The Resilient Health Care Net Summer Meeting, August 26-28, 2013 How everyday functioning in acute care really works: the case of nurses workarounds The Resilience of Everyday Clinical Work Tentative programme 15:00 17:00 07:00 08:30 Session 1: 08:30 09:00 09:00 09:30 09:30 10:00 10:00 10:30 10:30 12:00 12:00 13:30 Session 2: 13:30 14:00 Sunday August 25 Tutorial topic to be announced. Deborah Debono and Jeffrey Braithwaite Monday August 26 Breakfast The range of everyday clinical work Australian Institute of Health Innovation 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.) The 2011 Stanley Cup riot: A lesson in resilience. (Hunte, G. S.) Hospital discharge of the elderly using the ETTO principle to explain performance variability. (Laugaland, K., Åsa, K.) Coffee break The range of everyday clinical work Extended thematic discussion / panel Lunch Tradeoffs, workarounds, coping, dampening Individual Collective Tradeoffs in Healthcare and their Implications for Resilience. (Wears, R. L., Hunte, G. S.) How everyday functioning in acute care really works: the case of nurses workarounds. (Debono, D., Braithwaite, J.) Tensions and trade-offs in patient handover emergency care. (Sujan, M. A.) Coffee break Tradeoffs, workarounds, coping, dampening Extended thematic discussion / panel Dinner at Hindsgavl Presentation to the Resilient Health Care Net Summer Meeting Middelfart, Denmark 14:30 15:00 August 26 to 28, 2013 15:00 15:30 14:00 14:30 15:30 17:00 19:00
Australian Institute of Health Innovation s mission Our mission is to enhance local, institutional and international health system decisionmaking 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 Coiera Professor of Health Informatics, Centre for Health Informatics, AIHI, UNSW Professor Ken Hillman Professor of Intensive Care, Simpson Centre for Health Services Research, AIHI, UNSW Professor Johanna Westbrook Professor 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 researchbased 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 in a hospital ward to solve the problem of the smoke alarm Workaround the shortage that kept going of intravenous off because oftherapy nebulisers in asolution stands 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 inefficiencies But this can impair the capacity to engage in second order problem solving change the system so the problem does not reappear
Studying workarounds Studies 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