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Readers Write: Working Around Health IT: The Nurse, the Workaround, and the Question You Need to Ask

February 25, 2015 Readers Write 4 Comments

Working Around Health IT: The Nurse, the Workaround, and the Question You Need to Ask
By JoAnne Scalise, MSN, BSN, RN


Are nurses just BAD? (That’s not the question.)

Why are they so adamant about working around health information technology (HIT)? Is it to give the CIO chest pain? Annoy the IS people? Give their nurse leader heartburn?

How can a simple process — do this, then do this (perhaps multiplied a few or many more times) — turn into a spin with the Mad Hatter (teacup optional)?

It would be easy to leave it that “nurses don’t follow directions,” “nurses are difficult to deal with,” or my personal favorite, “nurses don’t like change” (of course, everyone else likes change!) Those crazy nurses are still wearing disco-era bellbottoms and a mullet. And if you are, that’s ok – it works for you. With 55 percent of the RN workforce at age 50+ (from a 2013 survey reported by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers), that may have been some of the best of times.

But what about making right now better? So much HIT is intended to make life better: for patients, for healthcare systems, and yes, for those crazy nurses. Better, as in efficient and safer for everyone – and in getting paid so we can take care of people tomorrow.

Even knowing that, why do nurses choose to work around the very things that could save their patient, their colleagues, their organization – and themselves? Why does an expert nurse scan a contraband wristband or label instead of the one on the patient for medication administration or specimen collection? Why circumvent the EHR when guidelines for use have been given? Why take that patient  (and personal and professional) risk?

This is the opening of dialogue. Not to defend what many call “the bad apple,” “the bad actor,” or those who just act “bad,” as in, “I don’t care about people” people. I’m not talking about nurses or specific roles. I’m referring to those outliers who are clear that they don’t care about patient safety or care, their colleagues, or healthcare. Those people are the rarest of the rare because they don’t last long in our system – we can’t tolerate bad apples or bad care. Bad is about behavior and not the person.

As a perennial patient safety student, I know that the professionals who have chosen to be entrusted with providing care to every one of us who enters the healthcare system do not take their responsibility lightly. As a nurse, I know (as do my clinician colleagues) that we have chosen wisely. Our responsibility to our patients and the healthcare system are our primary motivators. Care excellence is the goal we must fulfill in every patient encounter every day. Safety never sleeps.

Why then, the confounding issue of the workaround?

I have been fortunate to work with nurses around the country to help them keep their patients and themselves safe. I have had other departmental staff stand up and point their fingers at me and ask, “How are you going to make these nurses BEHAVE?” And this is with nurses in the room. On occasion, I even get the same question from the nurse leaders. Laboratorians, CIOs, and patient safety and quality professionals have other direct questions on the same topic. I’ve even been invited to speak to groups of lab leaders on “how to communicate with the nursing suite.” When presenting on the topic in national forums, the topic is often addressed in hushed tones by nursing and other leaders who share that the workaround is an “epidemic.”

Indeed, the workaround is a real and persistent danger and with exponential significance: the possible patient safety breach, the trust eroded for collaboration and communication, and the financial loss from the wasting of resources of the healthcare organization.

Health information technology spending was projected to top $6.8 billion in 2014, with individual hospitals and healthcare systems spending millions annually. Not using the purchased technology causes challenges in safety, in culture and process, in data collection and analysis, and in budgets. When enough end users simply “end it” and stop using the technology, the technology can end for that organization. With that end comes significant loss.

At the same time, some organizations decide to not engage the nurse or other end user for a variety of reasons, often because of time for conflict (“we can’t get caught up in nursing demands — they’re going to have to do it.”) I’ve been in meetings where the issue came up of end users (who were not represented or in attendance) and the statement was made, “We’re just going to ram it down their throats.” Tough love, but probably not so effective in the long run. Fortunately, they were eventually receptive to the benefits of end user inclusion and engagement in the decision process, with a very positive outcome.

When nurse and hospital leaders ask me, “What is the most important lesson you’ve learned about adoption?” I tell them that the most important lesson may seem to be a simple one. Engage your end users. You must engage them as you decide that you have an issue to solve. You must engage them before any technology decision is made. If you don’t, they will use the only opportunity that they have to influence this decision – and that is not to use it.

Some technology doesn’t make life easier. Not all technology is the best it can be. We all need to help make these products better through objective feedback and end user engagement in the decision process and ongoing use.

I believe we can support clinicians in moving from compliance to commitment, and not just in technology. I’ve developed a MAP (mindful leadership, authentic communication, personal accountability) to help you do just that so we can do less “around” and more “work.”

I’ll leave you today with what I think is the best question for responding to a workaround. So many times we ask, “Why won’t you do this?” The question implies resistance, and depending on how we say it, frustration and even accusation. The answers may tend to be defensive and deflect the true reason.

Ask instead, “Why can’t you do this?” You will get thoughtful and real answers that may benefit your practice and eventually improve the technology. And the work.

Let’s continue the conversation on how we can work through the workaround. I’ll bring my MAP.

JoAnne Scalise MS-Patient Safety Leadership, RN is the manager of nurse consulting for Sunquest Information Systems.

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Currently there are "4 comments" on this Article:

  1. Thanks for your piece. Asking why won’t you do something is certainly a confrontational question. Some might also feel some resistance to answer Why can’t you? Another approach is to ask “What would happen if you did this?” Sometimes why is actually a hard question, even on a good day!

  2. I once dreamed a dream; where the EMR didn’t create duplicate documentation- where the work process was changed to take advantage of electronic media and instant access to records to cut the amount of work a nurse did. That dream was shattered at every institution I tried to help implement an EMR. Every administrator was dazzled by the cost capture involved, especially since the biggest EHR programs are really based on billing databases, and aren’t really patient centered. The implementation of every EMR is always easier when you just duplicate the forms and adjust the documentation to meet the procedures already in place. When the nurse administrators don’t see the same forms on their desks, they howl for a version of the form they had before, or demand a paper copy, making the bedside staff slowly double their work load when an EMR is introduced. Give us an EMR that isn’t centered on billing, and really stop the double documentation.

  3. @Dan sounds like an epic dream…
    Hmm, an EMR centered around a patient and not a billing system. There is one, it’s called Epic but that doesn’t prevent double documentation.

    I agree with you all EMRs need to work on not forcing clinicians to double document all day long. However, we will have more patient focused and less billing focused EMRs when when hospitals and clinics stop needing money to pay the providers. Until then people care about capturing charges.

  4. I agree that the key to working with nursing staff, nursing leadership and practice staff is including them in the development of the solution. Establishing buy-in early on, and providing a voice for staff to air concerns goes a long way towards adoption of new process and systems. Of course, no one enjoys the experience of introducing a new project, program or technology to a room full of hostile staff. However, if given a chance to provide major contributions towards problem solving – nurses will lead the way towards adoption!

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