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Are Workarounds Ethical?

Ethics concern actions within relationships. When we ask, "What are the consequences of my conscious actions on others?", we’re doing ethics. When we ask this question in the context of patient care, we’re doing bioethics. We’re also doing bioethics when we ask big philosophical questions – when we ask, "What is the Good?" – and when we aim to make the care of the sick into the good-promoting enterprise it should be. When we see health care organized in ways that act against the good of patients, we’re looking at a moral problem as well as an organizational problem. We should ask, "What’s wrong with this picture? Why won’t this turn out well?"

Our topic this month is workarounds. I’ve been thinking about workarounds for some time, in discussions with nurses and physicians, and with workers in other professions in which safety is a priority and in which there are a lot of rules. There are at least three ways to define a workaround: as a temporary fix, a way to manage a one-time interruption to workflow or a situation in which following rules to the letter might compromise patient care; as a parallel set of rules and practices, created in response to an actual or perceived flaw in the official rules and practices; and, as a variety of practices that help a worker “get the job done,” by any means necessary. Talking about workarounds, especially with nurses, reveals strong feelings (please don’t take away my workarounds, because I need them to survive) as well as complex sets of beliefs: about safety and harm, reward and punishment, secrecy and openness, expectation and reality.

Thinking about how easy it is for me, a non-clinician, to resort to workarounds in my everyday encounters with technology – as one colleague put it, no one expects to be able to follow an instruction manual – reminds me to take these beliefs seriously, even as I ask clinicians: What does it mean to say a workaround “works”? What are the consequences of workarounds for patients? Could some workarounds point toward better solutions – and if so, who is responsible for getting there? What is the role of the organization in promoting workarounds? And why is it so hard to give up a workaround?

Studies of workarounds tend to focus on the technological side of health care: how clinicians interact with systems for ordering and dispensing medications, for example. But some workarounds create psychological shortcuts. One nurse had come up with her own rule for limiting interruptions during her shift: she didn’t make eye contact with patients. And discussing workarounds reveals frustration and distress over organizational mandates to “get the job done.”

So, what about workarounds that touch chaplaincy? Do chaplains use workarounds? Do chaplains observe workarounds, and if so, what do they think about what they see? And as clinical innovations may begin as workarounds – including, perhaps, workarounds of referral procedures that don’t match the situation at hand – what is the role of the chaplain in understanding how “what works” can work better for patients and their families?

A good article to read and share:
Spear, S. J. & Schmidhofer, M. (2005). Ambiguity and workarounds as contributors to medical error. Ann.Intern.Med., 142, 627-630.

Late addition:

A reader has asked for some examples of workarounds that involve chaplains. Examples of workarounds tend to come from practice, or from research studies. (I am not aware of any studies of workarounds in chaplaincy, but if you know of any, please pass along the citations.) Here are some examples of clinical workarounds, based on different definitions of workarounds. These definitions and examples may help other readers to identify workarounds in chaplaincy, or aspects of institutional culture that promote the development of workarounds and obscure the distinction between workarounds and problem-solving or sustained innovation.

Workarounds as informal temporary practices for handling exceptions to workflow. Involves immediate value judgement: Right now, X trumps Y.

Example: A hospital requires computerized entry of orders for pain meds. A patient requires pain medication beyond the scope of standing orders. Physician gives and nurse follows a one-time verbal order to prevent delay in delivering meds to patient.

Workarounds as sustained practices of not following rules or intentions, due to actual or perceived deficiency in system (bad rules) or inability to keep up with workflow if rules are followed. Involves ongoing value judgment: X trumps Y all the time.

Example: A hospital reminds all patient-care staff to make eye contact with conscious patients, as a demonstration of patient-centered care. A nurse finds that making eye contact with patients slows her down, as patients are more likely to speak to her if she does so, and talking with one patient means other patients have to wait. She avoids making eye contact.

Workarounds as products of lack of organizational clarity about goals, or what workers should do when actual conditions conflict with stated goals; mission reduced to "get the job done." Involves ongoing value judgments: Getting the job done is good because it is what management values; X seems to be what gets the job done; Do X, not Y.

Example: These workarounds may be less obvious to the worker, if an ethos of "getting the job done" means workarounds are defined and rewarded as problem-solving. Hint: If the "solution" allows the problem to be left in place, it's not problem-solving, it's a workaround.

Workarounds as first step toward innovation. Involves values-based decision: X is what I do now, Y may be better, let's find out.

Example: With respect to chaplaincy, there are possible examples involving the integration of chaplains into interdisciplinary patient care teams. If an institution's palliative care team does not yet include a chaplain, unit staff may perceive a deficiency, and devise a workaround in response to it. (When X happens, page chaplaincy.) Identifying this workaround, and exploring the possibility of including the chaplain on the palliative care team, may result in a clinical innovation that makes better use of limited resources.

She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.