Operational failures and interruptions in hospital nursing

Health Services Research, June, 2006 by Anita L. Tucker, Steven J. Spear

A growing body of evidence suggests more nursing time per patient results in better patient outcomes (Aiken et al. 2002; Kovner et al. 2002; Needleman et al. 2002). Despite this recognition, increasing patient loads (Aiken, Clarke, and Sloane 2001) and a developing nursing shortage (Buerhaus, Staiger, and Auerbach 2000) make it difficult for nurses to spend as much time with their patients as they would like. To date, much of the discussion regarding nursing time per patient has focused on increasing nurse staffing levels (e.g., Wilson 2004). However, there has been less attention on ensuring that work systems provide supplies, medications, equipment, and information in a timely and accurate fashion. We propose that units lose valuable caregiver time owing to ineffective supply systems, and therefore productive time can be reclaimed by improving work systems. In addition, supply problems interrupt patient care, potentially increasing patient safety risks. We suspect that similar issues affect residents, aids, therapists, and other health care professionals. To explore these propositions, we examined nursing work environments with a particular focus on the systems supplying information, equipment, and materials necessary for patient care. Although specific to nurses, this study may interest other health care professionals who work under similar conditions.

We start by reviewing literature describing the content of nursing work. The 2004 Institute of Medicine report characterized the process for planning and managing nursing work as follows: assess patients, identify desired outcomes for these patients, plan and implement treatments to achieve these outcomes, and re-evaluate patients to ensure that the treatments achieved the intended outcomes. As acknowledged in the report, however, this linear description fails to capture complexities inherent in providing patient care. As a result, many newly graduated nurses find that the practice of nursing differs markedly from what they learned in school, and consequently many new nurses leave the profession (Kramer 1974; Godinez et al. 2001; Roberts, Jones, and Lynn 2004). In addition, nurses lament patients' lack of understanding about the nursing role (Ajiboye 2004). Patients often expect more direct care time from their nurses than is possible, resulting in patient dissatisfaction (Staniszewska and Ahmed 1998). This suggests that a more accurate description of nursing would be valuable for both nursing students as well as the public.

What makes nursing work complex? One source of complexity lies in the continuously changing conditions of patients for whom nurses care (Benner, Hooper-Kyriakidis, and Stannard 1999). As new information about their patients becomes evident, nurses must solve problems in realtime, often changing which problem they are solving, and where in the problem-solving process they are (Taylor 1997). This requires nurses to modify their planned sequence of care before they can complete a full cycle from initial assessment to posttreatment evaluation (Taylor 1997). Thus, the nature of patient care requires nurses to move among assessment, planning, implementation, and evaluation in a back-and-forth manner rather than sequentially progressing through the steps to completion.

A second source of complexity stems from the coordination role that nurses play, ensuring that their patients receive ordered services from other health care workers (e.g., blood tests, radiology tests, and physical therapy) (McCloskey et al. 1996). As an indication of the time nurses spend coordinating care--as opposed to providing patient care--studies find that the average nurse only spends between 31 and 44 percent of her time on direct patient care activities, but between 34 and 49 percent on coordination-related activities (Minyard, Wall, and Turner 1986; Hendrickson, Doddato, and Kovner 1990; Quist 1992; Lundgren and Segesten 2001). Consequently, as nurses conduct their work, they must be continually mindful of what other people are doing (Page 2004). This creates a tightly coupled system (Perrow 1984), increasing the cognitive load on nurses (Beaudoin and Edgar 2003). In summary, factors inherent to caring for patients, such as the need to respond to new information and the need to interact with the larger system of care, increase the complexity of nursing work.

In addition to these unavoidable sources of complexity, care is also complicated by avoidable factors unrelated to patients' conditions. Disruptions in the supply of materials or information have received recent attention. For example, when interviewed about productivity, nurses talked about the negative impact of poorly functioning supply systems (McNeese-Smith 1999; Beaudoin and Edgar 2003). Research shows that nurses frequently experience operational failures (Tucker 2004), which are also called hassles (Beaudoin and Edgar 2003) or glitches (Uhlig et al. 2002). These breakdowns interfere with work, reducing employee effectiveness by increasing the time required to complete tasks. One study of nursing work found that, on average, nurses spend 42 minutes of each 8-hour shift resolving operational failures such as missing medications and broken or missing equipment (Tucker 2004). Other studies estimate that nurses spend from 10 percent (Linden and English 1994) to 25 percent (Miller, Deets, and Miller 1997) of their time looking for other staff members. Operational failures can also cause interruptions, as shown in a study that examined interruptions encountered by one hospital nurse during a 10-hour period. This study found that the nurse was interrupted 43 times, including 10 instances when necessary materials, equipment, or personnel were unavailable (Potter et al. 2004).