How staff shortages and high workloads in healthcare lead to bypassing necessary protocols

It's Tuesday morning, 7:45 a.m. In the ward, two colleagues are absent due to illness. The remaining nurses run from room to room while the alarms from the IV pumps and ringing phones fight for attention. In the ideal world – that of the quality plan and ISO standards – every action is preceded by a check and concluded by a record. But reality demands choices. The double medication check? That is rattled off by a colleague who should actually already be at a bedside across the hall. The extensive wound report? That has to wait until after the shift, or is summarized in a few keywords.

To a quality manager, these choices look like negligence. For the frontline healthcare worker, on the other hand, it's the only way to get through the day.

Why healthcare protocols perish in high staffing shortages in healthcare

Healthcare protocols, like any other type of protocols, are designed for normal, ‘middle of the road’  conditions. They assume a stable situation with sufficient time for each step. However, healthcare staff shortages create a dangerous paradox: while intended to improve safety, the protocol hinders immediate care.

When a care worker must choose between ticking off a five-step plan or preventing a confused patient from falling out of bed, the patient ‘wins’ – makes perfect sense. At that point, the administrative burden of the protocol becomes a risk factor because it demands the care worker's attention that is much more crucial to the patient's well-being at that moment.

Pragmatic adaptation: the logic behind circumventing healthcare protocols

Bypassing rules in a context such as the one outlined above is rarely a sign of laziness. It is a form of pragmatic adaptation: the ability of professionals to continuously adapt their practices to achieve their main goal – providing good care – in a given situation.

This form of improvisation – creating a ‘workaround’ – is often an expression of professionalism; it shows that the employee can fill gaps in the system when the protocol, for whatever reason, cannot be followed. The healthcare worker protects the patient from the shortcomings of the system, but at the same time exposes himself to criticism from audits.

How extreme workload in healthcare forces a return to basics

Healthcare staffing shortages increase the cognitive load – the amount of mental effort required to understand, remember, and use information during a task – of employees to a breaking point. When pressure increases, our brains automatically switch back to what's really important. In healthcare, this means that at such times the focus shifts to actions that directly affect the patient's well-being.

Formal steps, such as immediately scanning medication or updating a record in real time, are perceived as ‘noise’ that gets in the way of care. As a result, paper reality and practice continue to drift further apart. The employee does what's needed, but it means administrative actions go undone.

Focus shifts from bureaucracy to Safety-II

The traditional way of managing quality focuses on what goes wrong and tries to prevent it with even more rules and checks. In an industry known for its skyrocketing workload, this approach doesn't work because each new rule puts an additional burden on a system that is already on the verge of collapsing.

The solution lies in the Safety-II principle, developed by Erik Hollnagel. Instead of focusing on why things sometimes go wrong (the mistakes), Safety-II instead focuses on why things usually go right, despite difficult circumstances. It recognizes that the adaptability of employees is the real source of safety in a crisis.

For healthcare managers, this means a radical shift: design and manage processes not from an ivory tower, but based on practice. Don't ask why a protocol wasn't followed, but investigate what barriers on the workfloor made following the protocol impossible.

Make the audit a dialogue between paper and practice

Structural circumvention of care protocols under high pressure is not a discipline problem; it is a systemic signal. If an ISO 9001 audit reveals that the gap between the manual and the shop floor has become too wide, the normally well-functioning quality system loses its value.

The way forward requires courage from healthcare managers. It requires daring to shed bureaucratic burden and embrace the human touch. Only by engaging in a dialogue about how the work is really done – and why it makes sense to do it like that – can we create a healthcare system that is not only safe on paper, but also holds up in the stressful realities of everyday life.