Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study

Healthcare workers must balance competing priorities to deliver high-quality patient care. Rasmussen's Dynamic Safety Model proposed three factors that organisations must balance to maintain acceptable performance, but there has been little empirical exploration of these ideas, and little is known about the risk trade-offs workers make in practice. The aim of this study was to investigate the different pressures that healthcare workers experience, what risk trade-off decisions they make in response to pressures, and to analyse the implications for quality and safety. The study involved 88.5 h of ethnographic observations at a large, teaching hospital in central London. The analysis revealed five distinct categories of hospital pressures faced by healthcare workers: efficiency, organisational, workload, personal, and quality and safety pressures. Workers most often traded-off workload, personal, and quality and safety pressures to accommodate system-level priorities. The Pressures Diagram was developed to visualise risk trade-offs and prioritising decisions and to facilitate communication about these aspects of healthcare work.