Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals.

BACKGROUND: Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability. METHODS: A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis. RESULTS: Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work. CONCLUSIONS: The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.

Coming to Grips-How Nurses Deal With Restlessness, Confusion, and Physical Restraints on a Neurological/Neurosurgical Ward.

Physical restraints are viewed as potentially dangerous objects for patient safety. Contemporary efforts mainly focus on preventing bad outcomes in restraint use, while little attention is paid under what circumstances physical restraints are applied harmlessly. The aim of this research was to understand how physical restraints are used by neurology/neurosurgery ward nurses in relation to the protocol. In ethnographic action research, the Functional Resonance Analysis Method (FRAM) was used to map and compare physical restraints as part of daily ward care against the protocol of physical restraints. Comparison between protocol and actual practice revealed that dealing with restlessness and confusion is a collective nursing skill vital in dealing with physical restraints, while the protocol failed to account for these aspects. Supporting and maintaining this skillset throughout this and similar nursing teams can prevent future misguided application physical restraints, offering valuable starting point in managing patient safety for these potentially dangerous objects.

Aligning work-as-imagined and work-as-done using FRAM on a hospital ward: a roadmap.

INTRODUCTION: Modern safety approaches in healthcare differentiate between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined) as a means to further develop patient safety. Research in this area has shown case study examples, but to date lacks hooking points as to how results can be embedded within the studied context. This study uses Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with the work-as-done. The aim of this study is to show how FRAM can effectively be applied to identify the gap between work prescriptions and practice, while subsequently showing how such findings can be transferred back to, and embedded in, the daily ward care process of nurses. METHODS: This study was part of an action research performed among ward nurses on a 38 bed neurological and neurosurgical ward within a tertiary referral centre. Data was collected through document analysis, in-field observations, interviews and group discussions. FRAM was used as an analysis tool to model the prescribed working methods, actual practice and the gap between those two in the use of physical restraints on the ward. RESULTS: This study was conducted in four parts. In the exploration phase, work-as-imagined and work-as-done were mapped. Next, a gap between the concerns named in the protocol and the actual employed methods of dealing with physical restraint on the ward was identified. Subsequently, alignment efforts led to the co-construction of a new working method with the ward nurses, which was later embedded in quality efforts by a restraint working group on the ward. CONCLUSION: The use of FRAM proved to be very effective in comparing work-as-done with work-as-imagined, contributing to a better understanding, evaluation and support of everyday performance in a ward care setting.