How Burnout Affects Workarounds and Unfinished Care
I remember one of my first days as a nurse on my own. It was an hour into my shift and I was standing in the medication room, my face flushed with anxiety. I was trying to figure out how to assess my five patients and give each of them their medications within the allotted hour. It seemed nearly impossible to me, and I remember exasperatedly saying to a seasoned nurse, “How do you do it??!?!”.
As I gained more experience as a bedside nurse, I learned how to manage my time and how to prioritize. I found my own rhythm of giving patient-centered care. I made sure I saw my sickest patients first, considered managing pain as one of my highest priorities, and spent as much time as a patient needed with me in order to explain discharge instructions. However, even after years of experience, I rarely gave all morning medications to my five patients “on time” (within 30 minutes before or after its scheduled dose).
As a nurse, we’ve all had days where we couldn’t give the care we wanted to. We’ve had days where we couldn’t administer a medication on time, couldn’t change a dressing because we didn’t have the necessary supplies, or were unable to meet the demands of a patient. All of these can be labeled “unfinished care”. In the literature, this is also called missed, omitted, or delayed nursing care, rationing of care, care left undone, or unmet nursing care needs.
The prevalence of unfinished care has been reported between 55% and 98% among nursing staff in acute-care hospitals internationally (keep in mind that these numbers are often self-reported… so they’re likely even higher).
Unfinished nursing care is associated with negative nursing, patient, and organizational outcomes. It is strongly correlated with patient satisfaction, medication errors, urinary tract infections, patient falls, pressure injuries, critical incidents, quality of care and patient readmissions.
What does unfinished care have to do with burnout?
Unfinished care is not only associated with poor patient outcomes; it is also closely correlated with burnout!
Nurses who are burned out perform poor patient care. However, the inverse is also true - giving poor quality care is associated with burnout, job dissatisfaction and intention-to-leave. Nurses who reported on at least one aspect of care (such as skin care, administering meds on time, or planning nursing care) that remained undone at the end of their shift were more likely to report dissatisfaction at work.
The irony is that nurses WANT to give high quality care. When they can’t (due to staffing, lack of resources, lack of support, etc.), they become more burned out.
Studies show that when nurses want to give high quality care but are unable to, they have higher burnout scores in emotional exhaustion and depersonalization. Additionally, the more “missed care activities” (or unfinished work), the higher their intention-to-leave the job.
On the other hand, nurses are experts at workarounds! “Workarounds” are situations where a nurse experiences a block in workflow and, rather than complete the work process as intended (such as in protocols or standards), the nurse creates a solution to get around the block in work flow.
Here are a few examples of workarounds found in the literature (and some will likely sound familiar, as I imagine you’ve experienced them as well!):
· Scanning an intact medication label but giving a different dose of the same medication when the medication barcode was wet or unreadable
· Labeling a specimen with a generic patient label when a printer is jammed or broken
· Scanning medications and patient ID bands for multiple patients before beginning med administration
· Re-sheathing needles to work around the distance to the disposal container
· Not wearing gloves to work around a perceived greater risk of needle stick when gloves are the wrong size
· Charting that a med was given but giving a patient a medication at a later time due to complications in rescheduling the med
Workarounds are ethically complex. Research shows that workaround behaviors reflect nurses’ attempts to deliver patient centered care when workflow processes make that difficult (nurses are trying to advocate for the patient!). Typically, workarounds are used to compensate for inadequate technology, to bypass workflow blocks, and to sidestep poor work flow design. They are a response to systems that are not working.
Even though nurses often use workarounds to improve patients’ care, this can also jeopardize a patient’s health or wellness. For example, think about the procedure your hospital has in place to insert a foley catheter. Bypassing one of these steps can put the patient at risk for infection, no matter the nurse’s intentions.
Workarounds are tied to poor work environments (one of the biggest risk factors when it comes to burnout). A poor work environment can include inadequate staffing levels, poor leadership, lack of nurse involvement in decision making, and a lack of perceived resources.
Poor work environments as well as workarounds and unfinished work contribute to the possibility of negative outcomes for the organization. This can even include litigation and compliance issues.
The Bottom Line
Nurses want to give their patients the best care. When they can’t, they perform workarounds or are unable to finish their care. This leads to further burnout and continues the vicious cycle.
What can we do?
Is there an easy, non-punitive way to report workarounds and unfinished care in your work environment? If not, talk to your nurse leaders and ask them to create a way to do this. The more aware leadership or management become of workarounds and unfinished care, the more they can help build better workflows and system redesign. Ask them to read about burnout and the potential impact on compliance and litigation, and the effect of burnout on patient and organization outcomes.
Check out this link for more information on burnout to share with nurse leaders and to further your own knowledge!