Learning the rules of the game: how ‘good nurses’ negotiate workarounds

Abstract

Background: Electronic medication management systems (EMMS) aim to reduce medication errors. Rather than use them as prescribed by policy, nurses commonly employ workarounds. EMMS-related workarounds have been attributed to a mismatch between introduced technology and nurses’ workflow. Comparatively little attention has been focused on examining nurses’ enactment, explanations and experiences of using workarounds. This is a significant lacuna because nurses’ contextual rationalisation is integral, I will argue, to understanding their use of workarounds. Aims: To improve our knowledge and understanding of nurses’ use of workarounds with EMMS in order to inform policy and technology development. Methods: A qualitative study was conducted in four phases: scoping and process mapping; data collection and analysis; explanatory framework generation and member checking; and interpretation of emergent findings using existing sociological theory. The study sampled EMMS implementation stakeholders and nurses across all shifts and days of the week, from six wards in two Australian hospitals, representing two EMMS types and two models of nursing care. Data collection methods included observations, interviews and focus groups. Data analysis used a general inductive approach in which data were coded for emerging themes, framed by the research questions. Results: While sometimes EMMS related problems offered the best explanation for workarounds, nurses used workarounds largely to circumvent perceived barriers to being, or being perceived to be, a ‘good nurse’ in the sense of being time-efficient, safe, patient-centred and/or a team player. Whether nurses used workarounds, and how they felt about doing so, was moderated by a number of contextual factors. The use of workarounds provoked a range of emotions, in particular, feelings of tension. Interpretation: Nurses were motivated to use workarounds, even when doing so made them professionally vulnerable, primarily by the desire to be, or be perceived to be, a ‘good nurse'. Bourdieu’s concepts of habitus, field and capital offered useful constructs to interpret the intensity and complexity of the drivers of workarounds. Conclusion: Technology and policy designers need to be cognisant of creating potential barriers to being a ‘good nurse'. Unless they do so, problematic workarounds will continue unabated, and potentially useful workarounds will remain ‘underground’.