Faculty Learning Module 2

Managing the Complexity of Nursing Work: Cognitive Stacking

Introduction

How do nurses manage the complexity of their work? How do students develop the skills needed to manage nursing work? This module extends the discussion in Module One and describes what we are learning about the cognitive work of RNs that fosters the safe delivery of care in complex healthcare environments. In this module, you will learn about stacking, a continuous process of organization and prioritization embedded in RN work that occurs as care situations evolve. Currently stacking is learned primarily after graduation from a pre-licensure program. How might nursing educators in pre-licensure programs create opportunities for students to learn about and engage in this process to assist students to more effectively manage the complexity of their work and promote safe, quality patient care?

Objectives

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

• Explain the cognitive work of RNs during actual care delivery

• Examine the concept of stacking and its importance in managing work complexity

• Explore teaching strategies that introduce students to stacking and provide beginning experiences in which students can engage in workflow management decision-making before graduation

Contributors

• Patricia Ebright, DNS, RN

• Pamela Ironside, PhD, RN, FAAN, ANEF

• Cynthia Dobbs. MSN

• Susan O’Reilly, MA

Reviewers

• Corinne A. Wheeler, PhD, RN

Content

Teaching students to practice in today’s healthcare system is challenging! Not only must they learn the content knowledge and skills required to provide care, they must also learn to manage the complexity of the clinical environment. Drawing on studies of how new and experienced nurses manage the complexity of their work, in this presentation Patricia Ebright describes the concept of stacking and how critical this process is to the preparation of new nurses to provision of safe, quality care.

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Resources

Video

Teaching students to practice in today’s healthcare system is challenging! Not only must they learn the content knowledge and skills required to provide care, they must also learn to manage the complexity of the clinical environment. Drawing on studies of how new and experienced nurses manage the complexity of their work, in this presentation Patricia Ebright describes the concept of stacking and how critical this process is to the preparation of new nurses to provision of safe, quality care.

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Bibliography

Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Allison-Wesley.

Cook, R.I. & Woods, D.D. (1994). Operating at the sharp end: Te complexity of human error. In M.E. Boger (Ed). Human error in medicine (pp. 255-310). Hillsdale, NJ: Lawrence Erlbaum.

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.

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

Lindberg, C., & Lindberg, C. (2008). Nurses take note: A primer on complexity science. In C. Lindberg, S. Nash, C. Lindberg (Eds.), On the Edge: Nursing in the Age of complexity. (pp. 23-47). Bordentown, NJ: PlexusPres.

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.

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

Weick, K. (1993).The Collapse of Sensemaking in Organizations: the Mann Gulch disaster. Administrative Science Quarterly, Vol. 38.

Weick, K. (2002). The reduction of medical errors through mindful interdependence, in Medical Error: What Do We Know? What Do We Do? (San Francisco: Jossey-Bass).

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.

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Discussion

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. How do we (or could we) help students examine the relationships between the content knowledge needed in a given clinical situation and the ways the context impacts its application?

2. How well are our students prepared to practice in uncertain and time-pressured situations? What is one thing we might do to better help them develop their abilities to deal with these strategic factors?

3. In what ways and how often do we expose our students to novel care situations that require recognition of the relationships among content knowledge, typical patient profiles and the specific demands of a clinical situation or an individual patient?

4. RNs include knowledge of the work environment routines, norms, and resource availability and competencies in combination with other knowledge content to inform their decision-making about clinical care. In what ways can we introduce this complexity to our students to begin the more complicated decision-making needed for actual care delivery in real settings?

5. How can we incorporate an attention to mindfulness into our teaching so this becomes embedded in each students’ approach to patient care?

6. Clearly we cannot possibly provide students with experience in every potential situation that might arise during clinical. But can we provide experiences that make them become more aware of the difficulty surrounding decision-making in light of conflicting goals, the need for trade-offs between competing goals, time pressures, and when/how to get assistance for making the best decisions possible?

7. How can we better teach students to think in terms of clustered time with patients rather than simply thinking about the completion of individual tasks?