Complexity in Practice Environments

Abstract

The association between registered nurse staffing and patient outcomes, especially in acute care hospitals, has been investigated extensively over the past decade. A number of different aspects of the relationship between nursing care and patient outcomes have been examined. These range from examining the characteristics of the nurse providers, such as their education or experience, to the staffing patterns and the amount of nursing hours of care delivered to each patient. A meta-analysis of this research has found, overall, that there is an association between increased nurse staffing and lower odds of adverse patient events, although there are inconsistencies across various studies (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). The state of the science to date, however, is not sufficient to guide staffing practices with certainty. It has also been recognized that characteristics of the work environment influence the quality of care delivered by nurses and thus impact patient outcomes. Variables such as patterns of communication, clinical leadership, staff turnover, and the perception of a team culture also have demonstrated relationships to nurse performance and clinical outcomes (Page, 2004). However, many questions remain. A new phenomenon has been suggested as an additional characteristic of the practice environment that also might influence nurse performance both directly and indirectly. This phenomenon is called complexity compression and is defined as the stress that nurses experience when they are expected to assume additional, unplanned responsibilities while simultaneously carrying out multiple responsibilities in condensed time frames (Krichbaum et al., 2007). This phenomenon was suggested by practicing nurses as they described the multiple competing demands they faced in daily practice that created stress and often contributed to nurses' decisions to remain in or leave nursing. Focus groups were conducted with 58 nurse clinicians and resulted in the identification of multiple themes. Subsequent factor analyses of the themes identified three factors that appear to constitute complexity compression. These factors consist of the work of nursing, personal factors, and practice environment or system issues (Minnesota Nurses Association, 2009). The definitions and examples of the three factors will sound familiar to staff nurses. The work of nursing factor consists of elements that impact nurses' ability to care for patients and includes the variety of unexpected occurrences that directly interfere with nurses' ability to carry out their work. These include the additional demands on time due to continually increasing acuity of patients and the increasing responsibilities related to additional expectations for training and supervising students and a diverse ancillary staff. Other examples in this factor include the challenges of prioritizing multiple tasks, needs related to emotional or spiritual concerns of patients and families, and the unease created when nurses are required to perform tasks that they are not familiar with or prepared to carry out. Personal factors include elements that impact the individual nurses, such as fatigue from working long shifts or overtime and conflicts between the demands of work and family. …