Plexus Nursing and Complexity Call Pat Ebright 10-07-08 RN Stacking Plexus Nursing and Complexity Call Pat Ebright 10-07-08

Major barrier to making progress in safety and quality: failure to appreciate the complexity of work

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 Managing patient flow Work Complexity Patterns Missing equipment or supplies Interruptions Waiting on systems/processes Inconsistencies in care communication Lack of time Early learning curve for new processes/lack of fit with other work Care Management Strategy Patterns Stacking (Mindfulness and Sensemaking) Anticipating or forward thinking Proactively monitoring patient status Strategic delegation and hand-off decisions Memory aid Work-arounds Mindset SITUATIONS Ebright, Patterson, Chalko, Render, 2003

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 Has not been the focus of teaching 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

Stacking Study: Preliminary Analysis Discussions What factors contribute to stacking strategies? Novice RN - routine, linear list Experienced RN - redefining the stack – adding to, re-organizing, shedding Short versus long term goals (patient ed versus patient flow)

Stacking Study: Preliminary Analysis Discussions What factors contribute to stacking strategies? Psycho-Social influences versus quality of patient care (pushing back) Managing stress and situation awareness (influence of stress on memory, sensemaking) Gaps filling – novice versus experienced RN differences

Stacking Study: Preliminary Analysis Discussions What strategies are used to manage the stack? Movement from reactive to proactive as experience increases: Proactive reduction of stack through preparation “seeing the day”, avoiding cascades Collaboration and building relationships Containing the role of patients/families to reduce requests/interruptions

Stacking Stacking is an RN cognitive process involving decision-making about workflow priorities Is a dynamic process and dependent on the ability of the nurse to be mindful and engage in accurate sense-making in the midst of unpredictable and constantly changing situations

“and the invisible part…mindfulness and sensemaking” Nursing Work “and the invisible part…mindfulness and sensemaking” Move patient to new bed Nursing home assessment LPN she is covering BP machine problems Signature for narcotics New nursing assistant arrives Patient moved up in bed Cart Patient risk of falling Staffing Hand off assessment Narcotic keys Hang IV for her Staffing Beds Hang IV Fingerstick machine Checks updates in computer Checks updates in computer Planning for new shift Gets IV bags, Checks orders in binder Oral meds Checks orders in binder IV push Oral meds, topical cream Oral meds Insulin Hangs IV Pain med Topical cream Hangs IV Hangs IV Hangs IV Hangs IV Hangs IV IV push We are beginning to document the complexity of work and to identify patterns and themes related to latent failures. 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 IV pump alarm Other RN leaves floor Other RN returns IV pump alarm Weigh patient IV pump alarm IV pump alarm Dinner Other RN needs binder Water for patient Children on floor Water for patient Other RN dinner Wife of patient Pain med request Fingerstick machine calibration Narcotic keys Narcotic meds too many to put in cart MD asks to tape down IV Emily Patterson PhD VA-Getting At Patient Safety (GAPS) Center