In a busy Med-Surg unit, a nurse searches for a stat medication, which is twenty minutes overdue for administration; unable to locate it, he orders a replacement dose and leaves the unit to retrieve it from pharmacy. A busy Oncology nurse retrieves symptom control medications from the automatic dispensing cabinet early, placing the dose in her pocket so that she doesn't have to return to the cabinet at a time when there are usually multiple nurses in line for medication access. Another nurse on a Transplant unit chooses a "basic infusion" mode, overriding an alert, because of discrepancies between the smart pump drug library and actual nursing practice workflow. All of these typical clinical scenarios provide insight into the care delivery challenges faced by nurses throughout our daily work, as well as the unintentional risk of harm these challenges may present as nurses attempt to work around them.
Breakdowns and shortcuts throughout the course of care
As the clinical provider responsible for the coordinated delivery of product and services to patients and their families, nurses are committed to providing the best possible patient care experience to our customers and our healthcare organizations. However, all too often we must spend valuable time addressing system breakdowns like those described above, and while unintentional, those efforts may compromise safety or efficiency. With the introduction of robust yet disparate technologies at the point of care, and shifting patient population characteristics that require complex coordination of care, exponential risks can also occur. Any unmet need or inefficiency in workflows, tools, processes, and interactions with other healthcare providers that emerges throughout the course of nursing care may present a potential for risk to productivity, patient safety, or both.
Shortcuts, omissions in steps, or ad hoc efforts employed by nurses to mitigate such breakdowns are typically developed with the intent to minimize the operational gaps, support the constant prioritization and re-prioritization efforts that occur throughout the course of a nurse's shift, or to maximize value-added time spent with our patients and their families.1 Such system shortcuts may be a reaction to "upstream errors" away from the bedside that are a function of improper or inefficient system design. Breakdown and related shortcuts are a reflection of low levels of inter-professional collaboration, and usually indicate a significant disconnect between clinical, operational, financial and/or supply chain organizations in attempting to address a critical need in patient care delivery. Other possible causes of the breakdown and shortcut cycle may include:
- Human error, delay, equipment malfunction, or miscommunication2;
- Shortcomings in technology design, implementation, and workflow integration2;
- Lack of standardization3; and/or
- A culture of tolerance.
A multi-site study in 2017 aimed to describe the rate and categories of shortcuts that occur in current nursing practice. This study found that "in total, nurses reported 27,298 OFs [Operational Failures] over 4,497 shifts, a rate of 6.07 OFs per shift." The highest rate of those failures were attributed to efforts to use or locate equipment and supplies.4 Efforts to manage equipment and supplies also reflect one of the largest sources of non-value added nursing activities, or "actions performed by nurses that do not benefit the patient and should not be necessary in the delivery of patient care.5 While up to twenty percent of all nursing activities on a typical nursing unit can be characterized as non-value added5, some healthcare organizations are setting seventy percent targets for nursing value added activities in the form of direct patient care.6
Breakdowns interfere in nursing care delivery workflows which may contribute to nursing "burn-out," dissatisfaction and attrition.7 As leaders in executing upon ordered care plans, we aim to give our best when delivering care to our patients. Making this significant shift to maximize value add nursing activities by reducing time spent on non-value add activities is a formidable ask in a care setting of sicker patients, reduced staffing ratios, and other hazards of the work environment.
Managing breakdowns through solutions and innovation
Nurses are known to be creative problem solvers who are extremely skilled at overcoming obstacles presented throughout the course of care delivery on behalf of their patients. This creative mindset is reflective of the resourcefulness, resilience, and flexibility of our profession. It is also a valued trait, as nursing has once again been rated to be the most trusted profession in the United States workforce.8 Through our role as orchestrators of patient care, breakdowns and workarounds offer several compelling opportunities for nursing to act as innovation leaders, using their unique knowledge and expertise to the potential benefit of patients in terms of improved safety, streamlined care delivery, and reduction in workforce stressors through process improvements.
Nurses are often satisfied with―even proud of―our abilities to deliver patient care despite the numerous obstacles presented in the course of a shift.3 Advocating for and establishing a culture of safety is an opportunity for nurses, as leaders, to drive change in how breakdowns are managed in the healthcare enterprise and used as a platform for innovation. These efforts also align with the High Reliability Healthcare model, a framework used in many hospitals, derived from the study of industries such as aviation and manufacturing that "operate under hazardous conditions while maintaining safety levels that are far better than those of health care."9
Shared ownership of risk, collective and proactive risk identification and escalation, resiliency and recovery in error management activities, and empowerment towards continuous quality improvement9 are high-reliability concepts which may be applied to support a culture of safety related to breakdowns and workarounds in nursing. This could potentially involve:
- Moving from celebration, or tolerance of, workaround necessity to learning from operational failures, speaking up and advocating when risks occur, then advocating (and potentially leading the effort) for a better solution;
- Fostering an environment in which we and our colleagues feel safe to trust, report, and improve9; and
- Developing an environment of "collective mindfulness," a culture of safety in which all workers look for and report small problems or unsafe conditions before they pose a substantial risk to the organization or, most importantly, to patients.9
A potential method to address breakdowns and the resulting workarounds involves supporting the optimized use of innovative technology, process, and practice throughout care delivery models. This may be accomplished through:
- Ensuring that technology considered for use in patient care environments is evaluated with a Nursing mindset and perspective, by actual end-users, as well as Nursing leaders;
- Collaborating with other clinicians in discussions of product/process limitations, the timeline and priority for system upgrades, and the necessity for instructions, training, and support for end users;
- Understanding and raising shared awareness of the implementation process, planning for known risks, and communicating to end-users down times, changes in workflows, and the ultimate benefits received from introducing improved products or processes; and
- Establishing shared metrics for success to communicate to nursing stakeholders regarding innovation that reflects qualitative and quantitative as well as pre- and post-implementation data.
Finally, nurses' creative solutions to day-to-day breakdowns may represent excellent opportunities to identify and make incremental improvements or enhancements, and generate net new innovation. Supporting and mining this unique and abundant source of ideas has the potential to produce solutions that benefit nursing workflows, patient satisfaction, patient outcomes and the healthcare enterprise overall by:
- Creating a channel for nurses to bring breakdown solution ideas to the table, through committees, innovation centers, and other mechanisms for discussion within the organization;
- Promoting channels available within nursing practice innovation which individuals and teams of nursing innovators can use to conduct research on solutions of interest to the healthcare enterprise; and
- Allowing nurses to lead innovation efforts or cross-functional teams towards addressing breakdowns; in their role as provider of patient care for patients 24/7, nursing perspectives―assessing the needs and wants of patients, executing upon recommended plans of care, and interpreting patient outcomes1―represent a compelling viewpoint of value and authority.
Every day, during each shift, nurses encounter unmet needs, workflow inefficiencies and breakdowns related to tools, processes and interactions with other healthcare providers. While operational failures present potential risks to productivity and patient safety, they may also serve as a rich source of innovative ideas as well as opportunities to optimize workflows and maximize value-added nursing activity across the continuum of care.
Each month on the BD Institute for Medication Management Excellence blog, thought leaders explore topics of critical importance to medication management, and provide additional ways to learn.
Now that you've read about value-added care in nursing, check out the ANA Innovation Awards powered by BD, a new initiative to recognize nurse-led innovation that results in improved patient safety and outcomes.