Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study

Natalie Sanford,Mary Lavelle,Ola Markiewicz,Gabriel Reedy,Anne Marie Rafferty,Ara Darzi,Janet E Anderson

doi:10.1016/j.apergo.2022.103688

Abstract

Healthcare workers must balance competing priorities to deliver high-quality patient care. Rasmussen's Dynamic Safety Model proposed three factors that organisations must balance to maintain acceptable performance, but there has been little empirical exploration of these ideas, and little is known about the risk trade-offs workers make in practice. The aim of this study was to investigate the different pressures that healthcare workers experience, what risk trade-off decisions they make in response to pressures, and to analyse the implications for quality and safety. The study involved 88.5 h of ethnographic observations at a large, teaching hospital in central London. The analysis revealed five distinct categories of hospital pressures faced by healthcare workers: efficiency, organisational, workload, personal, and quality and safety pressures. Workers most often traded-off workload, personal, and quality and safety pressures to accommodate system-level priorities. The Pressures Diagram was developed to visualise risk trade-offs and prioritising decisions and to facilitate communication about these aspects of healthcare work.

Highlights

Healthcare workers and healthcare organisations encounter many pressures in everyday clinical work, for example, managing acutely unwell patients and maintaining the quality and safety of care with reduced staffing, fewer resources, and changing organisational priorities (Braithwaite et al, 2015; Kapur et al, 2016; Reader et al, 2018)
The analysis revealed five distinct categories of hospital pressures faced by healthcare workers: effi ciency, organisational, workload, personal, and quality and safety pressures
The analysis revealed five distinct categories of hospital pressures faced by healthcare workers: efficiency, organisational, workload, per sonal, and quality and safety pressures

Summary

Introduction

Healthcare workers and healthcare organisations encounter many pressures in everyday clinical work, for example, managing acutely unwell patients and maintaining the quality and safety of care with reduced staffing, fewer resources, and changing organisational priorities (Braithwaite et al, 2015; Kapur et al, 2016; Reader et al, 2018). Elements to be considered when prioritising include what is best for the patient and family, maintaining best practice, and what is acceptable to the organisation, as well as meeting personal needs such as maintaining work-life balance and avoiding burn-out (Farid et al, 2020; Hall et al, 2016; Reader et al, 2018). These priorities are often at odds with one another, necessitating that healthcare workers adapt flexibly so that work goals can still be met. This means that workers must make difficult decisions about how to manage risk trade-offs (Braithwaite et al, 2015; Reader et al, 2018)

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