Applied Ergonomics 47 (2015) 345e354

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Applied Ergonomics journal homepage: www.elsevier.com/locate/apergo

Strategic threat management: An exploration of nursing strategies in the pediatric intensive care unit Francis T. Durso a, *, Ashley N. Ferguson a, Sadaf Kazi a, Charlene Cunningham b, Christina Ryan b a b

School of Psychology, Georgia Institute of Technology, 654 Cherry Street, Atlanta, GA 30332, USA Nursing Research and Evidence-Based Practice, Children's Healthcare of Atlanta, GA 30329, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 3 October 2014

Part of the work of a critical care nurse is to manage the threats that arise that could impede efficient and effective job performance. Nurses manage threats by employing various strategies to keep performance high and workload manageable. We investigated strategic threat management by using the ThreatStrategy Interview. Threats frequently involved technology, staff, or organizational components. The threats were managed by a toolbox of multifaceted strategies, the most frequent of which involved staff-, treatment- (patient þ technology), examination- (patient þ clinician), and patient-oriented strategies. The profile of strategies for a particular threat often leveraged work facets similar to the work facet that characterized the threat. In such cases, the nurse's strategy was directed at eliminating the threat (not working around it). A description at both a domain invariant level e useful for understanding strategic threat management generally e and a description at an operational, specific level e useful for guiding interventions– are presented. A structural description of the relationship among threats, strategies, and the cues that trigger them is presented in the form of an evidence accumulation framework of strategic threat management. © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Keywords: Strategies Interviews Nursing

1. Introduction Healthcare delivery is a domain in which highly skilled workers must understand the situation well enough to adapt to changes in a way that keeps their performance high while ensuring their workload is within limits. Nursing is an integral part of that healthcare system. Nurses spend more time with patients than any other healthcare provider (DeLucia et al., 2009). They routinely engage in decision making and problem solving behavior (Tucker et al., 2002). For example, nurses in the pediatric intensive care unit (PICU) switch between tasks every 40 s and face high workload due to frequently interleaving tasks (Douglas et al., 2013). Tucker (2004) found that nurses spend approximately 42 min of each 8-h shift dealing with operational failures. Previous literature has focused on classifying such obstacles that nurses face. Faye et al. (2010) identified failure modes occurring in the medication management process and rated them based on likelihood of occurrence,

* Corresponding author. Tel.: þ1 404 894 6771. E-mail address: [email protected] (F.T. Durso). http://dx.doi.org/10.1016/j.apergo.2014.09.002 0003-6870/© 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.

impact on the patient, and impact on the nurse. They found that the most critical failure modes were related to equipment, the organization, and the patient. The work-system model (Smith and Carayon-Sainfort, 1989) points to task, organization, environment, equipment/technology, and the individual as five types of performance obstacles. The System Engineering Initiative for Patient Safety (SEIPS) model describes the interaction of the work system design and these five obstacles (Carayon et al., 2006). Similarly, Itoh et al. (2009) present a human error taxonomy that identifies communication, staff, patient, task, equipment, organizational, and environmental factors as possible contributors to errors. Borrowing from the threat and error management framework (Helmreich et al., 1999), we can view obstacles or operational failures that decrease an operator's effectiveness and increase her or his workload as threats to performing a task. Operators manage threats and errors by adopting strategies that allow them to accomplish the task in spite of the presence of these operational threats. Strategies are an important part of nursing. Carney (2009) searched CINAHL and PUBMED indexed journals for the words strategy, nurse, and management in the title and found about 8% of the titles referred to strategy. However, many of the articles on strategy were concerned

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with organizational strategies or policy issues (e.g., Amalberti and Hourlier, 2011). Some were aimed at social interaction strategies, such as strategies to ameliorate interpersonal conflicts (e.g., Stayt, 2007) and a few at job coping strategies (e.g., sympathy burnout, Yoder, 2010; male nurse minority, Asakura and Watanabe, 2011). At a clinical level, a number refer to specific diseases or treatments (e.g., removal of catheters; Griffiths and Fernandez, 2007). However, there have been only a few studies looking at general strategies used by nurses “in the moment” to manage healthcare delivery. When involved in direct patient care, nurses adapt to events in the environment e interruptions, communications, operating technology, patient status e and engage in goal-directed, “operational problem-solving behavior” in the process (Holden et al., 2012). Holden et al. (2012) found that when faced with new problems, such as the introduction of bar-coded medication administration, nurses applied preexisting problem solving behaviors, created new behaviors, or were unable to solve the problem. Nurses reprioritize and continuously engage in problem solving and modifying their task load due to the constant change in patients' conditions (Tucker and Spear, 2006). Nurses need strategies to manage the demands produced from administrative nursing tasks and even non-nursing tasks. Henneman and colleagues (Henneman et al., 2006; 2010) have found that critical care nurses use a variety of strategies to identify, interrupt, and correct medical errors. Nurses' strategies either depended on the nurses' knowledge (i.e., of the patient, coworkers, plan of care, policies/procedures) or methods of evaluating the situation (i.e., surveillance, anticipation, doublechecking, questioning, awareness of the “big picture,” and experiential knowing). Experiential knowing, for example, grew out of nurses' recollections of when they had “stopped because of some cue that something was not right” (Henneman et al., 2006, p. 74). Upon identifying an error, nurses attempted to “interrupt the error” or engaged strategies to correct it. Nurses use a variety of strategies to recognize errors and to decrease the adverse effects of those errors. Thus, while there is research on both threats and the strategies to manage them, it has been difficult to elicit such information from skilled nurses and to systematically analyze that information. One knowledge elicitation method aimed specifically at threats, strategies, and the cues that elicit them is the Threat-Strategy Interview (TSI; Durso et al., 2015). The TSI presents nurses with a specific task to which the nurses generate potential threats. Generating threats to a task came naturally to the nurses, and from this context flowed strategies used to manage a particular threat. Then, given this context of a strategy to a specific threat, nurses were able to generate the cues that led them to choose that strategy over the other strategies they had available. Anecdotally, articulating the cues often came with an introspective “aha” that suggested the nurse had brought to consciousness a connection previously tacit and part of her or his intuition (Kahneman and Klein, 2009; Klein, 1998). Through the TSI we hope to understand better Henneman's nurses when they spoke of “some cue that something was not right.” The purpose of the current study was to use the TSI to elicit strategic knowledge, create a taxonomy of nursing threats and strategy use, map threats and strategies, and develop a network describing the relationships among threats, strategies, and the cues that evoke them. 2. Method 2.1. Participants Participants were 9 nurses (one male) employed at the PICU and cardiac ICU (CICU) at Children's Healthcare of Atlanta's (CHOA)

Egleston and Scottish Rite pediatric hospitals. The nurses were between 31 and 63 years of age and all had worked at CHOA in a PICU or CICU for at least five years (M ¼ 14.6, SD ¼ 9.8). All nurses received a $50 gift card for participation. 2.2. Procedure Nurses were individually interviewed. All interviews were conducted at the workplace of the nurses and at a time of their convenience. The duration of each interview was approximately 2 h. Following some basic questions about demographics and nursing experience, the interviewer gave a critical work-related task, “management of an infant experiencing sudden respiratory distress while on ventilator support.” This task was chosen in consultation with two senior PICU nurses who indicated it to be an important task in which PICU and CICU nurses commonly engaged. The nurses were then asked a battery of questions about their specific experiences with the critical task. The nurses were told: “Now I want you to imagine that you have entered a situation in which you need to manage an infant experiencing sudden respiratory distress while on ventilator support. So, think about entering the acute situation.” The first six nurses were also asked to “Tell me something that might happen that would threaten your effective management of the situation” to elicit threats to this task. After eliciting threats from six of the nurses, we gave the remaining three nurses a list of threats generated in the previous interviews and asked them to select threats with which they were familiar. This helped to ensure multiple interviews for many of the elicited threats. If a threat were chosen by the nurse or the researcher for additional consideration, we then sought to elicit the cues used to establish and confirm the particular threat situation: “How do you become aware of the threat?” We refer to these as cues-to-threat. The nurse was then asked, “Tell me a strategy you use to keep the threat from interfering with management of an infant experiencing sudden respiratory distress while on ventilator support. You can think of a strategy as a plan or a method to achieve a goal. A strategy is not usually one action, but we sometimes think of it as an action.” Finally, the nurses were asked to give the cues they used to nominate or select a strategy. Such cues-to-strategy were elicited from the questions: “When would you choose to try this strategy? In what context or situation would you use this strategy? What would have to be true for you to use this strategy in the acute situation? This might be something in the environment, something in the way you’re thinking, or something about the situation as a whole.” 3. Results and discussion 3.1. Threats Each of the six nurses who were asked to generate threats produced between 3 and 9 threats, for a total of 39 threats (M ¼ 6.5, SD ¼ 2.6). Table 1 presents the elicited threats as well as the number of nurses from whom the threat was elicited. We began by classifying the threats based on the work facet of the threat. This was a classification scheme that takes advantage of prior schemes from Carayon et al. (2006) and Itoh et al. (2009). Table 2 compares the three classification schemes. Clinician rather than staff (Itoh et al.) or person (Carayon et al.) makes it clear such threats dealt with the facets of the nurse (e.g., skills, fatigue, confusion [situation awareness]). In our elicitation of threats, “staffing” threats (e.g., physician unavailable) struck us as being

F.T. Durso et al. / Applied Ergonomics 47 (2015) 345e354 Table 1 Threats for the task of “management of an infant experiencing sudden respiratory distress while on ventilator support.” Distinct threats

1 2 3 4 5 6 7 8 9 10 11 12 13 14

15 16 17 18 19 20 21 22 23 24

25 26 27 28 29 30 Total

# Nurses that generated this threat

# Nurses interviewed on this threat

Inadequate sedation Ambu bag unavailable Not enough support staff members Physician is unavailable Something wrong with ventilator Overstimulation from patient's family Endotracheal tube dislodged Didn't have a good history on the patient Patient agitation Drugs and narcotics aren't there Paired patient

3 3 3

3 2 2

2 2

2 1

1

3

1

2

1

1

1 1

1 1

1

1

Not having respiratory therapist support Not having experienced nurses Not having the appropriate size endotracheal tube Endotracheal tube covered with drape Not having the support of team members Inadequate supplies Not having other nurses to help you bag Intubation cart not there Not having correct resuscitation equipment Dealing with computer Equipment failure Ambu bag not working Having to review H&P, Notes, Lab Results, etc. on computer Suction not working Suction not available Child medically fragile Lack of intravenous access No arterial line Not having emergency equipment readily available

2 1 1

1 1 1 1 1 1 1 1 1 1

Table 2 Comparison of Carayon et al.'s (2006), Itoh et al.'s (2009), and the Work Facet classification scheme. The taxonomies differ primarily in their treatment of the humans involved in the system. SEIPS model-work system or structure (Carayon et al., 2006)

Work facet classification

Human error taxonomy for analyzing healthcare incident reports-contextual conditions (Itoh et al., 2009)

Tasks Technologies and Tools Environment Organization

Task Technology Environment Organization Staff Communication Clinician Patient

Task Equipment/Materials Environment Organization

Person

Communication Staff Patient

Three judges (authors F.D. & A.F., and another researcher) independently classified the distinct threats (N ¼ 30) in Table 3. Reliability ranged from 80% to 90% (M ¼ 85.6%) across the three pairwise reliability calculations. Disagreements were resolved by discussion. Judges had a background in healthcare research but were not clinicians. The classification was vetted by a PICU nurse consultant. Most of the threats generated were technology threats, followed by staff and organization. This resonated with previous research, which found that medication problems and orders, supply issues (Tucker and Spear, 2006), delays in medication, and unavailable equipment (Gurses and Carayon, 2007, 2009) occurred frequently. Threats due to the task, clinician, or communication were each only articulated once in 39 threats. The paucity of these threats could be due to a number of factors, including those related to the respiratory distress task we used. However, the possibility that nurses may be less acutely aware of these obstacles is a provocative one that deserves further investigation. 3.2. Strategies

1 1 1 1 1 1 39

347

19

worthy of their own class; often staffing was readily apparent from the nurses' comments (e.g., “I couldn't get the [respiratory therapist] to answer … he's down doing a transport or taking someone to another department or surgery or MRI”). Consistent with Itoh et al.'s and Carayon et al.'s nomenclature some staffing threats indeed seemed to be due to organizational problems (e.g., not enough support staff), however some seemed to be more transient (e.g., “you're hollering out to someone and no one's coming”). Thus, in our classification scheme, staff (referring to other staff members) is its own category. Similarly, a missing piece of technology was considered to be a technology threat unless there was some protocol, regulation, or policy stating that the technology was supposed to be present. When a policy requiring the presence of a piece of technology was violated, this was considered an organization threat.

3.2.1. Determining strategies Given the number of volunteers and the time each had available to participate in our study, we were able to conduct 19 complete structured interviews on 11 distinct threats (distinct threats 1e11 in Table 1). For these 11 distinct threats, we continued the interview process to elicit strategies used to manage the situation. The researcher and participant decided which threat(s) to interview based on the nurse's familiarity and interest in exploring the strategies for that threat. Using the procedures described in Durso et al. (2015) judges (authors F.D., A.F., S.K., and other researcher) classified the 401 actions nurses made regarding how they managed the threats into 176 strategies. Some strategies were simple, independent strategies in the sense that they did not cluster with other strategies (e.g., the drugs strategy in Fig. 1). Two or more simple strategies could cluster (e.g., call physician and call a different doctor in Fig. 1) to form sub-strategies within a superordinate strategy (e.g., get more sedation). Finally, we added a label to the strategies. We refer below to the superordinate itself as a complex strategy. All strategies obtained were vetted by a PICU nurse consultant. The 176 strategies yielded 58 simple, independent strategies, and 118 sub-strategies; these two types of strategies were superordinated into 48 complex strategies. Each nurse-threat interview on average yielded 9.26 strategies (SD ¼ 3.89) of which an average of 3.05 (SD ¼ 1.31) were independent simple strategies and 2.53 (SD ¼ 1.50) were complex strategies with 2.5 (SD ¼ 0.56) substrategies per complex strategy.

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Table 3 Work Facet classification of threats to performing the task of “management of an infant experiencing sudden respiratory distress while on ventilator support”. Numbers in parenthesis represent the number of interviews conducted for that threat. The last row represents the frequency with which a threat of that work facet was generated. Clinician factors

Communication factors

Environment factors

Organization factors

Patient factors

Staff factors

Task factors

Technology factors

Inexperienced nurse

Not having support of team members

Endotracheal Tube Covered with Drape

Didn't have Ambu bag available or set up (3)

Patient Agitation (1)

Paired Patient (1)

Not having the appropriate size ET tube

Overstimulation from family (3)

Didn't have a good history on the patient (1) Not having correct resuscitation equipment

Child medically fragile

Not having respiratory therapy support Physician Unavailable (2)

Suction not available

No arterial line

Lack of IV access

ET tube dislodged (2)

Inadequate Supplies

Not having other nurses to help you bag Not Enough Support Staff Members (2)

Intubation Cart not there Something wrong with ventilator (1)

Not having emergency equipment readily available Having to review history and physical examination notes, Lab Results, etc. on computer

1

1

4

8

3.2.2. Classifying strategies 3.2.2.1. Threat engagement classification. We began our classification of strategies by having two judges (authors F.D. & A.F.) classify each strategy as one of four types: prevent, mitigate, work-around, or ignore. Reliability was 87%. This scheme is similar to Holden et al.'s (2012) who state that problems may be removed, manipulated, or worked around. Holden et al., following Tucker and Edmondson (2003), also classify problem solving as first or second order. In our study, all strategies were classified as first order according to a pair of judges. Preventative strategies were those that the nurse set in motion before the acute situation arose, for example, making certain the Ambu bag was at the bedside at the start of a shift. Even though we asked during the TSI that they imagine the acute situation, nurses occasionally gave preventative strategies. However, our procedure of imagining the acute situation likely reduced the number of preventative strategies nurses articulated. Mitigation strategies were those that attempted to address the threat directly by reducing or eliminating the impact of the threat (cf., Holden et al., 2012 who use the terms remove and manipulate). For example, when threatened with a ventilator malfunction, asking a respiratory therapist to inspect the machine would be a mitigation strategy. Work-around strategies (see Halbesleben et al., 2008; Koopman and Hoffman, 2003) were those in which the clinician did not try to eliminate the threat, but instead continued to perform main task duties but in a way that recognized the threat existed. Thus, these strategies were theoretically different from strategies that would have been used had the threat not existed. An example of a workaround strategy for the threat of not having the desired drugs nearby was to give an available drug. Note, that in our classification of strategies, a work-around could include those that violated protocol or policy (Koppel et al., 2008) but also strategies that were allowed by policy.

Drugs & narcotics aren't there (1)

4

6

1

Dealing with computer Equipment failure Ambu bag not working Suction not working Inadequate sedation (3) 14

Finally, on rare occasions nurses identified a strategy that ignored the threat. Unlike the work-around, an ignore strategy does not modify procedures in the face of the threat. Distinguishing between a work-around and an ignore strategy often depended on the communicative context from the transcripts. An example of an ignore strategy for the threat of having two critical patients needing care (paired-patient) was to not worry about the less critical patient. Because we were using highly experienced nurses as our participants, one might expect few ignore strategies. Clearly, virtually all strategies elicited in our interviews with experienced nurses were either work-around (39%) or mitigation (54%) strategies. Only a few preventative strategies (5%) were mentioned, although given that they were to imagine being in the acute situation preventative strategies that they may routinely employ may have not been offered. Virtually no strategies were articulated that indicated the nurse had ignored the presence of the threat (2%). 3.2.2.2. Work facets classification. We next classified the strategies using the same modified rubric borrowed from Carayon et al. (2006) and Itoh et al. (2009) that we used to classify the threats. Table 4 presents definitions of the work facet strategies that we used. Unlike the threat engagement classification of strategies, considering the work facet that was affected or managed by the strategy often suggested more than one facet. Indeed, it is possible a priori to imagine patterns of classifications that are meaningful. For example, the concept of a “treatment” strategy would minimally involve a strategy that involves the patient and technology (e.g., administer drugs). An “examination” would minimally involve the patient and an increase in the clinician's understanding of the situation (e.g., perform a physical exam). “Delegation” would implicate both the task and staff (e.g., ask another nurse to check on your other patient).

F.T. Durso et al. / Applied Ergonomics 47 (2015) 345e354

349

Fig. 1. Chart of one nurse depicting the threat of inadequate sedation for the task of “managing an infant experiencing sudden respiratory distress while on ventilator support” along with its cues-to-threat, cues-to-strategies, strategies, sub-strategies, and actions.

Therefore, rather than force a strategy into one particular class, two judges (authors F.D. & A.F.) classified each strategy into as many classes as they desired while still making the classification informative. Although we implied one, two, or three categories

would be appropriate, on occasion a judge would select more. Reliability for this classification was 96%. Fig. 2 shows the distribution of work facets reflected in the strategies. Either by itself or in combination with other facets,

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Fig. 1. (continued).

Table 4 Strategy Work Facet classification definitions. Category

Strategy definitions

Clinician

A plan or method that directly manages or changes characteristics of the PICU/CICU healthcare provider including getting rest, increasing knowledge, creating artifacts (e.g., to improve memory), paying attention, maintaining situation awareness and motivation, controlling stress and other factors of the clinician. A plan or method that directly manages or changes the information exchange or collaboration between the PICU/CICU healthcare provider and other healthcare providers, other members of the hospital staff, members of the hospital administration, the patient, or the family. Essentially information is exchanged or exchanged more clearly between two individuals. A plan or method that directly changes the environment including the layout, object location, lighting, sound level, and other components of the space (e.g., family) that could produce confusion or distraction. A plan or method that directly manages or changes organizational policies, procedures, rules and regulations, or documents including medical documents, checklists, and manuals. A plan or method that directly changes characteristics of the patient including affecting the patient's health, comfort, or mental state. A plan or method that directly manages, redistributes, or leverages the crew size or personnel type currently working in the situation. Almost invariably, such strategies would involve communication, but if the ultimate use of communication was only in this naturally redundant sense, the strategy was considered a staff strategy. A plan or method that directly changes characteristics of the overall task itself including the demands, complexity, familiarity, number of goals, interruptions, or workload. A plan or method that directly leverages, manages, or alters equipment or materials (including biotechnology and medications).

Communication

Environment

Organization

Patient

Staff

Task

Technology

patient (41%) and staffing (40%) were most often implicated in the strategies, with technology (30%) and clinician (23%) also fairly often involved in the strategic thinking of our nurses. The nurses rarely articulated organizational strategies (1%) either solely or with other facets. It is also noteworthy that strategies offered by our nurses rarely (6%) touched on communication beyond simply calling for assistance. Looking at the strategic facets in more detail yielded the 25 patterns that appear in Table 5. The most frequent pattern was staff-alone which was 31% of the strategies given. The treatment pattern (18%, patient þ technology) together with staff-alone accounted for half of all the strategies. The next most frequent patterns improved the clinician's situation awareness: exams (7%, patient þ clinician), equipment inspections (5%, technology þ clinician), and assessing treatment (5%, patient þ technology þ clinician). A deeper appreciation of Table 5 can be achieved by considering the actual strategies that gave rise to the categories. Table 6 gives groupings of nursing strategies for the patterns discussed above in terms of the PICU/CICU level strategy. In addition to explicating the broad categories of Table 5, Table 6 conveys strategies at a level that may be more likely to facilitate interventions into design, training, or policy at the PICU/CICU level. For example, it is clear from Table 6 that most treatment strategies involve either sedation or manual ventilation. Far more staff strategies involve calling a physician than calling the respiratory therapist. These kinds of base rates among experts may be valuable in training new nurses. 3.3. Mapping strategies to threats We next mapped the strategies that nurses offered to the threats that they faced. When we looked at the threat engagement classification, it was evident that threats dealing with the environment, the

Percent

F.T. Durso et al. / Applied Ergonomics 47 (2015) 345e354

Table 6 A breakdown of the strategy Work Facet patterns from Table 5 into groupings at the level of the PICU/CICU.

45 40 35 30 25 20 15 10 5 0

Work Facet of the Strategy Fig. 2. Classification of strategies by work facet.

patient, or staff tended to be resolved by mitigation. Task and organization threats were typically worked-around. For technology threats, nurses mitigated the threat about half of the time and worked-around them about half of the time. The mapping of threats and strategies using this taxonomy appears in Table 7 on the far right. For each interviewed distinct threat, we then computed the mean frequencies of strategy classifications to create a strategy profile. For example, the strategy profile for the threat of physician unavailable was characterized primarily by staff strategies, with an occasional patient or technology strategy, but never any task, organization, or environment strategies. Table 7 shows the strategy profiles for each threat classified into the eight threat types. These classifications into threat categories tended to exhibit similar strategy profiles. For example, the two staff threats had strategy profiles that correlated 0.91. The strategy profiles for the technology threats also correlated highly, ranging from 0.76 (endotracheal tube dislodged and ventilator malfunction) to 0.96 (endotracheal tube dislodged and inadequate sedation). Our judges placed two threats, Ambu bag missing and no patient history, into the organization threat classification. These two threats

Table 5 Work Facet classification strategy pattern frequencies and percents. Pattern name

Pattern

Frequency

Percent

Staff Treatment Exam Patient Equipment/Meds Inspections Assessing Treatments Delegate Environment

Staff Patient þ Technology Patient þ Clinician Patient Technology þ Clinician

55 32 13 13 8

31.43 18.29 7.43 7.43 4.57

Patient þ Technology þ Clinician

8

4.57

Task þ Staff Environment Environment þ Communication Task Patient þ Task Clinician Technology Communication þ Staff Environment þ Clinician Organization Environment þ Staff Clinician þ Organization Staff þ Clinician Technology þ Task Communication þ Clinician þ Staff Patient þ Clinician þ Staff Environment þ Communication þ Clinician Patient þ Technology þ Staff Communication

7 5 5 4 4 3 3 3 3 2 1 1 1 1 1 1 1

4.00 2.86 2.86 2.29 2.29 1.71 1.71 1.71 1.71 1.14 0.57 0.57 0.57 0.57 0.57 0.57 0.57

1 0

0.57 0.00

Task Clinician Technology Consult Organization

Communication

351

Pattern of work facets

Frequency

Staff Get physician (for X) Get someone to help (for X) Therapist Code/PICU alert

24 18 7 5

Treatment (Patient þ Technology) (Extra) sedation (Pull tube) bag and mask Paralytic Extubate Restraints Medication

10 7 3 2 2 2

Exam (Patient þ Clinician) Assess (patient, facial expression) (Reposition and) listen to breathing/lungs

4 3

Patient Continue working on/treat patient Comfort patient CPR Manage the (more) critical patient

4 2 2 2

Equipment inspections (Technology þ Clinician) Check (monitor, ventilator, tube) Initial test of bag Plan meds

3 2 2

Assessing treatments (Patient þ Technology þ Clinician) Check IV (access) Airway, breathing, and circulation (ABCs)

4 3

did not have similar strategy profiles (r ¼ 0.11) suggesting the organization threat classification may be particularly broad and nebulous. Interestingly, the strategy profile associated with the threat of overstimulation from the patient's family was unlike any other strategy profile, producing primarily negative correlations with virtually all of the other profiles. This suggests that this particular threat is quite unlike the other tasks with which nurses deal. In fact, a separate literature on interacting with the family has emerged in the nursing literature (e.g., Miracle, 2006; Soderstrom et al., 2003; Stayt, 2007). An inspection of Table 7 suggests that for the most part a particular type of threat tended to be managed by a strategy dealing with a similar resource. For example, staff threats were handled by staff strategies, environment threats by environment strategies, patient threats by patient strategies. If a threat was not handled by a strategy of the same type, it tended to be handled by patient strategies. The mapping of threats and strategies using the Work Facets classification presented in Table 7 is complicated by the fact that, by chance, some combinations of threat and strategy are more likely than are others. For example, given that most of the threats were technology and most of the strategies were classified as patient, then finding a large number of technology threats handled by patient strategies could be due partly to the marginal probabilities. It is relatively easy to predict the expected values that could be attributed to the base rates of threats and strategies. One could then compare the empirically obtained frequencies with the expected values. Large positive values would indicate that the particular type of strategy occurred more frequently than would be expected by chance. Table 8 shows those difference scores. Interestingly, for virtually every threat, the inference we drew from Table 7 persists: The strategy employed tends to manage the same type of facet apparent in the threat. If there is a staffing threat, nurses manage

17.00 1.58 30.33 GM ¼ mean of the Threat Means for that type of threat; Cl ¼ Clinician; Comm ¼ Communication; Env ¼ Environment; Org ¼ Organization; Pt ¼ Patient; Tech ¼ Technology.

7 Technology

Strategy totals

1 Task

4 Staff

1

3 Organization

Patient

0 0 3 Clinician Communication Environment

3.4. Charts

44.17 10.88

2.83

5.17

1.33

27.00

20.67

10.08

16.25

16.38 16 6 11 35 2 1 1 3

16 1

15 25 2 2

176

27.00

12.00

16.00

11.50 9 1

12 9 2 1

3.75

16.00

20.00

9.00

10.50

7.33

0.33 0.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 1.00 0.00 0.25 1.33 1.33 2.00 8.00 6.00 0.00 0.00 3.00 3.00 6.00 9.00 9.00 3.00 3.00 5.00 6.00 8.00 5.67 5.67 2.00 1.00 2.50 9.00 9.00 4.50 8.50 13.00 6.00 6.00 4.00 3.00 4.00 5.67 8.00 0.00 0.00 2.00 0.00 2.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 1.00 0.00 1.00 0.00 0.75 11.33

0.33 0.33 2.50 3.00 2.75 6.00 6.00 1.00 0.00 0.50 2.00 2.00 4.00 2.00 7.00 5.67 4.67 0.33 0.33 0.50 0.00 0.25 0.00 0.00 0.00 2.50 1.25 8.00 8.00 0.00 0.00 1.00 0.00 0.25 1.67 1.67 3.00 1.00 2.00 0.00 0.00 5.50 11.00 8.25 6.00 6.00 2.00 3.00 3.00 3.00 2.75 0.67 0.67 0.50 4.00 2.25 9.00 9.00 1.50 0.00 0.75 9.00 9.00 6.00 3.00 4.00 8.33 5.33 0.33 0.33 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.67 4.67 0.00 1.00 0.50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 2.00 0.50 0.00 0.25 0.00 0.00 0.50 0.50 0.50 0.00 0.00 0.00 0.00 0.00 0.33 0.08 1.33 1.33 1.00 4.00 2.50 1.00 1.00 0.50 1.00 0.75 2.00 2.00 1.50 3.00 4.00 4.67 3.29 22 3

staffing resources. If there is a technology threat, nurses are more likely than would be expected by chance to manage technology resources. The single exception, and it is only mildly aberrant, was the management of organization threats.

Overstimulation from family GM No Ambu Bag No patient history GM Patient agitation GM Physician unavailable Not enough support staff GM Paired patient GM ET tube dislodged Vent malfunction No drugs nearby Inadequate sedation GM

# Int

Threats

# Nurses Intvwd

# Strategies elicited

Comm

Env

Org

Pt

Staff

Task

Tech

Facet totals

Mitigate

Work around

Ignore

Threat management classification of strategies

Prevent

Work facet classification of strategies

Clin

Facet totals

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Threat classification

Table 7 Strategy classifications for each threat. Row entries are the number of strategies containing that work facet averaged over nurses. A strategy can have more than one work facet.

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Another way to relate threats and strategies is through the cues that the nurse uses to select a strategy given a threat. We produced charts depicting these relationships for each of the 11 distinct threats. The final charts were vetted by an experienced PICU nurse. The nurse was familiar with the TSI, but did not participate in the interviews or coding of the data. Overall, the expert agreed that the charts captured a valid representation of how nurses managed threats. The only disagreement she had was with the strategy grouping in one chart focusing on particulars of drug administration. A chart depicting the relationships among threats, cues, and strategies appears in Fig. 1 for a nurse who was interviewed about the threat of a patient being inadequately sedated. At the far left of the chart are the task, threat, and the cues that alert the nurse to that threat. At the far right are strategies (e.g., drugs, get more sedation, sedation delivery assessment, assess facial expressions, cluster care) and sub-strategies (e.g., call physician and call a different doctor under the complex strategy of get more sedation) containing actions. The actions in the boxes are data from the transcripts, either quotes or close paraphrases of what the nurse said. Linked to the strategies are cues-to-strategies in the center column. Of course, cues-to-threats link to the threat, but occasionally they provide evidence in favor of a particular strategy. For example, “The patient is desatting” (dropping blood O2 levels) is a cue to the threat of inadequate sedation, but it also is a cue to the drug strategy and to the assess-facial-expressions strategy. Thus, the relationship between cues and strategies could be one to many, as well as many to one. Cues might lead either to a strategy, a sub-strategy, or even to a particular action. Most cues tended to suggest broad strategies: For example, “No matter what I've done with the sedation it has not fixed [the patient]” suggested get more sedation. Occasionally, the cue was specific to a particular action within a larger strategy (e.g., “bucking the ventilator” suggested the action to paralyze the patient). Not all cues increased the likelihood of selecting a strategy. Inhibitory cues, or blockers, were often mentioned in the context of eliminating a strategy while occasionally suggesting another. The blocker cues connect to the strategies they inhibit with dashed lines (e.g., a patent IV blocks the strategy of checking the IV). On occasion, a nurse would report a cue that would inhibit the entire schema for that threat; in other words, an exit cue might suggest to the nurse that the threat was no longer active. (There were no exit cues in the illustrative chart.) Cues tended to be either perceptual (e.g., patient is intubated; facial expression) in that the nurse detected something in the environment diagnostic of choosing a particular strategy; or cognitive in that the nurse recalled information (e.g., “I've had to give more than two boluses”) or reasoned (e.g., “if the resident that's on service isn't the brightest”) to a strategy. Of course, the nurse's cognitive apparatus is involved in interpreting even perceptual cues, such as whether the facial expression is anxious or pained. 4. Conclusions The strategic threat management employed by experienced nurses can sometimes seem like inscrutable intuition. We used a

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Table 8 Matching threat Work Facet classifications to strategy Work Facet classifications. The numbers represent difference scores between the expected and actual scores. Positive entries indicate the strategy was used more often than expected. An asterisked item is the strategy work facet with the highest positive differential for that threat. Strategy work facets

Type of threat

Clinician Communication Environment Organization Patient Staff Task Technology

Clinician

Communication

Environment

Organization

Patient

Staff

Task

Technology

0.02 1.17* 0.85 0.64 1.12 1.41

1.66 0.10 0.48 0.14 0.81 0.41

4.04* 0.13 0.88 0.66 1.48 0.89

0.17 0.84 0.23 0.17 0.38 0.23

2.57 1.04 4.42* 2.68 1.28 0.64

0.82 0.53 3.51 5.62* 0.07 0.83

0.88 0.98 1.71 0.04 5.11* 1.50

1.62 0.76 3.24 1.57 2.66 1.85*

recently developed knowledge elicitation procedure inspired by the threat and error management literature to extract strategies that operators use to manage threats, including the perceptual and cognitive cues used to help select those strategies. Once extracted, many understandable and consistent relationships among threats, strategies, and cues were apparent in the nurses' strategic threat management. Discussion of strategic threat management, as captured by the TSI, seems to be relatively easy for the nurses. Even in instances that might casually be attributed to intuition, the TSI often helped to make explicit something that was implicit. Initially nurses might speak of inspecting equipment or assessing a patient but not articulate the cues that guided strategy selection. For example, one nurse spoke of deciding between sedation and analgesia. The TSI probes led her to articulate that assessing facial expressions (e.g., wide eyes indicating anxiety) was the process she used to inform that decision. Ultimately, we were able to determine the perceptual details that would make up the cues that she used to select strategies. From another example, a nurse had the epiphany that whether or not she chose one strategy over another depended on whether she could see someone in the hallway at the time. Threats most often reflected technology, staff, or organization, and rarely task, clinician, and communication. The threats were managed with a toolbox of strategies. For patient threats, the nurses always aimed to mitigate the threat. They also tended to mitigate staff threats, but employed work-around strategies as well. On the other hand, technology threats produced both work-around and mitigation strategies equally often. The strategies sometimes focused on one aspect of the work, but they were often multifaceted e a cocktail of different work resources. The prominent strategies were staff, treatment (patient þ technology), exam (patient þ clinician), and patient. The strategy profile depended on the type of threat being managed in a rather systematic way. Specifically, threats centering on a particular work facet tended to be mitigated by strategies that also leveraged that type of work facet once expected values were taken into account. The current methodology has limitations. One limitation of the study was that a maximum of three nurses were interviewed on each threat. Additionally, the nurses were from only two facilities. These limitations may have affected generalizability. Of course, the use of the TSI shares limitations with other structured interviews, in particular relying on retrospective and subjective reports. 4.1. Strategic management of organization threats The single exception to the general finding that the primary facet of a strategy reflected the threat it was intended to address was the organization threat. For organization threats, nurses used strategies that affected the clinician more than would be expected by chance. When the organization failed to satisfy the nurses'

needs, the nurses inspected the technology or the patient, and in so doing improved their understanding of the situation without assistance from the hospital. Holden et al. (2012) suspect that nurses simply do not have access to the necessary resources to use organizational strategies; nurses do not typically possess the resources necessary to implement second order problem solving. Tucker and Edmondson (2003) define second order problem solving as addressing underlying causes allowing organizational learning to occur. The finding that most organization management involved work-around strategies is consistent with this literature. Finally, we suspect that “organization” may prove to be too broad and nebulous a category as defined here. Unlike our other categories, the strategy profiles of the organization threats were relatively uncorrelated suggesting that the strategic management of organization threats deserves more consideration. Researchers have been paying greater attention to organizational influences, both theoretically and methodologically. There is a large and important body of research that defines work processes and the system within which work occurs (Carayon et al., 2006). For example, the Macroergonomic Analysis and Design (MEAD, Kleiner, 2006) method elicits factors of the work environment that impede safe and optimal task completion. Although such approaches help in highlighting variances that threaten system safety, there remains a need for extracting strategic knowledge from experienced operators who often manage the threats. 4.2. Evidence accumulation framework The complexity of mapping strategies to threats became especially clear when we considered the cues used by nurses to trigger the strategies. By using a chart showing the perceptual or cognitive cue that produced evidence in favor of (or against) a strategy, the structural components of strategy selection could be represented. The cue-to-strategy mappings should not be thought of as a stimulus-response mapping, but instead as cues adding weight to the selection of a particular strategy, making the model an evidence accumulation one. Overall, the charts we constructed to show the relationship among cues, threats, and strategies, revealed a rich interconnectedness and a number of complex variations. Strategies seem to be triggered (or inhibited) by a variety of perceptual and cognitive cues. We believe these cues are considered as evidence for, or against, the applicability of a particular strategy. Some cues help the nurse identify the threat but also trigger strategies that are considered immediately in the particular situation. Not all cues are considered by experts. Further, research shows that under time-pressured situations people are less likely to sample all available information to reach decisions, thus making use of noncompensatory strategies (Payne et al., 1996). Noncompensatory strategies have been argued to be as effective as compensatory ones (Gigerenzer, 2008). It is possible that critical

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care nurses manage acute patient deterioration by engaging in noncompensatory strategies. Modeling strategy choice using an evidence-accumulation model could shed light on this issue. The information gathered about threats, strategies, and the cues that trigger them can prove useful in a number of ways. For example, the threat-strategy-cue structures of experienced nurses can be compared to that of novices and targeted simulation training could be initiated. The charts can also be used to predict the strategy that a nurse would choose given a particular set of cues. At a more theoretical level, there exist system approaches that intend to characterize cognitive work that rely on strategies. Thus far, while researchers (e.g., Hassall and Sanderson, 2012; Cornelissen et al., 2013) have developed formal ways of representing strategies in cognitive work analysis (e.g., Lintern, 2009; Vicente, 1999) there has been a need for coherent methods focused on extracting such strategies from experts. The results from the TSI could ultimately be embedded in cognitive work analysis. Acknowledgments We would like to thank Meera E. John and Nabila Nazarali for helping with data collection, Vlad L. Pop for conducting some of the interviews, and Sarah E. Gregg for data analyses. Thanks also to Kate Bleckley and Pat DeLucia for comments on an earlier draft of this paper. This work was supported in part by the Dudley Moore Foundation. References Amalberti, R., Hourlier, S., 2011. Human error reduction strategies in healthcare. In: Carayon, P. (Ed.), Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Lawrence Erlbaum Associates, Hillsdale, NJ, pp. 385e399. Asakura, K., Watanabe, I., 2011. Survival strategies of make nurses in rural areas of Japan. Jpn. J. Nurs. Sci. 8, 194e202. Carayon, P., Schoofs Hundt, A., Karsh, B.T., Gurses, A.P., Alvarado, C.J., Smith, M., et al., 2006. Work system design for patient safety: the SEIPS model. Qual. Saf. Health Care 15 (Suppl. 1), i50ei58. Carney, M., 2009. Enhancing the nurses' role in healthcare delivery through strategic management: recognizing its importance or not? J. Nurs. Manag. 17, 707e717. Cornelissen, M., Salmon, P.M., Jenkins, D.P., Lenne, M.G., 2013. A structured approach to the strategies analysis phase of cognitive work analysis. Theor. Issues Ergon. Sci. 14, 546e564. DeLucia, P.R., Ott, T.E., Palmieri, P.A., 2009. Performance in nursing. In: Durso, F.T. (Ed.), Reviews of Human Factors and Ergonomics, vol. 5. Human Factors and Ergonomics Society, Santa Monica, CA. Douglas, S., Cartmill, R., Brown, R., Hoonakker, P., Slagle, J., Schultz Van Roy, K., , et al.Carayon, P., 2013. The work of adult and pediatric intensive care unit nurses. Nurs. Res. 62, 50e58. Durso, F.T., Kazi, S., Ferguson, A.N., 2015. The threat-strategy interview. Appl. Ergon. 47, 336e344. Faye, H., Rivera-Rodriguez, A.J., Karsh, B.T., Schoofs Hundt, A., Baker, C., Carayon, P., 2010. Involving intensive care unit nurses in a proactive risk assessment of the medication management process. Jt. Comm. J. Qual. Patient Saf. 36, 376e384. Gigerenzer, G., 2008. Why heuristics work. Perspect. Psychol. Sci. 3 (1), 20e29. http://dx.doi.org/10.1111/j.1745-6916.2008.00058.x.

Griffiths, R., Fernandez, R., 2007. Strategies for removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst. Rev. 2. Art. No.: CD004011. Gurses, A.P., Carayon, P., 2007. Performance obstacles of intensive care nurses. Nurs. Res. 56, 185e194. Gurses, A.P., Carayon, P., 2009. Exploring performance obstacles of intensive care nurses. Appl. Ergon. 40, 509e518. Halbesleben, J.R.B., Wakefield, D.S., Wakefield, B.J., 2008. Work-arounds in health care settings: literature review and research agenda. Health Care Manag. Rev. 33, 2e12. Hassall, M.E., Sanderson, P.M., 2012. A formative approach to the strategies analysis phase of cognitive work analysis. Theor. Issues Ergon. Sci. 1e47. Helmreich, R.L., Klinect, J.R., Wilhelm, J.A., 1999. Models of threat, error, and CRM in flight operations. In: Proceedings of the Tenth International Symposium on Aviation Psychology, pp. 677e682. Columbus: OH. Henneman, E.A., Blank, F.S.J., Gawlinski, A., Henneman, P.L., 2006. Strategies used by nurses to recover medical errors in an academic emergency department setting. Appl. Nurs. Res. 19, 70e77. Henneman, E.A., Gawlinski, A., Blank, F.S.J., Henneman, P.L., Jordan, D., McKenzie, J.B., 2010. Strategies used by critical care nurses to identify, interrupt, and correct medical errors. Am. J. Crit. Care 19, 500e509. Holden, R.J., Rivera-Rodriguez, A.J., Faye, H., Scanlon, M.C., Karsh, B.-T., 2012. Automation and adaptation: nurses' problem-solving behavior following the implementation of bar-coded medication administration technology. Cognit. Technol. Work 1e14. Itoh, K., Omata, N., Anderson, H.B., 2009. A human error taxonomy for analysing healthcare incident reports: assessing reporting culture and its effects on safety performance. J. Risk Res. 12, 485e511. Kahneman, D., Klein, G., 2009. Conditions for intuitive expertise: a failure to disagree. Am. Psychol. 64, 515e526. Klein, G.A., 1998. Sources of Power: How People Make Decisions. The MIT Press. Kleiner, B.M., 2006. Macroergonomics: analysis and design of work systems. Appl. Ergon. 37, 81e89. http://dx.doi.org/10.1016/j.apergo.2005.07.006. Koopman, P., Hoffman, R.R., 2003. Work-arounds, make-work, and kludges. IEEE Intell. Syst. 18, 70e75. Koppel, R., Wetterneck, T.B., Telles, J.L., Karsh, B.-T., 2008. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J. Am. Med. Inform. Assoc. 15, 408e423. http://dx.doi.org/ 10.1197/jamia.M2616.Introduction. Lintern, G., 2009. The Foundations and Pragmatics of Cognitive Work Analysis a Systematic Approach to Design of Large-Scale Information Systems, first ed. Miracle, V.A., 2006. Strategies to meet the needs of families of critically ill patients. Dimens. Crit. Care Nurs. 25, 121e125. Payne, J.W., Bettman, J.R., Luce, M.F., 1996. When time is money: decision behavior under opportunity-cost time pressure. Organ. Behav. Hum. Decis. Process. 66, 131e152. Smith, M.J., Carayon-Sainfort, P., 1989. A balance theory of job design for stress reduction. Int. J. Indust. Ergon. 4, 67e79. Soderstrom, I.M., Benzein, E., Saveman, B.I., 2003. Nurses' experiences of interactions with family members in intensive care units. Scand. J. Caring Sci. 17, 185e192. Stayt, L.C., 2007. Nurses' experiences of caring for families with relatives in intensive care units. J. Adv. Nurs. 57, 623e630. Tucker, A.L., 2004. The impact of operational failures on hospital nurses and their patients. J. Operat. Manag. 22, 151e169. Tucker, A.L., Edmonson, A.C., Spear, S.J., 2002. When problem solving prevents organizational learning. J. Organ. Change Manag. 15, 122e137. Tucker, A.L., Edmondson, A.C., 2003. Why hospitals don't learn from failures. California Manage. Rev. 45. Tucker, A.L., Spear, S.J., 2006. Operational failures and interruptions in hospital nursing. HSR: Health Serv. Res. 41, 643e662. Vicente, K.J., 1999. Cognitive Work Analysis: Toward Safe, Productive, and Healthy Computer-based Work. Lawrence Erlbaum Associates, Mahwah, NJ. Yoder, E.A., 2010. Compassion fatigue in nurses. Appl. Nurs. Res. 23, 191e197.