Exploring performance obstacles of intensive care nurses
Introduction
Patient safety is a major problem in ICUs (Donchin et al., 1995, Rothschild et al., 2005, Pronovost et al., 2002). Patients in an ICU receive on average 178 activities per day, and 1% of these activities involve errors (Donchin et al., 1995). Twenty-nine percent of these errors have the potential to cause significant harm. The role of nurses in the quality and safety of ICU care has been clearly identified (Institute of Medicine, 2004, McSteen and Peden-McAlpine, 2006, Rogers et al., 2008); therefore, it is important to study their work in detail. Poor quality of working life (QWL), which may consist of job dissatisfaction and burnout (Carayon and Smith, 2000), and high workload are common problems experienced by ICU nurses (Malacrida et al., 1991, Oates and Oates, 1995). ICU practice is filled with high nursing workload situations (Crickmore, 1987, Malacrida et al., 1991, Oates and Oates, 1996). Nurses must continuously respond to the needs of patients and families, and routinely interact with the most intense emotional aspects of life.
The ICU work system may negatively affect nurses' work and consequently pose potential threats to the quality and safety of patient care (Dimick et al., 2001, Institute of Medicine, 2004, Carayon et al., 2006, Gurses et al., in press). For example, interruptions, overwork, fatigue, illegible physician writing, lack of information about the patient, and problems with equipment were reported to increase medication administration errors by nurses (Pape, 2001, Wakefield et al., 1998). Other predictors of medical errors include the number of hours worked by nurses (Rogers et al., 2004) and ineffective inter-provider communication (Donchin et al., 1995). The literature has also identified a number of work factors that can impact workload and QWL of ICU nurses (Malacrida et al., 1991, Oates and Oates, 1996, Carayon and Gurses, 2005), such as high patient mortality and morbidity (Anderson and Basteyns, 1981), communication problems with co-workers (Hay and Oken, 1972, Gurses and Xiao, 2006), high noise level (Topf and Dillon, 1988), low autonomy (Constable and Russell, 1986), lack of necessary equipment (Gilmer, 1981), and poorly designed information technology (Linden and English, 1994, Miller et al., 1997). Inadequate staffing is a cause of high nursing workload (Dimick et al., 2001). Due to inadequate staffing, nurses have reported spending considerable amount of time performing non-patient care activities such as housekeeping duties or delivering and retrieving food trays (Aiken et al., 2001).
Several studies have been conducted on working conditions and psychosocial work factors in the work environment of ICU nurses. However, these studies did not have much impact on improving ICU nurses' work (Institute of Medicine, 2004), most likely due to the lack of examination of the ICU work system in necessary detail to identify where to focus improvement and redesign efforts in ICUs. Although studies have investigated some of the challenges faced by nurses in their work environment such as communication problems and low staffing (Institute of Medicine, 2004, Aiken et al., 2002), to our knowledge, no previous study has systematically and comprehensively identified the factors in the work system of nurses, particularly ICU nurses, that may affect their performance, QWL and workload. We believe that a more micro-level approach to the ICU work system (Mohr and Batalden, 2002) that uses a systems viewpoint (macroergonomics) (Hendrick, 1991) is needed. A clinical microsystem has been defined as a “small organized group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients” (Mohr and Batalden, 2002, p. 48). The ICU work system can be conceptualized as a clinical microsystem that needs to be studied in-depth in order to identify the factors contributing to poor patient safety and nursing outcomes (Carayon et al., 2006).
The concept of performance obstacles (Peters and O'Connor, 1988) can be used to characterize and improve the ICU work system needed using the micro-level approach. We define performance obstacles as the work factors in the immediate work setting of ICU nurses that increase their workload beyond what is expected, and/or that negatively affect their QWL and/or their performance (quality and safety of care they provide). Very few studies have investigated performance obstacles in a healthcare setting (Tucker and Edmondson, 2003, Carayon et al., 2005). The purpose of this paper was to comprehensively identify, describe and quantify performance obstacles as perceived by ICU nurses. We investigated performance obstacles from a systems viewpoint (macroergonomics) using the work system model of the Balance Theory (Carayon and Smith, 2000, Smith and Carayon-Sainfort, 1989, Smith and Carayon, 2000). This model focuses on systems design, the elements of a work system, interactions among the elements and the impact of the design of the elements on processes and outcomes. Performance obstacles can arise from any element of the work system or interactions among the elements of the work system (Carayon et al., 2005).
Section snippets
Design
We conducted a qualitative interview study of ICU nurses. Individual, semi-structured interviews, together with the critical incident technique (CIT) (Flanagan, 1954), was used for two reasons. First, limited research has been conducted to identify the performance obstacles experienced by ICU nurses; therefore, an exploratory research approach was required to capture rich, detailed information on the performance obstacles as perceived by ICU nurses. Second, a thorough, in-depth understanding of
Results
This section presents findings from the qualitative study described in detail in Section 2. We also included some key findings from a quantitative study reported earlier (Gurses and Carayon, 2007) to provide complementary information to the qualitative study findings (Table 2). The quantitative study was completed as part of a larger research project on performance obstacles and its design was partially informed by this qualitative study. Seven main types of performance obstacles were
Discussion
ICU nurses experience a variety of performance obstacles in their work environment on a daily basis that can be grouped into seven main categories: obstacles related to physical work environment, family relations, supplies, equipment, information transfer and communication, help from others, and intra-hospital transport. The qualitative study helped us to describe obstacles in detail, which is crucial for redesign and improvement efforts. The quantitative study (Gurses and Carayon, 2007)
Conclusion
This study highlights the many design factors in the ICU work systems that create performance obstacles for nurses. The most frequent obstacles were related to the physical environment and family relations; however, every element of the work system can have performance obstacles. Human factors and ergonomics professionals and researchers should continue to examine the specific aspects of healthcare work systems in detail so that adequate interventions can be designed, implemented, and
Acknowledgments
This project was supported by a Health Services Research Dissertation Grant (# R36 HS14517-01) from the Agency for Healthcare Research and Quality. We are indebted to the participating ICU's nurses, their manager, and the ICU medical director for their willingness to cooperate in this research. We would like to thank Robert Kane, Kamisha Escoto, Ant Ozok and the two anonymous reviewers for their comments and feedback on the manuscript.
Ayse P. Gurses is an assistant professor in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine. She received a Ph.D. in Industrial and Systems Engineering at the University of Wisconsin-Madison in 2005. Her research interests include human factors engineering and patient safety, health information technology, computer-supported collaborative work, and quality management. Dr. Gurses's research has been funded by the Agency for
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Ayse P. Gurses is an assistant professor in the Department of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine. She received a Ph.D. in Industrial and Systems Engineering at the University of Wisconsin-Madison in 2005. Her research interests include human factors engineering and patient safety, health information technology, computer-supported collaborative work, and quality management. Dr. Gurses's research has been funded by the Agency for Healthcare Research and Quality, National Science Foundation, and Robert Wood Johnson Foundation.
Pascale Carayon is Procter & Gamble Bascom Professor in Total Quality in the Department of Industrial and Systems Engineering and the Director of the Center for Quality and Productivity Improvement at the University of Wisconsin-Madison. She received her Engineer diploma from the Ecole Centrale de Paris, France, in 1984 and her Ph.D. in Industrial Engineering from the University of Wisconsin-Madison in 1988. Her research areas include systems engineering, human factors and ergonomics, sociotechnical engineering and occupational health and safety. Dr. Carayon's current research is funded by the Agency for Healthcare Research and Quality, the National Science Foundation, the Robert Wood Johnson Foundation and various other foundations and businesses. She is a scientific editor for Applied Ergonomics. Dr. Carayon leads the Systems Engineering Initiative for Patient Safety (SEIPS) at the University of Wisconsin-Madison (http://www2.fpm.wisc.edu/seips/). She is the Secretary General of the International Ergonomics Association, and a Fellow of the Human Factors and Ergonomics Society.
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