Understanding Antecedents of Nurses' and Physicians' Workaround Behavior Regarding Hospital Information Systems: Qualitative Interview Study.

Background: Hospital information systems (HISs) aim to support users in their time-critical routines on hospital wards with accurate and timely information. However, if these systems create blockages to workflows, nurses and physicians develop workarounds to provide care to the patients, nonetheless. Workarounds are considered negatively when associated with risks and positively when seen as feedback and a source of innovation. Learning about the antecedents of workarounds allows for the establishment of control mechanisms, under the promise of enhanced patient safety. Objective: This study seeks to explore which antecedents shape nurses' and physicians' workaround behavior in the context of HISs, how they influence behavior and interrelate, and the intentions with which they are carried out. Methods: Using 26 qualitative interviews with nurses, physicians, and health information technicians from Germany and the United States and applying grounded theory analysis techniques, we identify antecedents of HIS-related workarounds and respective relations. Results: From the interview transcripts, we derive 506 open codes which we cluster into 3 direct causes (organizational prerequisites, human factor, and system), and 4 influencing factors (regulations, sector funding, role of software providers, and role of ownership and management). While Influencing Factors constitute higher-level influences, they do not directly impact nurses' and physicians' behavior but rather depict the defaults that lead to conditions for Direct Causes of workarounds. Conclusions: This study provides an understanding of the antecedents of workarounds performed by medical personnel regarding HIS use, structures and categorizes them, and lays the foundation for an understanding of users' deviant behavior. Moreover, by revealing cause-effect relationships between the antecedents, we take on a behavioral perspective and provide a basis for developing effective strategies to prevent the need for workarounds. We contribute to the research stream of workarounds in health care and emphasize that once the reported and derived direct causes and influencing factors of workarounds have been tackled, working conditions, patient safety, and the overall quality of health care may improve under full digital support.