Investigating stacking: How do registered nurses prioritize their activities in real-time?

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Abstract

Recent nursing graduates often find it challenging to prioritize competing tasks in the increasingly complex hospital environment. In order to develop a normative framework for task prioritization, Registered Nurses from a variety of settings were interviewed about how they prioritized their activities in the workplace. From 30 interviews, 422 prioritization decisions were coded when study participants were confronted with two tasks that could not be done simultaneously. The findings suggest a seven-level prioritization hierarchy of nursing activities: 1) addressing imminent clinical concerns, 2) high uncertainty activities, 3) significant, core clinical caregiving and managing pain, 4) relationship management, 5) documenting, helping others, and patient support, 6) system improvement and cleaning/preparing supplies, and 7) personal breaks and social interactions. Explicitly providing a normative framework for task prioritization during nursing education may help to accelerate learning this skill. For more experienced nurses, we believe that flexibility to deviate from this framework will be important for providing high-quality, personalized care that best matches the particular context.

Relevancy to industry

Nursing personnel comprises a significant portion of the human capital and operating budget for hospitals. Knowledge of what tasks are likely to be shed under severe workload conditions aids with optimizing hiring and allocation of nursing personnel.

Highlights

►Recent nursing graduates are provided little guidance on how to prioritize competing demands in their complex work setting. ►Experienced nurses across diverse care settings prioritize tasks in a similar fashion. ►Addressing imminent clinical concerns and performing tasks with high uncertainty are usually prioritized higher than standard core work activities. ►Personal breaks and social interactions are usually prioritized lower than other tasks.

Introduction

Many wonder whether recent graduates from nursing programs are fully prepared to safely and effectively prioritize multiple threads of activity in a hospital setting. The hospital environment is characterized by time pressure, uncertain information, conflicting goals, high stakes, stress, and dynamic conditions (Ebright et al., 2003, Ebright et al., 2004, Potter et al., 2004, Wiggins, 2008). As patient acuity increases and new tools like electronic health records and bar code medication administration are implemented, it will become even more complex to manage multiple threads of work simultaneously. Traditionally, planning has not been classified as a core nursing task, as evidenced by the paucity of discussion of planning by 116 nurses during interviews where they described their problem solving behaviors at the bedside (Hurst et al., 1991). Therefore, there is little guidance in existing nursing curricula about how to prioritize activities in nursing work, particularly with respect to what tasks can be delayed or dropped, and it is unclear how well the guidance that is available would relate to what is done by experienced nurses in actual settings. Therefore, in this paper, we propose a normative framework for task prioritization based on empirical data of how nurses prioritized one task over another at the bedside.

Although planning has not traditionally been classified as a core nursing task, there is a long history of nursing research on how complexity from managing multiple threads of work simultaneously impacts cognitive performance. For example, there have been studies on how multiple threads of activity complicate information processing (Grier, 1984), clinical judgment (Tanner, 1982), problem solving (McCarthy, 1981), and decision making (Jenkins, 1985). In addition, studies have looked at the effect of training (Sparks, 1982) and experience (Tanner et al., 1987) on cognition.

In prior research, the concept of stacking was investigated to better understand how registered nurses across a wide variety of hospital settings prioritized and planned their activities, as well as made real-time adjustments as unexpected events unfolded (Ebright et al., 2003). The stacking phenomenon had emerged from an exploratory observational and interview study of contributions to work complexity for registered nurses. In interviews, nurses naturally resonated to the analogy of starting, organizing, queuing, and restarting activities from a stack. The stack is somewhat like a “to do” list of action items where multiple items are happening in parallel and some require actions on the part of others to be completed. An important distinction from a “to do” list in a self-paced, low-consequence office environment is that the nurses were highly sensitive to patient safety risks, incorporating the skillful application of failure-sensitive strategies to proactively forestall potential paths to adverse patient outcomes.

Stacking is conceptualized as a strategy for improving re-planning in a macrocognitive work system. Re-planning is defined as adaptively responding to changes in objectives, from any of a variety of sources including supervisors and peers, obstacles, opportunities, events, or changes in predicted future trajectories (Patterson et al., 2010). A macrocognitive work system is defined as a system in which people use advanced technology to collaborate for the purpose of conducting work (Klein et al., 2003). Re-planning is one of five macrocognition functions, which inter-relate: detecting problems, sensemaking, re-planning, deciding, and coordinating. Macrocognition is defined as the adaptation of cognition to complexity (Klein et al., 2003). In this study, we asked the question: How do nurses prioritize one activity over another when they cannot both be done simultaneously? Interviews were conducted with registered nurses to elicit factors that contributed to directly observed “activity A vs activity B” prioritization decisions in the workplace. Codes were iteratively generated using qualitative techniques during data analysis. The final analytic codes are described in detail in Section 2.4, Data Analysis. The normative framework derived from the analyses is reported and potential applications and limitations are discussed.

Section snippets

Study participants

Registered Nurses (RNs) were recruited using IRB-approved procedures for the study. The nurses worked in multiple healthcare settings in three facilities of one large Midwest urban healthcare organization. The participants represented a diverse set of clinical areas, including emergency care, intensive care, obstetric care, pre-operative care, operative care, post-operative care, post-anesthesia care, acute care, and outpatient care. Recruitment was targeted to include nurses in three

Results

Overall, 422 prioritization decisions were coded. The findings are displayed in Fig. 1. To support interpretation, links with fewer than eight supporting statements were removed, based on being a natural break point in the data. The arrow in the figure indicates that the first factor is considered a higher priority than the factor to which the arrow is pointing.

The relationships are provided as a hierarchy of priorities framework in Fig. 2, with the highest level at the top.

As displayed in

Discussion

From 30 interviews, 422 prioritization decisions were coded. The findings suggest a seven-level prioritization hierarchy of nursing activities: 1) addressing imminent clinical concerns, 2) high uncertainty activities, 3) significant, core clinical caregiving and managing pain, 4) relationship management, 5) documenting, helping others, and patient support, 6) system improvement and cleaning/preparing supplies, and 7) personal breaks/social interactions.

Our main contribution from this study is a

Conclusions

The study findings suggest a seven-level normative framework for prioritizing nursing activities. Explicitly providing a normative framework for task prioritization during nursing education is anticipated to be useful in teaching nurses how to prioritize multiple competing demands. For more experienced nurses, we believe that flexibility to deviate from this framework will be important for providing high-quality, personalized care that best matches the particular context.

Acknowledgments

We thank Paul Buelow, PhD, for coordination and management support.

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