Complexity Compression: Nurses under Fire

1. Complexity Compression: Nurses under Fire A Collaborative Research Project: Minnesota Nurses Association and the University of Minnesota School of Nursing

2. MNA: - Donna Bjork - Carol Diemert - Niki Gjere - Lynn Jacox - Patty Koenig School of Nursing Kathie Krichbaum Ann Jones Christine Mueller Research Team

3. The Issues • Nursing shortage • Nurses’ work environments • Sick, complex patients • Patients’ family and cultural issues • Complex health care environment and system

4. Underscored in the literature • Keeping Patients Safe: Transforming the work environment of Nurses, IOM, 2004 • Understanding the Complexity of Registered Nurses Work in Acute Care Settings, Ebright et al, 2003,JONA, 33(12), 630-638 • Hassles: Their importance to nurses’ quality of work life, Beaudoin et al,2003, Nursing Economics, 21(3), 106-113. • The impact of operational failures on hospital nurses and their patients, Tucker, 2004, Journal of Operations Management, 22, 151-169.

5. Literature (Continued) • The Impact of Nursing Work Environments on Patient Safety Outcomes: The Mediating Role of Burnout/Engagement, Laschinger and Leiter, JONA, , 2006,36(5), 259-267. • Nurse Staffing and the Quality of Care in Hospitals, Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky. N Engl J Med, 2002, 346(22), 1715-1722. • Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction, Aiken, Clarke, Sloane, Sochalski, Silber. JAMA, 2002, 288, 1987-1993. • Understanding the cognitive work of nursing in the acute care environment, Potter, Wolf, Boxerman, Grayson, Sledge, and Dunagan, JONA, 2005, 35(7-8), 327-335.

6. Complexity Compression • The phenomenon that nurses experience when expected to assume additional, unplanned (unexpected) responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame. • The “tipping point” for nurses in the practice environment.

7. Research Collaboration Process • Identified and ‘named’ the problem (Complexity Compression) • Sought validation – “does it ring true?” • Conducted 10 simultaneous focus groups • Identified 147 factors contributing to Complexity Compression • Majority (total number) of factors associated with the themes of practice (32%); systems and technology (30%) • Analyzed qualitative data and identified six factors and associated sub-factors • Survey to determine level of agreement with factors/sub-factors identified • Survey to larger sample to further validate • Factor analysis based on results from larger sample

8. Themes Contributing to Complexity Compression • Personal - Variables that affect the individual nurse • Environmental - Variables that affect the immediate work environment • Practice - Variables that affect the ability to care for patients; the work of nursing

9. Themes Contributing to Complexity Compression (Continued) • Administration and Management - Variables that affect how the work of nursing is supported by administrators and managers • Systems - Variables that affect the mechanisms put in place by the organization to accomplish the delivery of health care to people • Autonomy/Control - Variables that affect the ability of the nurse to make decisions about the care and resources needed for patients

10. Personal Variables • Physical and mental exhaustion • Family/individual issues

11. Environmental Variables • Physical • Psychosocial • Cultural

12. Practice Variables • Delegation • Conflicting responsibilities • Floating/Cross Training/Unfamiliar tasks/needs • Time • No safety net • Patient/family issues • Culture-patients and staff • Mentoring/Precepting

13. Administration & Management Variables • Lack of understanding of nursing • Changes in upper management

14. System Variables • System failures • Multi-changes • Lack of safety net • Documentation • Regulatory/legal • Budget • Staffing • Technology

15. Autonomy/Control Variables • No input into decision making • Input not valued

16. Initial Questionnaire • For each variable, to what extent do you agree or disagree with variable as contributing to the phenomenon of complexity compression? 1=strongly agree to 4=strongly disagree • Within the last month, how often have you experienced the variable? 1=Rarely/never to 4=Almost always/Always

17. Validation of Survey Process • Sent to focus group participants • Stratified random sample of RNs employed in Minnesota • Mailed 1200; received 199 (16.5%) • Sample representative of MN nurses • 46 years • 20 years as RN • Works 35 hrs/week • 44% Diploma or AD • Works hospital inpatient and provides patient care

18. Validation Survey Process (Continued) • Rating for each variable • Variable contributing to Complexity Compression • Range: 3.04-3.55 (indicating good agreement/validation for variables) • Frequency experiencing variable • Range: 1.96-2.86 (moderate ratings indicating nurses experience complexity compression, but not on a daily basis)

19. Inadequacy of the staffing system put in place by the organization (system) Lack of understanding of nursing (administration) The difficulty of performing or prioritizing multiple tasks/functions/roles within a specified time frame (practice) Variables contributing the most to complexity compression

20. New, excessive, or changing forms and documentation systems required by the organization (system) The dilemmas experienced by the nurse when there are competing demands of equal importance (practice) Fatigue, tiredness, physical needs unmet (personal) Variables contributing the most to complexity compression

21. Process of Factor Analysis • Summarize all results • Rank order frequency of experience and importance of variable • Select top ranked items • Determine relationships between variables • Obtain true list of variables

22. Results of Factor Analysis • 23 variables ranked the highest • Correlations among items revealed 3 factors that make up “Complexity Compression” ~Direct Care items ~System items ~Personal items

23. Factors now defined (1) The work of nursing factor: this factor includes elements within the workplace that occur unexpectedly and that directly interfere with nurses’ ability to carry out their work; (13 variables -cultural issues (patient and organizational) delegation, mentoring/precepting, floating/cross-training, conflicting responsibilities, patient/family issues, time, system failure, psychosocial, lack of backup, no safety net, physical space)

24. Factors now defined (2) 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)

25. Factors now defined (3) 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)

26. Discussion • Language issues - eg What is your “last straw”, your “tipping point”, what puts you “over the edge”? • Are these really “unplanned” events? • Is there a “pattern” to these events? • How does the issue of “knowledge” or “cognitive” work of nurses relate? • Are there ways to address these factors and to reduce complexity compression?

27. Next Steps • Survey available on website www.mnnurses.org cdiemert@mnnurses.org krich001@umn.edu • Publication accepted NursingForum (Spring, 2007) • National and international sub-sample

28. Next Steps (Continued) • Larger descriptive study of phenomenon of complexitycompression in nursing organizations • Partnering with Nursing Organizations • use as a diagnostic tool at the unit level and/or organizational level • work with groups of nurses to tailor strategies addressing the phenomenon to a particular unit/facility