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RN Stacking Plexus Nursing and Complexity Call Pat Ebright 10-07-08.

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Presentation on theme: "RN Stacking Plexus Nursing and Complexity Call Pat Ebright 10-07-08."— Presentation transcript:

1 RN Stacking Plexus Nursing and Complexity Call Pat Ebright

2 Major barrier to making progress in safety and quality: failure to appreciate the complexity of work

3 Work Complexity Patterns Missing equipment or supplies Interruptions Waiting on systems/processes Inconsistencies in care communication Lack of time Early learning curve for new processes/lack of fit with other work Care Management Strategy Patterns Stacking (Mindfulness and Sensemaking) Anticipating or forward thinking Proactively monitoring patient status Strategic delegation and hand-off decisions Memory aid Work-arounds Coordinating Knowledge, Mindset, and Goals Knowledge Patterns Knowing individual patient information Knowing “typical” patient profiles Knowing unit routines and workflow Goal Conflict Patterns/Trade-offs Maintain patient safety Prevent getting behind Avoid increasing complexity Appear competent and efficient to coworkers Maintain patient/family satisfaction Maintaining patient flow Getting everything done Managing patient flow SITUATIONS Mindset Ebright, Patterson, Chalko, Render, 2003

4 Stacking Workload management strategy for dealing with task complexities. Represents list of multiple “to be done” tasks during actual workload situations and appropriate management of the stack

5 Stacking “Failure-sensitive” strategies for preventing error and minimizing bad outcomes Has not been the focus of teaching in schools of nursing Significant discriminator of novice versus experienced nurse practice

6 Mindfulness “Struggle for alertness” Ability to see the significance of early and weak signals and to take strong decisive action to prevent harm Trouble starts small and is signaled by weak symptoms that are easy to miss Small discrepancies can cumulate, enlarge and have disproportionately large consequences Weick KE, Suttcliffe KM. (2001). Managing the unexpected: Assuring high performance in an age of complexity. Jossey-Bass, San Francisco.

7 Sensemaking Process of transforming experiences into updated views of the system by “taking the time to make sense out of new and changing circumstances”

8 Stacking Study: Preliminary Analysis Discussions What activities are stacked – categories: –Drop everything –Hang on until…then do –Add to stack somewhere –Triggered by event – when admission arrives –Get to when you can –Get done if I’m lucky

9 Stacking Study: Preliminary Analysis Discussions What factors contribute to stacking strategies? –Novice RN - routine, linear list –Experienced RN - redefining the stack – adding to, re-organizing, shedding –Short versus long term goals (patient ed versus patient flow)

10 Stacking Study: Preliminary Analysis Discussions What factors contribute to stacking strategies? –Psycho-Social influences versus quality of patient care (pushing back) –Managing stress and situation awareness (influence of stress on memory, sensemaking) –Gaps filling – novice versus experienced RN differences

11 Stacking Study: Preliminary Analysis Discussions What strategies are used to manage the stack? Movement from reactive to proactive as experience increases: –Proactive reduction of stack through preparation “seeing the day”, avoiding cascades Collaboration and building relationships –Containing the role of patients/families to reduce requests/interruptions

12 Stacking Stacking is an RN cognitive process involving decision-making about workflow priorities Is a dynamic process and dependent on the ability of the nurse to be mindful and engage in accurate sense-making in the midst of unpredictable and constantly changing situations

13 Nursing Work “and the invisible part…mindfulness and sensemaking” Gets IV bags, Checks orders in binder 13:0014:0015:0016:0017:0018:0019:0020:00 Hangs IV IV push Oral meds, topical cream Checks updates in computer Hangs IV Planning for new shift Checks orders in binder Hangs IV Oral meds IV push Oral meds Insulin Hangs IV Pain med Checks updates in computer Topical cream Other RN needs binder Nursing home assessment Narcotic keys Staffing IV pump alarm Fingerstick machine calibration Hand off assessment IV pump alarm Narcotic meds too many to put in cart Narcotic keys Other RN leaves floor Signature for narcotics Move patient to new bed Water for patient New nursing assistant arrives MD asks to tape down IV LPN she is covering Children on floor Patient risk of falling Other RN returns Hang IV for her Pain med request BP machine problems Dinner Patient moved up in bed Water for patient Fingerstick machine IV pump alarm Beds Weigh patient Staffing Other RN dinner Hang IV IV pump alarm Cart Wife of patient Emily Patterson PhD VA-Getting At Patient Safety (GAPS) Center


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