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Nurse executives focus on complexity of care delivery


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Rebecca Hendren, for HealthLeaders Media, April 19, 2011

The average nurse is in cognitive overload, completing about 100 tasks per shift with an interruption every three minutes. At its annual meeting, the American Organization of Nurse Executives' put the spotlight on the current nature of nursing work to see how care delivery can be reshaped.

The sunny skies of San Diego proved an ideal setting for an upbeat meeting of the AONE annual convention last week. The nurse executives weren't letting uncertainty over healthcare reform dampen their moods. They arrived at the conference ready to learn from each other and share best practices for reshaping care delivery in the era of cost containment, increasing regulation, scrutiny, and accountability.

The well-attended conference focused on healthcare transformation within four areas: care delivery and sustainability, leading for the future, patient safety and quality, and leveraging technology.

I attended a fascinating presentation by Mary Sitterding, PhDc, RN, CNS, director, nursing research and professional practice at Indiana University Health, and Patricia Ebright, PhD, RN, CNS, associate dean of the Indiana University School of Nursing.

These nurses have conducted a great deal of research about the complexity of nursing work and they shared some interesting statistics.

Nurses are subject to a ridiculous amount of interruptions during their shifts, such as patients and families asking questions, colleagues needing assistance, or having to track down supplies. These interruptions mean nurses lose an average of 2.1 hours each day, which costs the U.S. economy $508 billion annually.

The researchers shared that one nurse who was observed illustrated cognitive shifts or interweaving among five patients 74 times in eight hours.

"Think about what that does to a nurse's ability to think," says Sitterding.

Sitterding described a study where researchers observed medication administration. The researchers found that interruptions occur in 53% of all observations. Of those medication administrations that included an interruption, 39% ended up with a clinical error.

We have to understand the current nature of nursing work to understand how to improve patient safety. The way care is carried out now is incredibly complex and requires nurses to perform many tasks at the same time and nurses must be constantly aware of unexpected situations that may arise.

The factors that contribute to work complexity are:

  • Actual demands in the practice field that affect the behavioral and cognitive care delivery work of RNs
  • Operational failures
  • Flawed facility design
  • Inadequate communication
  • Complicated or irrelevant policies
  • Task management

This leads nurses to perform cognitive task management to handle competing priorities:

  • What needs to be done first?
  • What can wait?
  • To what extent can care delivery be performed according to organizational policy or personal standards given competing goals?

"Cognitive task management is happening with every nurse on every unit in every hospital," says Sitterding.

She added that nurses are facing cognitive overload. All too often they face inattention blindness, i.e., they can't see the forest for the trees.

Strategies the speakers suggested nurse leaders implement to improve the cognitive load of nurses and thereby reduce errors include the following:

  • Policies that outline when and where distractions or interruptions are acceptable
  • Leadership/staff education on the relationship between distractions and patient care errors
  • Visual triggers signaling no-interruption zones where nurses can perform important tasks free from interruption