Gallup pollsters repeatedly report that the public views the nursing profession as the most ethical and honest profession.1 This level of public trust is humbling and is a reminder of the enormous responsibility the nursing profession bears. The American Nurses Association's (ANA's) Code of Ethics for Nurses2 provides the indisputable requirements for professional practice. One of the 9 provisions states, "the nurse promotes, advocates for and protects the rights, health and safety of the patient." To fulfill this obligation, nurses must possess the clinical competence, wisdom, and skill to recognize situations that may undermine the quality and safety of patient care and work in systems that support them to do so.
Critical care nurses work in systems that are complex, rapidly changing, and beleaguered with financial and workforce pressures. One response to these challenges is to find alternative ways to make an insufficient or detrimental system work for the nurse to get the job done and to achieve the desired patient outcome. While perhaps well intentioned to produce the desired result, workarounds created by nurses carry unrecognized ethical and safety risks. Workarounds are deviations from established practices and procedures that occur in response to various organizational, personal, and systemic factors.3,4 Regardless of the contributing factors, the impact of workarounds is that system processes to provide protection from error and injury are circumvented, thereby placing patients at risk. According to the ANA Code of Ethics for Nurses,2 our primary obligation is to our patients and it is a professional obligation to prevent harm; workarounds violate this basic tenet of ethical nursing practice.
Common Workarounds in Critical Care
Numerous types of workarounds can occur in the critical care setting. Two of the most common are medication verification and improper use of personal protective equipment (PPE). These examples are fruitful for examining the ethical consequences of workarounds.
Critical care nurses spend a large amount of their daily care of patients administering medications. This process is prone to error and the subsequent harm those errors can cause. Barcode medication administration is a common system solution to prevent such errors.5 Typically, the barcode medication administration process is electronically linked to the electronic medication administration record (EMAR). Medications and patient identification bracelets have barcodes that are linked to the EMAR, medications are sequestered in a manner that identifies them as patient specific, and there are redundant verifications of the order prior to administration. The expected safety check is that the medication and the patient are scanned during this process and via the EMAR, the nurse is alerted to any discrepancies. The scanning process also serves to provide documentation of the time of administration of the medication and other pertinent data such as vital signs, the reason why a medication was administered late, patient response to medications, and the reason why a medication was held. Many hospitals use a scanning barcode medication verification system coupled with the EMAR to enhance safe medication administration. In an example of a typical workaround, Melody, a nurse on a telemetry unit, noted that another nurse, Janice, was scanning empty medication packages during a medication pass. Melody asked Janice about the practice and Janice explained that at times the barcodes on the medications failed and this process helped her ensure that she could administer medications to her patients in a timely manner.
Barcode medication administration is the most commonly cited process for which nurses develop workarounds in the nursing literature.4,5 One contributing factor is the number of steps in the process that are technology dependent, including consistent wireless signal strength to support hardware function and readable barcodes on both the patient identification bracelet and medications. Other factors include missing barcode labels on medications, lack of medication availability, interruptions, and urgent situations.
Another potential workaround in the critical care setting is the misuse of required PPEs. Disease transmission requires an infecting organism, a susceptible recipient of the organism, and a method of transmission from the source to the recipient.6 Intensive care units serve patients who are often severely compromised and at risk for the development of hospital-acquired infections. As a result, the care of critically ill patients often necessitates that critical care nurses use some type of PPE to protect patients or themselves from disease transmission or contamination. For example, Jenny, a nurse in the medical intensive care unit, noted a colleague entering a patient's room without the required PPE. She reminded her colleague of the importance of wearing PPE to prevent the spread of infection. The colleague responded, "I was only in the room a moment and I did not touch anything."
The gap in the proper use of PPEs and other safety measures puts both the nurse and the patient at risk. Nurses often do not embed in their practice the essential steps to prevent infection.7 In addition, the workflow around proper hand hygiene, use of PPEs, and use of products that promote safety such as sharps protection are noted to be vulnerable to workarounds.3
Nurses often solve poorly designed systems that affect workflow by an initial adaptation that addresses the concern in the moment, known as first-order problem solving.8 The need to escalate the concern for more thorough organization analysis (second-order problem solving) is time consuming and may not occur.8 As a result, the potential arises for deviations from expected practice to become the new practice as nurses persist in using individually developed alternative solutions to address poorly designed workflow.
Ethical Implications
A foundational ethical mandate of nursing practice is to first do no harm. In an increasingly time compressed, efficiency-oriented culture of critical care, efficiency may take precedence over adherence to established systems aimed at reducing harms. Time constraints coupled with the rapidly changing patient condition and instability are major contributors to the use of workarounds.3 Nurses do not intend malice when engaging in workarounds that can lead to harm for the individual patient. Nurses may take a utilitarian stance to the issues, reasoning that if the patient gets the treatment or the desired outcome, the means to the end result do not matter. What is less visible in pursuing shortcuts is that not addressing the systems and processes that contribute to engaging in workarounds results in the potential for further ongoing harm. The lack of harm in the moment may contribute to greater harms in the long run.
Another unrecognized harm of workarounds may be an insidious erosion of the integrity of individual nurses and the profession. Each time we act in ways that we know are contrary to practice standards, we are consciously or unconsciously enabling an unsafe system to persist. When nurses fail to recognize the implications of workarounds on their integrity as nurses, gaps in professional practice can become so normalized that they are no longer detected. Over time, such practices can contribute to nurse dissatisfaction, disengagement, and an unhealthy work environment.
The Code of Ethics for Nurses explicitly states, "Nurses must participate in the development, implementation and review of adherence to polices that promote patient health and safety."2 Nurses are the first line of protection of patient safety and are accountable for their own nursing practice with adherence to established standards and processes. The Code goes further to underscore nurses' responsibility to recognize and take action to address deviations in individual practice and systems that pose real or potential threats to patient safety. The duty to communicate and escalate concerns that can harm patients belongs to each and every nurse.2 Not participating in workarounds while knowing others do does not excuse nurses from taking action to address the lapse in practice standards; it requires nurses to give voice to that concern, which will require that nurses become familiar with the provisions of the ANA Code of Ethics for Nurses2 and to work collectively to create a work environment where addressing such concerns is a regular and expected part of critical care practice.
The following are some suggestions for how critical care nurses can begin to take individual and collective action to address the root causes of workarounds and to devise solutions that preserve the integrity of the critical care nursing workforce.
Individual Action
Reflect on your own practice:
* Are you practicing according to the policies and procedures established at your institution?
* Are you engaging in workarounds?
* Do you see others engaging in workarounds?
* Are you familiar with the provisions of the ANA Code of Ethics? How might these provisions offer guidance to address these issues?
If you are engaging in workarounds, stop the practice and analyze the factors contributing to the deviation:
* What obstructs your ability to practice according to organizational policy and procedure?
* What needs to change to practice according to the standard? Personally? Within the system?
* What resources are available to support these changes?
* Discuss your concerns and recommendations using your organization's structures such as unit/organizational leadership, nurse practice council, patient safety officer, or risk manager.
If you see others engaging in workarounds, speak up:
* Bring the practice deviation to the individual's attention.
* Explore what may be contributing to the perceived need for a workaround.
* Discuss the ethical concerns raised when workarounds exist and persist.
* Encourage colleagues to use the aforementioned strategies to address the obstacles that led to the workaround.
Leadership Action
Raise awareness about the ethical imperative to keep patients safe by practicing according to practice standards:
* Openly discuss that workarounds exist; acknowledge some of the common reasons for deviations from policy, procedures, or practice standards.
* Create a safe environment for the staff to discuss workarounds; explore individual and system factors that lead nurses to develop workarounds.
* Develop surveillance mechanisms to detect the presence of workarounds and routinely document, then notice trends.
* Use the ANA Code of Ethics2 as a guide for discussion of the ethical implications of workarounds.
* Create norms of responsibility to recognize and speak up about existing workarounds and to work collaboratively to create a safe, healthy workplace.
* Assure that bedside clinicians are active participants in decisions affecting patient care processes, workflow, and use of technology.
* Bring concerns and recommendations to the attention of organizational leadership, patient safety officer, or risk manager.
Clinical Nurse Specialists/Clinical Educators
Recognize your role in establishing and supporting ethical practice by addressing workarounds.
* Identify gaps in staff knowledge and skills related to the impact of the specific workaround.
* Facilitate discussions with staff about the identification of individual and system obstacles.
* Collaborate with unit and organizational leadership and front-line staff in analyzing the contributing factors to workarounds.
* Design a systematic process to detect and respond to workarounds such as safety rounds or quality improvement processes.
* Provide support to staff through active listening and collaborative problem solving.
* Coach staff in the use of communication strategies that elevate the safety concerns of workarounds.
Conclusion
Critical care nurses are committed to high-quality, safe care of their patients. Yet there are inherent risks when they develop workarounds as a means to achieve efficiency, create short-term processes to achieve clinical goals, and compensate for ineffective systems. Critical care nurses must recognize these risks and take principled steps to realign their practice with accepted norms, policies, and standards and thereby mitigate threats to patient safety, quality care, and nurse integrity. Moreover, they are responsible for working with leaders and interprofessional colleagues to design and implement system improvements to address the sources of workarounds to protect the public trust.
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