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International Journal of Industrial Ergonomics 41 (2011) 389e393

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International Journal of Industrial Ergonomics

journal homepage: www.elsevier .com/locate/ergon

Investigating stacking: How do registered nurses prioritize their activitiesin real-time?

Emily S. Patterson a,*, Patricia R. Ebright b, Jason J. Saleem c

a School of Allied Medical Professions, College of Medicine, The Ohio State University, Atwell Hall, Room 543, 453 W 10th Ave, Columbus, OH 43210, USAb School of Nursing, Nursing 136, Indiana University, Indianapolis, IN 46202, USAc Indianapolis VAMC, Regenstrief Institute, 1481 West 10th Street, Indianapolis, IN 46202, USA

a r t i c l e i n f o

Article history:Received 28 August 2009Received in revised form10 September 2010Accepted 25 January 2011Available online 18 February 2011

Keywords:QualitativeInterviewsHuman factorsNursingDecision makingPrioritizationPlanning

* Corresponding author. Tel.: þ1 614 292 4623; faxE-mail addresses: patterson.150@osu.edu (E.S. Pa

(P.R. Ebright), jason.saleem@va.gov (J.J. Saleem).

0169-8141/$ e see front matter � 2011 Elsevier B.V.doi:10.1016/j.ergon.2011.01.012

a b s t r a c t

Recent nursing graduates often find it challenging to prioritize competing tasks in the increasinglycomplex hospital environment. In order to develop a normative framework for task prioritization,Registered Nurses from a variety of settings were interviewed about how they prioritized their activities inthe workplace. From 30 interviews, 422 prioritization decisions were coded when study participants wereconfronted with two tasks that could not be done simultaneously. The findings suggest a seven-levelprioritization hierarchy of nursing activities: 1) addressing imminent clinical concerns, 2) high uncertaintyactivities, 3) significant, core clinical caregiving and managing pain, 4) relationship management, 5) doc-umenting, helping others, and patient support, 6) system improvement and cleaning/preparing supplies,and 7) personal breaks and social interactions. Explicitly providing a normative framework for taskprioritization during nursing education may help to accelerate learning this skill. For more experiencednurses, we believe that flexibility to deviate from this framework will be important for providing high-quality, personalized care that best matches the particular context.Relevancy to industry: Nursing personnel comprises a significant portion of the human capital andoperating budget for hospitals. Knowledge of what tasks are likely to be shed under severe workloadconditions aids with optimizing hiring and allocation of nursing personnel.

� 2011 Elsevier B.V. All rights reserved.

1. Introduction

Many wonder whether recent graduates from nursing programsare fully prepared to safely and effectively prioritize multiplethreads of activity in a hospital setting. The hospital environment ischaracterized by time pressure, uncertain information, conflictinggoals, high stakes, stress, and dynamic conditions (Ebright et al.,2003; 2004; Potter et al., 2004; Wiggins 2008). As patient acuityincreases and new tools like electronic health records and bar codemedication administration are implemented, it will become evenmore complex to manage multiple threads of work simultaneously.Traditionally, planning has not been classified as a core nursing task,as evidenced by the paucity of discussion of planning by 116 nursesduring interviews where they described their problem solvingbehaviors at the bedside (Hurst et al., 1991). Therefore, there is littleguidance in existing nursing curricula about how to prioritizeactivities in nursing work, particularly with respect to what tasks

: þ1 614 292 0210.tterson), prebrigh@iupui.edu

All rights reserved.

can be delayed or dropped, and it is unclear how well the guidancethat is available would relate towhat is done by experienced nursesin actual settings. Therefore, in this paper, we propose a normativeframework for task prioritization based on empirical data of hownurses prioritized one task over another at the bedside.

Although planning has not traditionally been classified as a corenursing task, there is a long history of nursing research on howcomplexity from managing multiple threads of work simultaneo-usly impacts cognitive performance. For example, there have beenstudies on howmultiple threads of activity complicate informationprocessing (Grier, 1984), clinical judgment (Tanner, 1982), problemsolving (McCarthy, 1981), and decision making (Jenkins, 1985). Inaddition, studies have looked at the effect of training (Sparks, 1982)and experience (Tanner et al., 1987) on cognition.

In prior research, the concept of stacking was investigated tobetter understand how registered nurses across a wide variety ofhospital settings prioritized and planned their activities, as well asmade real-time adjustments as unexpected events unfolded(Ebright et al., 2003). The stacking phenomenon had emerged froman exploratory observational and interview study of contributionsto work complexity for registered nurses. In interviews, nurses na-turally resonated to the analogy of starting, organizing, queuing, and

E.S. Patterson et al. / International Journal of Industrial Ergonomics 41 (2011) 389e393390

restarting activities froma stack. The stack is somewhat like a “to do”list of action items where multiple items are happening in paralleland some require actions on the part of others to be completed.An important distinction from a “to do” list in a self-paced, low-consequence office environment is that the nurses were highlysensitive topatient safety risks, incorporating the skillful applicationof failure-sensitive strategies to proactively forestall potential pathsto adverse patient outcomes.

Stacking is conceptualized as a strategy for improving re-plan-ning in a macrocognitive work system. Re-planning is defined asadaptively responding to changes in objectives, from any of a varietyof sources including supervisors and peers, obstacles, opportunities,events, or changes in predicted future trajectories (Patterson et al.,2010). A macrocognitive work system is defined as a system inwhich people use advanced technology to collaborate for thepurposeof conductingwork (Klein et al., 2003). Re-planning is oneoffive macrocognition functions, which inter-relate: detecting prob-lems, sensemaking, re-planning, deciding, and coordinating. Mac-rocognition is defined as the adaptation of cognition to complexity(Klein et al., 2003). In this study, we asked the question: How donurses prioritize one activity over another when they cannot bothbe done simultaneously? Interviews were conducted with registe-red nurses to elicit factors that contributed to directly observed“activity A vs activity B” prioritization decisions in the workplace.Codes were iteratively generated using qualitative techniquesduring data analysis. The final analytic codes are described in detailin Section2.4, DataAnalysis. Thenormative frameworkderived fromthe analyses is reported and potential applications and limitationsare discussed.

2. Materials and methods

2.1. Study participants

Registered Nurses (RNs) were recruited using IRB-approvedprocedures for the study. The nurses worked in multiple healthcaresettings in three facilities of one large Midwest urban healthcareorganization. The participants represented a diverse set of clinicalareas, including emergency care, intensive care, obstetric care, pre-operative care, operative care, post-operative care, post-anesthesiacare, acute care, and outpatient care. Recruitment was targeted toinclude nurses in three categories of experience levels, with morerepresentation of experienced nurses. This recruitment strategyresulted in 4 nurses with less than a year of experience, 11 nurseswith 1e5 years of experience, and 15 nurses withmore than 5 yearsof experience. Ages of the participants ranged from 22 to 58 yearsold, with an average of 33.5 years old.

2.2. Interviews

Audio-taped interviews with one or two investigators wereindividually conducted with each nurse following three hours ofdirect observation by one investigator. The observations werescheduled to sample a wide range of time periods, between 7 AMand 10 PM. Weekends and night shifts were not included in theobservations in order to reduce variability due to unique resourcelimitations. Among the data collected was the elicitation of factorsthat contributed to observed decisions to prioritize one activity overanother during the observation period, particularly unexpected orsurprising decisions.

2.3. Data collection

Audio-taped interviews were transcribed in a de-identifiedmanner by one of the interviewers following the session. Due to the

unstructured nature of the wide-ranging interviews, questionswere asked opportunistically in the context of the conversation.Although the questions varied, the interviewers employed open-ended language such as “Tell me about”, “Talk to me about”, and“What was your thinking about” in order to avoid suggesting thatthe behavior was unusual or provoking defensive behavior due toasking “Why” questions.

Following is an example of how data collection specifically tar-geting a prioritization decisionwas initiated during an interview. Inthis case, the interview elicited the factors that contributed toa decision to prioritize caring for a newly arrived pediatric patientover team leader duties, which include assigning new patients tonurses and coordinating lunch breaks.

“Interviewer: It was about fifty minutes into the shift and[investigator] was following you.Then you’re informed thatyou’re team leader for today.Right at that point you were at the nurse’s station when youwere informed and then a patient came in, a patient that wasa child in [room number]. and you start working with that[patient]. So talk to me at that point in time why you wentahead, did that, and not go immediately to check for patientscoming in. What was your thinking around that?”

The elicitation of factors contributing to the decision to priori-tize caring for a new patient [coded as F¼ Significant, core clinicalcaregiving] over the team leader duty of assigning newly arrivingpatients to other nurses [coded as H¼ helping others] spannedseveral pages of transcription. Support for coding F>H includedthese quotes:

� “It would depend on was it my turn to take a patient. Justbecause you’re team leader you know you are still a part of therotation.It’s not like you have to make assignments oranything like that. We just take turns.”

� “But it depends on howmany nurses were there and was it myturn to have a patient and maybe I knew that it was slow in themorning and I had plenty of time to look at that other stuff. I’mjust supposing but I think that’s probably it. That was probably7:15. We don’t do much that early in the morning.”

� “At [7:50] nobody goes to lunch for three hours. So the patientwould be more my priority.”

In addition to directly observed prioritization decisions, theinterview data included general observations about how the nursesprioritized their activities. Although thesedata are less reliable in thesense that theyare not basedon actual decisions thatwere observed,the data are reported together since the prioritization relation-ships did not change when they were removed, and including theseincreased the overall sample size.

2.4. Data analysis

Thirty out of thirty-three registered nurses completed both theobservations and the subsequent interviews. Standard qualitativemethods were employed during data analysis for parsing andcoding (Roth and Patterson, 2005). The final twelve codes andexamples are provided in Table 1.

During the piloting phase, potential codes were brainstormed ina series of meetings with researchers with nursing and humanfactors backgrounds. Following these meetings, two coders usedfive simultaneous groups of codes to code transcripts from twointerviews that were randomly assigned to coders. Differences incoding judgments were resolved via discussion and the overallnumbers of codes were reduced to a manageable set that hadwould likely have sufficient inter-rater reliability.

High uncertainty activities

Personal breaks and social interactions

Addressing imminent clinical concerns

Managing painSignificant, core clinical caregiving

Cleaning/preparing suppliesSystem improvement

Documenting Helping others Patient support

Relationship management

Fig. 2. Normative hierarchy of nursing tasks.

Table 1Codes, descriptions, and examples of tasks.

Code Description Example

A Managing pain Getting an ‘as needed’ (PRN) narcotic for apatient who is complaining of pain

B Personal breaks/Socialinteractions

Showing a picture of a newborn niece to acolleague

C Cleaning/Preparingsupplies

Organizing supplies that will be used in thenext operation

D Documenting Writing an assessment of the patient’s statusbased on a physical exam in the chart

E Addressing imminentclinical concerns

Putting a patient back onto a ventilator toallow respiration after an accidentaldisconnect

F Significant, coreclinical caregiving

Conducting a patient assessment;administering medications; changingdressings; carrying out physician orders

H Helping others Helping a physician to insert a central lineused to draw blood samples

I System improvement Ordering depleted suppliesL Legal considerations Documenting detailed information that

might become evidence in a future lawsuitP Patient support Teaching patients and caregivers how to

give an insulin shot in the home settingR Relationship

managementSetting expectations with patients andfamily members about what will happenduring the shift and how best tocommunicate with the nurse

U High uncertaintyactivities

Using a new medical device for the first time,such as an ultrasound machine

U: High uncertainty activities

A: Managing pain

B: Personal breaks/Social interactions

D: Documenting

C: Cleaning/Preparing supplies

E: Addressing imminent clinical concerns

F: Significant, core clinical caregiving

H: Helping others

I: System improvement

L: Legal considerations

P: Patient support

R: Relationship management17

19

10

17

20

22

15

12

20

10

30 55

8

8

8

8

9

10

Fig. 1. Summary of prioritization relationships.

E.S. Patterson et al. / International Journal of Industrial Ergonomics 41 (2011) 389e393 391

The final codingwas done in the format of X> Y to represent thatone code was prioritized more highly than the other. For anysegment, multiple codes were used as necessary. The majority ofsegments had a single code and the largest number of codes persegmentwas three.One investigator segmentedandcoded theentiredataset. One code was added in the process of coding (L¼ Legalconsiderations). An example of code L is documenting reasons fora lengthy stay in the emergency department prior to disposition incase the documentation would be needed as evidence in a futurelawsuit.

3. Results

Overall, 422 prioritization decisions were coded. The findingsare displayed in Fig. 1. To support interpretation, links with fewerthan eight supporting statements were removed, based on beinga natural break point in the data. The arrow in the figure indicatesthat the first factor is considered a higher priority than the factor towhich the arrow is pointing.

The relationships are provided as a hierarchy of prioritiesframework in Fig. 2, with the highest level at the top.

As displayed in Fig. 2, the top prioritization level was to respondto clinical emergencies (E: Address imminent clinical concerns).Overall, there was strong support for this category being the mostimportant and this finding is not surprising. This category hadmany connections to other categories, all of which were judged tobe less important. In addition, nearly all (87%) of the study partic-ipants (72 statements) reported this category to be more importantthan others.

The second highest priority level was high uncertainty activities(U). This category had the most statements in relationship to anyother category, suggesting that managing uncertainty is centrallyimportant to nursing. A particularly strong connection was that itwas repeatedly prioritized higher than traditional nursing activities(F: Significant core clinical caregiving) (55 statements). This cate-gory was judged to be lower in the hierarchy primarily becauseevery comparison between the two categories judged level two as

lower than level one (note: this relationship is not displayed inFig. 1 since there were only six supporting statements).

For the third level, significant, core clinical caregiving andmanaging pain are displayed at the same level of importance.Although they theoretically could be combined, the interview datasuggest that nurses categorize them differently, possibly due toorganizational incentives to improve pain management. Analysisrevealed that there appeared to be a notion of “core nursing work”against which other tasks, such as system improvement, wereprioritized against. Core work was comprised of traditional nursingroles of significant, core clinical caregiving activities, such as con-ducting patient assessments, administering medications, changingdressings, and carrying out physician orders. These were generallyprioritized higher than tasks that were viewed as important, withthe main distinction being that tasks at the third level could not beshed, even under extreme workload conditions, whereas lowerlevels of the hierarchy could be shed occasionally.

Tasks at the third level were viewed by many of the studyparticipants as important tasks. For example, a theme was thatmany of the nurses believed that managing pain proactivelyimproves clinical outcomes and reduces workload (24 statements).One participant stated:

“In order for me to be able to give her pain medicine, she needsto eat, and I can’t give it until then and therapy will be early. So,that’s generally where it runs in the morning. For that first run,one of the main questions is always, “Have you ordered yourbreakfast?” Because if they haven’t ordered their breakfast, ittakes an hour for it to come and then therapy is going to becalling me and making appointments to come. and thenwhen

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they haven’t had any food, I can’t medicate, therapy is mad atme, they hurtmore, parents aremad. It’s just like a never-endingcycle.”

The fourth level, relationship management, was prioritized lesshighly than managing pain (17 statements), with no exceptions.Nevertheless, the hierarchical relationship between the third andfourth level of the hierarchy is less clearly supported than the otherdistinctions because relationship management was prioritized oversignificant core clinical caregiving activities more often than thereverse (30 vs. 8 statements). A possible explanation for frequentlyprioritizing relationship management higher than core nursingwork is that a majority (53%) of the study participants (39 state-ments) reported that early investments in creating high trustrelationships with patients and family made the work easier andreduced interruptions later. For example, one participant stated:

“Patients can be really draining, making twelve and a half hoursa long shift.If I can let them know ahead of time or make themfeel like I am ahead of the game, they will relax more. If I spendpart of my time, especially early on in the shift if I don’t knowthe parents and the child proving myself, then the parents willrelax with their kid and will even then spend better quality timewith them if they are comfortablewith the nurse.With teens, itis harder to prove myself to them and the parents, so I work onthat a little bit harder, so that I don’t have to spend more timethan I would have to spend if they weren’t trusting.”

The sixth levelwas system improvement and cleaning/preparingsupplies. Even at this level, the study participants provided inter-esting insights about the importanceof these activities. For example,some nurses were frustrated when theywere unable to find time toorder missing supplies, because they felt that the advance organi-zation helped them to avoid problems during busy periods later(e.g.,when treating a patient, during surgery,when newpatients areadmitted). Similarly, several nurses felt that preparing awrittenplan(paper artifacts that are informally called ‘brains’) allowed them tobe better prepared to respond to requests for information by others.One nurse described:

RN: “I just like to knowhowoften I’mgoing to givemed[ication]s.It helps me if I knowwhen everybody’s med[ication]s are due,what kind of med[ication]s they’re on.So just give me this fiveor ten minutes and then I’ll go. So I think every nurse gets frus-trated when you don’t have that initial organization because Ithink that’s key. If you can at least start out organized, you canmake notes, you can catch up on your charting, you can dowhatever, but you know you’re organized so you know what’sgoing on, you feel like you can take on whatever is going tohappen that’s going to be different from what your plannedschedule is.”

During the interviews, some individuals expressed that theydiffered from their colleagues in that they almost never dropped ordelayed a particular task at the fifth or sixth level of the hierarchy.For example, one acute care nurse described that he would rout-inely prioritize patient education over timely medication admin-istration, and stated that his manager would not agree with thatprioritization decision. He reasoned that investment in patient andfamily education might reduce future hospital admissions andavoid patient harm due to misunderstandings about what to doafter discharge. Another nurse prioritized cleaning the workspaceat the beginning of the shift to increase her ability to respond tounexpected requests later and manage her anxiety.

At the lowest level in the hierarchy, there was broad consensusthat personal breaks and socialization with co-workers were thelowest priority as compared to other work activities. There were

four exceptions where breaks were prioritized higher than otheractivities. All four exceptions were expressed with a sense of guilt,indicating that they believed that they should have been lower inthe hierarchy. For example, one nurse explained that she always atebreakfast before going into patient rooms because she had to waitan hour after taking a medication before eating and she was notwilling to get up an hour earlier.

4. Discussion

From30 interviews, 422 prioritization decisionswere coded. Thefindings suggest a seven-level prioritization hierarchy of nursingactivities: 1) addressing imminent clinical concerns, 2) high uncer-tainty activities, 3) significant, core clinical caregiving and manag-ing pain, 4) relationship management, 5) documenting, helpingothers, and patient support, 6) system improvement and cleaning/preparing supplies, and 7) personal breaks/social interactions.

Our main contribution from this study is a proposed normativehierarchy of priorities. Our data also provide an initial estimate ofconsensus across specialties, frequency about how often deviationsto the normative rules occur, and the types of locally rational factorsthat contribute to the deviations. To our knowledge, there is cur-rently no accepted standard for how to prioritize nursing tasks(although see Kalisch (2006) for categories of missed nursing careactivities, which are primarily patient support and documentingactivities in our framework, and Bittner and Gravlin (2009) forfactors contributing to missed care activities).

Our findings also suggest some implications for improving thedesign of healthcare environments. For example, reducing uncer-tainty in the ability to accomplish activities within a predictableamount of time would enable nurses to more efficiently groupactivities. The high prioritization of uncertain activities coulddisrupt the workflow, increase inefficiency, such as by increasingthe distance walked by the nurse, increase patient handling, whichhas been linked to back pain (Hignett, 1996), or increase the itemsin a stack, which may increase the likelihood that other tasks mightbe dropped or delayed.

For training nurses, emphasis on the third, fourth, and fifthlevels of the hierarchy might be warranted since there was morevariability on those levels than the top and the bottom and theinterviews with the experienced nurses yielded a much richerunderstanding of tradeoffs with tasks at these levels. In particular,being proactive on certain tasks was believed to reduce the overallamount of time spent on them, such as pain management, orga-nizing supplies, and setting expectations with patients and fami-lies. Similarly, explicitly training nurses how to generate a writtenplan for the shift (‘brains’) would be valuable, perhaps by providingexamples of how experienced nurses do them in different clinicalsettings.

Overall, a theme from the comments at these levels of thehierarchy was that failing to do certain tasks early during a shiftwould likely create more workload later due to a ‘snowball effect.’

For more experienced nurses, this normative framework forprioritizing stacked activities is anticipated to be less useful. Acentral tenet of resilient organizations is allowing experts to flex-ibly deviate from normative models by selectively relaxing con-straints, taking ‘shortcuts’, and employing alternative strategies toachieve the same ends in order to tailor to a particular situation(Weick and Sutcliffe, 2007). Therefore, we would not recommenddesigning policies or information technology support systems thatare rigidly based on this model, and in particular would not applysanctions for deviating from this prioritization scheme.

Finally, although this paper only reports findings regarding hownurses prioritized one activity over another, in several instancesstudy participants refused to accept the “A vs B” framing during

E.S. Patterson et al. / International Journal of Industrial Ergonomics 41 (2011) 389e393 393

the interviews. Decisions at a more strategic level were described,similar to strategic and tactical distinctions made in research ondriving strategies, such as choosing a particular highway ata strategic level to avoid accidents (Lee, 2006). Training nurseshow to escape these dilemmas is another possible contributionfrom this study. Specifically, participants described strategies thatare similar to workload management strategies (Huey andWickens, 1993) of:

� Delay tasks: Relax time constraints, such as doing two dressingchanges a shift rather than three.

� Reduce performance criteria: Change the nature of an orderedactivity or allocate fewer resources to accomplish a task (e.g.,less thorough assessment, fewer social interactions withpatients and families, reduced time spent teaching patients,less verification that communicated information was fullyunderstood by others).

� Recruiting: Recruit additional resources directly from othernurses, nursing aides, or charge nurses, calling out for helpfrom anyone within earshot, and teaming up to accomplishwork as a general strategy (e.g., informally agreeing to do ‘teamnursing’ by pooling care for patients together over a shift)

� Being proactive: Perform tasks ahead of time to save timelater; conducting actions to prevent tasks from escalatinglater, such as anticipating discharge requests, obtaining painmedications before patients requested them, and anticipat-ing patient or family requests based on historical patterns toincrease trust.

There are some limitations to the methodology employed in thisstudy. Although the rich interview data provided unique insightsthat were not anticipated in advance, a survey questionnairedirectly asking nurses to respond to standardized descriptions ofcases would reduce variability due to context, interpretation offactors, whether the cases were drawn from direct observation orself-report, and variation in data segmentation and analytic codingchoices. This methodology also did not investigate the relativeimportance of all of the factors in relationship to each other, simplythe ordinal relationship (A> B). In addition, there might be activi-ties and relationships that were missed because the study partici-pants were not specifically asked about particular factors andrelationships. Finally, this paper only reports on the hierarchy ofactivities as a general rule, when findings about the exceptions tothe hierarchies might themselves yield additional insights fortraining nurses, including subtle cues that expert nurses can use todetermine when to deviate from the normative framework.

5. Conclusions

The study findings suggest a seven-level normative frameworkfor prioritizing nursing activities. Explicitly providing a normativeframework for task prioritization during nursing education isanticipated to be useful in teaching nurses how to prioritizemultiplecompeting demands. For more experienced nurses, we believe thatflexibility to deviate from this framework will be important forproviding high-quality, personalized care that best matches theparticular context.

Acknowledgments

We thank Paul Buelow, PhD, for coordination and managementsupport.

Role of the funding source

This research was funded by a grant from The National PatientSafety Foundation’s (NPSF) Research Grants Program (2005 James S.ToddMemorial Research Award; Dr. Ebright, Principal Investigator).Dr. Saleem is supported by a VA HSR&D Career Development Award(CDA 09-024-1). The views expressed in this article are those of theauthors and do not necessarily represent the view of the Depart-ment of Veterans Affairs. Both of these sponsors had no role in studydesign, collection, analysis, and interpretation of data, writing ofthe report, and decision to submit the paper for publication.

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