Exploring The Invisible Work Of Nursing: A Case Study Of Simulated Increases In Intensity Of Care On Nurses' Cognitive Load, Clinical Judgment, Stress, And Errors

Abstract

Nurses have never before had so much data at the bedside, nor the complex patients and practice environments found in acute care settings today. Processing large amounts of information from multiple sources may result in cognitive overload which may negatively impact patient outcomes. To meet the challenge of improving quality of care, a conceptual model was created to guide research exploring the associations between the cognitive work of nursing, nursing care, and the complex context of the hospital setting. The purpose of this research was to explore the invisible cognitive work of nursing by examining relationships between cognitive load, nursing surveillance and clinical judgment, contextual complexities, and their potential impact on patient care outcomes. Research question 1 examined how simulated increases in intensity of care influenced nurses’ cognitive load, clinical judgment, perceived stress, and errors. Research question 2 asked how nurses describe the cognitive work of nursing while engaging in a simulated patient care scenario. A novel multiple-case study design with multiple sources of evidence was used. Eligible cases included three new to practice baccalaureate-prepared RNs employed in acute care medical-surgical settings. A patient care simulation with increasing intensity of care was developed in collaboration with a simulation center in a large healthcare system in the Southeastern US. Time series analysis and pattern matching compared outcomes of cognitive load, performance, and stress using the NASA-TLX instrument at seven time points. Errors in nursing care were counted and clinical judgment using the Lasater Clinical Judgment Rubric (LCJR) was assessed. Explanation building used data from participant interviews during simulation debriefing. Cross-case synthesis compared findings from the other analytic strategies to determine similarities across cases. Findings suggest as the intensity of care in the simulation increased, cognitive load and stress increased. Performance findings were equivocal; in each case errors or omissions of care were noted, but LCJR scores ranged from 37-42 indicating exemplary clinical judgement. Convergence of findings supported the conceptual model of the invisible work of nursing and identified an additional component, social capital, as a mechanism to support clinical judgement of new to practice RNs.