Our findings build on and extend the work of Halbesleben et al (2008) [16
] and Alper and Karsh (2009) [3
]. Although the literature examining nurses’ use of workarounds has increased since 2008, there are still relatively few peer reviewed studies examining nurses’ workaround behaviours as a primary focus and most that do are located in the USA. There is considerable heterogeneity in the aim, methods, settings and focus of the reviewed studies. Some studies observe the frequency and causes of workarounds; others examine attitudes of professionals to circumvention of rules. There are few studies that examine the effect of workaround behaviours in terms of measured outcomes [16
]. Workaround behaviours, for example, have been shown to consume organisational resources [59
], impact on health professionals occupational health and safety [79
] and patient medication safety [46
]. However, for the most part, the consequences of workarounds are offered tentatively rather than being solely empirically based [16
]. Workarounds have a cascading effect often impacting other microsystems [48
] thus their effect may not be immediately evident making it difficult to harness and quantify their impact.
Contributing to the relatively underdeveloped body of healthcare research focused on workarounds, given their influence on patient safety, is the difficulty in investigating them. This underlies the use of multiple rather than single research approaches to uncover workarounds’ interwoven processes and characteristics [4
]. While survey questionnaires have been employed [37
], the primary methods used in the reviewed studies included a combination of observation and interviews [1
], which are resource intensive. In addition, the possibility for such research to identify glitches or deficiencies in technology and workers ‘breaking’ rules is fraught with potential implications, that is, financial, legal and political [88
Workarounds both straddle and widen the gaps in health care delivery [89
]. Overall they are reported negatively. There are claims that their implementation: destabilises patient safety [4
]; undermines standardisation [56
]; increases physical and cognitive workload [49
]; hides actual practice and opportunities for improvement thus preventing organisational learning [1
]; and creates further problems and workarounds [24
]. However, other accounts of workarounds describe them as mindful behaviours [60
] that provide opportunities for improvement [48
] and both compromise and promote patient safety [48
]. Nurses justify workarounds as necessary circumventions to deliver timely and customised patient-centred care in complex and highly variable systems [36
]. The potential pathways of workarounds to innovation and excellence and the connection of workarounds with resilience are being recognised [26
Studies demonstrate that workarounds are individually or collectively enacted. When enacted as a collective process, they rely heavily on: a shared view that rules are flexible [42
]; a tacit agreement to enact [42
]; and an understanding of who will and will not workaround [74
]. There is some evidence, from a small number of studies, that group norms [40
], local and organisational leadership [58
], professional structures [24
] and relationships [49
] and others’ expectations [44
] influence the implementation of workarounds. Despite the collegial nature of nursing work and the demonstrated effect of organisational and local culture on clinicians’ behaviour and attitudes [91
], the influence of social networks, relationships, expectations and local and organisational culture on the enactment and proliferation of workarounds is under investigated.
There are suggestions that nurses’ notions of what constitutes a ‘good’ nurse, their ideologies, knowledge and experience, influence their implementation of workarounds [24
]. For example, nurses viewed problem solving as part of nursing and perceived that an ability to do so alone demonstrated competency. They reported a sense of gratification at being able to solve problems individually, protect patients and deliver care [24
]. There is evidence that nurses justify working around rules and policies for the benefit of the patient [36
]. However, the importance of adhering to protocols was considered by other nurses to be central to a professional approach to patient care [38
]. Introducing technology incites ambiguity in practice and changes the meaning of nursing work [93
] which may undermine confidence and threaten a professional’s image.
Workarounds continue to be ill defined [16
] with less than half of the studies reviewed offering a definition for workarounds or related concepts. Those that did were primarily published since Halbesleben and colleagues’ articulation of this shortcoming in 2008 [16
]. The lack of clarity may reflect the uncertainty about how workarounds are conceptualised in clinical settings and by researchers. For example, some authors suggest that workarounds lead to potential errors [34
], while others propose that these behaviours are the error [52
]. Importantly, there is lack of clarity in how nurses themselves differentiate workarounds from related constructs [65
]. Contributing to the confusion is that some workarounds are viewed as normal practice, with clinicians being unaware that they are in fact workarounds. Furthermore, at times informal workarounds become sanctioned practices [48
]. Imprecision in how workarounds are defined and reported poses challenges for researchers and those who would synthesise the evidence.
This scoping review identifies gaps in the literature, which offer opportunities for future research. Further studies are needed that investigate nurses’: workarounds as a primary focus; individual and collective conceptualisation of their own and their colleagues workarounds in situ; workaround behaviours and measured patient outcomes; team and organisational cultures on the enactment and proliferation of workarounds.
This review examined empirical peer reviewed studies written in English. A limitation of literature reviews is that imposed by research and publication timelines, which create a lag between those studies included in the review and new published information. While every attempt was made to capture all published papers in this area using systematic and comprehensive search strategies, some may have been missed.
The main challenge in studies of this type is that workaround behaviours are difficult to delineate from other behaviours [16
]. We applied an operational definition of workarounds to behaviours described in the reviewed studies and were inclusive rather than exclusive. It is possible that we missed some workaround behaviours. Alternatively it is possible that we included some behaviours that may not be workaround behaviours. We attempted to ameliorate this effect by employing two reviewers to independently cross-examine randomly selected studies in phases one and two and all of the studies in phase three.