Background: Patient falls are considered preventable adverse events. They present an unnecessary danger to patients, often cause injury, lead to increased healthcare expenditures, and are a motive behind lawsuits. Despite development of various fall prevention strategies, patients continue to fall. Objective: The objective of this research was to conduct a Cognitive Work Analysis (CWA), on an inpatient nursing unit to identify and analyze the interplay between workers, patients, the physical environment, social context, and work flow as it related to the risk of patient falls. CWA is an engineering method that seeks to identify the constraints that the environment and the processes impose on the worker in order to reduce workplace error and improve productivity. Significance of Research: No reported studies in the nursing literature have comprehensively examined a nursing unit using cognitive engineering methods. Methods: Both qualitative and quantitative data collection methods were used. Qualitative methods included a field study of the nurses’ work processes and environment, a patient fall case study investigation and a focus group. Quantitative methods included a time motion study and the administration of National Aeronautics and Space Administration Task Load Index (NASA-TLX). NASA-TLX assesses subjective workload, a factor that has emerged as being increasingly important in system evaluations. The data from all methods was used to develop a hierarchy of the work domain. Discussion: A major strength of CWA is the systematic examination of unique nursing work domains that promotes the design of solutions that best fits the problem of interest and the particular work domain being studied. The field of engineering can offer guidance and experience in new techniques such as cognitive work analysis that can set new standards for patient safety focused system analysis in healthcare.
Session #1125 - Nursing Informatics Research: Supporting Patient Safety and Quality of Care
The 29th Annual MNRS Research Conference (April 1-4, 2005)