1. Understanding Real Work Complexity for Design and Implementation of IT Patricia Ebright, BSN, MSN, DNS Associate Professor School of Nursing, Indiana University May 15, 2007

2. Presentation Outline A new framework for understanding complexity of nursing work Research findings about nursing work complexity Implications for IT design, implementation and evaluation

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

4. 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

5. Implications for IT Implementation to 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

6. Implications for IT Implementation to 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

7. 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.

8. Woods, Johannesen, Cook, Sarter, 1994

9. 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

10. 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

11. 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

12. 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 Mindfulness Sensemaking Ebright, Patterson, Chalko, Render, 2003

13. 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

14. 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

15. 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

16. 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.

17. Sensemaking Process of transforming experiences into updated views of the system by “taking the time to make sense out of new and changing circumstances”

18. 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

19. 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 competent Wilson, Ebright; 2004

20. Novice Nurse Near Miss and Adverse Event Situation Themes 1. Clinically-focused critical thinking 2. Seeking assistance from experienced nurses 3. Knowledge of unit and workflow patterns 4. First time experiences 5. Time constraints 6. Hand-offs 7. Influence of peer pressure and social norms 8. Losing the BIG picture 9. Novice assisting novice Ebright, Urden, Patterson, Chalko; 2003

21. Nursing Work “and the invisible part…mindfulness and sensemaking” Gets IV bags, Checks orders in binder 13:0014:0015:0016:0017:0018:0019:0020:00 Hangs IV IV push Oral meds, topical cream Checks updates in computer Hangs IV Planning for new shift Checks orders in binder Hangs IV 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 Fingerstick machine calibration 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 Weigh patient Staffing Other RN dinner Hang IV IV pump alarm Cart Wife of patient Emily Patterson PhD

22. 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

23. 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

24. 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.