Presentation
Identifying Gaps Between Nursing Policy and “Work as Done” in a Large Hospital System
SessionPoster Session 2
DescriptionBackground
Regular unit huddles (Ghoul et al., 2025), bedside shift report (Ofori-Atta et al., 2015), and other rounding practices (Bayram et al., 2023) are evidence-based nursing practices designed to improve communication efficacy, patient experience, and patient safety. In large hospital systems around the world, initiatives to standardize nurse workflows in the form of uniform unit huddles and bedside shift reports have been conducted with mixed success.
Team huddles are often implemented in nursing workflows to ensure effective organizational communication and prioritize unit-level goals, with goals often pertaining to safety, throughput, and patient satisfaction. Similarly, bedside shift report practices are implemented on nursing units to standardize workflows during shift report with aims of improving patient safety, nurse accountability, and patient satisfaction (Baker, 2010). However, the implementation of both nurse huddle and bedside shift report policies across hospital systems have produced mixed success, with limited quantitative studies demonstrating the positive trends related to policy implementation (Pimentel et al., 2021; Bressan et al., 2018).
Gaps between large-scale policy design and frontline team-member workflows have been defined as gaps between “work as imagined” and “work as done” (Hollnagel, 2017). Such gaps with respect to nursing workflows may manifest during the implementation of standardized policies across different nursing specialties at various facilities in a large hospital system.
This study aimed to identify the barriers and facilitators of nursing policy implementation across a large hospital system and identify nurse workarounds from prescribed workflows that highlight incongruence between work as imagined and work as done.
Methods
This study was conducted at a large hospital system in the Southeastern United States. Observed nursing units were each operating under the same huddle and bedside shift report policies and observations were conducted at four acute care facilities (two community hospitals and two large tertiary hospitals) with medical-surgical units, emergency departments, and critical care units observed at each facility. In total, 24 observations were conducted with each unit being observed during morning and evening huddles and reports.
Observations consisted of impromptu interviews with nursing team members and leadership, including nurse managers, charge nurses, floor nurses, and technicians. Interviews pertained to team members’ perceptions of policy incongruence, normal workflows, and workarounds for “standard work” as defined by huddle and bedside shift report policies. Unit huddles and shift reports were observed in real-time, with detailed notes taken on the workflows of team members during each observation. Data from these observations were used to create hierarchical task analyses of each huddle and shift report observed. These workflow mappings, contextualized by nurse interview data, were then compared with current system-wide policies to identify gaps between work as done and work as imagined.
Results
Results from this study identify important differences in workflows by facility and by nursing specialty across both unit huddle and bedside shift report practices. Moreover, all specialties and facilities showed substantial workflow differentiations between observed workflows and policy standardization.
Huddle practices were found to be largely divergent regardless of stratification by specialty, unit, or time of day. System huddle policy requires specific unit census and safety information be discussed at the start and end of each shift with all nursing team members using specific “huddle boards”. While these boards were used in each huddle, usage varied by unit, with many units using supplemental tools or workarounds to replace certain functions of the system-mandated huddle process. Moreover, while huddles were generally viewed as “necessary” by team members, staff found that information presented were redundant with other communications or not pertinent to their upcoming shift.
Bedside shift report practices were found to be largely convergent towards three archetypal workflows. While policies for bedside shift report were designed for medical-surgical units, they had been implemented system-wide across all acute-care specialties. Because of this, workarounds were commonplace, particularly for emergency department nursing teams. Task analyses identified three shift report archetypes: in-room, outside-room, and hybrid. In observed EDs, hybrid reports were most common (50%) where nurses often used discretion when discussing patient care while in front of the patient to often manage disruptive patients and avoid nonoptimal workload balancing caused by untimely patient demands. In contrast, medical-surgical units and critical care floors used both in-room (37.5% and 50%, respectively) and hybrid (50% and 37.5%, respectively) shift report methods.
Discussion
This study identifies important differences between policy-mandated standard workflows and “work as done” by frontline nurses in a large hospital system. Findings demonstrate that policy workarounds are often deemed reasonable by frontline staff due to the incompatibility of policy with the nuances of their workflows.
This work serves to highlight differences between “work as imagined” and “work as done” in the form of system-wide policy and observed workflows, respectively, to highlight the need for policy implementation tailored to the existent workflows of frontline team members.
Regular unit huddles (Ghoul et al., 2025), bedside shift report (Ofori-Atta et al., 2015), and other rounding practices (Bayram et al., 2023) are evidence-based nursing practices designed to improve communication efficacy, patient experience, and patient safety. In large hospital systems around the world, initiatives to standardize nurse workflows in the form of uniform unit huddles and bedside shift reports have been conducted with mixed success.
Team huddles are often implemented in nursing workflows to ensure effective organizational communication and prioritize unit-level goals, with goals often pertaining to safety, throughput, and patient satisfaction. Similarly, bedside shift report practices are implemented on nursing units to standardize workflows during shift report with aims of improving patient safety, nurse accountability, and patient satisfaction (Baker, 2010). However, the implementation of both nurse huddle and bedside shift report policies across hospital systems have produced mixed success, with limited quantitative studies demonstrating the positive trends related to policy implementation (Pimentel et al., 2021; Bressan et al., 2018).
Gaps between large-scale policy design and frontline team-member workflows have been defined as gaps between “work as imagined” and “work as done” (Hollnagel, 2017). Such gaps with respect to nursing workflows may manifest during the implementation of standardized policies across different nursing specialties at various facilities in a large hospital system.
This study aimed to identify the barriers and facilitators of nursing policy implementation across a large hospital system and identify nurse workarounds from prescribed workflows that highlight incongruence between work as imagined and work as done.
Methods
This study was conducted at a large hospital system in the Southeastern United States. Observed nursing units were each operating under the same huddle and bedside shift report policies and observations were conducted at four acute care facilities (two community hospitals and two large tertiary hospitals) with medical-surgical units, emergency departments, and critical care units observed at each facility. In total, 24 observations were conducted with each unit being observed during morning and evening huddles and reports.
Observations consisted of impromptu interviews with nursing team members and leadership, including nurse managers, charge nurses, floor nurses, and technicians. Interviews pertained to team members’ perceptions of policy incongruence, normal workflows, and workarounds for “standard work” as defined by huddle and bedside shift report policies. Unit huddles and shift reports were observed in real-time, with detailed notes taken on the workflows of team members during each observation. Data from these observations were used to create hierarchical task analyses of each huddle and shift report observed. These workflow mappings, contextualized by nurse interview data, were then compared with current system-wide policies to identify gaps between work as done and work as imagined.
Results
Results from this study identify important differences in workflows by facility and by nursing specialty across both unit huddle and bedside shift report practices. Moreover, all specialties and facilities showed substantial workflow differentiations between observed workflows and policy standardization.
Huddle practices were found to be largely divergent regardless of stratification by specialty, unit, or time of day. System huddle policy requires specific unit census and safety information be discussed at the start and end of each shift with all nursing team members using specific “huddle boards”. While these boards were used in each huddle, usage varied by unit, with many units using supplemental tools or workarounds to replace certain functions of the system-mandated huddle process. Moreover, while huddles were generally viewed as “necessary” by team members, staff found that information presented were redundant with other communications or not pertinent to their upcoming shift.
Bedside shift report practices were found to be largely convergent towards three archetypal workflows. While policies for bedside shift report were designed for medical-surgical units, they had been implemented system-wide across all acute-care specialties. Because of this, workarounds were commonplace, particularly for emergency department nursing teams. Task analyses identified three shift report archetypes: in-room, outside-room, and hybrid. In observed EDs, hybrid reports were most common (50%) where nurses often used discretion when discussing patient care while in front of the patient to often manage disruptive patients and avoid nonoptimal workload balancing caused by untimely patient demands. In contrast, medical-surgical units and critical care floors used both in-room (37.5% and 50%, respectively) and hybrid (50% and 37.5%, respectively) shift report methods.
Discussion
This study identifies important differences between policy-mandated standard workflows and “work as done” by frontline nurses in a large hospital system. Findings demonstrate that policy workarounds are often deemed reasonable by frontline staff due to the incompatibility of policy with the nuances of their workflows.
This work serves to highlight differences between “work as imagined” and “work as done” in the form of system-wide policy and observed workflows, respectively, to highlight the need for policy implementation tailored to the existent workflows of frontline team members.
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments