Complexity Complexity Compression: Nurses Compression: Nurses

under Fireunder Fire

A Collaborative Research A Collaborative Research Project:Project:

Minnesota Nurses Association and the Minnesota Nurses Association and the University of Minnesota School of NursingUniversity of Minnesota School of Nursing

Research TeamResearch Team

MNA:MNA: - Donna Bjork- Donna Bjork - Carol Diemert- Carol Diemert - Niki Gjere- Niki Gjere - Lynn Jacox- Lynn Jacox - Patty Koenig- Patty Koenig

School of NursingSchool of Nursing– Kathie KrichbaumKathie Krichbaum– Ann JonesAnn Jones– Christine MuellerChristine Mueller

The IssuesThe Issues

Nursing shortageNursing shortage Nurses’ work environmentsNurses’ work environments Sick, complex patientsSick, complex patients Patients’ family and cultural issuesPatients’ family and cultural issues Complex health care environment and Complex health care environment and

systemsystem

Underscored in the Underscored in the literatureliterature

Keeping Patients Safe: Transforming the work Keeping Patients Safe: Transforming the work environment of Nurses, environment of Nurses, IOM, 2004IOM, 2004

Understanding the Complexity of Registered Understanding the Complexity of Registered Nurses Work in Acute Care Settings, Nurses Work in Acute Care Settings, Ebright et Ebright et al, 2003,al, 2003, JONA, 33JONA, 33(12), 630-638(12), 630-638

Hassles: Their importance to nurses’ quality of Hassles: Their importance to nurses’ quality of work lifework life, , Beaudoin et al,Beaudoin et al, 2003, 2003, Nursing Nursing Economics, 21(3), 106-113.Economics, 21(3), 106-113.

The impact of operational failures on hospital The impact of operational failures on hospital nurses and their patients, nurses and their patients, Tucker, 2004, Tucker, 2004, Journal Journal of Operations Management, 22of Operations Management, 22, , 151-169151-169..

Literature Literature (Continued)(Continued) The Impact of Nursing Work Environments on Patient The Impact of Nursing Work Environments on Patient

Safety Outcomes: The Mediating Role of Safety Outcomes: The Mediating Role of Burnout/Engagement,Burnout/Engagement, Laschinger and Leiter, Laschinger and Leiter, JONA, , JONA, , 2006,36(5), 259-267.2006,36(5), 259-267.

Nurse Staffing and the Quality of Care in Hospitals,Nurse Staffing and the Quality of Care in Hospitals, Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky. Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky. N N Engl J Med, 2002, 346(22), 1715-1722.Engl J Med, 2002, 346(22), 1715-1722.

Hospital Nurse Staffing and Patient Mortality, Nurse Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,Burnout, and Job Dissatisfaction, Aiken, Clarke, Sloane, Aiken, Clarke, Sloane, Sochalski, Silber. Sochalski, Silber. JAMA, 2002, 288, 1987-1993.JAMA, 2002, 288, 1987-1993.

Understanding the cognitive work of nursing in the acute Understanding the cognitive work of nursing in the acute care environment,care environment, Potter, Wolf, Boxerman, Grayson, Potter, Wolf, Boxerman, Grayson, Sledge, and Dunagan, Sledge, and Dunagan, JONA, 2005, 35(7-8), 327-335.JONA, 2005, 35(7-8), 327-335.

Complexity CompressionComplexity Compression

The phenomenon that nurses The phenomenon that nurses experience when expected to assume experience when expected to assume additional, unplanned (unexpected) additional, unplanned (unexpected) responsibilities while simultaneously responsibilities while simultaneously conducting their conducting their multiple responsibilities in a multiple responsibilities in a condensed time frame.condensed time frame.

The “tipping point” for nurses in the The “tipping point” for nurses in the practice environment.practice environment.

Research Collaboration Research Collaboration ProcessProcess

Identified and ‘named’ the problem (Complexity Identified and ‘named’ the problem (Complexity Compression)Compression)

Sought validation – “does it ring true?”Sought validation – “does it ring true?” Conducted 10 simultaneous focus groupsConducted 10 simultaneous focus groups

– Identified 147 factors contributing to Complexity Identified 147 factors contributing to Complexity CompressionCompression

– Majority (total number) of factors associated with the Majority (total number) of factors associated with the themes of practice (32%); systems and technology (30%)themes of practice (32%); systems and technology (30%)

Analyzed qualitative data and identified six factors and Analyzed qualitative data and identified six factors and associated sub-factorsassociated sub-factors

Survey to determine level of agreement with factors/sub-Survey to determine level of agreement with factors/sub-factors identifiedfactors identified

Survey to larger sample to further validateSurvey to larger sample to further validate Factor analysis based on results from larger sampleFactor analysis based on results from larger sample

Themes Contributing to Themes Contributing to Complexity CompressionComplexity Compression

Personal - Personal - Variables that affect the Variables that affect the individual nurseindividual nurse

Environmental - Environmental - Variables that affect Variables that affect the immediate work environmentthe immediate work environment

Practice - Practice - Variables that affect the ability Variables that affect the ability to care for patients; the work of nursingto care for patients; the work of nursing

Themes Contributing to Themes Contributing to Complexity Compression Complexity Compression (Continued)(Continued)

Administration and Management - Administration and Management - Variables Variables that affect how the work of nursing is supported by that affect how the work of nursing is supported by administrators and managersadministrators and managers

Systems - Systems - Variables that affect the mechanisms Variables that affect the mechanisms put in place by the organization to accomplish the put in place by the organization to accomplish the delivery of health care to peopledelivery of health care to people

Autonomy/Control - Autonomy/Control - Variables that affect the Variables that affect the ability of the nurse to make decisions about the ability of the nurse to make decisions about the care and resources needed for patientscare and resources needed for patients

Personal Variables Personal Variables

Physical and Physical and mental exhaustionmental exhaustion

Family/individual Family/individual issuesissues

Environmental VariablesEnvironmental Variables

PhysicalPhysical

PsychosocialPsychosocial

CulturalCultural

Practice VariablesPractice Variables DelegationDelegation Conflicting responsibilitiesConflicting responsibilities Floating/Cross Floating/Cross

Training/Unfamiliar Training/Unfamiliar tasks/needstasks/needs

TimeTime No safety netNo safety net Patient/family issuesPatient/family issues Culture-patients and staffCulture-patients and staff Mentoring/PreceptingMentoring/Precepting

Administration & Administration & Management VariablesManagement Variables

Lack of Lack of understanding of understanding of nursingnursing

Changes in upper Changes in upper managementmanagement

System VariablesSystem Variables

System failuresSystem failures Multi-changesMulti-changes Lack of safety netLack of safety net DocumentationDocumentation Regulatory/legalRegulatory/legal BudgetBudget StaffingStaffing TechnologyTechnology

No input into No input into decision makingdecision making

Input not valuedInput not valued

Autonomy/Control VariablesAutonomy/Control Variables

Initial QuestionnaireInitial Questionnaire

For each variable, to what extent do you For each variable, to what extent do you agree or disagree with variable as agree or disagree with variable as contributing to the phenomenon of contributing to the phenomenon of complexity compression? 1=strongly complexity compression? 1=strongly agree to 4=strongly disagreeagree to 4=strongly disagree

Within the last month, how often have you Within the last month, how often have you experienced the variable? 1=Rarely/never experienced the variable? 1=Rarely/never to 4=Almost always/Alwaysto 4=Almost always/Always

Validation of Survey Process Validation of Survey Process Sent to focus group participantsSent to focus group participants Stratified random sample of RNs employed in Stratified random sample of RNs employed in

Minnesota Minnesota – Mailed 1200; received 199 (16.5%)Mailed 1200; received 199 (16.5%)

Sample representative of MN nursesSample representative of MN nurses– 46 years46 years– 20 years as RN20 years as RN– Works 35 hrs/weekWorks 35 hrs/week– 44% Diploma or AD44% Diploma or AD– Works hospital inpatient and provides patient careWorks hospital inpatient and provides patient care

Validation Survey Process Validation Survey Process (Continued)(Continued)

Rating for each variableRating for each variable– Variable contributing to Complexity Variable contributing to Complexity

CompressionCompression Range: 3.04-3.55 (indicating good Range: 3.04-3.55 (indicating good

agreement/validation for variables)agreement/validation for variables)

– Frequency experiencing variableFrequency experiencing variable Range: 1.96-2.86 (moderate ratings Range: 1.96-2.86 (moderate ratings

indicating nurses experience complexity indicating nurses experience complexity compression, but not on a daily basis)compression, but not on a daily basis)

Variables contributing the most to Variables contributing the most to complexity compressioncomplexity compression

Inadequacy of the staffing system put in Inadequacy of the staffing system put in place by the organization place by the organization (system)(system)

Lack of understanding of nursing Lack of understanding of nursing (administration)(administration)

The difficulty of performing or The difficulty of performing or prioritizing multiple prioritizing multiple tasks/functions/roles within a specified tasks/functions/roles within a specified time frame time frame (practice)(practice)

Variables contributing the most to Variables contributing the most to complexity compressioncomplexity compression

New, excessive, or changing forms and New, excessive, or changing forms and documentation systems required by the documentation systems required by the organization organization (system)(system)

The dilemmas experienced by the nurse The dilemmas experienced by the nurse when there are competing demands of equal when there are competing demands of equal importance importance (practice)(practice)

Fatigue, tiredness, physical needs unmet Fatigue, tiredness, physical needs unmet (personal)(personal)

Process of Factor AnalysisProcess of Factor Analysis

Summarize all resultsSummarize all results Rank order frequency of experience Rank order frequency of experience

and importance of variableand importance of variable Select top ranked itemsSelect top ranked items Determine relationships between Determine relationships between

variablesvariables Obtain true list of variablesObtain true list of variables

Results of Factor AnalysisResults of Factor Analysis

23 variables ranked the highest23 variables ranked the highest

Correlations among items revealed 3 Correlations among items revealed 3

factors that make up “Complexity factors that make up “Complexity Compression”Compression”

~Direct Care items~Direct Care items

~System items~System items

~Personal items~Personal items

Factors now defined (1)Factors now defined (1) The work of nursing factorThe work of nursing factor:: this this

factor includes elements within the factor includes elements within the

workplace that occur unexpectedly and that workplace that occur unexpectedly and that

directlydirectly interfere with nurses’ ability to carry interfere with nurses’ ability to carry

out their work; (13 variables -cultural issues out their work; (13 variables -cultural issues

(patient and organizational) delegation, (patient and organizational) delegation,

mentoring/precepting, floating/cross-mentoring/precepting, floating/cross-

training, conflicting responsibilities, training, conflicting responsibilities,

patient/family issues, time, system failure, patient/family issues, time, system failure,

psychosocial, lack of backup, no safety net, psychosocial, lack of backup, no safety net,

physical space)physical space)

The systems factor: This factor includes those unforeseen elements in the workplace that originate in the organization’s structure and administration and that affect the ability of nurses to carry out their responsibilities within the time allotted. ( 8 Variables – documentation, changes in upper management, lack of understanding of nursing, budget, no input into decision-making, regulatory/legal, technology, staffing)

Factors now defined (2)Factors now defined (2)

The personal factor: This factor comes from within the individual nurse and/or her immediate personal situation and contains unexpected occurrences that interfere with her/his ability to carry out work related responsibilities in the allotted time. (2 Variables -physical/mental exhaustion, family/individual issues)

Factors now defined (3)Factors now defined (3)

DiscussionDiscussion

Language issues - eg What is your “last Language issues - eg What is your “last straw”, your “tipping point”, what puts you straw”, your “tipping point”, what puts you “over the edge”?“over the edge”?

Are these really “unplanned” events?Are these really “unplanned” events? Is there a “pattern” to these events?Is there a “pattern” to these events? How does the issue of “knowledge” or How does the issue of “knowledge” or

“cognitive” work of nurses relate?“cognitive” work of nurses relate? Are there ways to address these factors Are there ways to address these factors

and to reduce complexity compression?and to reduce complexity compression?

Next StepsNext Steps Survey available on website Survey available on website

www.mnnurses.orgwww.mnnurses.org

cdiemert@mnnurses.org cdiemert@mnnurses.org

krich001@umn.edukrich001@umn.edu

Publication accepted Publication accepted NursingNursing ForumForum (Spring, 2007)(Spring, 2007)

National and international sub-sampleNational and international sub-sample

Next Steps Next Steps (Continued)(Continued)

Larger descriptive study of Larger descriptive study of phenomenon of phenomenon of complexitycomplexity compressioncompression in nursing organizations in nursing organizations

Partnering with Nursing OrganizationsPartnering with Nursing Organizations

– use as a diagnostic tool at the unit level and/or use as a diagnostic tool at the unit level and/or organizational levelorganizational level

– work with groups of nurses to tailor strategies work with groups of nurses to tailor strategies addressing the phenomenon to a particular addressing the phenomenon to a particular unit/facilityunit/facility