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Complexity of Care Is Associated With Distressing Environmental Factors

Solomon, Deborah MSN, RN, ACNS, BC; Albert, Nancy PhD, RN, CCNS, CCRN, NE-BC; Sun, Zhiyuan MS; Bowers, Anna Mary MSN, RN; Molnar, Marci BSPA, RN, CMSRN

doi: 10.1097/NUR.0b013e318221f2d3
Feature Article

Purpose: The purpose of this study was to describe work and cognitive complexity patterns and assess predictors of increased complexity of care.

Design: Prospective, cross-sectional, correlational design, using a convenience sample and survey method.

Setting: Four nursing units at a large, Midwest tertiary-care medical center.

Sample: Participants were 38 nurses.

Methods: A 3-part survey included nurse caregiving complexity, environmental (unit) stress factors, and nurse/work characteristics (including role responsibility level).

Findings: Standardized sum score for work complexity was higher than cognitive complexity (P < .001). Nurses with more role responsibilities and environmental stressors had higher work (ρ = 0.37, P = .009) and cognitive complexity scores (ρ = 0.54, P < .001). After controlling for the number of role responsibilities, environmental stressors, and nurse/work characteristics, work complexity pattern scores were higher for breakdown in communication processes in nurses working off-shifts (P = .013) and interruptions in tasks on typical/busy workdays (P < .001). After controlling for nurse/work characteristics, work complexity patterns were not associated with role responsibilities, and cognitive complexity patterns were not associated with role responsibilities or environmental distress. In multivariable analysis, work complexity pattern scores remained associated with environmental distress scores (P = .024) and with 3 work complexity pattern factors: items placed in separate areas (P = .007), waiting for nonavailable systems (P = .010), and difficulty assessing proper resources (P = .015).

Conclusions: After controlling for nurse/work characteristics, role responsibilities, and environmental stressors, work complexity was associated with environmental distress.

Implications: Future research may increase understanding of relationships found in this study, and process improvement initiatives may provide targets for decreasing complexity of work patterns.

Author Affiliations: Clinical Nurse Specialist at Cleveland Clinic, Ohio (Ms Solomon); Director, Nursing Research and Innovation in the Nursing Institute, and Clinical Nurse Specialist, Kaufman Center for Heart Failure, Cleveland Clinic, Ohio (Dr Albert); Biostatistician, Department of Quantitative Health Sciences, Cleveland Clinic, Ohio (Mr Sun); Director, Nursing Education for Technology and Simulation, Cleveland Clinic, Ohio, and Adjunct Online Faculty, St Joseph's College of Maine, Standish (Ms Bowers); and Nurse Manager, Cleveland Clinic, Ohio (Ms Molnar).

Internal funding was received for this study.

Correspondence: Deborah Solomon MSN, RN, ACNS, BC, 9500 Euclid Ave, Mail Code Hsb-188, Cleveland, OH 44195 (

© 2011 Lippincott Williams & Wilkins, Inc.