Graduate nurses experience stress transitioning from student to practicing professional nurse, moving from a familiar educational environment into the workforce, where expectations are to rapidly function as a competent nurse. This study identified the stresses and challenges experienced by cohorts of graduate nurses working in 6 acute care hospitals, during specific timed data periods, to better understand factors that may influence graduate nurse retention. Results report graduate nurses do not feel skilled, comfortable, and confident for as long as 1 year after being hired, highlighting the need for healthcare organizations to provide extended orientation and support programs to facilitate successful entry into practice.

The graduate nurse experience.

A growing body of evidence suggests more nursing time per patient results in better patient outcomes (Aiken et al. 2002; Kovner et al. 2002; Needleman et al. 2002). Despite this recognition, increasing patient loads (Aiken, Clarke, and Sloane 2001) and a developing nursing shortage (Buerhaus, Staiger, and Auerbach 2000) make it difficult for nurses to spend as much time with their patients as they would like. To date, much of the discussion regarding nursing time per patient has focused on increasing nurse staffing levels (e.g., Wilson 2004). However, there has been less attention on ensuring that work systems provide supplies, medications, equipment, and information in a timely and accurate fashion. We propose that units lose valuable caregiver time owing to ineffective supply systems, and therefore productive time can be reclaimed by improving work systems. In addition, supply problems interrupt patient care, potentially increasing patient safety risks. We suspect that similar issues affect residents, aids, therapists, and other health care professionals. To explore these propositions, we examined nursing work environments with a particular focus on the systems supplying information, equipment, and materials necessary for patient care. Although specific to nurses, this study may interest other health care professionals who work under similar conditions.

We start by reviewing literature describing the content of nursing work. The 2004 Institute of Medicine report characterized the process for planning and managing nursing work as follows: assess patients, identify desired outcomes for these patients, plan and implement treatments to achieve these outcomes, and re-evaluate patients to ensure that the treatments achieved the intended outcomes. As acknowledged in the report, however, this linear description fails to capture complexities inherent in providing patient care. As a result, many newly graduated nurses find that the practice of nursing differs markedly from what they learned in school, and consequently many new nurses leave the profession (Kramer 1974; Godinez et al. 2001; Roberts, Jones, and Lynn 2004). In addition, nurses lament patients' lack of understanding about the nursing role (Ajiboye 2004). Patients often expect more direct care time from their nurses than is possible, resulting in patient dissatisfaction (Staniszewska and Ahmed 1998). This suggests that a more accurate description of nursing would be valuable for both nursing students as well as the public.

What makes nursing work complex? One source of complexity lies in the continuously changing conditions of patients for whom nurses care (Benner, Hooper-Kyriakidis, and Stannard 1999). As new information about their patients becomes evident, nurses must solve problems in realtime, often changing which problem they are solving, and where in the problem-solving process they are (Taylor 1997). This requires nurses to modify their planned sequence of care before they can complete a full cycle from initial assessment to posttreatment evaluation (Taylor 1997). Thus, the nature of patient care requires nurses to move among assessment, planning, implementation, and evaluation in a back-and-forth manner rather than sequentially progressing through the steps to completion.

A second source of complexity stems from the coordination role that nurses play, ensuring that their patients receive ordered services from other health care workers (e.g., blood tests, radiology tests,and physical therapy) (McCloskey et al. 1996). As an indication of the time nurses spend coordinating care—as opposed to providing patient care—studies find that the average nurse only spends between 31 and 44 percent of her time on direct patient care activities, but between 34 and 49 percent on coordination-related activities (Minyard, Wall, and Turner 1986; Hendrickson, Doddato, and Kovner 1990; Quist 1992; Lundgren and Segesten 2001). Consequently, as nurses conduct their work, they must be continually mindful of what other people are doing (Page 2004). This creates a tightly coupled system (Perrow 1984), increasing the cognitive load on nurses (Beaudoin and Edgar 2003). In summary, factors inherent to caring for patients, such as the need to respond to new information and the need to interact with the larger system of care, increase the complexity of nursing work.

In addition to these unavoidable sources of complexity, care is also complicated by avoidable factors unrelated to patients' conditions. Disruptions in the supply of materials or information have received recent attention. For example, when interviewed about productivity, nurses talked about the negative impact of poorly functioning supply systems (McNeese-Smith 1999; Beaudoin and Edgar 2003). Research shows that nurses frequently experience operational failures (Tucker 2004), which are also called hassles (Beaudoin and Edgar 2003) or glitches (Uhlig et al. 2002). These breakdowns interfere with work, reducing employee effectiveness by increasing the time required to complete tasks. One study of nursing work found that, on average, nurses spend 42 minutes of each 8-hour shift resolving operational failures such as missing medications and broken or missing equipment (Tucker 2004). Other studies estimate that nurses spend from 10 percent (Linden and English 1994) to 25 percent (Miller, Deets, and Miller 1997) of their time looking for other staff members. Operational failures can also cause interruptions, as shown in a study that examined interruptions encountered by one hospital nurse during a 10-hour period. This study found that the nurse was interrupted 43 times, including 10 instances when necessary materials, equipment, or personnel were unavailable (Potter et al. 2004).

For clarity, in this paper we call these workflow problems “operational failures,” defined as the inability of the work system to reliably provide information, services, and supplies when, where, and to whom needed (Tucker 2004). Examples of operational failures include the pharmacy inadvertently sending only half of the prescribed dose of a patient's medication, broken or missing equipment, and stocked-out supply items. Furthermore, several articles have illustrated the dire consequences for patients—including medication error, procedures carried out on the wrong patient, and hospital-acquired infection—when health care workers received incomplete or incorrect information, services, and items (Bates 2002; Chassin and Becher 2002; Gerberding 2002; Cleary 2003; Volpp and Grande 2003).

Given these sources of complexity, it is perhaps not surprising that health care organizations have been characterized as complex adaptive systems, where employees face high levels of uncertainty in their daily work (McDaniel and Driebe 2001). Organizational theorists suggest that under such conditions, resilient employees quickly implement positive adaptive behaviors that are matched to the immediate situation (Mallak 1998). Thus, the ability to flexibly respond to challenging situations, using materials at hand, can enable health care employees to function effectively (Weick 1993). Research suggests that experienced nurses are skilled at responding to changing patient conditions (Benner and Tanner 1987; Hansten and Washburn 2000), as well as compensating for operational failures (Tucker and Edmondson 2003).

In this paper, we propose that these two very different sources of complexity warrant different strategies for mitigating potentially negative effects. The first cause is inherent to medical work: new information about a patient becomes evident, triggering a change in caregiver work plans. The inevitability of changing patient conditions suggests that benefits can be gained by designing work to be robust to interruption. The second cause results from faulty work systems: a glitch or error occurs and the caregiver has to compensate for the operational failure. Interruptions due to work system failures are, at least theoretically, avoidable and therefore work systems can be improved to reduce future occurrences. Reducing the time nurses have to spend responding to faulty work systems will allow more time for patient care.

https://interruptions.net/literature/Tucker-HSR06.pdf

Operational Failures and Interruptions in Hospital Nursing

ObjectiveIn an effort to better understand turnover rates in hospitals and the effect of new nurses on them, this study sought to describe the characteristics and attitudes toward work of newly licensed RNs, a population important to both the nursing profession and the health care system.Met

Newly licensed RNs' characteristics, work attitudes, and intentions to work.

The role of simulation in nurse education.

A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse.

Population growth and aging increase the demand for skilled nurses. Hospitals face the challenge of supplying experienced and qualified caregivers. The cost of training new nurses remains significant. Nursing educators are pivotal in developing the nursing workforce, especially under tightening constraints. This article examines the development of a nursing internship program aimed at attracting and retaining newly graduated nurses and its effect on retention to the institution.

Charlotte Hebert

Papers

New graduate RN internship program: a collaborative approach for system-wide integration.