Understanding Real Work Complexity for Design and Implementation of IT

Patricia Ebright, BSN, MSN, DNSAssociate Professor

School of Nursing, Indiana UniversityMay 15, 2007

Presentation Outline

A new framework for understanding complexity of nursing work

Research findings about nursing work complexity

Implications for IT design, implementation and evaluation

Major barrier to making progress in safety and quality:

failure to appreciate the complexity of work

Environmental and Technology Design

Physical structure and process designs that streamline real work at the point of care.

Information technology formats and access that support decision making related to actual clinical and workload management of care

Implications for IT Implementationto Support RN Work

IT needed that supports decision making related to clinical and workload management of care within context of actual work

Need content, timing, format, accessibility

Implications for IT Implementationto Support RN Work

IT that supports easy access to real-time patient flow across departments

Anticipation/warning of unpredictable events (military IT for real-time adjustments)

IT that facilitates properties of communication to support hand-offs

IT Solutions That Facilitate Properties and Affect Communication/Handoffs

Co-presence Visibility Audibility Co-temporality Simultaneity Sequentiality Reviewability Revisability

Clark & Brennan. Grounding in communication, in Perspectives on Socially Shared Cognition, L. Resnick, J.M. Levine, and S.D. Teasley, Eds. Washington, DC:Amer.Psychol. Assoc., 1991.

Woods, Johannesen, Cook, Sarter, 1994

Studies

Expert RNs in med-surg acute care/adults

Novice RNs in med-surg and critical care/adults and pediatric

Critical Care RNs/adults and pediatric - Medication Administration of Critical Drugs in ICUs

RNs and Physicians in Primary Care/adults - Factors Affecting Pain Management Decision Making

Case study analyses of errors, near misses and specific processes/procedures

Current stacking study funded by NPSF

Overall Purpose of Data Collection/Analyses

Identification of contributors to work complexity

Identification of strategies used to manage complexity for desired outcomes

Identification of cognitive work leading to clinical and workload management decisions

Methods

Studies

• Direct observation during actual work and/or cognitive task analysis interviews of individual RNs about actual work

Ongoing case study analyses

• First Story/Second Story near miss/adverse event data collection - trending

• Healthcare worker focus groups on specific process/procedures

Work Complexity Patterns

•Missing equipment or supplies

•Interruptions

•Waiting on systems/processes

•Inconsistencies in care communication

•Lack of time

Care Management Strategy Patterns

•Stacking

•Anticipating or forward thinking

•Proactively monitoring patient status

•Strategic delegation and hand-off decisions•Memory aid

Coordinating Knowledge, Mindset, and Goals

Knowledge Patterns Knowing individual patient information

Knowing “typical” patient profiles Knowing unit routines and workflow

Goal Conflict Patterns/Trade-offs•Maintain patient safety•Prevent getting behind•Avoid increasing complexity•Appear competent and efficient to coworkers•Maintain patient/family satisfaction•Maintaining patient flow•Getting everything done

SITUATIONS

MindfulnessSensemaking

Ebright, Patterson, Chalko, Render, 2003

Is nursing mostly about patient flow?

To what extent does managing/prioritizing patient flow influence decision trade-offs?

Emergency Dept – out the door or upstairs

Operating Room – turning the room over

Medical Surgical units – getting patient ready for: tests, PT, RT, visitors, physician, others

Intensive Care Units - making another bed available for a critical patient

Primary Care Settings– getting patient in the room ready for the Primary Care Provder

Stacking

Workload management strategy for dealing with task complexities.

Represents list of multiple “to be done” tasks during actual workload situations and appropriate management of the stack

Stacking

“Failure-sensitive” strategies for preventing error and minimizing bad outcomes

Until recently, not a focus in schools of nursing

Significant discriminator of novice versus experienced nurse practice

Mindfulness

“Struggle for alertness” Ability to see the significance of early and weak

signals and to take strong decisive action to prevent harm

Trouble starts small and is signaled by weak symptoms that are easy to miss

Small discrepancies can cumulate, enlarge and have disproportionately large consequences

Weick KE, Suttcliffe KM. (2001). Managing the unexpected: Assuring high performance in an age of complexity. Jossey-Bass, San Francisco.

Sensemaking

Process of transforming experiences

into updated views of the system by

“taking the time to make sense out of

new and changing circumstances”

Stacking Study: Preliminary Analysis Discussions

What activities are stacked – categories:

• Drop everything

• Hang on until…then do

• Add to stack somewhere

• Triggered by event – when admission arrives

• Get to when you can

• Get done if I’m lucky

Expert and Novice Work During Complex Situations

Expert goals driving work:

First and foremost – patient focused

Novice goals driving work:

Meet patient needs

Do not get behind

Complete all work

Appear competentWilson, Ebright; 2004

Novice Nurse Near Miss and Adverse Event Situation Themes

1. Clinically-focused critical thinking2. Seeking assistance from experienced nurses3. Knowledge of unit and workflow patterns4. First time experiences5. Time constraints6. Hand-offs7. Influence of peer pressure and social norms8. Losing the BIG picture9. Novice assisting novice

Ebright, Urden, Patterson, Chalko; 2003

Nursing Work“and the invisible part…mindfulness and

sensemaking”

Gets IV bags, Checks orders in binder

13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00

Hangs IV

IV push Oral meds,topical cream

Checks updates in computer

Hangs IV

Planning for new shift

Checks orders in binder

Hangs IV

Hangs IV

Hangs IV

Oral meds

IV push

Oral meds

Insulin

Hangs IV

Pain med

Checks updates in computer

Topical cream

Other RN needs binder

Nursing home assessment

Narcotic keys

Staffing

IV pump alarm

Fingerstickmachinecalibration

Hand off assessment

IV pump alarm

Narcotic meds too many to put in cart

Narcotic keys

Other RN leaves floor

Signature for narcotics

Move patient to new bed

Water for patient

New nursing assistant arrives

MD asks to tape down IV

LPN she is covering

Children on floor

Patient risk of falling

Other RN returns

Hang IV for her

Pain med request

BP machine problems

Dinner

Patient moved up in bed

Water for patient

Fingerstick machine

IV pump alarm

Beds

Weighpatient

Staffing

Other RNdinner

Hang IV

IV pump alarm

Cart

Wife of patient

Emily Patterson PhD

Healthcare Environment Implications

Identification and reduction of system gaps that contribute to complexity

Planning for change –

-identification of new workflow process challenges

-education regarding how to manage implementation of new technology in real work

Managing Transitions for Novices

If it’s about decision trade-offs, how do we design IT for novices who come with few alternatives?

Situation awareness amidst competing goals (mindfulness ad sense making)

Skills and ability for managing the stack safely and efficiently

Alerts to available experts about novice work and DSS support for checking and balancing

Summary

Understanding complex transactions imbedded in RN work will require thorough analysis of the work through application of multiple methods of data collection including observation and interviews

Findings regarding the work of nursing suggest implications for IT solutions related to: design, content, accessibility, support of novice characteristics, and implementation and evaluation.