Written By: Beth Boynton RN, MS & Doug Hall
The secret is out. The illusion is exposed. The truth is known: “Hospitals are dangerous places.”
Healthcare workers have known this for a long time and tried to tell friends and family but few let the warnings change their long-held image of ideal hospital care. Many nurses and other healthcare workers also held onto this illusion of ideal hospital care and thought they were the ones who were failing when faced with sicker patients and fewer staff. Statistics are now published and mainstream media run stories of the reality of today’s healthcare.
Enter Cognitive Stacking – the nurse’s overloaded brain.
Cognitive means intellectual activity such as thinking, reasoning, remembering, reevaluating, planning, calculating and extrapolating. Stacking is, well, stacking.
Cognitive Stacking is similar but not the same as multi-tasking. Multi-tasking is a term from computer engineering in which processes are completed so fast that they appear to be done at the same time. Studies have disclosed that people do not perform well even with very simple tasks performed at the same time.
Multi-tasking usually involves only a few functions, lasts only a few minutes and usually doesn’t involve making 100% accurate decisions involving the life of another. For example, combing your hair while feeding the dog, putting on a shoe, and answering the phone.
Overload and Cognitive Stacking negatively affects the health and employment satisfaction of healthcare workers. It is a work environment in which nurses are overwhelmed with information, data and distractions that ultimately can result in job dissatisfaction, burn-out and injury to a patient. And this overload is relentlessly present in every minute, hour, and shift.
Raising awareness among healthcare consumers, professionals, advocates, and administrators is an important step towards creating workplaces that support the work RNs do. The following is a realistic recreation of ten minutes in the life of a Registered Nurse on a busy medical-surgical unit. In addition, add the sounds of I.V. pump alarms, patient vital sign alarms, overhead announcements, phones, and colleague conversations. Can you imagine yourself as the nurse or patient on this unit? How might you feel? What are your thoughts?
The scene opens at the nurses’ station:
0:00 The patient in 314B pulled that Foley catheter out again.
The family in 309A wants to talk to you.
That colostomy bag in 322A needs to be changed soon.
What’s taking so long? My mother is screaming in pain.
Can I borrow an Aldactone from 326A for 307B?
1:00 You have a call holding on line 1.
Is it OK for my brother to eat with a blood sugar of 53?
Did the blood work get done for the patient in 311?
Were there any abnormal labs for my other patients?
Was the physician notified of my nephew’s problem?
Has anyone talked to the patient about surgery being cancelled?
2:00 Which Mr. Smith is getting the blood transfusion?
Mr. Jones says he’s allergic to the new antibiotic ordered.
The pre-op patient in 313 is eating a hamburger.
Did you know The Joint Commission is here today?
Did you hear that Joe Smith in CCU got fired?
Did the emergency surgery patient get prepped?
3:00 Dr. Brown wants Mr. Green’s MRI done tonight.
How do I get to the gift shop? And, do they have daisies?
Can you show me how to use the new PCA pumps?
The patient in 301B has an infected incision.
Did you call?
Can you take this call? It’s the daughter of 302A. She’s upset.
Can you give me a quick in-service on these glucometers.
Can you cover my patients while I go to lunch?
4:00 Where’s the X-ray tech for that stat I ordered.
The patient in 310B needs to go to ICU, now!
Did we get the medical records for the patient in 305B.
Is prochlorperazine the same as trifluoperazine?
Is it OK to bolus 2200 units of heparin with a PTT of 45?
Pharmacy is on the phone for you.
Will you call the kitchen? I didn’t get my coffee today.
Do you know if it’s going to rain or snow tomorrow?
P.T. wants to know when 320B got back from surgery.
We’re out of soap at this hand-wash station.
I need a thermometer battery. Where are they?
5:00 Chris just called in sick. Can you work a double?
Can you help me start an I.V. in 320B?
Can you co-sign this morphine I’m wasting?
How do I convert micrograms per minute to milligrams per hour?
When can we talk about your yearly evaluation?
And, I want you to work on your time-management skills.
Excuse me, but did you wash your hands?
The patient in 303A is disoriented times 3.
Did you call?
6:00 Who’s on-call for Dr. Jones?
Medical Records says we need to document better.
We need housekeeping in 314 do you know their number?
I’m a student. Can I ask you a few questions?
Dietary is on the phone for you.
Your L.P.N. just went to the E.R. with a back strain.
Notify your staff that there is to be no overtime.
Read this memo. Don’t miss the Discharge Planning meeting.
I just got stuck by needle left on a gurney.
7:00 There is no more gauze. Can you call someone?
The new graduate is crying in the stairwell.
Is Vioxx the generic for Zyvox?
Will you get me some vanilla pudding? I got Jello instead of pudding.
Look at these pictures. My dog had puppies.
Your fresh post-op is here and doesn’t look very good.
The patient is 306 just fell in the bathroom. Can you help?
8:00 The I.V. is empty in 302B.
The car repair shop wants to know if you want white wall tires?
The patient in isolation has a potassium of 2.5. What should I do?
I’m new here. I was told to ask you where Billi Rubin works.
The letter G just came off my keyboard.
What is the NPO deficit replacement formula?
Dr. Smith wants to know if 325A has Respiratory Alkalosis.
What are the drops per minute to equal 125 milliliters per hour?
9:00 The lab tech can’t find the patient in 322A.
Ten visitors are in 300A and 300B is complaining.
The patient in 312A says someone stole her get-well gifts.
The computer is slow. Who do we call?
Your kids are on-hold on line 5.
Did you finish charting that code blue from yesterday?
Dr. Jones forgot his password.
The family of 319 is taking him home AMA.
Call the Rapid Response Team for 303B! His blood pressure is crashing!
10:00 Did you call about my not getting my coffee?
The service here is horrible!
Only 7 hours and 50 minutes to go for this shift.
Oh, I forgot, I may have to do a double…
Raising awareness will help to recognize the complexity of RN work, minimize interruptions, and contribute to effective solutions that involve:
- Assertiveness training and practice.
- Adequate staffing.
- In depth Root Cause Analysis.
- Safety Engineering.
“This article demonstrates the very common problem of nurse overload and how this can lead to a deterioration of care in the hospital setting. Unfortunately this problem is very real, very prevalent and only shows signs of getting worse.”
– JFSEM Editorial Staff