Are Workarounds Ethical in Health Care Systems?

New book by research scholar Nancy Berlinger explores the improvised strategies that are part of work in health care systems and the implications for patient safety and harm.

“There is more than one ‘clean hands’ problem in health care work,” writes Nancy Berlinger, a Hastings Center research scholar and a specialist in health care ethics, at the opening of her new book, Are Workarounds Ethical? Managing Moral Problems in Health Care Systems, published by Oxford University Press.

The book examines the everyday ethical uncertainties that doctors, nurses, and other health care professionals face in caring for patients amid organizational resource allocation pressures, and the unofficial, sometimes problematic ways that they respond, including trying to wash their hands, symbolically, of situations seen as “legally risky, morally dodgy, or emotionally unclean.” These improvised practices, commonly known as “workarounds,” are difficult for health care professionals to discuss openly because they often involve departures from official rules, and their effects are often unclear, including the benefits and risks to patients.

Berlinger describes workarounds as “shortcuts, fixes, patches to bridge the gap between the rules of work and what’s actually happening.” She says, “In everyday conversation, doctors, nurses, social workers, and other health care professionals often refer to their own experiences devising or using workarounds as ‘being creative.’”  Workarounds can also take the form of avoiding patients or interpersonal situations considered difficult.

Situations that drive health care professionals to devise workarounds range from routine trade-offs to “get the job done” more quickly or avoid obstacles created by flawed systems, to efforts to compensate for upstream problems, such as misaligned financial incentives. If, for example, a patient is ineligible for needed care, health care professionals may bend the rules by “tailoring the chart” so that the patient can meet an eligibility threshold.

While workarounds are, to some extent, inevitable features of a complex system such as health care, which is “inherently flawed and ever-evolving” and which “cannot be fixed,” Berlinger sees practical opportunities for improvement. She provides recommendations to health care professionals and institutional leaders for reflecting on the ethical problems they face and generating ideas for mitigating them.

Are Workarounds Ethical?is a magnificent example of practical health care ethics that starts from the mundane ways health workers try to compensate for the inevitable flaws and frustrations encountered in every health system,” writes Dr. James Sabin, clinical professor of population medicine and psychiatry at Harvard Medical School and director of the Harvard Pilgrim Health Care Ethics Program. “Leaders of health systems will benefit from a deeper understanding of how to engage physicians, nurses, and other health workers in collaborative efforts to take better care of patients and of themselves.”