Real-time assessment of nurse work environment and stress.

Martha Shively, Thomas Rutledge, Barbara A. Rose, Patricia Graham, Rebecca Long, Erin Stucky,Matthew B. Weinger, Timothy DresselhausMedical errors in inpatient settings pose animportant threat to safe patient care (Balas,Scott, & Rogers, 2004, 2006; Rogers, Hwang,Scott, Aiken, & Dinges, 2004). Nurses who di-rectly assess and monitor patients are integralto care delivery and therefore potential con-tributors to both committing and preventingerrors before they happen (Institute of Medi-cine, Committee on the Work Environment forNurses and Patient Safety, & Board on HealthCare Services, 2004, p. 29). The Institute ofMedicine recommends assessing nursing workenvironments to identify factors that may con-tribute to preventable errors and to guide thedevelopment and implementation of interven-tions to mitigate these errors.Several authors have reviewed the evidenceconcerning work environment factors influenc-ing patient safety in nursing practice. Jennings(2008) reviewed the research regarding stressand burnout in nurses and highlights the needfor research that links stress with patient out-comes and safety. In one human factorsresearch project, Sexton, Thomas, & Helmreich(2000) concluded that nurses underestimatedthe effect of stress on performance and likeli-hood of error. In an assessment of nurses in thepediatric intensive care unit (ICU) setting,Montgomery (2007) concluded that fatigue, ex-cessive workload, and the care environment canadversely affect performance of nurses and maycontribute to medical error. Carayon and col-leagues examined studies of patient safety andworkload in ICUs and concluded that nursingworkload impacts work stress and patient safety(Carayon, Alvarado, & Systems EngineeringInitiative for Patient Safety, 2007; Carayon& Gurses, 2005). Carayon and Gurses alsoconcluded that greater nursing workload is as-sociated with adverse patient outcomes.Methods for studying relationships betweensafety factors and patient outcomes amongnurses are still evolving. Whitman, Sereika, andDachille (2003) described the use of ecologicalmomentary assessment (EMA) methods to as-sess daily activities of registered nurses (RNs) inacute care settings. Hendrich, Chow, Skiercyn-ski, and Lu (2008) reported a time and motionstudy using personal digital assistants to exam-ine real-time work activity and physical workstress (energy expenditure) in medical-surgicalnurses. EMA involves repeated sampling ofsubjects’ current behaviors and experiences inreal time, in subjects’ natural environments.EMA aims to minimize recall bias, maximizeecological validity, and allow study of micro-processes that influence behavior in real-worldcontexts. EMA studies assess particular eventsin subjects’ lives or assess subjects at periodicintervals, often by random time sampling, us-ing technologies ranging from written diariesand telephones to electronic diaries and phys-iological sensors (Shiffman, Stone, & Hufford,2008). EMA has been shown to be reliable andfeasible in capturing multiple dimensions ofphysician work (Dresselhaus et al., 1998). Theuse of EMA provides real-time responses tostructured surveys and offers opportunity forexpanded assessments of multiple dimensionsof nursing work (e.g., clinical activities, work-load, sleep, fatigue, and stress) to furtherelucidate factors that may contribute to med-ical errors.The focus of this study was on real-time as-sessment of the work environment and stress inlight of the perceived importance of workloadand stress as factors influencing patient safetyand the need for greater understanding ofthese factors. Work environment safety factorsAbstract: Ecological momentary assessment methods were usedto examine real-time relationships between work environmentfactors and stress in a sample of 119 registered nurses (RNs) inacute and critical care settings of three hospitals. The RNs carriedhandheld computers for 1 week of work shifts and were randomlysurveyed within 90-min intervals to self-report work activity,perceived workload, and stress. Mixed effects linear regressionanalyses were completed to predict the stress score in thesample. The number of patients assigned significantly predictedstress; the greater the number of assigned patients, the higher thereported stress (po.01). Age, gender, adult versus pediatricfacility type, familiarity with patients, and proportion of directcare tasks were not significant predictors of stress. Furtherresearch is needed to link work environment factors and stresswith errors among nurses.