Some nurses store extra pillows and blankets in a little-used closet to ensure they are available when needed. Others circumvent their institution's medication administration system by prescanning patient bar codes instead of following proper procedure for scanning at the bedside.
Ask a group of nurses to describe how they get the job done, and they'll talk about workarounds—shortcuts and fixes for situations in which work rules or procedures don't match work realities. Because nurses frequently must adapt to changing conditions within highly regulated organizations, workarounds are normal, a tool for managing daily work.
But is workaround behavior ethical? When speaking to clinical audiences that include nursing scholars, educators, students, and practitioners, I'm often asked, “Are you really going to talk about workarounds?” and “Are you going to tell us that workarounds are unethical? Because we can't do the job without them.” The ethics of workarounds is clearly a meaningful and important topic for nurses and other clinicians. I've found that they're eager to discuss this issue but unsure whether it's safe to do so or how to get started. Nurses may also perceive ethics narrowly, as “compliance.”
Empirical studies that aim to describe the pressures that trigger workaround behaviors in nursing often define workarounds as deviations or violations1, 2—terms that can suggest wrongdoing. Some nursing scholars have directly considered whether these common behaviors are ethical. In a 2015 commentary in AACN Advanced Critical Care, Karen Stutzer and Cynda Hylton Rushton rightly call on health care leaders and educators to acknowledge that time-pressed clinicians often make their own judgments about which rules to follow and which to work around.3 These authors also aim to help nurses recognize why failing to alert unit managers or organizational leaders to the underlying problems driving this behavior—such as supply shortages, conflicting or inadequate guidance, or bullying—can mask unsafe conditions until someone is harmed. It's particularly concerning when workarounds become entrenched in unit-level work, because they become difficult to see. Deviations become norms, and exceptions become “the way we do things here.”
Workarounds are a response to pressures of competing obligations; for example, to be efficient yet thorough, to make flawed systems work, to treat patients equally despite structural inequalities affecting health care access. They are ethically important in at least three ways. First, they may reflect efforts to do better by patients. When nurses “get creative” with the goal of providing better care or allocating resources more fairly, they are motivated to respond to a perceived flaw in the design of a work system and a perceived need—even duty—to compensate for it (“perceived” because people may not agree about whether a design is flawed or how to respond). Second, when a creative fix or improvement unfolds unofficially or secretly—if, for example, a nurse discloses a stash of supplies to some colleagues but conceals it from supervisors—the effort to conceal points to a situation that is ethically problematic, even if one is trying to do the right thing. Third, nursing environments featuring constant pressure to save time can lead to shortcuts that make conditions less safe or encourage avoidance of patient care situations perceived as time consuming.
IS IT FAIR TO BEND THE RULES?
Bending the rules is another workaround behavior aimed at improving health care, particularly in situations in which resource allocation rules are perceived by clinicians to be unfair or flawed when applied to individual patients or patient populations. For example, people with behavioral health or substance abuse conditions may have limited options for securing or paying for appropriate treatment. Immigrants may not qualify for coverage or services available to other low-income patients with equivalent health care needs. A clinician advocating for a patient in these situations may be tempted to “tailor the chart,” selectively describing the patient's condition to meet eligibility criteria for emergency treatment or obscuring any disqualifying information.
Bending the rules to help a patient is ethically problematic. Because health care resources are limited, workarounds of eligibility criteria that divert resources toward one person divert them away from another person with equivalent needs and, possibly, a stronger claim on those resources. Also, when a clinician chooses to advocate for some patients but not others for subjective reasons, this introduces unfairness—in the form of bias—into resource allocation processes.4
Safety net health care systems, and organizations in other settings in which resource allocation challenges arise frequently, need to respond to these foreseeable situations so that clinicians don't perceive themselves to be forced to bend rules rather than comply with policies they perceive to be unjust. Leaders and administrators can support clinicians and reduce the likelihood that workers will perceive that bending the rules is their only option by providing opportunities for nonpunitive discussions about difficult situations, setting organizational policies that reflect clinicians’ perspectives, and establishing advocacy priorities. This should be framed as an ongoing organizational ethics challenge in safety net systems operating on breakeven margins or with structural deficits that have limited opportunities to change the public policies financing health care. Organizational administrators should aim to identify which rule-bending situations can be relieved by knowledge and process (such as how to establish eligibility for certain services). Fair and transparent policies for the use of internal charity-care funds may reduce the perception that nurses must “work the system”—or fight the system—to obtain resources for a patient. Administrators should also acknowledge which problems have no ready solution and aim to share in the management of system-induced workarounds (for example, “boarding” an uninsured patient in the hospital because she or he lacks coverage for services that are needed for a safe and effective discharge), so that clinical burdens are distributed fairly.
There's more to workarounds than an effort to manage the tension between getting it done and doing it right. Devising a workaround can also be a source of professional and psychological satisfaction, an opportunity to be creative and use one's experience to manage problems.
Clinical innovation may begin when a nurse is faced with a tool that doesn't work as it should, or as well as it could. The initial effort to fix or improve this tool is likely to involve some deviation from the standard operating procedure. The application of clinical wisdom to ensure a device is more comfortable for a patient to use, or a computer system is easier for a clinician to use, is a workaround of a standard perceived as flawed. Recognizing that pragmatic, on-the-spot improvisations, or different clinicians using the same tool “my way,” are not the same as inventions that have been evaluated does not diminish the motivation to fix or improve. Rather, a workaround aimed at fixing or improving a tool is the first draft of an innovation: it looks promising, it seems to work, and its value is not yet known.
Clinicians who innovate need access to timely, reliable quality improvement (QI) processes to help them evaluate whether what they've devised is, in fact, safer or more effective than using a tool as designed, and whether their new design can be refined and improved. Ethical pragmatism means being willing to put one's fixes up for evaluation, to make sure that what seems to work really does.4 Unofficial fixes or too many variations can lead to confusion about how a task should proceed; and in health care tasks, failure can mean harm to another person. Keeping quiet about improvisations and fixes, or sharing “my way” with some colleagues but not others, is not ethically sufficient in health care for reasons beyond the potential harm that can result from concealing aspects of patient care from scrutiny. If a workaround really is pointing toward a better way to work, how will other patients benefit from this innovation if the nurse is unwilling to participate in the evaluation and sharing of this knowledge?
Nurses and other clinicians who value the experience of creativity through clinical and organizational problem-solving may, with some justification, worry about what will happen when they go public with their first attempt at a clinical innovation. Will they be told to stop, or even penalized, without being offered another solution to the problem? Will they get credit for their idea and a stake in developing, evaluating, and disseminating it—aspects of innovation that may be psychologically meaningful as well as fair? Or will their ideas be co-opted?
These are valid concerns in any organization, especially hierarchical ones, and serve as reminders that organizations can and should support the process of clinical innovation through internal QI processes, discussions across units with similar challenges, and participation in external networks that support clinical innovators. Organizations that discourage open discussions about clinical problem-solving ensure that a practice with an unknown value will continue to occur unofficially.
RECOMMENDATIONS FOR ORGANIZATIONS
How can nurses function efficiently and as creative problem solvers and effective advocates without resorting to practices that may be ethical in intent yet ethically questionable or even harmful in their consequences?
First, leaders of systems that employ nurses, and leaders within nursing, should talk about how competing pressures—to deliver value, be efficient, do more with less, make it work, get the job done, be a team player—drive nurses and other clinicians to improvise solutions to relieve these pressures. Leaders should acknowledge that quick fixes that keep the system moving often violate rules (putting clinicians in a difficult position) and may occur outside of institutional processes designed to improve safety and quality (putting patients at risk).
Second, leaders of health care organizations should avoid taking a “no workarounds” position. This is unrealistic—the pressure that drives workaround behavior cannot be completely removed from the system. Instead, they should support QI research and discussions about how employees confront and respond to the ethical challenges they encounter in their everyday work. This will help nursing leaders to understand how changing conditions, the design of work systems, the desire to improve or innovate, resource allocation problems, and issues of power and hierarchy within teams or organizations are interrelated.
Finally, professional nursing societies should encourage their leaders and members to make a practice of discussing pressures produced by systems that may compel nurses and other staff to improvise during their normal workday while discouraging them from openly discussing such pressures. These discussions can take the form of facilitated, optional sessions at annual meetings of professional societies, grand rounds–type discussions in health care settings, or workshops convened by nurse scientists and nursing educators to focus on specific problems or research gaps. A “journal club” strategy, in which participants read and discuss an article, can be an effective way to prompt conversation about topics that may feel sensitive, such as workarounds, and learn about organizational strategies that improve patient safety or clinical problem-solving.
For discussion leaders who aim to help nurses analyze problems and participate in potential solutions, asking, “What's your best workaround?” and offering examples from their own practice is another way to acknowledge reality and get the conversation started.