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Letter From the Editors

Workarounds as the Catalyst to Drive a Culture of Innovation in Neonatal Care

Kelley, Tiffany PhD, MBA, RN; Brandon, Debra PhD, RN, CCNS, FAAN; McGrath, Jacqueline M. PhD, RN, FNAP, FAAN

Author Information
doi: 10.1097/ANC.0000000000000517
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Do you consider yourself to be an innovative nurse? The concept of innovation is frequently permeating conversations around the future of nursing. Many may hear the term innovation, and wonder “what does it really mean to me as a nurse?” and others may think “innovation does not really apply to me.” Yet, you may be surprised to learn that you are innovating in your role as a nurse every day in your work with the infants in the neonatal intensive care unit.


An innovation is a new product, service, or process.1 An innovation is a discovery made when one recognizes a problem or barrier to completing a necessary task or caregiving activity. Neonatal nurses innovate daily at the bedside. Neonatal nurses with “longevity” in the profession (eg, nearing retirement) remember when very few products or processes were tailored to our unique population. When providing care at the bedside today, nurses still encounter barriers toward effective care delivery that require creative problem-solving. These barriers must be removed to deliver the required and desired care to the infant and the family. As nurses, these barriers often lead us to create workarounds.

Every day, nurses are faced with a problem (or many problems) that they need to work around when delivering patient care. Workarounds are present in patient care environments because of limitations, omissions, or gaps in the organization. The organization could be the unit, hospital, or hospital system that might include many different hospitals. For decades, nurses prided themselves in being able to work around persistent problems.2–4 Nurses are left with no other choice, as that workaround is what stands between the nurse and his or her infant's care. However, we now need to view these workarounds differently for what they are: clues to larger system-level problems that must be addressed at an organizational level.


The problems solved through workarounds are examples of innovation done on a one-to-one basis. You might have a neonate that requires a wound care dressing that is too large for that infant. This necessitates cutting the product to size, resulting in frayed edges that compromise the wound bed. Appropriate-sized devices have been a persistent problem in neonatal care. The need for a workaround to address a problem may happen multiple times per day for neonatal nurses. A scalable innovation would be to create products that are sized to fit the needs of neonates, and many of the neonatal products available today came from the innovative ideas of nurses. Being an innovative nurse is important to providers, infants, and their families across the nation and globe!

Another workaround is the nurse's paper brain or report sheet used during handoff to gather all the information needed to know one's patient in one place that can be referenced over the course of your workday. Yet, most of that information being gathered and written already exists in the patient's health record. Each day you and your peers are repeating a process that is fraught with the potential for errors, is risky to the patient's care, and could be eliminated with the right system-level tool or solution. Every nurse uses this process each day because it was the best possible solution before technology advanced into wireless networks and small portable computer devices (eg, smartphones). Yet, with such advances, we have the capability to ensure every nurse has the same information across shifts. To do so would reduce the risk of incorrect or omitted information given during handoff among many other benefits to the nurses, patients, families, and organization.

Equipment can often be a difficult thing to find when needed for feedings or IV medication administration. At times, nurses cannot find the necessary equipment and the patient's feed or medication may be unnecessarily delayed. Working around this presents the potential for impact on the patient's care. Instead of bargaining with our peers or hiding equipment in drawers, there must be a better way to determine the number of feeding pumps and syringe pumps necessary each day for a unit. Secondary to the number of devices, tracking tools may be of benefit.

These are just 3 prevalent examples of problems nurses frequently face each day while at work caring for patients. All 3 of these are solved today through workarounds. Yet, not one of these issues needs to remain a workaround. Not one of these should remain a case for “we've always done it this way.”


One may wonder why we need to eliminate the need for workarounds. After all, nurses are exceptionally skilled at creating solutions to these problems faced each day and often multiple times per day.2 Yet, just because we have always done it this way as a profession does not mean that it is the best way for it to be done. This expression does mean that nurses or the nurse who says this is not open to change through innovation. The nursing profession cannot continue to thrive, grow, and advance with the ever-changing healthcare landscape without also innovating and finding new ways of leveraging the new tools into our practice environments and the profession at large.


The future of nursing must acknowledge the current culture as one that is well equipped to solve some of the most challenging issues facing out profession. Staffing, technology, and continual improvements in neonatal care are just 3 areas where we know we have opportunities to make improvements. As a profession, we must move beyond the workaround and recognize these as system-level problems being solved through individual-level workarounds. As we move beyond the workaround, it opens the door for us to embrace the potential for viewing these workarounds as scalable solutions in the form of new products, solutions, or processes that can be applied across the nursing profession. Neonatal phototherapy and the Bili-Bonnet are 2 solutions invented by nurses.5 Pay close attention to what you see as problems and consider how you can solve them. You might be the next nurse to invent and patent a product we are all in need of each day. You might be the next nurse to build a company around that innovation. By opening these doors, you might be the next nurse to invent and subsequently patent an innovation that will impact thousands to millions of people. You may turn your innovation into a company that allows for others to benefit from what you have created out of an idea. You first need to know it is an option to you as a nurse. Second, you need to know that you are already innovating each day through your workarounds. Third, be proud of your idea, keep it between you and those whom you trust, and then work to bring it to life.

Tiffany Kelley, PhD, MBA, RN
[email protected]

Debra Brandon, PhD, RN, CCNS, FAAN
Coeditor; Advances in Neonatal Care
[email protected]

Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Coeditor; Advances in Neonatal Care
[email protected]


The coeditors of Advances in Neonatal Care would like to thank Dr Kelley for her insight in developing this editorial. Dr Tiffany Kelley is a doctorally-prepared pediatric nurse who has gone on to specialize in informatics and most recently innovation. Dr Kelley made a discovery related to the dependency of nurses' report sheets and identified a way to develop a software solution to su pport nurses' information needs at an organizational level instead of as a workaround (eg, sheet of paper). That innovation is called Know My Patient and she went on to develop a company around that innovation, Nightingale Apps. Dr Kelley is working to bring that app into the hands of as many nurses as possible. Dr Kelley acknowledges her innovation and company and this could be considered a conflict of interest; however, no payment or exchange of funds occurred in the writing of this editorial. The coeditors share this information in an attempt to help neonatal nurses consider pursuing their innovations in practice rather than continuing to use “workarounds” to provide best care on a daily basis.


1. Merriam-Webster. Innovation. Merriam-Webster, Incorporated. Accessed March 24, 2018.
2. Berlinger N. Workarounds are routinely used by nurses—but are they ethical? Am J Nurs. 2017;117(10):53–55.
3. Tucker AL, Edmondson AC. Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003;45(2):55–72.
4. Tucker AL, Heisler WS, Janisse LD. Designed for workarounds: a qualitative study of the causes of operational failures in hospitals. Perm J. 2014;18(3):33–41.
5. Cosier S. 8 medical inventions created by nurses. Mental floss. Accessed March 24, 2018.
© 2018 by the National Association of Neonatal Nurses.