Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life

Health Services Research, April, 2009 by Ayse P. Gurses, Pascale Carayon, Melanie Wall

A major challenge for intensive care units (ICUs) is improving quality and safety of nursing care. For example, a recent study found that there was one error for every five medication doses administered in a medical-surgical ICU. The medication administration stage was especially susceptible for errors (Kopp et al. 2006). Nurses play a substantial role in the care provided in ICUs (McSteen and Peden-McAlpine 2006; Rogers et al. 2008). Another related challenge for ICUs is to improve nursing quality of working life (QWL). QWL is nurses' reactions to the outcome of complex interactions between work system components described in seminal work by Smith and Carayon (Smith and Carayon-Sainfort 1989; Carayon and Smith 2000; Smith and Carayon 2000). Improving nursing QWL is critical because poor QWL leads to high nursing turnover (Hayes et al. 2006)--a significant problem for ICUs in the United States (Stone et al. 2007b).

Poor ICU work system design may negatively affect the quality and safety of nursing care as well as nursing QWL (Institute of Medicine 2004). In this paper, the term "ICU work system design" refers to the design of all ICU work system tasks, technologies, physical environment, and organization, as well as the interactions among them, which eventually affect care providers, processes, and outcomes (Carayon et al. 2006). Interruptions, overworking, illegible writing, ineffective communication, and equipment problems, among others, result from poor ICU work system design. Such hazards can increase nursing errors (Institute of Medicine 2004; Suresh et al. 2004; Baggs 2007; Stone et al. 2007a) and also negatively affect QWL (Gurses and Xiao 2006; Poncet et al. 2007; Schmalenberg and Kramer 2007).

Work system design characteristics may affect quality and safety of care and QWL through workload (Carayon, Alvarado, and Hundt 2007). We tested whether workload mediates the relationships between work system design characteristics and nursing QWL, as well as between work system design characteristics and nurses' perceived quality and safety of care. Literature supports that high nursing workload adversely affects quality and safety of care (e.g., Lang et al. 2004) and QWL (McVicar 2003). Furthermore, some work system design characteristics such as understaffing (Dimick et al. 2001) and inadequate collaboration among care providers (Spence et al. 2006) can increase ICU nursing workload.

The concept of performance obstacles can be used to study ICU work system design. Performance obstacles are "the work system design characteristics that inhibit performance and are closely associated with the immediate work setting" (Peters and O'Connor 1988). Performance obstacles can negatively impact employees' QWL (Peters and O'Connor 1980; O'Connor et al. 1982). However, conflicting results are reported on the impact of obstacles on performance, with some studies indicating a negative impact (O'Connor et al. 1984a; Steel and Mento 1986), and others indicating no impact (Pooyan et al. 1982; O'Connor et al. 1984b). It is plausible to claim that performance obstacles negatively affect quality and safety of care and QWL.

RESEARCH OBJECTIVE AND HYPOTHESES

The overall study objective was to investigate the relationships between performance obstacles, workload, perceived quality and safety of care, and QWL among ICU nurses. More specifically, we aimed at (1) identifying performance obstacles that affect nursing workload, perceived quality and safety of care, and QWL in ICUs, and (2) understanding the role of workload as a mediator in the relationships between performance obstacles and perceived quality and safety of care as well as between performance obstacles and QWL. A conceptual model (Figure 1) was developed and empirically tested.

The model includes four constructs: performance obstacles, workload, QWL, and perceived quality and safety of care. Workload is nurses' subjective experiences reflecting the combined effects of both task demands while performing direct and indirect care activities and demands imposed on them by the obstacles in the work system (Carayon and Gurses 2005). The multidimensional workload concept covers issues of the amount of work and the physical, mental, emotional, and temporal demands of the work (Carayon and Alvarado 2007; Carayon and Gurses 2008). In this study, we focused on quantitative workload attributed to time pressure. QWL corresponds to nurses' stress, fatigue, and job satisfaction. Perceived quality and safety of care is nurses' perception regarding both performance and satisfaction with the quality and safety of the care they provide. The conceptual model asserts that performance obstacles affect perceived quality and safety of care as well as QWL through workload. In other words, performance obstacles increase nurses' workload, which, in turn, can negatively affect their QWL and perceived quality and safety of care.

[FIGURE 1 OMITTED]

The conceptual model was based on job design and occupational stress theories (Herzberg 1966; Smith 1987), specifically the Balance Theory (Smith and Carayon-Sainfort 1989; Carayon and Smith 2000; Smith and Carayon 2000). The Balance Theory can guide efforts in assessing and designing work systems that produce the right level of workload, high quality and safety of care, and QWL from a systems perspective (Carayon et al. 2006). According to this theory, a work system such as an ICU can be characterized by five components: task, organization, environment, technology, and individual. These five interact with and influence one another. Flaws in the design of these components and interactions are the underlying sources of performance obstacles (Carayon et al. 2005). If performance obstacles can be identified, it may be possible to redesign the work system and processes to eliminate or "balance out" their impact.