We’ve all experienced it over the years…the frustration of having some piece of equipment, computer program, patient care process, person, or policy get in the way of getting the job done. Sometimes it’s because the thing or situation that’s standing in our way is broken. Other times it’s because there’s no rule in the playbook that addresses exactly an unusual circumstance. The end result is often the creation of a work-around…and nurses can be extremely creative!
 
Work-arounds circumvent established procedures, policies, and processes. In some cases, they truly may be needed to get an essential task accomplished because the current system has not yet caught up to the realities of clinical practice. The work-around may ultimately indeed be the right way, but just continuing to do it informally may be viewed as a much quicker and easier path to travel than the journey to making it a permanent solution. Depending on the nature of the issue and the organizational change process that’s needed, there may be tedious processes to follow, forms to fill out, a chain of command to invoke, a business case to make, committees to form, places to go, and people to see. 
 
In other words, the real solution can appear a far-off, daunting task that requires considerable expenditure of time and energy and quite possibly a measure of stretching way beyond a personal comfort zone into organizational bureaucracy. There’s a very real chance that the proverbial “squeaky wheel” that brings the matter to light could wind up the owner of the issue and be expected to be part of the solution. However, if the work-around makes things look like everything is working just fine, there’s no obvious burning platform as the catalyst for necessary change. The problem may remain invisible to the larger system and go unsolved. If leadership is unaware, there’s no opportunity to submit requests for maintenance or budget for new equipment, system upgrades, or even necessary material or human resources.
 
Another category encompasses the work-arounds that may simplify the job or allow it to be accomplished faster, but bypass safety measures put into place to reduce risk. Ignoring established safety practices that are perceived as cumbersome is an example. Staff may become so good at these that the work-around escapes detection. These types of work-arounds can evolve to become the usual practice or even the cultural norm.  They may be passed along to new staff members as tips or tricks to be more efficient to the point that staff stops seeing the strategy as a work-around at all. Direct observation might be the only way to spot this situation. Nurses who follow the rules can experience considerable moral distress when they discover that co-workers are using such work-arounds inappropriately. They are then placed into the very difficult position of either turning a blind eye (which has significant ethical and even professional regulatory implications), or acting as a whistle blower to management.
 
My advice is that if a work-around is felt to be necessary, there’s a problem with the current system that must be addressed. That includes those situations where the work-around is done to make the job easier or faster but bypasses safety measures. Perhaps the safety measures could be maintained and risks reduced if the system was re-designed in a way to make it easier to do the right thing while still meeting all of the standards and regulations. Our knee-jerk in healthcare often involves creating a new form to fill-out or coming up with a new tedious process that gives the illusion of a safety improvement, but instead just adds another barrier that people look for ways to overcome. We need to think broadly and be truly innovative. Strategies include researching current best practices, connecting with staff at other organizations to learn how they manage similar issues, and even investigating if there are applicable innovative solutions in industries outside of healthcare. 
 
We do need to make processes associated with nursing practice and healthcare in general safer, easier, more efficient, and more effective. The appearance of a work-around is a red flag for an improvement opportunity.  Rather than allow it to persist or remain obscure, bring the situation to light and be an advocate for necessary change.  Keep in mind the old adage: if you always do what you’ve always done, you will always get what you’ve always got. When confronted with a work-around, take on the challenge and demonstrate individual leadership, advocacy, and the courage to engage in true problem resolution. 
 
Happy Nurses Week!
 
Linda Laskowski-Jones, APRN, MS, ACNS-BC, CEN, FAWM, FAAN
Editor-in-Chief, Nursing2016
Vice President: Emergency & Trauma Services
Christiana Care Health System – Wilmington, Delaware