The strategic importance of thinking time: creating a mind-set for safety.

Abstract

AS WE CELEBRATE THE NEW YEAR, I recommend a book by John Naisbitt, Mind Set! Reset Your Thinking and See the Future (1). Naisbitt's basic premise, that a mind-set is a specific worldview that predetermines the interpretation of new information, provides an interesting lens for approaching change for the upcoming year. * Among nurse educators, there is an enduring mind-set that we teach students to prevent errors from reaching patients. That mind-set is shattered by the growing volume of data about patient safety, indicating that significant changes must be made. Many of the safety findings that are emerging, such as those pertaining to nurse-patient ratios, are outside the control of nurse educators. However, emerging work on the interruption-prone nature of contemporary nursing practice promises to have significant explanatory power for many of the findings concerning safety in nursing practice. In an article entitled An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors, Patricia Potter and colleagues report on a study aimed at exploring how interruptions in the workplace influence nurses' ability to anticipate and carry out the actions directed by their clinical judgment (2). In their research, they found that RNs averaged 76.6 cognitive shifts - shifts in attention from one patient to another during the conduct of the nursing process - during their work period, or 9.3 cognitive shifts per hour. These cognitive shifts involved patients. In one time frame, a nurse shifted between two patients four times in 13 minutes. The authors of the study also measured the number of activities that needed completion by an RN during any point in time. This number, defined as a cognitive stacking measure, ranged from 11 to 21. When the nurse had a cognitive stacking measure of 16 to 17, four omissions of care were noticed, including missed assessments, incomplete patient education, missed interventions, and failure to communicate patient information to a health care colleague. Nurses were found to average 30 interruptions per shift, and almost half of these occurred during a nursing intervention. These numbers are staggering and underscore a reality of nursing practice that is well understood by nurses - that the demands on nurses to multitask are extraordinary. While nurse educators struggle to teach students to think critically and to set priorities, the need to switch back and forth between two different patient histories, trajectories of illness, and care plans four times in 13 minutes on a general medical-surgical unit illuminates a significant nursing problem. Nurses need the time to think, a place to think, and the freedom from interruption to allow thinking to occur. …