Aligning work-as-imagined and work-as-done using FRAM on a hospital ward: a roadmap

Abstract

IntroductionModern safety approaches in healthcare differentiate between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined) as a means to further develop patient safety. Research in this area has shown case study examples, but to date lacks hooking points as to how results can be embedded within the studied context. This study uses Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with the work-as-done. The aim of this study is to show how FRAM can effectively be applied to identify the gap between work prescriptions and practice, while subsequently showing how such findings can be transferred back to, and embedded in, the daily ward care process of nurses.MethodsThis study was part of an action research performed among ward nurses on a 38 bed neurological and neurosurgical ward within a tertiary referral centre. Data was collected through document analysis, in-field observations, interviews and group discussions. FRAM was used as an analysis tool to model the prescribed working methods, actual practice and the gap between those two in the use of physical restraints on the ward.ResultsThis study was conducted in four parts. In the exploration phase, work-as-imagined and work-as-done were mapped. Next, a gap between the concerns named in the protocol and the actual employed methods of dealing with physical restraint on the ward was identified. Subsequently, alignment efforts led to the co-construction of a new working method with the ward nurses, which was later embedded in quality efforts by a restraint working group on the ward.ConclusionThe use of FRAM proved to be very effective in comparing work-as-done with work-as-imagined, contributing to a better understanding, evaluation and support of everyday performance in a ward care setting.

Building a Functional Resonance Analysis Method Model: Practical Guidance on Qualitative Data Collection and Analysis

“…Field notes are the observer’s efforts to record, synthesize and understand the data. Tresfon et al (2022) conducted observations over 10 days on a nursing ward to observe the use of restraints to develop a work-as-done FRAM model of the practice. During the observations data was collected using “in field jottings” that the observers later elaborated on in the form of field notes (Tresfon et al).…”

Coming to Grips—How Nurses Deal With Restlessness, Confusion, and Physical Restraints on a Neurological/Neurosurgical Ward

“…In this paper, we report on the findings resulting from the comparison between practice and the protocol. A more elaborate report of the entire realignment efforts on the ward can be found in Tresfon et al (2022).…”

“…The FRAM model of prescribed restraint use according to the hospitals' protocol. Reviewing the protocol showed strong similarities with the national guidelines, which use the same steps as named in the protocol.Source.Adopted fromTresfon et al (2022).…”

Safety Requirements Elicitation Method for Medical Devices Using FRAM

“…Tresfon and others [9] showed that FRAM is very effective in comparing work-as-done with work-as-imagined, as it contributed to a better understanding, evaluation and support of everyday performance in a ward care setting.…”