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Understanding the Cognitive Work of Nursing in the Acute Care Environment

Potter, Patricia PhD, RN, FAAN; Wolf, Laurie MS, CPE; Boxerman, Stuart DSc, CHE; Grayson, Deborah MSN, RN, COHNS; Sledge, Jennifer MSW; Dunagan, Clay MD; Evanoff, Bradley MD, MPH

Journal of Nursing Administration: July-August 2005 - Volume 35 - Issue 7 - p 327–335

Objective To combine human factors engineering techniques with qualitative observation of nurses in practice to analyze the nature of nurses' cognitive work and how environmental factors create disruptions that pose risks for medical errors.

Background Few researchers have examined the nature of nurses' cognitive work while in practice with patients. Researchers have described the broad range of thinking processes required in the acute care work setting, but have failed to examine how such processes are conducted and influenced by the complex care environment. A combined research methodology enables researchers to better understand how the nursing process becomes disrupted and the potential influence of this disruption on the safe and effective care of patients.

Methods An ethnographic study, using mixed-methodological approaches, involved 7 staff registered nurses. The quantitative and qualitative data collection included field observation and summarative interviews.

Findings A high number of cognitive shifts and interruptions, and a nurse's cumulative cognitive load, create the potential for disrupting a nurse's attention focus during care of patients. A majority of interruptions occurred as nurses performed interventions, particularly medication preparation.

Conclusion New attention must be given to how care systems and work processes complement or interfere with nurses' cognitive work.

Research Scientist (Dr Potter), Research Coordinator (Ms Sledge), Professional Practice, Barnes-Jewish Hospital, St. Louis, Mo; Ergonomist (Ms Wolf), BJC Corporate Health, St. Louis, Mo; Associate Professor and Director (Dr Boxerman), Health Administration Program, Clinical Research Nurse Coordinator (Ms Grayson), Associate Professor of Medicine (Dr Dunagan), Associate Professor of Occupational and Environmental Medicine (Dr Evanoff), Washington University, St. Louis, Mo.

Corresponding author: Dr Potter, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90 30 604, St. Louis, MO 63141 (

© 2005 Lippincott Williams & Wilkins, Inc.