presentation to the resilient health care net summer meeting...australian institute of health...
TRANSCRIPT
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: [email protected]
Wiki: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite
Web: http://www.aihi.unsw.edu.au