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

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

  Mindfulness

Sensemaking

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 competent

Wilson, Ebright; 2004

Novice Nurse Near Miss and Adverse Event Situation Themes

Clinically-focused critical thinking

Seeking assistance from experienced nurses

Knowledge of unit and workflow patterns

First time experiences

Time constraints

Hand-offs

Influence of peer pressure and social norms

Losing the BIG picture

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

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

We are beginning to document the complexity of work and to identify patterns and themes related to latent failures.

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.