Academic journal article Online Journal of Issues in Nursing

The Complex Work of RNs: Implications for Healthy Work Environments

Academic journal article Online Journal of Issues in Nursing

The Complex Work of RNs: Implications for Healthy Work Environments

Article excerpt

Abstract

This article describes the complex work of registered nurses (RNs) in current healthcare settings and presents strategies for promoting healthy work environments in the midst of this complexity. First it addresses the complexity in delivering patient care by reviewing recent research on the work of nursing and explaining the concept of RN stacking. Then it considers four important activities for supporting RN decision making and establishing a healthy work environment, namely, "designing out" system barriers to care, designing and implementing appropriate technology, focusing on nursing direct care functions, and supporting the new RN.

Citation: Ebright, P., (Jan. 31, 2010) "The Complex Work of RNs: Implications for Healthy Work Environments" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol15No01Man04

Keywords: cognitive work of nursing, complex adaptive system, complexity science, complex work environments, mindfulness, patient care assignments, prioritizing, RN stacking, RN work complexity, situation awareness, stacking, trade-off decisions, workflow management

The complexity of nursing work has received increased attention since the Institute of Medicine (IOM) issued its report on medical errors in 2000. Healthcare providers and administrators are now focusing efforts on learning how industries other than healthcare deal with operation breakdowns and catastrophic failures related to errors, and how they increase the reliability of their processes to promote safety and quality (Weick & Sutcliffe, 2007). Research addressing the work of nursing has identified the marked complexity surrounding the delivery of care in our current healthcare environments, and has begun to understand why intended outcomes are often not achieved, even with excellent education programs and redesigned healthcare systems.

Understanding the complexity (difficulty) of delivering nursing care is essential for making changes that effectively promote the healthy work environments advocated by the American Association of Critical Care Nurses (AACN, 2005). This article presents new understandings about the complex cognitive work (organizing, prioritizing, and making decisions) of nursing. This cognitive work, called "stacking," has many implications for the development of healthy work environments. To achieve the intended outcomes of healthy work environments, namely quality care, safe patient outcomes, and nurse recruitment and retention, it is necessary to direct attention to the invisible, cognitive work of nurses, i.e., work that promotes suitable work flow and care delivery, and to factors that support or complicate this invisible work. Failure to understand how registered nurses (RNs) make decisions in the context of actual care delivery will lead to the design of processes, environments, and technologies that increase the complexity of RN cognitive work. This failure in turn will lead to increased RN stress and dissatisfaction, decreased RN retention, and ultimately unsafe care.

First, I will present the latest research findings describing the complexity of nursing decision making involved in the delivery of care. Next I will describe the implications of these research findings for promoting healthy work environments and the intended goals of quality care, safe patient outcomes, and nurse retention and recruitment. In conclusion I will address four important activities that will support the decision-making work of nurses, namely, (a) "designing out" system barriers to care, (b) designing and implementing technology, (c) focusing on the direct care function, and (d) supporting the new RN.

The Complexity in Delivering Care

This section will describe the complexity of delivering patient care. First it will present recent research on the work of nursing. Then it will discuss the concept and implications of a phenomenon called 'stacking. …

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