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Transcript of Understanding Real Work Complexity for Design and Implementation of IT Patricia Ebright, BSN, MSN,...
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.
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.