Complexity Compression:
Nurses under Fire
A Collaborative Research Project:
Minnesota Nurses Association and the University of
Minnesota School of Nursing
Research Team
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MNA:
- Donna Bjork
- Carol Diemert
- Niki Gjere
- Lynn Jacox
- Patty Koenig
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School of Nursing
– Kathie Krichbaum
– Ann Jones
– Christine Mueller
The Issues
Nursing shortage
 Nurses’ work environments
 Sick, complex patients
 Patients’ family and cultural issues
 Complex health care environment and system
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Underscored in the literature
Keeping Patients Safe:Transforming the work environment of
Nurses, IOM, 2004
 Understanding the Complexity of Registered Nurses Work in
Acute Care Settings, Ebright et al, 2003, JONA, 33(12),
630-638
 Hassles:Their importance to nurses’ quality of work life,
Beaudoin et al, 2003, Nursing Economics, 21(3), 106113.
 The impact of operational failures on hospital nurses and their
patients, Tucker, 2004, Journal of Operations
Management, 22, 151-169.
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Literature (Continued)
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The Impact of Nursing Work Environments on Patient Safety
Outcomes: The Mediating Role of Burnout/Engagement, Laschinger
and Leiter, JONA, , 2006,36(5), 259-267.
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Nurse Staffing and the Quality of Care in Hospitals, Needleman,
Buerhaus, Mattke, Stewart, and Zelevinsky. N Engl J Med,
2002, 346(22), 1715-1722.
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Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job
Dissatisfaction, Aiken, Clarke, Sloane, Sochalski, Silber. JAMA,
2002, 288, 1987-1993.
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Understanding the cognitive work of nursing in the acute care
environment, Potter, Wolf, Boxerman, Grayson, Sledge, and
Dunagan, JONA, 2005, 35(7-8), 327-335.
Complexity Compression
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The phenomenon that nurses experience
when expected to assume additional,
unplanned (unexpected) responsibilities while
simultaneously conducting their
multiple responsibilities in a condensed time
frame.
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The “tipping point” for nurses in the practice
environment.
Research Collaboration Process
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Identified and ‘named’ the problem (Complexity Compression)
Sought validation – “does it ring true?”
Conducted 10 simultaneous focus groups
– Identified 147 factors contributing to Complexity Compression
– Majority (total number) of factors associated with the themes of
practice (32%); systems and technology (30%)
Analyzed qualitative data and identified six factors and associated subfactors
Survey to determine level of agreement with factors/sub-factors
identified
Survey to larger sample to further validate
Factor analysis based on results from larger sample
Themes Contributing to
Complexity Compression
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Personal - Variables that affect the individual
nurse
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Environmental - Variables that affect the
immediate work environment
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Practice - Variables that affect the ability to care
for patients; the work of nursing
Themes Contributing to Complexity
Compression (Continued)
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Administration and Management - Variables
that affect how the work of nursing is supported by
administrators and managers
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Systems - Variables that affect the mechanisms put in
place by the organization to accomplish the delivery of
health care to people
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Autonomy/Control - Variables that affect the
ability of the nurse to make decisions about the care
and resources needed for patients
Personal Variables
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Physical and mental
exhaustion
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Family/individual issues
Environmental Variables
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Physical
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Psychosocial
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Cultural
Practice Variables
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Delegation
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Conflicting responsibilities
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Floating/Cross
Training/Unfamiliar tasks/needs
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Time
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No safety net
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Patient/family issues
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Culture-patients and staff
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Mentoring/Precepting
Administration & Management
Variables
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Lack of understanding
of nursing
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Changes in upper
management
System Variables
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System failures
Multi-changes
Lack of safety net
Documentation
Regulatory/legal
Budget
Staffing
Technology
Autonomy/Control Variables
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No input into decision
making
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Input not valued
Initial Questionnaire
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For each variable, to what extent do you agree or
disagree with variable as contributing to the
phenomenon of complexity compression? 1=strongly
agree to 4=strongly disagree
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Within the last month, how often have you
experienced the variable? 1=Rarely/never to
4=Almost always/Always
Validation of Survey Process
Sent to focus group participants
 Stratified random sample of RNs employed in
Minnesota
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– Mailed 1200; received 199 (16.5%)
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Sample representative of MN nurses
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46 years
20 years as RN
Works 35 hrs/week
44% Diploma or AD
Works hospital inpatient and provides patient care
Validation Survey Process (Continued)
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Rating for each variable
– Variable contributing to Complexity Compression
 Range: 3.04-3.55 (indicating good agreement/validation
for variables)
– Frequency experiencing variable
 Range: 1.96-2.86 (moderate ratings indicating nurses
experience complexity compression, but not on a daily
basis)
Variables contributing the most to
complexity compression
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Inadequacy of the staffing system put in place by
the organization (system)
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Lack of understanding of nursing
(administration)
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The difficulty of performing or prioritizing
multiple tasks/functions/roles within a specified
time frame (practice)
Variables contributing the most to
complexity compression
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New, excessive, or changing forms and documentation
systems required by the organization (system)
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The dilemmas experienced by the nurse when there
are competing demands of equal importance
(practice)
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Fatigue, tiredness, physical needs unmet (personal)
Process of Factor Analysis
Summarize all results
 Rank order frequency of experience and
importance of variable
 Select top ranked items
 Determine relationships between variables
 Obtain true list of variables
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Results of Factor Analysis
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23 variables ranked the highest
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Correlations among items revealed 3 factors
that make up “Complexity Compression”
~Direct Care items
~System items
~Personal items
Factors now defined (1)
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The work of nursing factor: this factor
includes elements within the workplace that occur
unexpectedly and that directly interfere with nurses’
ability to carry out their work; (13 variables -cultural
issues (patient and organizational) delegation,
mentoring/precepting, floating/cross-training,
conflicting responsibilities, patient/family issues, time,
system failure, psychosocial, lack of backup, no safety
net, physical space)
Factors now defined (2)
The systems factor: This factor includes
those unforeseen elements in the workplace
that originate in the organization’s structure and
administration and that affect the ability of
nurses to carry out their responsibilities within
the time allotted. ( 8 Variables – documentation,
changes in upper management, lack of
understanding of nursing, budget, no input into
decision-making, regulatory/legal, technology,
staffing)
Factors now defined (3)
The personal factor: This factor comes from
within the individual nurse and/or her immediate
personal situation and contains unexpected
occurrences that interfere with her/his ability to
carry out work related responsibilities in the
allotted time. (2 Variables -physical/mental
exhaustion, family/individual issues)
Discussion
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Language issues - eg What is your “last straw”, your
“tipping point”, what puts you “over the edge”?
Are these really “unplanned” events?
Is there a “pattern” to these events?
How does the issue of “knowledge” or “cognitive”
work of nurses relate?
Are there ways to address these factors and to
reduce complexity compression?
Next Steps
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Survey available on website www.mnnurses.org
cdiemert@mnnurses.org
krich001@umn.edu
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Publication accepted Nursing Forum (Spring,
2007)
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National and international sub-sample
Next Steps (Continued)
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Larger descriptive study of phenomenon of
complexity compression in nursing organizations
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Partnering with Nursing Organizations
– use as a diagnostic tool at the unit level and/or
organizational level
– work with groups of nurses to tailor strategies addressing
the phenomenon to a particular unit/facility