Cognitive work analysis to evaluate the problem of patient falls in an inpatient setting

Abstract

Objective: To identify factors in the nursing work domain that contribute to the problem of inpatient falls, aside from patient risk, using cognitive work analysis.

Design: A mix of qualitative and quantitative methods were used to identify work constraints imposed on nurses, which may underlie patient falls.

Measurements: Data collection was done on a neurology unit staffed by 27 registered nurses and utilized field observations, focus groups, time-motion studies and written surveys (AHRQ Hospital Survey on Patient Culture, NASA-TLX, and custom Nursing Knowledge of Fall Prevention Subscale).

Results: Four major constraints were identified that inhibit nurses' ability to prevent patient falls. All constraints relate to work processes and the physical work environment, opposed to safety culture or nursing knowledge, as currently emphasized. The constraints were: cognitive 'head data', temporal workload, inconsistencies in written and verbal transfer of patient data, and limitations in the physical environment. To deal with these constraints, the nurses tend to employ four workarounds: written and mental chunking schemas, bed alarms, informal querying of the previous care nurse, and informal video and audio surveillance. These workarounds reflect systemic design flaws and may only be minimally effective in decreasing risk to patients.

Conclusion: Cognitive engineering techniques helped identify seemingly hidden constraints in the work domain that impact the problem of patient falls. System redesign strategies aimed at improving work processes and environmental limitations hold promise for decreasing the incidence of falls in inpatient nursing units.

Figure 1

Hospital unit floor plan. The three rooms with a direct viewing angle are marked by the gray, dashed rectangles.

Figure 2

Abstraction–decomposition hierarchy for domain, shown in part. Gray blocks represent key constraints for discussion and are detailed at the level of physical function.

Figure 3

Results from NASA-TLX Workload Analysis. See text for more details on anchors.