LR17 / Acute care and workload of Registered Nurses (CRM)

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Assessment of risk and harm
Patient safety theme the SCP/clinical risk management practice is aimed at
The CRMP practice focus on work complexity and workload in acute care settings as affecting patient safety
Objective of the CRM practice
One study was designed to identify and describe work complexity for RNs in acute care units and its relationship to cognitive factors and performance behaviors of RNs during actual work situations. It addressed 3 areas: human and environmental issues affecting RN work in acute care settings during actual work situations; specific cognitive factors driving RN performance and decision making during actual care situations, and strategies used by experienced RNs to manage work successfully [p.631, 1].

Other study aimed to establish perceptions that registered nurses have regarding their roles performed in current day inpatient care. More precisely, it observe the range of activities that registered nurses engage in, determine the perceptions of registered nurses regarding their roles, compare the observed range of actual activities with the perceptions of registered nurses’ roles [p.135, 6].

Short description of the CRM practice, including any references for further information
One study used a human performance framework “Sharp End and Blunt End” which clarified patterns of work complexity that threaten continuity in patient care, having the potential to contribute to medical errors, and decreasing RN work satisfaction [p.637, 1].

In a study carried out in an acute care inpatient unit at a large mental health was showed that related to patient safety and risk management, the themes of ‘safety’ in the nonparticipant observations and ‘risk management’ in the focus groups were virtually interchangeable. The focus groups emphasized the defensive practice aspects of risk management. From the observations, activities related to patient safety included carrying out routine 15-min checks on all patients, searching for missing patients, carrying out constant observation on some patients, and ensuring the unit environment was secure. Maintaining unit safety was deemed fundamental to nursing practice in inpatient care. Consultation with other nurses and the multidisciplinary team was considered a vital component in maintaining safety on the unit. Protection of the nurse from possible legal consequences of their practice was a significant finding [p.136, 6].

Innovator of the SCP, country of origin
USA [p.631, 1]
New Zealand [p.134, 6].
Involved health care staff
In a study of USA: 8 expert Registered Nurses with at least 5 years of medical-surgical experience [p.631, 1].

In a study of New Zealand: Registered nurses over three rotating shifts [p.135, 6].

Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
One study was realized in USA, in 2 separate facilities with 7 different units belonging to 1 Midwest healthcare network. The care units included 4 general medical-surgical, 2 medical, 1 postprocedural, and 1 orthopedic unit. The acute care units: 4 general medical-surgical, 2 medical, 1 postprocedural, and 1 orthopedic unit [p.631, 1].

One study was realized in New Zealand, an acute care inpatient unit in a large mental health service [p.135, 6].

Summary of evidence for effectiveness, including references
One study supports understanding of factors related to the work complexity of Registered Nurses (RN) in healthcare environments, cognitive factors driving performance and decision making, strategies used by healthcare workers to manage care in demanding environments, and potential areas for redesign and education [p.631, 1]. As effective strategies to cope and adapt in work situations to manage workload demands was found:
1. Stacking
2. Anticipating or forward thinking
3. Proactively monitoring patient status
4. Strategic delegation and handoff
5. Stabilizing and moving on
6. Memory aids [p.634, 1].Also, was showed that minimizing gaps and discontinuities that distract the RN from focusing on critical clinical reasoning about individual would benefit patient safety and increase RN satisfaction. [p.637, 1].‘NurseWeek’ and the American Organization of Nurse Executives reported findings from surveys completed by 4,108 RNs about their perceptions of the nursing shortage, its impact, their career plans, and their work environment. Respondents reported that the nursing shortage was a problem factor in nurses’ ability to maintain patient safety, detect patient complications, carry out physician orders in a timely manner, and collaborate with other team members [2].

Improving patient safety depends on understanding that such work environments require worker flexibility in adapting to variation in patient needs and environmental factors [3, 4].

Other study was focused on the functioning of a crisis-orientated model of care, as participants described nursing care that focused on triage, assessment, stabilization, and the containment of risk, which are all common features of crisis intervention. By adopting such a model, nurses could then accept the realistic expectations of their roles in this setting and view their practice in a more positive way. [p.140, 6]. The findings suggest that nurses believe that practice is driven more by the needs of the organization than the patient. [p.139, 6].

It was found that mental health nurses had limited opportunities to develop therapeutic relationships and that the emphasis was often on managing the environment and other staff [8].

Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
Results of one study cannot be generalized because of the small and nonrandomized sample [p.637, 1].

In other study, there are no described evidence for transferability, but this support international studies in suggesting that high acuity and issues of safety are the main drivers of acute admissions [p.140, 6].

The demand for available beds and the high acuity of the users of the service, place nurses under pressure to develop new roles to essentially ‘manage’ unmanageable situations [7].

Summary of available information on feasibility, including references
The complexity and demands of the work environment are cited as contributors to patient safety. Improving patient safety depends on understanding that such work environments require worker flexibility in adapting to variation in patient needs and environmental factors [p.630, 1].

In acute inpatient settings, mental health nurses are often the only persons around whose time for caring is long enough to develop trusting therapeutic relationships with patients. Changes in technology and management systems related to patient care occupy nurses’ time, and may result in less direct contact with patients. [p.135, 6].

Administrative activities, for which there was broad agreement between observations and perceptions, were seen as detracting from the patient contact/therapeutic role of the registered nurse. Whilst it cannot be denied that administrative activities do take nurses away from patients, the perception was that these activities are so demanding and time-consuming that little time is left for interactions with patients [p.139, 6].

The demands on registered psychiatric nurses to complete an ever-growing mountain of paperwork and administrative duties have limited therapeutic time with their patients [9].

Nurses experienced the demand for quick treatment with high patient turnover as a hindrance to good treatment and quality of nursing care [7].

Existing implementation tools, including references
One study utilized the quantitative and qualitative data collection included field observations, followed by semistructured interviews The researchers were guided by the human performance framework “Sharp End and Blunt End” [p.631, 1], used in another study also[5].

In other study was used a qualitative descriptive exploratory approach nonparticipant observation and focus group interviews. Nonparticipant observation took place first, and observers recorded the range of activities of registered nurses in the acute inpatient setting. Focus group interviews were used to establish the perception that registered nurses had regarding their roles in the acute inpatient setting. [p.135, 6].

Potential for/description of patient involvement in the CRM practice, including references
In some studies not specified. In others focus group participants acknowledged that creating and sustaining a nurse–patient relationship in a busy inpatient unit was difficult to achieve but that it remained central to their daily practice. They recognized that they needed to make the most of any opportunity to engage patients and that the primary nurse allocation of patients meant that each nurse was expected to interact with their patients on any given duty in order to document patient progress. This was deemed a real challenge in a busy inpatient unit [p.136-137, 6].
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Patricia R. Ebright, Emily S. Patterson, Barbara A. Chalko, Marta L. Render (2003), Understanding the Complexity of Registered Nurse Work in Acute, Jona, vol.33, No. 12, pp 630-638
[2] NurseWeek. AONE/NurseWeek survey of registered nurses. Available at: asp. Accessed December 10, 2002.
[3] Institute of Medicine. Committee on Quality Healthcare in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
[4] Cook RI, Woods DD. Operating at the ‘sharp end:’ The complexity of human error. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum; 1994:255-310.
[5] Woods DD, Johannesen LJ, Cook RI, Sarter NB. Behind Human Error: Cognitive Systems, Computers, and Hindsight. Wright-Patterson AFB, Ohio: Crew Systems Ergonomic Information
and Analysis Center (CSERIAC); 1994.
[6] Willem J. Fourie, Stuart McDonald, John Connor, Steve Barlett (2005), The role of the registered nurse in an acute mental health inpatient setting in New Zealand: Perceptions versus reality, International Journal of Mental Health Nursing, 14, 134-141.
[7] Long, C. G., Blackwell, C. G. & Midgley, M. (1992). An evaluation of two systems of in-patient care in a general hospital psychiatric unit: Staff and patient perceptions and attitudes. Journal of Advanced Nursing, 17, 64–71.
[8] Gijbels, H. (1995). Mental health nursing skills in an acute admission environment: Perceptions of mental health nurses and other mental health professionals. Journal of Advanced Nursing, 2, 460–465.
[9] Whittington, D. M. & McLaughlin, C. (2000). Finding time for patients: An exploration of nurses’ time allocation in an acute psychiatric setting. Journal of Psychiatric and Mental Health Nursing, 7, 259–268.
Dr. Lavinia Panait
National School of Public Health and Management, Romania
Any additional information on the CRM (e.g. implementation barriers and drivers)
Participants in one study appeared at times to struggle with the realities of inpatient practice as it conflicted with their perceived vision of health nursing. There is a need to establish what is fundamental to acute inpatient care practice and identify specific minimal standards relating to nursing practice in this specialty context. This may require a review of the current job description for registered nurses in order to create descriptions that more accurately reflect the roles that nurses are expected to perform [p.140, 6].