Nurses and Healthcare Hacks: Our Workaround Culture

Laura A. Stokowski, RN, MS

Disclosures

January 09, 2018

Hacking Comes to Healthcare

The word "hack," as a noun, used to mean "rough cuts or blows,"[1] until the digital age, when "hack" denoted an attack on a computer or other electronic device. The word was appropriated by the public over the last decade, evolving into a common term for a tip or trick to make something easier or faster. Today, it's possible to find hacks for almost any aspect of life, from parenting to planning a funeral. There are even "life hacks" for nurses—many of them benign, such as using hydrogen peroxide to get blood stains out of one's scrubs—but hacks are also used by nurses in healthcare settings to circumvent practices viewed as inefficient or unnecessary.

Workplace hacks are unofficial and may be shared among nursing colleagues by word of mouth. The rationale for keeping mum on workplace hacks is that they often contravene formal policy; and, therefore, their use is technically a rules violation. But what can nurses do when the rules don't match reality?

Nurses may view their use of workplace hacks as their own way of doing something, but the concealed nature of these practices suggests an awareness that the "higher ups" wouldn't approve. Hacks—often termed "workarounds" in the research literature—are not the same as errors, but there are some shared features. Both workarounds and errors involve a departure from a standard. Both could result in harm to a patient. And both could put a nurse in a risky situation.

Medscape spoke with the author of a recent article in the American Journal of Nursing, titled, "Workarounds Are Routinely Used by Nurses—But Are They Ethical?"[2] by Nancy Berlinger, PhD, a research scholar at The Hastings Center. Dr Berlinger explained the use of workarounds by nurses and why we need to lift the veil of secrecy surrounding these common practices in healthcare.

Nancy Berlinger, PhD

Medscape: Is a "workplace hack" the same as a "workaround"? How would you define these terms?

Dr Berlinger: A hack is a type of workaround. A workaround is how a healthcare professional (often a nurse or a nurse practitioner [NP]) responds to the pressures created by their complex work systems when rules don't match reality, supply doesn't match demand, or goals—such as being efficient and being thorough—conflict in real time. So, the professional must figure out how to resolve this conflict while continuing to keep up with the workflow. We see this problem all the time in nursing. The word "hack" suggests a type of workaround that aims at getting a job done quickly or fixing or patching a problem. They can be perceived as harmless, time-saving tricks. If you google "dinner hack," you'll find ways to get a meal on the table faster, for example.

The underlying belief is that a hack that allows you to do something faster must be better. That's arguable because fast can mean hasty. You don't necessarily make dinner better by turning the oven up to 500 degrees if the recipe calls for a lower temperature and a longer cooking time. But there can be a good reason for altering a recipe or a protocol. The point is that it's easy, when you're under pressure, to put speed ahead of other concerns. If you think some task will take too much time relative to other duties, you may be inclined to look for ways to shorten that task. In a medication administration protocol or a safety checklist, skipping a step can increase the risk for patient harm.

We've had a proliferation of patient safety checklists over the past decade, and nurses are typically responsible for complying with them. Now, we are seeing some evidence of resistance to checklists. Too many checklists can breed checklist fatigue, like alarm fatigue that induces nurses to ignore or silence alarms and to become desensitized to them. If a checklist or other protocol feels imposed without opportunities for feedback, or cannot be readily integrated into other tasks, nurses may start looking for their own ways to modify the process or may comply with the process but avoid speaking up about problems in its use.[3] The result is uncertainty in how work is meant to proceed.

Another type of hack is to change a piece of equipment or technology to make it work better. People with diabetes have even written software to hack their own insulin pumps rather than waiting for manufacturers to update them. These patients share their device hacks online. Nurses are often toolmakers and tool adapters, too.

Another category of workarounds is prompted by resource allocation issues. Nurses might perceive a mismatch between a hospital policy and a specific case or practice environment. This type of workaround is often called "bending the rules," with the goal of helping a patient or a patient population.

Figure. Types of workaround behavior. Adapted from Are Workarounds Ethical? Managing Moral Problems in Health Care Systems (Oxford University Press, 2016).

Medscape: What are some examples of resource allocation workarounds?

Dr Berlinger: These often arise when the patient has a clear medical need, but the allocation rules for a limited resource exclude this patient. This is a common problem affecting low-income, uninsured, undocumented patients who are excluded from federally funded benefits. NPs are familiar with this problem because often they are the professionals responsible for the care of patients in federally qualified health centers or other primary care clinics. Or, a nurse responsible for screening patients in the emergency department (ED) may see a patient who appears to need inpatient psychiatric care, but there is some barrier to admitting the patient to a psychiatric unit. The ED team may come up with a medical reason to admit the patient and "tailor the chart," selectively describing the patient's needs to emphasize those facilitating admission. That's a type of workaround that a nurse or physician may characterize as "getting creative" or "working the system" in the interest of the patient.

Medscape: Are all workarounds bad?

Dr Berlinger: They are problematic, and they need to be understood on their own terms rather than lumped with harm (bad) or innovation (good). Workarounds are responses to system-created pressures. They're associated with secrecy rather than sharing. They may conflate unproven practices with innovations that have been evaluated. Short-term fixes may conceal underlying problems in how work is organized or resources are allocated. All of these aspects of workarounds have potential consequences for patients and their care. When speaking to professional groups about the ethics of workarounds, I always get two responses. Nurses acknowledge that they rely on workarounds but may be reluctant to talk about them because they are considered taboo and need to be kept secret. Nurses also worry that I'm going to tell them that workarounds are unethical because, in their view, they can't do their jobs without them. These reactions gave me insight into the mixed messages that nurses and other healthcare professionals receive. Nurses are constantly being told to work leaner, do more with less, stretch resources, and pitch in and be heroes. The pressure to be efficient builds, and they cope with their workplace reality by looking for ways to fix problems quickly and to save time. In the struggle between efficiency and thoroughness, efficiency tends to win.

And sometimes workarounds are used in a social way to welcome new nurses during onboarding by showing them, "This is how we do things here." The new nurse may not realize that he or she is being shown an unofficial practice. Or the new nurse may think, "This is part of being a good nurse and being part of the team."

Medscape: Why are nurses unwilling to talk openly about their workplace hacks that they perceive to be harmless or innovative?

Dr Berlinger: When a nursing journal asked me to write about this topic, the editor told me that they had posted some questions about workarounds on Facebook, and respondents said things like, "I will take my workarounds to the grave." They were proud of their workarounds, but they felt a need to keep them secret. We need to better understand why a practice is perceived as integral to nursing but also perceived as taboo.

A person can be injured by how a healthcare worker decides to do his or her work. Those are the ethical stakes. But simply telling workers to follow the rules isn't sufficient because the healthcare environment requires workers to adapt to changing conditions, such as surges in the ED. When adaptations and unwritten rules become a new, unofficial, but apparently efficient or necessary way to work, the rules and the reality are out of sync. That's what I'm interested in: How do healthcare workers cope with different sets of rules, one of them secret? And what should we do about this, in the interest of patient safety and also in the interest of workers themselves?

Medscape: Are nurses keeping mum about their workarounds because they fear recrimination? Or are they simply afraid that someone will tell them to stop doing it?

Dr Berlinger: There's a "gotcha" aspect to our culture. We tacitly reward workaround practices by emphasizing efficiency and rewarding people who "pitch in," until something goes wrong, and then we look for someone to blame and punish. Paying more attention to how normal work gets done, rather than waiting for something to go wrong, would help us to understand where workarounds fit in relation to rules, errors, and innovation.

I first became interested in workarounds when looking at medical error. Whenever I gave talks about harmful medical errors, I got questions about workarounds. Healthcare professionals know these practices are nonstandard, and they may feel uneasy about whether they are safe. And nurses get conflicting information about what is safe and unsafe. Remember Ebola? The hospitals in the United States that were receiving Ebola patients were getting different instructions every day about masking, gowning, and gloving because certain precautions and hazards weren't yet clear. Those are not everyday circumstances, but even under normal conditions, healthcare work is stressful, and healthcare professionals may feel it's on them to compensate for the pressures created by the system itself.

Medscape: What about the overlap between workarounds and innovation? If we discourage workarounds, don't we risk suppressing true creativity?

Dr Berlinger: A nurse-scholar once said to me, "A workaround is the rough draft of an innovation." It's a mistake to call any workaround an innovation or an improvement. A workaround has to be evaluated for safety and effectiveness, so its value is clear, before it can be called an innovation. And if it's better, it needs to be broadly shared, so all patients benefit. The benefits of an innovation in healthcare shouldn't be limited to the patients of the innovator. We need ways for clinical innovators to evaluate their "rough drafts" to see whether they are, indeed, improvements. The MakerNurse project funded by the Robert Wood Johnson Foundation is an example of how to provide space and training for nurses to build and test tools. This project looked at which professions excelled in making tools and found that nurses were great at it. But nurses also kept quiet about what they were making or modifying because they were afraid that if they talked about what they were doing, someone would take their tools away. The MakerNurse movement puts tool-making workshops into hospitals so healthcare professionals don't have to devise hacks in secret. Their designs can be tested and potentially become standardized tools, and real innovation can be shared.

We also need quality improvement processes that are attractive and friendly to all nurses, not just clinician investigators. We need ways for people to talk about the conditions of their work without feeling as though it's a "gotcha" session. Helping nurses and NPs to feel safe talking about what they do at work is so important.

Medscape: How can we get past using hacks for the problems we encounter to improve work processes for nurses and improve care for our patients?

Dr Berlinger: We need to invite nurses to take a critical look at nursing work in different settings—hospitals, clinics, and so on—and ask them, "What are the problems that you see? And, if you could redesign your work processes to eliminate or diminish these problems, what would you do?" We should ask nurses and their colleagues to think constructively about solutions and about overcoming barriers to solutions. Problems can seem intractable, and working on problems in patient care often involves getting past the feeling that "that's the way things are; there's no way this will ever be fixed."

An individual professional cannot fix systemic problems. Nursing work, and all healthcare work, takes place within complex systems that have certain characteristics, such as change and adaptation, common to complex systems. Healthcare work has additional built-in sources of stress, such as exposure to suffering, conflict, and, often, management focused more on bottom-line concerns—which are real concerns—than on patient care. Pressure builds up, and one way we deal with pressure is to try to relieve it, to look for a fix or shortcut that will get us through a task. We can't always get ourselves out of the system, and we can't stop the system to repair it. These points have been made in the study of system error, and they are relevant to everyday work as well. A "safe" workplace culture should be one in which it's safe to talk about the everyday work environment. Suggesting to nurses and other workers that they must fix problems on their own is ultimately a discouraging way to work.

And how we educate nurses should aim to prepare them for the complex work environment they will face. It's not sufficient to reduce professional practice to compliance with a code of ethics or adherence to scope of practice or to "caring" or "being an advocate." Nurses also need to be prepared for their roles in the system, in addition to their roles in patient care, and for the competing claims on their attention.

Medscape: What about the resource allocation workarounds you mentioned, especially when the motivation to help the patient is strong? How should we approach those challenges?

Dr Berlinger: Nurses often identify themselves as the patient's advocate. When a patient needs help in getting a resource out of the system, a nurse might describe her own role like this: "I'm going to get my patient what she needs. I'm going to knock on every door. I'm going to get creative." These are laudable emotions. But what does that mean—to "get creative"? Do you mean that you would stretch the truth to get this patient something that could benefit her but for which she is ineligible? Some professionals would resolve this dilemma by concluding that it's appropriate to secure a resource for a patient even if this involves stretching the truth or concealing information. It's hard to tell a patient, "I can't help you," when it looks like there's a way to do so.

But there's another question here: Can a nurse really be every patient's advocate? That's unlikely. So how do we decide which patients we will "go the extra mile" for? Tia Powell, a psychiatrist who directs the Montefiore Einstein Center for Bioethics at Montefiore Medical Center in the Bronx, New York City, says that it's important for nurses and doctors to know their own "cuteness index." By this, she means acknowledging which patients are more appealing to them and which are less appealing. Nurses may be motivated to do more for patients who appeal to them, as in "that's a good family," or "that's a good baby." Giving more of yourself—of your time, of your knowledge of the system—can be a type of workaround, if it involves bending the rules or diverting resources toward the patient you like and therefore away from some other patient or future patient.

This is so tough because being an advocate and making a bureaucracy work for your patient can make you feel good about yourself and your job. That's not bad, but it's ethically dodgy. You may have allocated resources unfairly while trying to do a good thing. How can the system support nurses who face this dilemma?[2]

For more on workarounds in healthcare, and particularly on the ethical issues raised by these common practices, see Dr Berlinger's book, Are Workarounds Ethical? Managing Moral Problems in Health Care Systems (Oxford University Press, 2016).

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