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A3626 - Using Cognitive Work Analysis to Understand ICU Nurse Decision-Making About Patient Mobility
Author Block: A. Krupp1, L. Steege2, W. J. Ehlenbach3, B. King2; 1School of Nursing, University of Pennsylvania, Philadelphia, PA, United States, 2School of Nursing, University of Wisconsin, Madison, WI, United States, 3School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States.
Rationale: Early patient mobility in the intensive care unit (ICU) is a well-established intervention to improve patient outcomes. However, evidence also suggests that ICU early mobility programs are not consistently implemented or sustained across hospitals. ICU nurses provide the most amount of direct patient care and are responsible for constant patient monitoring. Therefore, they are best-suited to assess patient readiness for mobility and to coordinate and initiate such interventions. However, few studies clearly describe the role of ICU nurses in delivering early mobility interventions. We sought to examine characteristics of the work environment that affect nurses’ ability to make patient mobility decisions and nurses’ information processing needs and cognitive workflows associated with patient mobility decisions. Methods: We recruited registered nurses (RNs) from two ICUs in two hospitals. We conducted one-to-one interviews with 20 RNs and direct observation with a subset of four RNs. We audio recorded and transcribed the interviews and two researchers independently coded each one. We used Directed Content Analysis and the Work Domain and Strategies Analysis frameworks to guide our interviews, observations, and coding. These frameworks provide a human factors engineering approach to systematically understanding aspects of cognitive work processes in complex environments. Results: The Work Domain Analysis identified multiple unit, nurse, and patient constraints that impacted nurse decision making about patient mobility. One of the most significant constraints on mobility decisions for ICU nurses was the divide between the immediate purpose of the ICU (to establish and maintain patient physiologic stability) and the long-term purpose of hospitalization (for patients to resume to their pre-hospital abilities). The Strategies Analysis provided detailed descriptions of how nurses sought out multiple information sources (e.g. patient assessment, colleague, electronic health record) to inform mobility decisions. Decision shortcuts included knowing the patient and having a pre-determined goal for specialty patient populations. Conclusions: ICU nurse decision making for patient mobility is complex. The results of this study show interdependencies between patients, nurses, other members of the interprofessional care team, and the unit on nurse mobility decisions. Further research is needed to understand how nurses organize and integrate information from multiple sources when making mobility decisions.