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Faculty Learning Module 1

Appreciating the Complexity of Nursing Work: Implications for Nursing Education


In the past, it was common that we educators assumed that keeping students safe in practice meant assuring that each student had appropriate amounts of content knowledge and technical skills prior to any clinical experience. This assumption comes from the belief that there is a direct and corresponding relationship between a student’s acquisition of knowledge and its application in practice. We now have many studies that challenge these assumptions and beliefs, leading us to question: How do students learn to make decisions about what knowledge to apply when, for how long, and under what conditions? How does the context of students’ clinical experiences (including conflicts, obstacles, hazards, multiple data sources, and so forth) influence their abilities to think about, organize, and prioritize their care? How well are our students prepared to practice in rapidly evolving situations rife with distractions, incomplete information, time pressures, and stress? Appreciating the complexity of nursing work can guide the integration of QSEN competencies into nursing curricula by focusing our attention on the interaction among the systems at work in any clinical situation and how students learn to provide safe, quality nursing care.

This module will assist you to understand nursing work through exploring principles of complexity science and properties of complex adaptive systems. You will recognize the complexity factors characteristic of current healthcare environments and obtain a new appreciation for the competencies required of RNs, both new and experienced, in delivering safe and quality care in these settings.


Upon completion of this section, you will be able to:

  • Identify the characteristics of complex adaptive systems

  • Discuss the challenges of preparing students to practice in complex systems

  • Explore teaching strategies that prepare students to deliver safe, quality nursing care within complex adaptive systems

  • Patricia Ebright, DNS, CNS, RN

  • Pamela Ironside, PhD, RN, FAAN, ANEF

  • Susan O’Reilly, MA

  • Anne Martin, RN, MSN, ACNP, CNE

  • Corinne A. Wheeler, PhD, RN


So you might be asking yourself, “How do we know nursing work is complex?” How do complex work environments influence nursing practice and the quality and safety of nursing care? Instead of asking you to read about it, listen to Patricia Ebright, a nursing teacher-scholar who has spent her career investigating work complexity and the implications of this complexity for practice.

Appreciating the Complexity of Nursing Work, Part 1
Appreciating the Complexity of Nursing Work, Part 2
  • Fundamentals

  • Simulation

  • Related Links

  • Bibliography

  • Citations


Preparing students for the complexity of nursing work is critical to the provision of safe, quality care. Yet how well are our students currently prepared to practice in complex environments? What kinds of experiences can we create throughout our programs that provide students with experiences in thinking about work complexity and how this affects their practice? Redesigning Fundamentals in Nursing provides a strategy for assisting beginning students to explore and experience issues of work complexity during a beginning clinical course (this strategy is described for use in a long term care or rehabilitation setting, although it could be easily adapted to other settings). It is designed to show how familiar experiences in Fundamentals courses (providing personal care) can be enhanced to introduce students to the QSEN competencies and how the provision of personal care always occurs in complex environments.

Simulation Materials

Simulation is another useful strategy you can use to give your students experience navigating the complex work of nurses. In simulation, the characteristics of complex work environments can be built into the experience so that every student has the opportunity to practice providing care in complex situations without the risk of causing harm.

From 2007-2009 the National Council of State Boards of Nursing funded a study conducted by Ironside and Jeffries to determine if students’ patient safety competencies improved with experience in multiple-patient simulations. For a report of the findings from this study, see the 2009 Special Issue of Nursing Outlook1.

It is often the case that simulation experiences are designed to assist students to respond to crisis situations involving a single patient (manikin) by providing opportunities for them to detect physiological demise and intervening appropriately. This simulation experience was designed to mimic more average, everyday experiences in which a new nurse is assigned to care for 4 patients in a general care (step-down) unit. The simulation was designed to include common safety risks that occur in the complex care delivery situations in which nurses practice — distractions/interruptions, handoffs, and conflicting information about patients’ conditions.

Below are the resources you will need to conduct this simulation. You are welcome to use these materials as they are, or to adapt them as you see fit.


In this section, you can find a series of short presentations, including a description of this multiple-patient simulation experience, tips for setting up the simulation, ways you can rotate the patient alterations that occur during the experience, and how to orient students to this experience. In addition, the report you can use to begin the simulation is provided. This is downloadable to your computer or to a jump drive for transfer to the simulation area. It can be played with any media player.

  • Description of the Simulation (video)

  • Tips for Simulation Process (video)

  • Patient Alteration Descriptions (video)

  • Orientation of Students (video)

  • Report 1 (.mp3 file)

  • Report 2 (.mp3 file)


These files include the programming information for setting up the simulation experience on a Laerdal SimMan©.

Note: You will need to download these to your computer or thumb drive for transfer to your simulation area.

  • Mr. Henderson.sce

  • Henderson OK.sce

  • Irachi.sce

  • Irachi OK.sce

  • Ross.sce

  • Ross OK.sce

  • Shufflebotham.sce

  • Shufflebotham OK.sce

Sound Files

These files are for use if you don’t have a high-fidelity simulator. These can be downloaded to your computer or a thumb drive for use in the simulation. Simply place the media player under the manikins pillow or at the head of the bed.

Note: There is a substantial amount of blank space on each file so that the cough (for instance) occurs at precisely 7 minutes into the simulation. These recordings need to be restarted with each simulation as appropriate for the patients you have set up. You will not use every recording for every simulation.

  • Confused (.mp3 file)

  • Cough (.mp3 file)

  • Dizzy/PVCs (.mp3 file)

  • TIA (.mp3 file)


This file contains the forms you need for the simulation. As you prepare for the simulation, there are patient charts you can download and print. Place these on clipboards or binders to simulate how students typically review chart information. There are scripts for the student and faculty orientation to the simulation experience that will review in print many of the points you heard in the presentations above. There are guidelines for the debriefing that occurs after each simulation experience. There is an instrument you can use to document whether students demonstrated particular QSEN competencies during the simulation. All of these files are downloadable to your computer for printing.

  • Student Orientation to Multiple-patient Simulation (.docx)

  • Faculty Orientation to Multiple-patient Simulation (.doc)

  • Debriefing guidelines(.docx)

  • Instrument to measure safety competencies

Related Links

Gonzaga University in Spokane, Washington has used complex adaptive systems as the organizing framework for their entire nursing program. Visit the Gonzaga web site for more information.


Benner, P. (2000). The wisdom of our practice. American Journal of Nursing, 100, 99-105.

Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (1999). Clinical wisdom and interventions in critical care. Philadelphia, PA: Saunders.

Bittner, N.P. & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration, 39, 142-146.

Buerhaus, P.I., Needleman, J., Mattke, S., & Stewart, M. (2002). Strengthening hospital nursing. Health Affairs, 21, 123-132.

Cook, Render, & Woods. (2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal,3, 20, 791-794.

Ebright, P.R. (2004). Understanding nurse work. Clinical Nurse Specialist, 18, 168-170.

Ebright, P.R., Patterson, E.S., Chalko, B.A., & Render, M.L. (2003). Understanding the complexity of registered nurse work in acute care settings. Journal of Nursing Administration, 33, 630-638.

Ebright, P.S., Urden, L.S., Patterson, E.S., & Chalko, B.A. (2004). Themes surrounding novice nurse near-miss and adverse-event situations. Journal of Nursing Administration, 34, 531-538.

Frankel, R.M. (2009). Empathy research: A complex challenge. Patient Education and Counseling, 65, 1-2.

Ironside, P.M. (2001). Creating a research base for nursing education: An interpretive review of conventional, critical, feminist, postmodern, and phenomenologic pedagogies. Advances in Nursing Science, 23(3), 72-87.

Kalisch, B.J. (2006). Missed nursing care: a qualitative study. Journal of Nursing Care Quality, 21, 306–313.

Kalisch, B.J., Landstrom, G., & Williams, R.A. (2009). Missed nursing care: Errors of omission. Nursing Outlook, 57, 3-9.

Kirchbaum, K., Diemert, C., Jacox, l., Jones, A., et al. (2007). Complexity compression: Nurses under fire. Nursing Forum, 42, 86-94.

Klein, G. (1998). Sources of power: How people make decisions. Cambridge, MA: MIT Press.

Potter, P., Wolf, L., Boxerman, S., et al. (2005). Understanding the cognitive work of nursing in the acute care environment. Journal of Nursing Administration, 35, 327-335.

Rubin, J. (1996). Impediments to the development of clinical knowledge and ethical judgment in critical care nursing. In Benner, P.E., Tanner, C.A. & Chesla, C.A. Expertise in Nursing Practice: Caring, Clinical Judgment & Ethics, (pp. 170 -192). New York: Springer.

Smith, A.P., & Buerhaus, P.I. (2007). An interview with Peter I. Buerhaus, PhD, RN, FAAN: On hopes and threats for nursing’s future. Nursing Economics, 25, 183-185.

Spichiger, E., Wallhagen, M.I., & Benner, P. (2005). Nursing as a caring practice from a phenomenological perspective. Scandinavian Journal of Caring Science, 19, 303-309.

Tucker & Spear, (2006) Operational failures and interruptions in hospital nursing. Health Services Research. 41, 643–662.

Wiggins, M.S. (2008). The challenge of change. In C. Lindberg, S. Nash, C. Lindberg, C. On the Edge: Nursing in the Age of Complexity, (pp. 1-21). Bordentown, NJ: PlexusPress.

Woods, Johannesen, Cook, & Sarter (1994). Human Error: Cognitive Systems, Computers, and Hindsight. Crew Systems Ergonomic Information and Analysis Center, Wright Patterson Air Force Base, Dayton OH.


1 Ironside, P.M., Jeffries, P.R., & Martin, A. (2009). Fostering patient safety competencies with multiple patient simulation experiences. Nursing Outlook, 57, 332-337.

After you have reviewed the module presentations and resources, consider how this material is relevant to your own work and experience. The following is a list of questions for self-reflection or for use in class.

  1. Thinking of all the clinical courses in our curriculum, how and in what ways do students experience the complexity of nursing work? Are there experiences students currently have that could become richer or more reflective of current practice if viewed through the lens of complex adaptive systems?

  2. What are the barriers we face in preparing students to navigate the complexity of current healthcare environments?

  3. What’s one thing I could try in my class tomorrow that would help my students appreciate the complexity of nursing work and the threats this poses to the quality and safety of care?

  4. What strategies have you already tried in the courses you teach that help students appreciate the complexity of nursing work?


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