EXPLORING THE INVISIBLE WORK OF NURSING: A CASE STUDY OF SIMULATED INCREASES IN INTENSITY OF CARE ON NURSES’ COGNITIVE LOAD, CLINICAL JUDGMENT, STRESS, AND ERRORS By LAURA ANNE VASEL A Dissertation Submitted to the Graduate Faculty of Georgia Baptist College of Nursing of Mercer University in Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY Atlanta, GA 2020 © 2020 LAURA ANNE VASEL All Rights Reserved EXPLORING THE INVISIBLE WORK OF NURSING: A CASE STUDY OF SIMULATED INCREASES IN INTENSITY OF CARE ON NURSES’ COGNITIVE LOAD, CLINICAL JUDGMENT, STRESS, AND ERRORS By LAURA ANNE VASEL Approved: ___________________________________________________________________ Lanell M. Bellury, PhD, RN (Chair) Date ___________________________________________________________________ Justus J. Randolph, PhD (Internal Committee Member) Date ___________________________________________________________________ Patricia Ebright, PhD, RN (External Committee Member) Date ___________________________________________________________________ Tammy D. Barbé, PhD, RN (Associate Dean, Graduate Programs) Date ___________________________________________________________________ Linda A. Streit, PhD, RN (Dean) Date ACKNOWLDEGEMENTS I would like to first acknowledge my dissertation committee for their dedication as nurse faculty and for the time and thoughtfulness shared with me during this research process. I cannot express enough gratitude for my chair, Dr. Lanell M. Bellury, for her countless hours reviewing my work, holding me accountable, and forever helping me see the logical argument in every phase of this dissertation. I will forever be grateful for her commitment to helping me grow as a scholar. To my internal committee member, Dr. Randolph, for providing me with direction for my research and opportunities to explore research that was the best fit for my ideas. To Dr. Patricia Ebright, my external committee member, I am honored that you were here to guide me in my research. I had valued your research in the highest regard and truly feel privileged to have you serve on my committee. To Dr. Helen Hodges who not only taught my first doctoral course but also supported me as an internal committee member for my proposal defense. I am forever grateful for your kind words, commitment to quality, and gift of feedback. To Dr. Kathie Lasater for granting permission to use the LCJR in this study. I would also like to acknowledge Dr. Linda Streit, as the dean you have always been welcoming and supportive for every Community of Scholars event. I also would like to acknowledge that my education would not have been possible without the Nurse Faculty Loan Program, and I acknowledge the support of administration and commitment to preparing faculty scholars that enabled this funding to be available throughout my studies. To Dr. Tammy Barbé for role modeling all the best practices in the nursing education cognate courses. iv I would also like to acknowledge my family, especially my husband Todd who has seen this journey and supported me every step of the way. Thanks also to my three wonderful children: Logan, Liam, and Wyatt for allowing me so much time on the computer and never forsaking my need to study and write. To my mom, thank you for taking my calls every day and asking how my studies were going. I know she is proud of me. She and my and dad always made me feel like I could accomplish anything I set my mind and heart to do. To my brother Bryan and his family for always welcoming me into their Atlanta home when I was on campus. To my sister Ali for our happy hours and marathons and to my sister Melissa for always asking me about my running. It is each one of you who gave me distractions when I needed them and kept me grounded in the real world beyond dissertation. Special thanks to my friend and colleague, Dr. Cindy Rubenstein. It was one phone call sharing how there was a spot open in a doctoral program that started me on this journey, and for your unending support and sage advice I will be forever grateful. Finally, to all the faculty at Georgia Baptist College of Nursing, each and every one of you have welcomed me to this community of scholars, and most importantly, made me feel like I belong. v TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................... iv LIST OF TABLES ............................................................................................ xi LIST OF FIGURES ......................................................................................... xii ABSTRACT .................................................................................................. xiv CHAPTER 1. INTRODUCTION TO THE STUDY .......................................................... 1 Statement of the Problem ........................................................... 2 The Impact of Technology ................................................. 3 Cognitive Load Theory ................................................................ 5 Critique of the theory........................................................ 6 Application of Cognitive Load Theory to Nursing Care ........... 7 Purpose of the Study .................................................................. 8 Research Questions .................................................................... 8 Conceptual Framework ............................................................... 9 Significance of the Study ........................................................... 12 Definition of Terms ................................................................... 13 Summary ................................................................................ 16 2. REVIEW OF RELATED LITERATURE .................................................... 17 Surveillance ............................................................................. 17 Nursing Workload ..................................................................... 19 Workload Models ............................................................ 19 Cognitive Work .............................................................. 20 Cognitive Load ......................................................................... 22 Cognitive Load Theory .................................................... 22 Measuring Cognitive Load ................................................ 23 NASA-TLX ..................................................................... 25 Cognitive load and nursing practice .................................. 26 Work Complexity Contributors ................................................... 29 External Complexity Contributors ..................................... 29 Nurse staffing ...................................................... 30 Technology and information overload...................... 31 Efforts to reduce information overload .................... 32 Interruptions of Care ...................................................... 33 Internal Complexity Contributors ...................................... 35 Nursing stress ...................................................... 35 Nursing education and experience .......................... 38 vi TABLE OF CONTENTS (Continued) CHAPTER Page Patient Care Outcomes ............................................................. 41 Patient Safety ................................................................ 42 Heart failure and patient safety ........................................ 44 Inferences ............................................................................... 44 Summary ................................................................................ 46 3. METHODOLOGY .............................................................................. 47 Research Design ...................................................................... 47 Design Quality ............................................................... 48 Analytic Considerations in Case Study Design .................... 49 Setting.................................................................................... 51 Case Selection ......................................................................... 53 Simulation: Increasing Intensity of Care ..................................... 54 Simulation Scenarios ...................................................... 55 Simulation Protocol ........................................................ 56 Intentional increases in intensity of care ................. 57 Protocol development ........................................... 57 Instruments ............................................................................ 60 Demographic Questionnaire ............................................. 60 NASA-TLX ..................................................................... 61 Clinical Judgment and Nursing Errors ................................ 63 Narrative Data ............................................................... 66 Procedures .............................................................................. 67 Simulation Planning and Development .............................. 68 Data Collection Procedures .............................................. 69 Planned Quantitative Data Analysis ............................................ 71 Revised Data Analysis ............................................................... 73 Data Preparation ............................................................ 73 Pattern Matching and Time-Series Analysis ........................ 74 Predictions .........................................................