Changing our lens: seeing the chaos of professional practice as complexity

Changing our lens: seeing the chaos of professional practiceas complexity

MARLENE KRAMER PhD , RN , M SN , F A AN1, BARBARA B.BREWER PhD , RN , MA L S , M BA

2,DIANA HALFER MSN , RN , N E A - B C

3, PAT MAGUIRE RN , MN , N E A - B C4, SUMMER BEAUSOLEIL RN , B S N ,

C CRN5, KRISTIN CLAMAN RN

6, MAURA MACPHEE P hD , RN7 and JUDY BOYCHUK DUCHSCHER RN ,

B S c N , MN , P h D8

1President, Health Science Research Associates, Apache Junction, AZ, 2Clinical Associate Professor, College ofNursing, University of Arizona, Tucson, AZ, 3Administrator, Ann & Robert H. Lurie Children’s Hospital ofChicago, Chicago, IL, 4Senior Kaizen Specialist, MetroWest Medical Center, Framingham, MA, 5Cath LabSpecialist, Fletcher Allen Health Care, Burlington, VT, 6Clinical Nurse, Renown Medical Center, Reno, NV USA,7Associate Professor, University of British Columbia, Vancouver, British Columbia and 8Assistant Professor,University of Calgary and Executive Director, Nursing The Future, Calgary, Alberta, Canada

Correspondence

Marlene Kramer

Health Science Research

Associates

3285 N. Prospectors Rd.

Apache Junction

Arizona 85119

USA

E-mail: [email protected]

KRAMER M., BREWER B.B., HALFER D., MAGUIRE P., BEAUSOLEIL S., CLAMAN K., MACPHEE M. &

DUCHSCHER J.B. (2013) Journal of Nursing Management 21, 690–704.Changing our lens: seeing the chaos of professional practice as complexity

Aim The purpose of this evidence-based management practice project was to

analyse dimensions of the Getting my Work Done issue, the only one of seven

issues of highest concern for which 907 nurse interviewees were unable toidentify effective strategies, formulate a ‘best management practice’, integrate

the practice into clinical settings and evaluate results.

Method/process The evidence-based management practice process was used toidentify the major impediment to Getting Work Done–assignment to multiple

patients with simultaneous complex needs. Best management practice consisted of

class presentation of a clinical-management problem scenario to 144 residents innine Magnet hospitals, a private action commitment, class discussion and

terminal action commitments.

Results Responses indicated that this ‘best management practice’ was effective inhelping newly licensed registered nurses manage and handle multiple patients with

simultaneous complex needs. A major avenue of resolution was perception of

professional practice responsibilities as a series of complex, interrelated, adaptive systems.Conclusions/implications for nursing management Perception and use of the

principles of complexity science assists newly licensed registered nurses in

mastering management dilemmas that inhibit professional practice. In manyparticipating hospitals, plans are underway to expand this best practice to include

input and perception exchange among experienced nurses, managers and physicians.

Keywords: complex adaptive systems, evidence-based management practice, multiple

patient/simultaneity complexity, professional practice

Accepted for publication: 7 February 2013

Introduction

‘It’s chaotic! I have five patients; often, one or

more need care at the same time. How do I

decide which patient is more important? What is

the ‘right’ thing to do? If it’s life and death, no

problem. It’s chaotic then, too, but not because

of different patients needing something, rather

690DOI: 10.1111/jonm.12082

ª 2013 Blackwell Publishing Ltd

Journal of Nursing Management, 2013, 21, 690–704

the same patient needing multiple things at the

same time. I feel bad, very unprofessional when I

have to consciously decide to withhold needed

care to a patient… Several times, I’ve thought

about leaving nursing… Another cause of the

chaos is constant interruptions by doctors, PT,

lab, other nurses… I’m scared to death I will

harm or kill a patient when I have to make

choices between patients!’.(NLRNs 6–8 months post-hire)*

Newly licensed registered nurses’ (NLRNs) percep-

tions and descriptions of clinical situations as ‘chaotic’

(Cornell et al. 2010) were the major and most frequent

response to adaptation difficulties from 907 nurses

(330 NLRNs, 401 experienced clinical nurses, 138

nurse managers and 38 educators) interviewed in a

qualitative study in 20 US Magnet hospitals (Kramer

et al. 2012a,c). The focus of the previous study was to

ascertain components/strategies of nurse residency pro-

grammes (NRPs) that nurses and managers identify as

effective in helping NLRNs become socialized into the

professional practice role of clinical nurse. This sociali-

zation is accomplished through mastery of seven dilem-

mas repeatedly cited as issues of highest concern for

NLRNs when they leave the dependent, precepted

stage of NRP and enter the independent, clinical prac-

tice role (Kramer 1974, Schmalenberg & Kramer 1979,

Paterson et al. 2001, Krugman et al. 2006, Nursing

Executive Center 2007, Berkow et al. 2009, Pellico

et al. 2009, Kramer et al. 2013a, Kramer et al. 2013b).

Of the seven issues–delegation, clinical autonomy, priori-

tization, registered nurse (RN)–physician collaboration,

restoration of self-confidence through feedback, construc-

tive conflict resolution and Getting Work Done–the last

was identified as the issue of greatest concern and the

only one for which interviewees could not identify effec-

tive NRP strategies/components (Kramer et al. 2012a,c).

This absence of effective strategies is what generated

this evidence-based management practice (EBMP)

project.

Evidence-based practice, a decision-making process

originating with the medical profession to diagnose

and treat illness/injury, has been adopted by nursing

as an approach to practice improvement (Levin 2008).

In contrast to medicine, nursing matured as a profes-

sion within bureaucratic organisations (Kramer &

Schmalenberg 2012,). Although Titler et al.’s (2001)

adaptation of the Iowa model put evidence-based

practice into the context of practice improvement

within an organisation, it did not clearly address inter-

nal data that needs to be gathered or the extent to

which internal data supports and clarifies issues and

their relevance to the organisation. This EBMP study

is descriptive in design. It focuses on the management

component of the clinical nurse role. The EBMP pro-

ject reported here follows Levin’s (2008) adaptation

of the Iowa model: develop answerable questions, col-

lect/analyse best internal (organisational) and external

(literature) data, critically appraise the evidence, and

develop and evaluate effectiveness of implementing a

best management practice.

Purpose and questions

The purpose of this EBMP study was to analyse,

through a critical appraisal of the data, the dimensions

of the Getting Work Done issue. From this, a poten-

tial ‘best management practice’ would be developed,

integrated into practice in nine Magnet Hospitals and

evaluated for effectiveness. The questions to be

answered included: What are the major impediments

to NLRNs getting their work done? What best man-

agement practice will help with this problem?

Four sources of internal data were used to answer

the questions and achieve the objectives of this study.

The first source was digitally recorded responses of

907 nurse interviewees in 20 Magnet hospitals

(Kramer et al. 2012a,c) to the Getting Work Done

issue. These responses have not been reported else-

where as strategies suggested did not meet the criteria

of effectiveness for resolution of the issue. The second

source of internal data was a spontaneously drawn

NLRN sketch (Figure 1) by three of the NLRN inter-

viewees in this same qualitative study, in response to

the question ‘What are similarities and differences in

your nursing practice now (6–8 months post hire)

from when you were with your preceptor?’ After the

site-visits, the NLRN sketch was emailed to the on-

site investigators in the 20 hospitals, requesting them

to present the NLRN sketch to their current group of

NLRNs (n = 348) asking what the sketch said to them

and if there were additions or changes they would like

to make. Ninety-six per cent (n = 334) of the 348

NLRNs confirmed that the sketch accurately depicted

differences in practice ‘between when I was with my

preceptor and now when I am on the staffing roster

and on my own’. The third source of internal data,

collected specifically for this EBMP study, was an

*Unless referenced otherwise, all data in quotes are excerpts from

recorded nurse interviews related to the Getting Work Done issue.

These data have not been published elsewhere. Excerpts related tothe same topic, from multiple interviewees are separated by ellipses

points.


Journal of Nursing Management, 2013, 21, 690–704 691

An evidence-based management practice for new graduates

email survey of on-site investigators in the 34 magnet

hospitals participating in the seven-study research

programme (Kramer et al. 2011) requesting informa-

tion regarding the nursing care models and delivery

systems operative in their organisations. The last

source of internal data was 46 personal and email

interviews with Health Science Research Associates

and clinical nurses in the USA and Canada. These in-

terviewees were selected to represent a variety of dif-

ferent clinical units, types of hospitals, and hospital

practice experiences. These nurses provided examples

of NLRN management and clinical dilemmas, as well

as information and insight into the dimensions of the

Getting Work Done issue.

Critical appraisal of data

Dimensions of the issue

Why do NLRNs, 6–9 months post hire, report that

Getting Work Done is the issue of highest concern as

they integrate into the professional practice role of

clinical nurse? Why do more than 5000 front-line

nurse leaders in a NLRN preparation–practice gap

study rank order competencies such as independent

practice, anticipating risks, and keeping track of mul-

tiple responsibilities at the very bottom of 36 needed

NLRN competencies (Berkow et al. 2009)?

Many of the 907 NLRNs and experienced nurse in-

terviewees cited clinical examples, called ‘scenarios’

(Boxes A and B) to illustrate the Getting Work Done

difficulty. These were almost always accompanied by

assessments of how they felt about the decisions they

had made, and doubts as to whether they had made

the ‘right’ or correct decision. These findings, coupled

with the fact that the nurse interviewees in the parent

study (Kramer et al. 2013a) that was carried out in

‘Best of the Best’ Magnet hospitals that had established

NRPs, were unable to identify strategies effective in

addressing the Getting Work Done issue, led to selec-

tion of an EBMP approach for development/testing of

a ‘best practice’.

Components of the professional practice role

According to the literature and the interviewees,

the professional practice role of clinical nurse is responsi-

bility and accountability for providing care and

RN

RN

RN

PT Pt.

Pt.

Pt.

Pt.

Pt.

Preceptor

NLRN

Pa ent FamilyChaplainDie cian

MDPharmacist

Physical TherapistRespiratory Therapist

Social Worker

Pt. Family

NLRN

Pt. Pt.

Pt.Pt.

Pt.

MD

Pa ents’ Families

Transi on Stage(Post-hire to 3 months)

Integra on Stage(4 months to 1 year)

Note: The limited shaded area in theprecepted-NLRN experience means theyhave 'some' responsibility (definitely with the family) for answering ques ons and dealing with other departments etc. butthat the Preceptor "manages" the situa on for virtually all five pa ents--that's why theshaded area is small.

Figure 1: NLRN Sketch of differences between Transition and Integration Stages of Nurse Residency Programs

Figure 1

Differences in Newly Licensed Registered Nurses’ (NLRN) conceptualization of the dominant professional Nurse parctice role during transi-

tion and integration stages of professional socialization.


692 Journal of Nursing Management, 2013, 21, 690–704

M. Kramer et al.

managing clinical situations for multiple patients, simul-

taneously (Ebright et al. 2003, Lindberg 2008, Kramer

et al. 2010, 2012a,c). Providing care encompasses all

dimensions of nursing and includes all care interven-

tions–physical, psychological, teaching and technologi-

cal, such as ‘search of a disease or treatment on the

internet for self, patient or physician’. Managing clinical

situations consists of interactions and communications

between/among clinical nurses, patients’ families, physi-

cians, therapists, chaplain, etc. Environmental elements

and interactions–increased technological demands, seem-

ingly unending documentation, multiple health-care pro-

viders, high levels of interdisciplinary coordination and

collaboration and planning for the continuum of care–

are also components of managing clinical situations (Pe-

sut 2008, Kramer et al. 2010).

Simultaneity complexity

This dimension of the professional practice role is

particularly problematic. ‘The difficulty in getting my

work done is because several of my patients need me to

do something at the same time’. Labelled the multiple

patient-simultaneity complexity (MP/SC), MP/SC is

unique to the professional practice role of clinical nurses.

With the possible exception of emergency department

physicians, other health-care professionals provide ser-

vice to clients, sequentially (Kramer et al. 2010).

According to NLRNs, clinical nurses and managerial in-

terviewees, simultaneous means ethical, moral and legal

responsibility, and accountability for assigned patients

‘even when not in the physical presence of the patient’.

This includes on-going caring, concern, proactive moni-

toring of patient status, observation, surveillance, aware-

ness of patient profiles and cognizance of potential

latent failures (Ebright et al. 2003, Lindberg 2008, Kra-

mer et al. 2010, Kramer & Schmalenberg 2012).

Most of the MP/SC scenarios cited by NLRNs and

clinical nurses illustrated difficulties and dilemmas in

the nursing care component of practice (see Box A). In

Box B, a 4-month post-hire NLRN describes a MP/SC

scenario illustrating difficulties involving primarily man-

agement but also care components. This scenario includes

the NLRN’s critique of her clinical reasoning process.

Perceptions of not making the ‘right’ decision, of

not managing MP/SCs correctly are what causes

nurses to judge themselves as ‘poor nurses’ who ‘let

their patients down’. “Fear of not making the ‘right’

decision when faced with competing needs/demands

from several patients is what causes me to not feel

good about myself as a professional nurse”. An expe-

rienced intensive care unit (ICU) nurse, 14 years into

her career, described this memorable experience occur-

ring during her 1st year of practice:

Box A

Joe and Mrs Alstairs multiple patient-simultaneity complexity (MP/SC) scenario

Joe, a 22-year-old hockey player, was one of my five patients. Admitted with a swollen belly, unexplained, recurring fever, weight loss

and itchy skin. A year ago, he was diagnosed with Hodgkin’s disease and had radiation treatment. When I admitted him, he told me, with

a bright, happy smile and tug on the blond curls of his ‘soon-to-be wife’, that he had been ‘cured’. He had been feeling great up to about

a month ago when he was admitted for diagnostic tests. He’d had a slew of them–liver and kidney function, computed tomography (CT)

scans, bone marrow and lymph node biopsies.

Another of my patients was Mrs Alstairs, in her 60s, she has been in and out several times with pancreatic cancer, treated surgically and

with chemo, but still wretched with pain. She was on IV morphine and could barely make it from one administration to the next. When I

did my initial assessment this morning, I sat with her for a while and we talked about distraction methods–a good book on tape to listen

to–that would help her handle the pain a little when it was getting near to her next dose of morphine but not yet time. I read her the sum-

maries of some books and got her recorder and head phones all set up.

The morning had been going fine. At about 10 minutes to 9, as I was on my way to draw up Mrs Alstairs’ IV morphine, which she can

have at 9, Dr Marsh stopped me, says ‘good morning’ and asked if I have Joe today. When I nodded, he said he was on his way in to

see him and asked me to come along. I figured that I had enough time before 9, so I went. After some preliminary ‘how’s the belly today’,

Dr Marstairs said ‘Joe, I have the reports of your tests and it’s not good. Your Hodgkin’s has come back strong; you are already at Stage

IV-b. The outlook is worse when the cancer re-occurs and spreads in less than a year’. As soon as Dr Marsh began his report, I had put

my forearm on Joe’s shoulder and reached for his hand. Joe was absolutely shocked (as was I); his face paled, his eyes got big and

bulgy. Dr Marsh patted him briefly on the arm, said ‘Beth is a good nurse and will take good care of you’. He told Joe to write down ques-

tions that he had and that he’d be back to see him tomorrow and would answer his questions then. And with that, he left! Joe looked at

me with his shocked look, eyes brimming with tears and said: ‘He’s leaving? Please don’t leave me! What did he mean? Am I going to

die? Like now? I’m so young; I have my whole life ahead of me. Marge and I are talking about getting married this summer’.

At the same time that I was trying to listen to and comfort Joe, I was reviewing in my head what I knew about Hodgkin disease (cancer

of the lymph nodes, seen in young adults, prognosis not as bad as it used to be, but very bad if it reoccurs within the 1st year). I also

have to admit that I thought about how I would feel if this were happening to me–I am only 2 years older than he is). Joe was clutching

me like I was a lifeline. I just held on to him and let him cry, and said: ‘Don’t worry, Joe. I’m not leaving you. Go ahead and cry and share

with me whatever you’d like. Let me know if you’d like me to phone Marge or your parents’. In my head, I knew that Mrs Alstairs would

be in severe pain; she needed her IV morphine; it was already past 9.




‘I was working 12-hour nights. Usually in the

ICU, we have two patients. One of my patients

was 28-year old, Carla, with necrotizing pancre-

atitis, who I’d been caring for, for about

two weeks. She was very sick, requiring 1 : 1

care almost the entire time. Multiple vasopres-

sors, continuous renal replacement therapy, an

open fasciotomy in her right arm. After many

family meetings, Carla’s father made the decision

to withdraw care. Her family dynamics were

very difficult and her family was not coming in

to be with her after they withdrew life support.

When I came on at 19:00 hours, Carla had just

been terminally extubated.

My other patient was Miriam, a critically ill

woman who had arrested in the field, and was

continuing to arrest on and off in the unit. Once I

got into her room, I was not really able to leave it

because of constant interventions needed to keep

Box B

Management component multiple patient-simultaneity complexity (MP/SC) scenario

I came on shift and received report from the night nurse for my five patients. One of my patients, Mrs B has chronic obstructive pulmonary dis-

ease (COPD). She’s from _______ and needs home oxygen. She has to be discharged by 11:00 with all necessary supplies (O2 tanks) so

her husband can drive 400 miles, stay overnight and then complete the 800 mile trip the next day. (They only had enough money to stay in a

hotel one night.) An oxygen delivery company had been contacted and oxygen for the trip was due to arrive by 09:00. At 07:30, I called the

oxygen company to confirm the process and the delivery time; everything was set and ready to go. I planned the care of my patients in antici-

pation of Mrs B’s 11:00 discharge by passing medications and charting on her first.

Another of my patients, Mrs S, a diabetic dialysis patient, was to receive dialysis this morning and then be discharged home. When I did my

medication pass and assessments, I noticed that Mrs S’s IV was not flushing well, but I thought it best and to leave it in for now. There was

no point in taking it out and starting a new IV because when she was discharged, she probably wouldn’t need it. I also noticed that she had

not touched her breakfast. I encouraged her to eat, and she said ‘I’m not hungry, I’ll eat later’. I did not give Mrs S her insulin because her fin-

ger-stick blood glucose was not within parameters.

At almost 10:00, Mrs B’s oxygen tanks that had been promised for 09:00 still had not arrived. I called the oxygen company and was told that

they were no longer handling this patient’s case, and that the case had been transferred to a completely different oxygen delivery company.

In my mind, I was frantically thinking, ‘why didn’t you call me and tell me this earlier?!’ Despite my frustration I calmly asked for the contact

information for the ‘new’ oxygen company. But, before calling them, I decided that I needed to inform and reassure Mrs B and her husband

about this new situation. It also occurred to me to ask them how many oxygen tanks they needed and were expecting to receive. They said

they needed five tanks total (for the overnight hotel stay and for the whole trip home). I then called the ‘new’ oxygen company, who said that

they had not received the information about the number of oxygen tanks and why they were to be delivered by 11:00. They said they were set

to deliver only two tanks! I was getting more and more frantic with every phone call and was afraid I might be communicating my anger and

despair to Mr and Mrs B.

At almost 11:00; the dialysis nurse called for Mrs S. I prepared her and transport came to take her to dialysis. I decided that the oxygen tank

situation was getting out of control and that I needed help, so I called the social worker and turned the situation over to her. Finally, at 12:30,

two oxygen tanks were delivered and Mrs B was discharged with a plan that she receives three more at the hotel.

At almost the same time, dialysis called me to say that Mrs S. was hungry and wanted her lunch tray, which was in her room. I informed the

dialysis nurse I did not have time to bring Mrs S’s lunch tray down to the dialysis room because I was in the process of discharging Mrs B, my

COPD patient. I suggested that she call the kitchen and have them bring a lunch tray to dialysis.

Next, I was told to get Mrs B’s former room ready to receive a new patient. The room had been cleaned but there was no bed. I had to search

the whole floor for an empty bed. Meanwhile, I still had to take care of my other three patients, catch up on documentation and grab some

lunch.

About 14:00, as I was trying to get the new patient’s room together, Mrs S, my dialysis patient came back to the floor. At about the same time,

the dialysis nurse called to tells me how much fluid was pulled off and that Mrs S’s vital signs, etc., were stable. I asked if she had eaten her

lunch and the dialysis nurse said that she had obtained the tray from the kitchen but that Mrs S did not touch the food. I went to check on Mrs

S. Her speech was slurred and she showed markedly decreased mentation from my morning assessment. I called the dialysis nurse back to

ask her about the patient’s mentation during dialysis. She said it was normal for patients to be fatigued and somewhat mentally slow post-dial-

ysis. It’s not that I did not believe her, but something (my clinical judgment?) was telling me that this was not normal for Mrs S, particularly as

she had had no breakfast or lunch. I called my charge nurse and we both started assessing Mrs S. About this time, Mrs S became unrespon-

sive; blood glucose level is 61. IV access was compromised from that morning–did I make a mistake in my earlier assessment? Should I have

restarted the IV first thing this morning? A new IV was started and a rapid response was called at 16:15. She was given dextrose 50; by

16:30, she was stable, alert and oriented.

Self-analysis: The most important lessons I learned from the situation with Mr and Mrs B and the oxygen tanks were to make sure you keep

a good line of communication with your patient and keep them informed. I think that my patient and her husband would have been extremely

upset and frustrated if I had not kept them in the loop regarding the changes throughout the morning. If you try to weigh and balance Mrs B’s

situation with the many other possible patients’ needs and situations, it probably doesn’t come out very high on the scale. But it was important

to them. If I could not have gotten this situation straightened out, it would have meant that she would have had to stay another night, and pos-

sibly three more in the hospital (this all happened on a Friday). Neither Medicare nor the hospital would have been happy about that! I alsolearned to use my resources (i.e. social worker). Without using the help of the social worker it may have taken longer to get the patient dis-

charged and on her way home. In hindsight, I should have called the social worker sooner instead of taking my time and attention to contact

the two oxygen companies several times, thus neglecting my other patients.



M. Kramer et al.

her alive. Multiple (5) vasopressors, lots of IV flu-

ids, the need to keep her paralysed in order to

ventilate her. Her ABGs were awful; I had to do a

lot of hand bagging because her O2 saturation

would become very low on the ventilator. I was in

the middle of hand bagging Miriam when the

respiratory therapist came to tell me that Carla

was asystole on the monitor. I had not been in to

see her at all since I had started with Miriam.

There was no one in the room with her when she

died. As her nurse I really should have been there

with her. I felt then, and still feel, very guilty that

I did not know whether she was in pain or not,

and that she died alone. I should have been there

with her, but I had to make a choice. I remember

when I first became a nurse, and a patient would

code and die in the ICU without their family being

around. One of the very experienced night nurses

told me:

“No one ever dies alone here. We’re with them

even if their family can’t be”. That’s always

stuck with me. Carla dying alone and possibly in

pain, still haunts me to this day’.

In addition to negative feelings about self as a nurse,

MP/SCs lead to decreased quality of patient care,

nurse practice satisfaction and increased job turnover.

It is also the number one cause of NLRNs leaving the

profession during their 1st year of clinical practice

(Kramer et al. 2012b).

Nursing care models and care delivery systems

Care models are supposed to answer the question

‘What is nursing?’ Gambino (2008) defines care models

as the philosophy of patient care that guides everyday

practice; he outlines 18 care models operational today.

With outrage in their voices–‘nursing is far more than

that!’–nurse interviewees reported that Webster’s Dic-

tionary (Agnes & Guralnik 2001) defines nursing as the

duties or profession of a nurse/the medical care given

by a nurse.

Lack of agreement on the definition of nursing

affects professional practice in two ways: ‘When we

don’t all define nursing the same there is no frame-

work for decision making to guide/justify nursing care

priorities’. Differences among RN in concepts of ‘what

is nursing’ are reflected in unwillingness to ‘fill in’ or

help one another in MP/SC situations. Clinical nurses

are reluctant to leave their own patients to help a

co-worker when they don’t agree that what the co-

worker intends to do is nursing.

From the perspective of all interview groups, the

dominant care model/definition of nursing is Nightin-

gale’s alterable medium theory: i.e. Nursing is the

planned, scientific alteration in patients’ internal and

external environments enabling the laws of nature to

act, thus facilitating the healing process (Selanders

1998). Not always defined so completely, the essence

of the definition from practicing nurses’ perspectives is

that ‘nursing alters or improves patients’ internal and

external environments so that nature takes its course

and patients get well’:

‘This is what we were taught in undergraduate

and graduate programmes… Florence’s definition

is much more helpful and useful than that defini-

tion about nursing being the diagnosis and treat-

ment of human responses to actual and potential

problems–does that mean if the patient doesn’t

respond negatively to bad news, you can assume

that the news is OK with him?… Some models

like Watson’s, focus mainly on patient’s internal

environment… Primary was supposed to focus on

the continuum of care, but it doesn’t anymore’.

Nightingale was the first to recognize the importance

of relationships and interactions as factors affecting

patient care and health. It is also the model most adapt-

able to the changing world in which we live and is used

by many State Boards of Nursing (Gambino 2008).

Nightingale’s understanding of the relationship between

health and environment not only initiated development

of nursing knowledge through research and theory, it is

also the model used by the Institute of Medicine of the

National Academies (2004) in its definition of clinical

nurses’ professional nursing practice environment

(PNPE). By combining Nightingale’s definition with

Donabedian’s (1988) structure–process–outcome para-

digm, the IOM defines PNPE as an alterable medium in

which structures and processes or practice are altered to

improve quality of patient outcomes.

Nursing care delivery systems answer questions as

to how care is organised and delivered to patients.

Systems often vary by patient unit. Care delivery sys-

tems are necessary to accomplish both the care and

the clinical management components of professional

practice. The care delivery systems most frequently

described were professional teamwork, group practice

or a partnership/buddy system.

There are opposing views as to whether care models

and care delivery systems are the same or different

(Kramer et al. 2012c). Mark (1992) defines them as the

same; Shirey (2008) says they are different. At two

recent Comprehensive Magnet Workshops, the Ameri-




can Nurses Association Credentialing Knowledge Center

(ANCC) offered a programme entitled: What is the

difference between professional practice models and care

delivery systems? (American Nurses Credentialing

Knowledge Center 2012). From the perspective of

NLRNs and experienced nurse interviewees, confusion

and disagreement about care models or care delivery

systems is a problem because each answers a different

question. This is particularly true when the care model

and the delivery system are identified as one and the

same.

The e-mail survey of the on-site investigators in 34

Magnet hospitals (Kramer et al. 2011), including the

20 hospitals in the qualitative interview study and the

nine hospitals participating in this EBMP project indi-

cated that in 18 hospitals, care models and delivery

systems were defined the same: relationship-based

care, family-centred care, patient-centred care or syn-

ergy. In the other 16 hospitals, the dominant care

models were caring, Nightingale and synergy. In these

hospitals, the major delivery systems were modified

primary, modified team, or group practice.

NLRN appraisal of NLRN sketch

The dominant clarifications and additions to the

NLRN sketch suggested by at least half of the 348

NLRNs in 75% of the 20 hospitals is of particular

significance because it suggested a complexity science

approach for resolution of the MP/SC dilemma:

‘Forget the transition drawing on the left: we

grow out of that when we move from our pre-

ceptor. The professional practice role is the one

on the right… You’ve got to show the patients

for all RNs as well as all the people they must

interact with on behalf of their patients… Each

one of these ‘RN–patient assignment circles is an

interconnected whole–what happens in one circle

rebounds or impacts the others… Next, you need

to draw a huge circle around all the RNs and

their group of patients. That’s pictures the unit…A circle around all units would be a picture of the

hospital… Charge nurses and the nurse manager

need to be inside this large circle with lines to all

RNs, to physicians and to other disciplines…’.

Newtonian and complexity sciences

The Newtonian paradigm (Lindberg & Lindberg 2008)

has been the view of the world for more than a century.

Patients are viewed as having broken mechanisms or

parts that can be repaired. Processes are understood

and analysed as linear and predictable. The dawn of

complexity science led to the discovery that the universe

is not stable, closed, predictable or controllable in ways

scientists had thought. New models of thinking assert

interconnection over fragmentation, networks over hier-

archy, influence over control and direction over destina-

tion (Anderson 2003, Baghbanian et al. 2012). The

chief applicability of complexity science to professional

practice is viewing clinical units, agents and hospitals as

complex adaptive systems (CAS) (Institute of Medicine

& Committee on Quality of Healthcare in America

2001, Lindberg 2008, Sturmberg et al. 2012). In CASs,

a system is a structure or object (abstract or concrete)

whose state and variability evolves over time. It is a

group of coordinated elements or agents which, taken

together, constitute a whole. Complex systems are built

up from large numbers of mutually interacting subunits

whose repeated interactions result in rich, collective

behaviour that feeds back into the behaviour of individ-

ual parts. CASs are unstable, non-linear, flexible, con-

tinually evolving and self-organising in response to

feedback. Interactions are focused around the system’s

attractor (for example, shared vision, goals of hospital-

ization), which pull, guide or channel the system. The

stronger the attractor, the more active the system. Dis-

turbances close to the attractor (e.g. loss of a resource,

diagnosis of cancer) create a more active system. When

a system responds adaptively to a disturbance, it allows

for emergence of the best solution for each patient

(Rickles et al. 2007, Lindberg 2008, Sturmberg et al.

2012).

Newtonian and complexity science as reflected in

systems of work organisation

In all industrialized societies, there are basically two

systems for organising work: the part-task model and

the whole-task model. In the first of these models a

worker can be trained, usually in a relatively short

amount of time, to perform a part of the whole task

(for example, making unoccupied patient beds). This

part-task model embraces values of efficiency, speed,

accuracy and safety through repetitive performance of

the same task by the same worker. The degree of

resistance to the task is known and predictable (Cor-

win 1961, Kramer 1974). This system has long been

labelled the bureaucratic system of work largely

because it requires at least one department whose

major goal is to keep the system operating efficiently.

The part-task, bureaucratic system is reductionistic

(i.e. the whole is broken down into discrete, measur-

able parts–departments–and the whole is equal to sum

of parts). It is the system encountered by most NLRNs

in their initial employment in hospitals.



M. Kramer et al.

In academia, NLRNs are taught the whole-task, goal-

oriented, professional model of practice. Practitioners, in

ever-increasing complex, internally controlled disciplines

require extensive, up-to-date knowledge, judgment and

decision-making. They also require a larger, more com-

prehensive context of practice so as to engage in safe,

effective professional practice leading to quality patient

outcomes. The essence of professional practice is moral,

legal, ethical responsibility and accountability for all

aspects of nursing practice (Corwin 1961, Kramer 1974).

The professional system of work organisation is not

synonymous with the complexity science world view par-

adigm, but there are some parallels, specifically emphasis

on ‘whole-task’ work, interconnection over fragmenta-

tion, relationships and interactions over solo perfor-

mance, networks over hierarchy, and influence over

control. Conversely, nursing’s recent emphasis on out-

comes over process is counter to complexity science’s

emphasis on direction over destination. These similarities

and differences illustrate that, in this increasingly complex

world in which we live and practice our profession, we

need to search and reach for the best in both paradigms.

Clinical Examples/Scenarios have long been used by

nurses and researchers to exemplify MP/SCs and other

issues (Kramer 1974, Davis et al. 1975, Kramer &

Schmalenberg 1977 , Schmalenberg & Kramer 1979,).

They are recommended for use in analysis/differentia-

tion of clinical reasoning and critical thinking (Lindberg

& Lindberg 2008, Pesut 2008, University of Newcastle

2009). They also demonstrate differences in practice, in

practice environments and in nurses’ clinical reasoning

and decision-making over time. These are evident when

a 1971 scenario (see below) is compared with a present

day MP/SC scenario (as shown in Box A):

‘It’s 4:30 p.m. You are the only RN on a 20-bed

post cardiac unit. Your nurse aide is on meal

break. While making rounds, you discover a

patient crying because she fears she will have a

repeat post-surgical psychotic break tomorrow

after her surgery. While comforting her, you

hear the dinner cart with its pots of food being

delivered. You know that you need to dish up

food and get trays out to patients, so that they

can eat and cart can be returned for delivery of

food to patients on other floors. What to do?

You need to stay with this patient, but the other

patients need their food… The dominant solu-

tion was to dish up/serve trays as this would

benefit the largest number of patients and dinner

cart is needed on other units’.

(Kramer 1974)

In addition to marked differences in hospital environ-

ments and nurse practice conditions in 1974 and today,

the above scenario also shows the lessening dominance

of Newtonian linear thinking in decision making: care

for 19 patients is more important than care for one

patient and the dinner cart was needed to serve food to

patients on other units. In the above reference, it is also

noted that new graduates indicated that they would get

better performance ratings from the supervisor if they

got the food served and the dinner cart returned.

Development of a potential best managementpractice

Analyses of qualitative interview study data and of the

EBMP project data just presented indicated that about

one-third of the NLRNs, clinical nurses and managers

perceived the complexity of patient RN assignments,

practice settings, patients’ internal and external environ-

ments and interaction among these from a CAS perspec-

tive, although they often did not use those words. The

following interview excerpts contributed to the decision

to utilize MP/SC scenarios and a CAS approach in the

development and testing of a best management practice

for the Getting Work Done issue. The first excerpt from

operating room nurses, illustrates a systems approach to

prioritization:

‘On any given day, a seemingly normal case can

go from routine to chaotic… From the new

grad’s perspective, everything was going fine.

Then the surgeon unexpectedly gets into the liver.

He yells for a ligasure machine. Tech calls for

more suture and lap sponges to mop up the

blood. Anaesthetist calls for more blood and in

the same breath, for a cell saver and heparin… In

a situation like this, new grads panic. Too many

people each wanting something different at the

same time. Truly they don’t know which way to

go first; its sheer chaos for them… Experienced

nurses would have heard blood being sucked into

the suction canister before announcement of the

bleed, and would know that the tech would need

more sponges and that the patient would need

more blood… Most seasoned nurses are giving

supplies to techs before they ask for them. Suc-

tion is high priority and necessary to repair the

vessel or lacerations and to give visualization to

the surgeon so he can see to fix whatever is

wrong… The key to new grads being successful

in situations like this is willingness to use all their

senses, knowledge and connections to learn and




to plan ahead and be able to manage and assess

the situation from a multiple system perspective’.

(Kramer et al. 2012a)

The following description of an effective NRP class

as well as interview data from many nurse managers

illustrates the necessity/value of looking at a clinical

unit as a whole, as a complex system, and helping

NLRNs identify priority systems for the dominant

patient population on the unit:

‘After ABC, for oncology patients–pain control is

top priority… In the ER, after ABC, next priority

is doing what you need to do to get patients home

or transferred out of the ER so there’s room for

other patients. I know that sounds very bureau-

cratic or money hungry, but we are here to provide

a service. You are not doing that if patients are

struggling to breathe or are in severe pain in the

waiting room, while others who have been seen

are lying there waiting to be transferred… I never

thought about it before but, in a way, that’s also

true on rehab. Who’s scheduled first for therapy?

You pass meds, do assessments, and get them

ready so they can make therapy appointments on

time. That’s why those patients are here’.

(Kramer et al. 2012c)

The practice

From all the MP/SC scenarios gathered, the Joe–Mrs

Alstairs dilemma (Box A) was selected for its applicabil-

ity across multiple clinical units. Nine of the 20 qualita-

tive study Magnet hospitals (Kramer et al. 2012a,c)

were selected for representative distribution by geo-

graphic location, type of hospital, and type of residency

program (Kramer et al. 2011). In these hospitals, on-

site investigators worked with nurse educators to

develop/present a NRP class/session for NLRNs about

8 months post-hire. NLRNs were asked to read the

Joe-Mrs. Allstairs (Box 1) scenario and, anonymously,

write down answers to three questions: (1) What would

you do in this situation? (2) How do you think you

would ‘feel about yourself as a nurse’ if you made and

acted on this decision? (3) What, if anything, could you

do to prevent such a situation from happening again?

The reason for this immediate, private commitment

was to stimulate individual, personal clinical reasoning

and decision-making based on data at hand. A private

decision or commitment to an intervention before class

discussion allowed the individual more freedom to

change his/her mind with fewer feelings of embarrass-

ment, defensiveness or inadequacy.

After completing the above, each NLRN placed his/

her anonymous responses into an envelope addressed to

the Health Science Research Associates authors. Educa-

tors then conducted the class discussion focused on the

scenario and the same three questions above. At end of

discussion, the NLRNs were asked to write down what

they thought of this activity–did they enjoy it and what

did they learn? Would they make different decisions

after the class than what they said as the beginning?

Anonymous responses were then placed in the same

envelope for mailing to authors. The only information

provided to educators was that Getting Work Done was

the dilemma or issue of highest concern to NLRNs and

the only one for which 907 nurse interviewees (Kramer

et al. 2012a,c) could not identify effective NRP strate-

gies. The reason for the initial private commitment to a

solution to the MP/SC dilemma, followed by discussion

and then re-evaluation was to ascertain whether the dis-

cussion helped NLRNs consider the possibility of valid

alternative solutions, a better view of themselves as

nurses and the efficacy of viewing the patient care unit as

a series of interrelated, interconnected parts (i.e. CAS).

After the class, educators were asked to complete a

questionnaire citing number of months NLRNs were

post-hire and an estimate of the percentage of NLRNs

who, at the end of the class, favoured the following:

(1) felt that there was one ‘right’ thing to do, (2) felt

bad or unprofessional because of the decision they

had initially made and (3) enjoyed/learned something

from the discussion. Educators were also requested to

provide their assessment of the usefulness of this class

activity in helping NLRN deal with MP/SC dilemmas.

Evaluation of best management practice

Critical appraisal and analysis of internal–particularly

the suggestions for improvement and clarification in

the NLRN sketch–and external data led the investiga-

tors to expect that when presented with a MP/SC sce-

nario, some NLRNs would use systems and

complexity thinking, and lateral rather than vertical

thinking (de Bono 1970) to support their clinical rea-

soning (University of Newcastle 2009, Alfaro-LeFevre

2013), while other would not. Although individual

responses to initial questions might well be along

Newtonian, linear lines (for example, one right answer

that would make NLRNs feel bad if they could not

do their best for both patients), it was expected that

after hearing peer viewpoints, decisions and rationale

for decisions, a larger percentage of NLRNs would

reflect complexity/systems thinking in their post-class

responses and descriptions of what they had learned



M. Kramer et al.

from the class discussion. Analysis of the evidence

indicates that this is what happened.

Ten classes, attended by 144 NLRNs, were held in

nine Magnet hospitals. Class size ranged from four to 45

with 75% of the classes having between 10 and 15

NLRNs. Number of months post-hire ranged from 6 to

12 months with 92% of the NLRNs between 7 and

9 months post-hire. In all but one hospital, the class was

held as a regular part of the integration stage of the NRP.

A total of 27 different solutions/actions were pro-

posed in response to the question: What would you

do in the Joe–Mrs Alstairs (Mrs A) MP/SC? These

were consolidated into five outcomes/goals with a

total of 11 action categories (Table 1). Seventy-five of

the 144 respondents (63%) proposed more than one

goal or solution. In response to the question, ‘How

would you feel about yourself as a nurse if you made

and carried out your decision’, replies from the 144

NLRNs were grouped into five categories from ‘very

positive’ to ‘very negative’ (Table 2). For the third

question, ‘What could you do to prevent such a situa-

tion from occurring again?’, responses were grouped

into four categories with eight actions (Table 3). The

NLRN responses to questions at the end of the class

Table 1

Goals, behavioural descriptions and frequency of selected actions as identified by participants before class discussion intervention

Goal/outcome Description of action/number of citations

A. Both patients receive care needed 1. Stay with Joe; call another RN discretely from within Joe’s room (cell, alert button?) to give

morphine to Mrs A (n = 52)

2. Stay with Joe a short time; explain about give meds to another patient. Give or find other RN to

give morphine to Mrs A. Return to Joe for as long as it takes to provide support he needs (n = 28)

3. Stay with Joe a short time (5 min); acknowledge his shock; ask Joe what support methods he

usually uses. Leave to give morphine to Mrs A, call pastoral care, chaplain, social worker, family

or NP to stay with Joe (n = 13)

4. Notify charge nurse that you will be tied up for some time; have responsibility for Mrs A and your

other patients transferred to other RNs (n = 2)

B. One patient receives care 1. Stay with Joe as long as he needs; write down the questions he has so physician can answer

them (n = 15)

2. Give morphine to Mrs A. Initiate pain consult/PCA pump for Mrs A. (n = 13)

3. Talk to Joe, then tell him you are leaving to get answers to his questions either by getting

physician back into the room or by going on-line and printing out web information for him (n = 6)

C. Both patients receive needed care;

develop ID plan of care

When physician asks you to join him to see Joe, ask physician:

1. Why he wants me? Ask him to wait 5 minutes while you give (or get another RN to give)

morphine to Mrs A; then go with physician to Joe’s room (n = 12)

2. What he is going to do? After he tells you, ask him what his plan of care is? Point out that Joe

will need both psychosocial support and information/answers for his many questions (n = 3)

D. Physician sanction 1. Inform charge nurse/manager about physician’s behaviour/handling of situation. Write physician

up for his behaviour (n = 13)

E. Decrease patient assignment 1. Ask charge nurse to reassign Joe or Mrs A to another nurse (n = 4)

PCA, patient-controlled analgesia; NP, nurse practitioner; RN, registered nurse; ID, interdisciplinary.

Table 2

Categories, descriptions and frequency of ‘how I would feel’ if selected action, as identified by participants before class discussion interven-

tion, is performed

Category Description of feelings/number of citations

A. Very positive* Like a real professional nurse; very good; like I had made the right decision and was able

to help both patients; confident and competent (n = 40)

B. OK, satisfied, comfortable As long as each patient received some of what they needed; satisfied that I had

done the best I could under the circumstances; I had my priorities straight, content

with decision (n = 21)

C. Hopeful that I would learn

‘right’ thing to do, challenged

Have faced these situations many times. I’m embarrassed to ask others what I should

have done first (n = 12)

D. Stressed, anxious, nervous Torn and conflicted between two patient’s needs; unsure of my knowledge and prioritizing,

blindsided by the physician (n = 24)

E. Schizophrenic, guilty, angry, very bad,

sad, heartbroken; blame self for inadequacies

Like a machine, less like a person; no-win situation; disappointed in self and in nursing;

unfeeling; hopeless; both patients clearly in pain; no other choice as I cannot do for both

patients at the same time (n = 47)

*I could really identify with Joe because I am a cancer survivor. Physicians expect nurses to take control of psychosocial support for patients

so this wasn’t as much of a dilemma for me.




Table 3

Goal/outcome, descriptions, and frequency of ‘how I would prevent re-occurrence’ as identified by participants before class discussion inter-

vention

Goal/outcome Description of actions/number of citations

A. RN–physician collaboration 1. Ask/discuss plan of care with physician before seeing Joe; discuss timing of psychosocial support and

providing information to Joe (n = 45)

2. Ask physician to delay visit to Joe while you or other RN give morphine (n = 36)

3. Ask physician not to leave until you have a few minutes with Joe to see what questions might need to

be answered immediately; while physician answers Joe’s questions, give morphine to Mrs A (n = 13)

B. Better pain management 1. Investigate pain control options; get order for increased dosage or get PCA pump; get pain management

consult (n = 12)

C. Physician sanction 1. Report physician’s behaviour and handling of patient to nurse manager; encourage development of better

bedside manner (n = 6)

2. Tell physician that it is very inappropriate for him to leave room after delivering these results (n = 2)

D. Not preventable 1. 07:00–11:00 hours is busiest time; other RNs would not be available to give Mrs A her morphine (n = 16)

2. Faced with this many times every day. No-one can do everything; have to be prepared for anything to

happen (n = 14)

PCA, patient-controlled analgesia; RN, registered nurse.

Table 4

Categories, descriptions, and frequency of ‘what learned from class and activity’ as identified by participants after class discussion intervention

Categories Description of ‘what was learned’ and number of citations

A. Very helpful; learned a great deal 1. Included suggestions for both professional functions–psychosocial and knowledge

transmission–needed by Joe, as well as professional nursing function for Mrs A.

(a) Good to hear perspectives of others; had no idea there were so many possible ‘right’ answers;

helpful to learn colleagues have same feelings and reactions that I do; good brainstorming; liked

team discussion (n = 50)

2. Clarification of management dilemmas/challenges

(a) Can delegate tasks to PCA but not care functions; when delegated, RN retains responsibility; in

professional teamwork/group practice, other RN is responsible for pre- and post-assessment

of patient (n = 8)

(b) Learned difference between prioritizing tasks and prioritizing patients (n = 7)

(c) Complexity of nursing; need to look at big (my assignment) picture/system and also bigger

(unit, physicians, other RNs and their patients) picture/system (n = 6)

(d) Time management (n = 3)

(e) Importance of pre-planning/preventative actions (n = 1)

3. Build self-confidence needed to be professional (n = 4)

(a) Speak up and ask physician his plan of care

(b) Discussing/explaining one’s ideas to peers

4. Learned more about myself and how I think/react; differences between critical thinking and

clinical reasoning (n = 2)

B. Great learning activity/scenario 1. Good exemplar; comparable to real life situation occurs regularly, every day; good example of

type of decision-making and clinical reasoning have to do (n = 21)

2. Examples and discussion like this provide opportunity to think outside the moment of occurrence;

help get past ‘task’ focus to a deeper level of involvement (n = 8)

3. More situational classes/discussion and less project work; more relevant to my practice than poster

projects (n = 3)

C. Differences by clinical unit 1. Different units have different patient problems, needs, and priority systems (n = 6)

2. Physical needs more important in ICUs (n = 3)

3. Learn more about alternative pain management (n = 3)

Very beneficial; made me think about other options that my unit environment does not foster (n = 3)

Value of RN–physician collaboration and the struggles other units face with this (n = 3)

D. School activity 1. We need to take on a full patient load in school so learn how to do this, but not possible because

of licensure (a non-licensed nurse can never be accountable & responsible for full patient load).

Nurses face these situations every day and each one is a little different; need to be prepared for

everything; why prioritizing is so important (n = 8)

E. NRP and second degree nurses 1. Average age of cohorts of second degree nurses is 30 years and all have had previous work

experience; needs to be considered in planning NRP; this exercise spanned the gap between

2nd degree and first degree nurses; we both benefited and learned from one another (n = 4)

F. Nothing new 1. Did not learn anything new; can’t control many situations; just have to do your best; grin and

bear it; don’t be so hard on ourselves (n = 4)

ICU, intensive care unit; NP, nurse practitioner; NRP, nurse residency programme; PCA, patient-controlled analgesia; RN, registered nurse.



M. Kramer et al.

were grouped into six categories with 15 detailed

actions (Table 4).

Analysis of educators’ post-class questionnaires indi-

cated that educators perceived that a smaller percent-

age of NLRNs felt bad, angry or conflicted about the

decisions they would have made after the class discus-

sion than what NLRNs indicated immediately after

reading the Joe–Mrs Alstairs scenario at the beginning

of the class (22% after compared with 49.3% before

the class discussion). Educators also reported that

after the class, NLRNs demonstrated increased recep-

tivity to the possibility that there was more than one

‘right’ decision depending upon unit, physicians, nurse

colleagues, care delivery system and availability of

other RNs. Educators in all but one hospital indicated

that they would very much like to incorporate this

practice or activity into their NRP.

Summary

There was overwhelming agreement (99%) among

NLRNs and educators that the MP/SC scenario analy-

sis was thought-provoking, beneficial, enlightening and

provoked sharing of many similar MP/SC scenarios.

This best management practice class was less meaning-

ful to NLRNs in specialty (children’s) hospitals, partic-

ularly when the scenario reflected a specialty different

from that of the NLRNs. A class with a mix of

NLRNs from various clinical units in the same hospital

was reported to be exceedingly beneficial for the fol-

lowing reasons. NLRNs learned that: (1) clinical units

defined professional nursing practice in different ways,

(2) priority systems of patient problems and needs var-

ied by units, and (3) support from professional team

members (RNs and physicians) was more the norm on

some units than on others. In two classes, educators

commented that the class discussion stimulated more

participation and contributions from NLRNs who, in

other NRP classes, were usually silent and non-partici-

pative; the reason for this was unknown.

The Joe–Mrs Alstairs scenario was less functional in

hospitals having robust intradisciplinary/interdisciplin-

ary family-centred or relationship-based care delivery

systems. The NLRNs indicated that this was because

these services and systems made the ‘best choice’ obvi-

ous and readily available. Comparison of NLRNs’

comments written immediately after reading the MP/

SC scenario, and educators’ responses to questions on

the post-class questionnaire indicated that two of the

expected outcomes/goals were achieved. At the begin-

ning of the class, almost half of the NLRNs responded

negatively–stressed, angry, conflicted (Categories D &

E in Table 2) – to the question ‘How would you feel

if you had carried out your decision?’ After the class

discussion, in six of the nine hospitals, educators esti-

mated that 100% of the NLRNs in their class would

no longer feel bad because they were unable to meet

the simultaneous needs of both patients.

Complexity systems theory or science was not men-

tioned or suggested to on-site investigators or educators

in any of the project instructions. On-site investigators

did, however, see the NLRN sketch and would know of

the suggestions NLRNs had made for its clarification/

improvement. They were not informed of the suggestions

made by the aggregate 348 NLRNs in the email survey

or that it involved perceiving each RN’s multiple patient

assignment, as well as the unit as a whole, as a complex

system with many interconnected and interrelated agents.

It was anticipated that, with the heavy confirmation from

participants that their MP/SC assignments were perceived

as a whole, as a single complex unit, NLRNs would cite

more than one avenue for resolution of the scenario

dilemma. They would reason that, dependening upon

the severity of the disturbance to the patient’s vortex, and

availability and collaboration with other agents in the

system (other RNs, physicians, management and assistive

personnel), multiple options would need to be consid-

ered. Data indicate that at the end of the class, one-third

of the NLRNs responded that they had learned that there

were multiple, not just one, correct answer to the MP/SC

dilemma. Half of the educators in the 10 classes

estimated the same. In one hospital that had close rela-

tionships with a College of Nursing and many NLRNs

educated by this College, NLRNs were clearly more

familiar with and used complexity concepts, theory and

principles in their clinical reasoning than did NLRNs

from other hospitals.

Conclusions and implications for nursingmanagement

Based on results from this EBMP study, the authors

conclude that this class has considerable potential as a

best management practice for resolving the MP/SC

issue frequently cited as NLRNs’ major problem in

Getting Work Done. Evidence indicates a reduction in

NLRNs’ negative feelings about consequences of their

MP/SC decisions and there was an increase in collabo-

ration with other disciplines after the class discussion.

Twelve years ago, in their analysis of the crisis in

health care quality, the IOM (Institute of Medicine &

Committee on Quality of Healthcare in America, 2001)

recommended viewing health-care organisations as

Complex Adaptive Systems. For those organisations not




already doing so, it is time that systems and complexity

science and its applicability to management of complex

systems be introduced to nurse residents. Porter-O’

Grady et al. (2010) stress that coursework in manage-

ment of complex systems is necessary for clinical nurse

leaders to develop the system thinking, and microsys-

tem-mesosystem level quality improvements that are

necessary to raise the quality of patient outcomes. The

complex systems that clinical nurses must manage also

demand this.

Another suggestion comes directly from NLRNs,

experienced nurses, managers and educators in two of

the hospitals participating in this EBMP project. It

started with several NLRNs verbally relating to their

fellow clinical nurses and managers as much of the

Joe–Mrs Alstairs situation as they could remember and

asking them what decision they would have made:

‘We received the shock of our lives. We thought

we had done such a good job but they brought

up facts and issues we hadn’t even thought of…One RN said: first off, this is probably a medical

diagnostic unit; you knew that Joe had had lots

of tests done. You should have expected that the

physician would be giving Joe the results of those

tests. So, when he asked you to join him, all you

needed to do was raise your eyebrows and he

would have laid out his plan of care. I wouldn’t

be the least bit surprised if it was not a common

practice for this physician to seek out the

patient’s RN when he had bad news to relay…There are two parts to “support” in a situation

like this–psychosocial and relaying specific infor-

mation that the patient asks for. Information

needs to be given in doses the patient can handle.

Most physicians dislike doing the emotional sup-

port bit; many believe that this is the job of the

RN and is an area where nurses excel! What you

need to do is to work out with the physician who

is going to do “what” and “when”. When you

both meet with the patient, you and the physician

discuss the joint plan of care with him. You say

something like: “Look Joe, we know this is a

shock to you. I’m going to stay here with you,

we’ll talk about it, I’ll call anyone you’d like and

then, as you have questions and need more infor-

mation, we’ll write those things down. We’ll

decide if we need to get in touch with Dr __ right

away or if you want to talk with him over the

phone, or if it can wait till he comes in tomor-

row” …You get the idea? Up front and open. All

three of you work out a plan with Joe’.

The final suggestion came from two clinical nurses in

another hospital, both of whom were enrolled in MSN

programs. It’s a take-off from the Nursing Executive

Advisory Center (2011) 15 best practices for enhancing

individual nurse investment in improvement of quality

of patient care. One of the advocated best practices is

‘Inter-assignment Rounding’ (i.e. rounding between

two clinical nurses and the physicians responsible for

the patients assigned to these nurses). Such rounding

provides opportunity for physicians and RNs to coordi-

nate/collaborate on patient plans of care, thereby

improving quality. Clinical nurses also reported that

informal meetings (Kramer et al. 2012a) with physicians

for discussion of clinical scenarios such as the one used

in this EBMP project and development of joint plans of

care ‘are terrific and result in much better patient care.

Acknowledgements

Participation in this evidence-based management

practice project required considerable time, effort and

commitment on the part of the on-site investigators,

clinical educators and residency coordinators in the

nine participating Magnet hospitals where the effective-

ness of this evidence-based best management practice

was evaluated. The authors acknowledge the generous

and enthusiastic participation and wish to thank: Shir-

ley Wiesman, Clinical Nurse Specialist and on-site

investigator, Barb Seliger, Education Specialist, Nurse

Orientation Educator, NICHE Site Coordinator, Aspi-

rus Wausau Hospital, Wausau, WI; Julie Gardner, Resi-

dent & Training Coordinator, Harrison Medical

Center, Bremerton, WA.; Beth A. Smith, Professional

Development Specialist, Nurse Residency Coordinator

and on-site Investigator, Hospital of the University of

Pennsylvania, Philadelphia, PA; Casey O’Brien, Clinical

Education Coordinator, Ann & Robert H. Lurie

Children’s Hospital of Chicago, Chicago, IL; Jane

Jostes-Wanek, Education Nurse Specialist, Donna Po-

duska, ACHE Chief Nurse Executive, Poudre Valley

Hospital, Fort Collins, CO; Roberta Basol, Care Center

Director, Intensive Care/Surgical Care and Clinical

Practice, and on-site Investigator, St Cloud Hospital, St

Cloud, MN; Janet C. Engvall, Graduate Nurse Resi-

dency Coordinator, Center for Professional Practice

Development, The Miriam Hospital, Providence RI; Pat

Horgan, Manager, Clinical Education; Beverly S. Kar-

as-Irwin, Director, Professional Practice and Research,

and on-site investigator, The Valley Hospital, Ridge-

wood NJ; Lauren R. Goodloe, Director of Medical &

Geriatric Nursing, Administrative Director–Nursing

Research and Assistant Dean for Clinical Operations;



M. Kramer et al.

Deborah Fisher, Clinical Director, Pediatric Palliative

Care & Pain Management, Nursing Research Facilita-

tor, Virginia Commonwealth University Medical Cen-

ter, Richmond, VA. We also thank Wendy C. Budin,

Director of Nursing Research and On-site Investigator,

NYU Langone Medical Center, New York City, NY,

for her generous participation in constructing Figure 1

(NLRN sketch) from the e-mail comments and

hand-drawn figures received from NLRNs.

Source of funding

Health Science Research Associates (HSRA) is a volun-

teer, non-profit association of nurse researchers and

mentors who are interested in and conduct research

focused on “Healthy work environments that enable

RNs(and particularly NLRNs) to engage in the profes-

sional practices essential for quality patient outcomes”.

HSRA is unincorporated and ineligible for grants.

Research is supported through honoraria, awards, pre-

sentation and consultation fees.

Ethical approval

The on-site investigators in each of the participating

hospitals obtained Review Board Approval through

their individual organizations.

References

Agnes M. & Guralnik D.B. eds (2001) Webster’s New World

College Dictionary, 4th edn. IDG Books Worldwide, Inc.,

Foster City, CA.

Alfaro-LeFevre R. ed (2013) What is critical thinking, clinical rea-

soning, and clinical judgement? In What is Critical Thinking and

Clinical Reasoning? 5th edn., pp. 1–23. Saunders, St Louis, MO.

American Nurses Credentialing Knowledge Center (2012) Com-

prehensive Magnet Workshops. Available at http://Mwork

[email protected], accessed 26 January 2012.

Anderson R.A. (2003) Nursing homes as complex adaptive

systems. Nursing Research 52 (1), 12–21.

Baghbanian A., Torkfar G. & Baghbanian Y. (2012) Decision-

making in Australia’s health care system and insights from

complex adaptive systems theory. Journal of Health Scope 1

(1), 29–38.

Berkow S., Virkstis K., Stewart J. & Conway L. (2009) Assess-

ing new graduate nurse performance. Nurse Educator 34 (1),

17–22.

de Bono E. (1970) Lateral Thinking: Creativity Step by Step.

Harper & Row, New York.

Cornell P., Herrin-Griffith D., Keim C. et al. (2010) Transform-

ing nursing workflow, part 1: the chaotic nature of nurse

activities. Journal of Nursing Administration 40 (9), 366–373.

Corwin R. (1961) The professional employee: a study of conflict in

nursing roles.American Journal of Sociology 66 (6), 604–615.

Davis M.Z., Kramer M. & Strauss A. (1975) Nurses in Practice:

A Perspective on Work Environments. CV Mosby, St Louis,

MO.

Donabedian A. (1988) The quality of care: how can it be

assessed? Journal of the American Medical Association 260,

1743–1748.

Ebright P.R., Patterson E.S., Chalko B.A. & Render M.L.

(2003) Understanding the complexity of registered nurse work

in acute care settings. Journal of Nursing Administration 33

(12), 630–638.

Gambino M.L. (2008) Complexity and nursing theory: a seismic

shift. In On the Edge: Nursing in the Age of Complexity(C.

Lindberg, S. Nash & C. Lindberg eds), pp. 49–72. Borden-

town, NJ, Plexus Press.

Institute of Medicine and Committee on Quality of Healthcare

in America (2001) Crossing the Quality Chasm: A New

Health Care System for the 21st Century. National Acade-

mies Press, Washington DC.

Institute of Medicine of the National Academies (2004) Keeping

Patients Safe: Transforming the Work Environment of

Nurses. National Academies Press, Washington DC.

Kramer M. (1974) Reality Shock: Why Nurses Leave Nursing.

C.V. Mosby Co., St Louis, MO.

Kramer M. & Schmalenberg C. (1977) Path to Biculturalism:

Conflict Resolution; the Mating of Dreams and Reality.

Contemporary Publishing, Inc., Wakefield, MA.

Kramer M. & Schmalenberg C. (2012) Magnet hospitals: institu-

tions of excellence. kommentar: institutions of excellence. Pflege:

Die Wissenschaftliche Zeitschrift f€ur Pflegeberufe 4, 299–304.

Kramer M., Schmalenberg C. & Maguire P. (2010) Nine struc-

tures and best leadership practices essential for a magnetic

(healthy) work environment. Nursing Administration Quar-

terly 33 (4), 4–17.

Kramer M., Maguire P., Brewer B. & Schmalenberg C. (2011)

Clinical nurses in magnet hospitals confirm productive,

healthy unit work environments. Journal of Nursing Manage-

ment 19, 5–17.

Kramer M., Brewer B. & Maguire P. (2013a) Impact of healthy

unit work environments on new graduate nurses’ environmen-

tal reality shock. Western Journal of Nursing Research 35

(3), 348–383. Available at: http://wjn.sagepub.com/content/

early/recent, accessed 11 March 2011.

Kramer M., Maguire P., Halfer D., Brewer B. & Schmalenberg

C. (2013b) Nurse Residency programs: components and strat-

egies effective in professional socialization of newly licensed

registered nurses. Western Journal of Nursing Research 35

(4), 459–496. Available at: http://wjn.sagebub.com/cgi/

content/abstract/0193945911415555, accessed 4 August 2011.

Kramer M., Maguire P., Halfer D. et al. (2012a) The organiza-

tional transformation power of nurse residency programs.

Presented at the North Star Summit Invitational conference,

June 15, 2011. Nursing Administration Quarterly 36 (2),

155–168.

Kramer M., Halfer D., Maguire P. & Schmalenberg C. (2012b)

Impact of healthy work environments and multistage nurse

residency programs on retention of newly licensed registered

nurses. Journal of Nursing Administration 42 (3), 148–159.

Kramer M., Maguire P., Schmalenberg C. et al. (2012c) Strate-

gies and components of nurse residency programs effective in

new graduate nurses’ integration and management of profes-

sional role responsibilities. Western Journal of Nursing




Research 35 (4), 459–496. Available at: http://wjn.sagebub.

com/cgi/content/abstract/0193945911415555, accessed 4 August

2011.

Krugman M., Bretschneider J., Horn P.B., Krsek C.A., Moutafus

R.A. & Smith M.O. (2006) The national post-baccalaureate

graduate nurse residency program: a model for excellence in

transition to practice. Journal for Nurses in Staff Development

22 (4), 196–205.

Levin R. (2008) Evidence-based practice: if it ain’t broke, don’t

fix it. Research and Theory for Nursing Practice: An Interna-

tional Journal 22 (3), 168–170.

Lindberg C., Nash S. & Lindberg C. (eds) (2008) On the Edge:

Nursing in the Age of Complexity. Plexus Press, Bordentown,

NJ.

Lindberg C. & Lindberg C. (2008) Nurses take note: a primer

on complexity science. In On the Edge: Nursing in the Age of

Complexity(C. Lindberg, S. Nash & C. Lindberg eds),

pp. 23–48. Plexus Press, Bordentown, NJ.

Mark B.A. (1992) Characteristics of nursing practice models.

Journal of Nursing Administration 22 (11), 57–63.

Nursing Executive Advisory Center (2011) Instilling Frontline

Accountability: Best Practices for Enhancing Individual

Investment in Organizational Goals, pp. 61–65. Advisory

Board Company, Washington, DC.

Nursing Executive Center (2007) The Nursing Executive Center

New Graduate Nurse Performance Survey. Advisory Board

Company, Washington, DC.

Paterson B.L., Thorne S.E., Canam C. & Jillings C. (2001)

Meta-Study of Qualitative Health Research: A Practical

Guide to Meta-Analysis and Meta-Synthesis. Sage Publica-

tions, Thousand Oaks, CA.

Pellico L.H., Brewer C.S. & Kovner C.T. (2009) What newly

licensed registered nurses have to say about their first experi-

ences. Nursing Outlook 57 (4), 194–203.

Pesut D.J. (2008) Thoughts on thinking with complexity in

mind. In On the Edge: Nursing in the Age of Complexity

(C. Lindberg, S. Nash & C. Lindberg eds), pp. 211–238.

Plexus Press, Bordentown, NJ.

Porter-O’Grady T., Clark J.S. & Wiggins M.S. (2010) The case

for clinical nurse leaders: guiding nursing practice into the

21st century. Nurse Leader February 8 (1), 37–41.

Rickles D., Hawe P. & Shiell A. (2007) A simple guide to chaos

and complexity. Journal of Epidemiology and Community

Health 61, 933–937.

Schmalenberg C. & Kramer M. (1979) Coping with Reality Shock:

Voices of Experience. Nursing Resources, Wakefield, MA.

Selanders L.C. (1998) The power of environmental adaptation:

Florence Nightingale’s original theory for nursing practice.

Journal of Holistic Nursing 16, 247–263.

Shirey M.R. (2008) Nursing practice models for acute and criti-

cal care: overview of care delivery models. Critical Care

Nursing Clinics of North America 20 (4), 365–373.

Sturmberg J.P., O’Halloran D.M. & Martin C.M. (2012)

Understanding health system reform–a complex adaptive sys-

tems perspective. Journal of Evaluation in Clinical Practice

18, 202–208.

Titler M.G., Kleiber C., Steelman V.J. et al. (2001) The Iowa

model of evidence-based practice to promote quality care. Crit-

ical Care Nursing Clinics of North America 13 (4), 497–509.

University of Newcastle (2009) Clinical Reasoning: Instructor

Resources University of Newcastle. School of Nursing and

Midwifery, Faculty of Health, Newcastle.



M. Kramer et al.

Changing our lens: seeing the chaos of professional practice as complexity

Documents

Transcript of Changing our lens: seeing the chaos of professional practice as complexity