DEFINING THE CHARACTERISTICS AND INSTRUMENT DEVELOPMENT OF NURSE WORKAROUNDS DURING MEDICATION ADMINISTRATION

Abstract

AbstractBackground. Nurses may use workarounds when they circumvent or eliminate a task during the medication administration process. Environmental, technological, and systemic barriers to following medication administration protocols are some of the reasons that nurses use workarounds. There is substantial qualitative research supporting the type of workarounds nurses use during medication administration, but currently there are no instruments available to quantify the type and frequency of workarounds that nurses use during medication administration. Aim. The purposes of this study were to: (a) complete a comprehensive literature review to understand the state of the science related to nursing workarounds and medication administration; (b) conduct a concept analysis of workarounds during the medication administration process; (c) use the findings of the concept analysis to develop an instrument to quantify the type and frequency of workarounds; and (d) to conduct initial psychometric testing of the newly developed instrument. Design and methods. A comprehensive literature search was conducted to understand workarounds and medication administration. A concept analysis, using the Walker and Avant (2005) method, was used to define the concept, and to identify defining characteristics, antecedents, and consequences of nursing workarounds during medication administration. Using the concept analysis findings, an instrument was developed and administered to a sample of acute care registered nurses. Content validity and face validity were assessed. Preliminary psychometric analysis was conducted through exploratory factor analysis. Construct validity was assessed with comparison to the Halbesleben, Rathert and Bennett instrument, a previously validated instrument measuring the construct of nursing workarounds. Results. Study results were reported in three manuscripts to be submitted for publication in peer-reviewed journals. Presented in the first manuscript, the results of the review determined that there is a need for continued research of nursing workarounds and a lack of a validated instrument to measure the type and frequency of workarounds when administering medications. The second manuscript included findings from a concept analysis that elucidated antecedents, eight defining characteristics, and consequences of workarounds. Eight defining characteristics were identified as either human factors or system factors that described workarounds: (a) goal driven adaptation or improvisation of a current policy or process; (b) inconsistent practice with policy; (c) staff actions that do not follow explicit or implicit rules, assumptions, workflow regulations, or intentions of system designers; (d) intentional action outside of the process; (e) nonstandard method for accomplishing work; (f) informal or temporary practice adaptation; (g) bypassed work procedures; and (h) out of sequence or omission of one or more steps in a process. Included antecedents were poorly designed workflows and knowledge of expected policies and practices. Consequences included achieving efficiency, personal satisfaction, process revisions and possible patient harm. The final manuscript presented the initial psychometric analysis of a newly created instrument containing three subscales that measured the type and frequency of workarounds. Based on exploratory factor analysis using principal axis factoring of eighteen items, twelve items were retained comprising three subscales: (a) defining characteristics, (b) type of workarounds, and (c) frequency of workarounds. Cronbach’s alpha ranged from .83 to .92 for the three subscales. As hypothesized, convergent validity was supported by the Spearman Rho correlations ranging from .27 to .47 with the Halbesleben, Rathert and Bennett instrument total and subscales. Divergent validity was supported with Spearman Rho correlations ranging from -.09 to .15 with the Halbesleben, Rathert and Bennett subscales. Conclusion. The three studies provided a psychometric evaluation of an instrument measuring the type and frequency of workarounds that registered nurses may use when administering medications. Initial testing of the three subscales of the Savage Workaround Instrument demonstrated good reliability and initial evidence of validity. Future research should be conducted on a larger sample size to verify the testing results.