info. Editorial Review: Associate Editor's comments Authors Responses for the support of our paper. We have revised the paper accordingly and explained the changes we have made in response to each of the reviewers comments in the remainder of this table. In the process of responding to the reviewers comments, we have made minor changes to clarify and improve the paper. These changes have also been underlined in the manuscript. We have added a Background section to the Abstract (first paragraph in the Abstract). The Background includes contextual information. Please format your abstract according to the guidelines for authors < Potential referees will be asked to review the manuscript having seen only the title and abstract, so it is important that these are both informative and concise. 2. Tables Please ensure that the order in which your tables are cited is the same as the order in which they are provided. Every table must be cited in the text, using Arabic numerals. Please do not use ranges when listing tables. Tables must not be subdivided, or contain tables within tables. Please note that we are unable to display vertical lines or text within tables, no display merged cells: please re-layout your table without these elements. Tables should be formatted using the Table tool in your word processor. Please ensure the table title is above the table and the legend is below the table. For more information, see the instructions for authors on the journal website. **Please note: if you are submitting an uneditable document (e.g. PDF), We have formatted the Abstract according to the guidelines for authors. The tables are cited in the same order as which they are provided. Each table has now been cited in the text using Arabic numerals. The tables have been reformatted; the vertical lines and merged cells have been removed. There is a title above each table. The files uploaded are in an editable form (.docx). 2

4 we will not be able to process this for production purposes. Please upload the editable source files (e.g..docx,.tex) as additional files. 3

5 Reviewer comments Significant contribution to the literature. I sometimes wondered if some of the methodology of the lit search process should be in a supplemental part b/c many readers don't care about that (even though we know the devil is in the details). Reviewer 1: Ross Koppel Authors Responses. We have endeavoured to conduct a rigorous and comprehensive study and we appreciate your confirmation of this. We have conformed to the journal style and papers using similar scoping literature review methods published in this journal. Well written, well organized. for your confirmation of the paper. Three substantive comments: 1. What of workarounds that are common (or not) but not known by the clinicians to be workarounds. (I've seen nurses alter the listed size of the IV bag b/c they were taught to do that...but it's a serious (and somewhat dumb workaround). But no one saw it as a workaround... just normal procedure. for raising this important point. We have amended the text accordingly. The amendments are in the third sentence of the first paragraph of the section Individual clinician factors in the Results and in the sixth sentence of the sixth paragraph of the Discussion. 2. Some (a small percent) of workarounds are just lazy. We note the reviewer s suggestion that a small percent of workarounds are lazy. Our examination of the reviewed studies identified that while one study included a participant quote in which a nurse explains working around the patient ID check when you get lazy (Dougherty et al 2012, p. 1306), another study by Tucker and Edmondson (2003, p. 63) makes a point that nurses are not uncommitted, lazy or incompetent and often work overtime without pay. To identify that laziness may account for some workarounds but not for all, we have added four sentences, following the third sentence, to the second paragraph of the section, Individual clinician factors in the Results. 3. Often dumb administrators say: "let's outlaw workarounds." OK, idiotic but it is a reaction. Now small stuff: We note the reviewer s view and point about this being merely an administrative reaction. 4

6 In the abstract, they say ":.perceived impact of nurses use of workarounds in the implementation of safe patient care in acute care settings." But I wonder if this sentence is better without the word "safe" in it. "safe" moved the discussion in a judgmental way that's not helpful here. Quote: "This review offers evidence that image management may play a role in nurses use of workarounds." Could the authors be more clear about what they mean by "Image management", please. Thanks. We have removed the word safe from this sentence in the Abstract as suggested. The final sentence in the Conclusion section of the Abstract has been reworded to clarify what we mean by image management. In addition, a sentence has been added following the second sentence in the second paragraph of the section, Proliferation of workarounds that further explains the notion of protecting one s reputation of competence or managing one s image of competence. I'd note that most of the studies are multi method (see their table). This deserves a bit more emphasis. it's important. We have emphasised this point in two ways. We have edited the first sentence of the third paragraph reporting on the data collection methods of the Results section. We have also drawn attention to most of the studies being multi method by adding a sentence (second sentence) in the second paragraph of the Discussion. Congrats to the authors on a valuable paper. We appreciate your assessment. Level of interest: An article of outstanding merit and interest in its field Quality of written English: Acceptable Statistical review: No, the manuscript does not need to be seen by a statistician. Declaration of competing interests: no competing issues. 5

7 Reviewer comments Minor Essential Revisions Reviewer 2: Laurie Rack Authors Responses for your positive comments. Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Acceptable Statistical review: No, the manuscript does not need to be seen by a statistician. Declaration of competing interests: I declare that I have no competing interests' Is the question posed original, important and well-defined? We appreciate your feedback. Research question is identifiable and understood. With that said, this is a specific area of interest as the workarounds specifically relate to nurses which are commonly cited in the literature. The fact that the workarounds are not only related to electronic health records, medication administration, etc makes it a new are of generalized workaround literature. Are the data sound and well controlled? Appropriate Is the interpretation (discussion & conclusion) well balanced and supported by the data? 6

8 Appropriate Are the methods appropriate and well described, and are sufficient details provided to allow others to evaluate replicate the work? Appropriate What are strengths/weaknesses of methods? Limitations with any research & publication timelines have to do with the timing of the end of study inclusion & new published information. The authors list that as an appropriate limitation. We appreciate the reviewer noting this point and we have added a sentence to the Limitations section of the Discussion (second sentence of the first paragraph) that reports this limitation. Enough information to replicate study. Can the writing, organization, tables and figures be improved? Page 20-1st line tensions emerged unclear of what that means here. May need reworded. See below regarding figure 1 Figure 1 that I am reviewing has several areas that need formatted for a better understanding: for highlighting the need to clarify this sentence. The third sentence in the first paragraph in the section Nurses conceptualisation and rationalisation of workarounds has been reworded to improve clarity. The figure has been reformatted to improve clarity and understanding. The split words now fit on the same line as requested. We have also reformatted the boxes containing the selection criteria. Australian needs to fit on top line; Sociological needs to fit on top line; etc or abbreviate, but should not remain split as they are 7

9 Reviewer comments This paper presents a scoping review of an important emerging area in patient safety workarounds by healthcare professionals. This review focuses on the workaround practices of nurses in the acute care setting. This is an important topic particularly because of the number of technologies now recommended to improve patient safety including medication safety such as bar coding, electronic prescribing and computerised records. This topic is important in terms of considering how these technologies operate in practice. Reviewer 3: Susan Semple Authors Responses We thank the reviewer for their succinct and comprehensive synopsis of the paper. 1.Abstract/Introduction As the authors discuss, defining the term workarounds can be difficult. However the authors have clearly stated their definition and this appears to be an acceptable one to adopt for this review. Discretionary Revisions I think it may be useful to include the definition of workarounds (in abbreviated form) in the abstract of the paper. We have included an abbreviated definition of workarounds in the first sentence of the Background section of the Abstract. 2. Methods The search strategy for this complex area is adequately described and the rationale for the search terms is explained. On the whole the methods used to select papers for inclusion (post hoc development of selection criteria) are adequately described. Major Compulsory Revisions As part of the search - were any government-funded or other patient The study s research strategy was designed to capture peer reviewed empirical 8

10 safety organisations websites or contacts used to identify reports or papers? papers. We did not contact nor examine the websites of government-funded or other patient safety organisations websites or contacts to identify reports or papers. While we had acknowledged the inclusion of only peer reviewed studies under Limitations in the Discussion section of the paper, we have revised the Abstract and Method section of the paper to emphasise this point by adding the words peer reviewed to the fifth sentence of the Background section of the Abstract and to the second sentence in the fifth paragraph of the Background section of the Introduction. In figure 1 I found the phase 2 selection process and little unclear. The Phase 1 criteria are very broad, I would find a bit more detail on the process used to narrow the inclusion at Phase 2 helpful. We appreciate the reviewer s request for clarification of the selection process and opportunity to present this more clearly. We have clarified the selection process in two ways. 1. We have reformatted and reworded the Selection Criteria boxes in Figure 1 to improve the clarity. 2. We have provided more detail that was previously incorporated in Figure 1, within the manuscript text to explain the process used to narrow the inclusion criteria at Phase 2 (pages 9-10). A standardised analysis framework was used to extract data from the included studies. It was not clear if all papers were reviewed independently by the first two authors or just 10 randomly selected papers were reviewed in duplicate. 3.Results We have added or rephrased sentences two through six in the first paragraph of the section Analysis and synthesis in the Method section to clarify this process. This provides a useful overview of the area including the types of workarounds used by nurses, factors contributing to their development and proliferation, perceived impact, conceptualisation and rationale. 9

11 Major Compulsory Revisions Specific examples of workarounds are given in Table 5. I think that for some of the examples in Table 5 it would be helpful for the reader to know what the individual study (or studies) was examining. E.g.it might be helpful to start with something like: In a study of use of CPOE, dead zones caused the computers to freeze so the nurses used paper lists of pertinent patient information. In my opinion the example in Table 5 The workaround developed as a result of too much cognitive head data is to use written and mental chunking schemas requires some clarification. Discretionary Revisions It would be useful to know if any of the studies tried to measure the impact of the workaround practices on patient safety in terms of measured outcomes e.g. actual medication errors or adverse events for this feedback. We have revised and updated Table 5 to include information about what the individual study (or studies) examined and provided additional illustrative examples. for this feedback. This example offered in Table 5 has been revised to be clearer. The reviewer highlights an issue that requires further investigation. Few studies measure the impact of workarounds in health care in terms of measured outcomes. We have acknowledged this issue and added sentences five and six to the first paragraph of the Discussion. We have also added sentence eight in the same paragraph as a suggestion of one reason why it is difficult to ascertain the impact of workaround practices on patient safety in terms of measured outcomes. We have also drawn attention to this issue by highlighting it as an area for further research in the discussion of current gaps and suggestions for future research (second sentence, seventh paragraph of the Discussion). Minor Essential Revisions In the Tables there are a number of abbreviations that should be clarified perhaps in a legend to the Table. 4. Discussion Abbreviations in Tables 5 and 6 have been included in appropriate Legends for each Table. We have revised the tables to improve clarity. The results of the review are well discussed in relation to the previous reviews in this area. 10

12 Discretionary Revisions It would be useful to have a succinct discussion of the current gaps in the literature and recommended areas for future research to focus on. Level of interest: An article of importance in its field We have adopted the reviewer s suggestion and included a succinct discussion of current gaps in the literature and areas for further research as the seventh paragraph of the Discussion. Quality of written English: Acceptable Statistical review: No, the manuscript does not need to be seen by a statistician. Declaration of competing interests: I declare that I have no competing interests 11