Nurses as a source of system-level resilience: Secondary analysis of qualitative data from a study of intravenous infusion safety in English hospitals

BACKGROUND: Deviations from local policy and national recommended best practice are common in the administration of intravenous infusions, but not all result in negative consequences. Some are the result of nurses’ clinical judgement. However, little is known about such practices and their effects on the safety of intravenous infusions. Our objective was to explore ways in which nurses contribute to system-level resilience when administering intravenous infusions. METHODS: We conducted a secondary analysis of qualitative data from debriefs and focus groups from a mixed methods study of errors and policy deviations in intravenous infusion administration across 16 English hospitals. Analysis focused on nurses’ contributions to system-level resilience, drawing on Larcos’s et al. framework of types of resilience. RESULTS: Five types of system-level resilience were identified in nurses’ behaviour: anticipatory resilience, responsive resilience, resilience based on past experience, workarounds and nurses performing informal ‘risk assessments’ in relation to how best to treat individual patients. Examples of practices contributing to infusion safety were found for each of these types of resilience. CONCLUSION: Our findings suggest nurses are a key source of system-level resilience. Some behaviours that may be considered deviations from policy or best practice are the result of reasoned clinical judgement to improve infusion safety in response to the specific situation at hand. Adaptive behaviour is necessary to cope with the complexity of practice. There is a tension between standardisation and supporting flexibility in safety management.