Operational failures and interruptions in hospital nursing

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

In addition to workload pressure, nurses had to complete time-specific procedures for patients, such as administering medications within certain time periods, monitoring vital signs during and after blood transfusions, and preparing patients for procedures (i.e., surgery).

Finally, in addition to the volume of work, nurses managed a wide breadth of responsibilities. Nurses performed, on average, 84 different types of activities. Examples included examining patients, checking medication administration records to determine what medications were due, administering medication and other therapies, removing patient-controlled analgesia pumps, reviewing laboratory results, communicating patient-related information to doctors, educating patients and families, and writing discharge documentation. In addition, nursing work involved cognitive components, such as administering medications that were contingent upon the patient's laboratory test results or vital signs. Table 1 displays details from each observation.

Partitioning, Interweaving, and Reprioritizing Care

We observed that nurses used at least three tactics for managing their time-sensitive, high volume workloads. First, nurses partitioned care for each patient through the shift, rather than performing all tasks for one patient at one time. This tactic stemmed primarily from medical necessity, such as the need to administer medications or to assess vital signs at regular intervals. Second, because most nurses were responsible for multiple patients, nurses had to switch back and forth between different patients' care. We define "interweaving" as providing care for multiple patients in a cyclical fashion, where the caregiver repeatedly switches among patients, as opposed to providing care in a sequential, nonoverlapping manner. To illustrate interweaving, one nurse, Kendra Brown, switched among her five patients 74 times during her 8-hour shift. The longest uninterrupted time spent on behalf of one patient, an elderly woman scheduled to have her remaining leg amputated that day, was 28 minutes.

Third, we noticed that the nurses' had to continually adapt their work plans. They could not definitively sequence work at the shift's start, but instead had to constantly problem solve by adding, subtracting, and reordering tasks as patients' conditions changed and as new information emerged. We termed this problem solving activity "reprioritization." Newly admitted or discharged patients often caused reprioritization as nurses had to fit the new patient--or tasks associated with discharge--into their work load. It also occurred because of changes in existing patient's care plans. For example, Fiona Murphy, a medical/ surgical nurse at Hospital 3, was walking to her patient's room to administer a dose of furosemide, a diuretic, when she saw the patient's doctor in the hallway. Fiona deliberately started a conversation with the doctor to learn his latest thinking regarding the patient's plan of care. The doctor, concerned about the poor condition of the patient's kidneys, gave a verbal order to discontinue the furosemide. Afterwards, Nurse Murphy threw away the syringe containing the medication, commenting, "We just got lucky." We observed similar events at three other hospitals when doctors dynamically cancelled medication that nurses had already prepared and were about to administer.