Navigating the invisible barriers to performance achievement

FigureWith the increasing expectations that frontline nurses guarantee optimal patient outcomes, nurse managers must support their teams with the necessary resources to meet these high-level job demands. Oftentimes, direct care nurses struggle to provide timely, quality care to their patients due to the presence of “invisible barriers.” These barriers can best be defined as intangible interruptions or delays in workflow that aren't necessarily directly correlated or associated with the given task. They are often overshadowed by the bottom line and are thus “invisible.” Nurse leaders may not realize the impact of these invisible barriers and look to direct cause-and-effect interventions instead of addressing the underlying issues. One striking example is the association of insufficient job resources with burnout and disengagement.1 The classic work by Bakker and Demerouti shows the tight interplay between job demands and job resources and how misalignment of resources with respect to job expectations will demotivate the employee and ultimately affect job performance.1 Inherent in these struggles is the presence of invisible barriers in daily operations, such as operational failures and workflow interruptions. Operational failures are best defined as inefficiencies in normal organizational operations. Failure of one department or process can have a downstream effect on dependent departments, impeding their workflow and contributing to negative outcomes. Failure of multiple departments or processes further compounds successful execution of the end goal. Tucker and colleagues show the interplay among nine departments just for a patient's room to be deemed safe and ready to receive a new admission.2 Such operational failures affect nurses, who are at the forefront of healthcare organizations and depend on numerous departments. In fact, nurses may spend 10% to 12% of their shift addressing operational failures, which can amount to 1 hour of a 12-hour shift.3 Knowledge of invisible barriers may help when addressing challenges related to retention and job satisfaction, and their contribution to burnout and patient outcomes; these factors are often addressed solely with strategies for improving resilience and employee engagement.4 However, through strategic planning, nurse managers can remove barriers that prevent a smooth workflow, thereby improving aspects of the work environment, which, in turn, can reduce stress and enhance outcomes.1 The purpose of this article is to identify various causes of nursing disruptions and provide strategies nurse leaders can use to navigate these invisible barriers to improve nursing workflow and organizational outcomes. METHODS A literature review conducted on PubMed, CINAHL, and Scopus of articles published from 2018 through 2023 using the keywords nursing, patient outcomes, tasks, workflow, operational failures, barriers, and interruptions, yielded 1,020 articles. These search results were screened for articles that identified common barriers to workflow in the acute care setting. Articles specific to the non-acute care setting (such as long-term care, rehabilitation, home care, and psychiatric nursing), theoretical studies (conceptual, simulation, and those done by nursing students), review articles, and articles not available in English were excluded. The remaining 23 articles were analyzed to identify and delineate the invisible barriers. This literature review identified operational failures and interruptions as the main invisible barriers, with subthemes of nurse response, psychological impact, and organizational impact. The Balanced Scorecard and Lean Six Sigma were selected as the strategic tools for addressing invisible barriers because they're commonly utilized in healthcare and proven to be effective.5 RESULTS Types of invisible barriers Operational failures. The first category of invisible barriers, operational failures, includes four domains: equipment/technology, material resources, human resources, and communication.3,6 Equipment/technology is composed of computers, devices, and the electronic health record (EHR).3,7 Challenges with equipment, such as a broken vitals machine, often hinder the nurse's ability to care for patients in a timely manner.3 Software challenges, such as EHR feasibility or functionality, contribute to the nurse's mental workload.8 Material resources include nursing supplies (for example, gauze or needles) and medications. Inadequate supplies, such as linen or medications, result in delays in care or medication administration.3,9,10 Human resources include nurses and unlicensed assistive personnel.6 Insufficient staffing increases the workload and number of tasks to be completed.6 Finally, communication addresses the process and efficacy of communication among hospital staff.7,11 Inability to contact the physician or ancillary staff prevents effective and timely communication.6 Deficiencies in these areas, processes, or workflows interrupt the frontline nurse, preventing the nurse from caring immediately for the patient. In addition, these disruptions often result in secondary tasks, including administrative issues, patient needs, care coordination, resolving errors, medication management, and social interactions.9 Collectively, these events lead to protocol nonadherence, delays in care, and missed care.6,7 Interruptions. Interruptions comprise the second category of invisible barriers to nursing care. These interruptions include attending to patients' physical and emotional needs, emergencies, and alarms; and communicating with patients, family members, or staff.7,12,13 Nurses are interrupted approximately five to six times an hour, most often by patients, family, or staff.7,10,13 However, these human interruptions decrease by 6 p.m., likely due to fewer staff working at that time.14 Interruptions during a task increase task completion time by 9.1%.13 During EHR-related tasks alone, nurses can be interrupted up to 14 times an hour, resulting in one error per shift.8 These delays are especially significant during ED triage, where 57% of assessments can be interrupted, impacting time for initial patient treatment.15 Nurse response to interruptions. Interruptions result in a temporary cessation of the nursing task until the nurse can best “triage” the interruption, which is determined by the importance of the interrupted task, the method of communication, and the nurse's skill set.16-18 Nonetheless, nurses respond to interruptions in one of four ways: 1) Task Switch (stopping the primary task to complete interruption task); 2) Task Integration (performing the primary and interruption task simultaneously; in other words, multitasking); 3) Postpone (giving a verbal response indicating an intent to perform the interruption task later); and 4) Reject (rejecting the interruption task).16 Redirection is primarily influenced by the perceived level of importance, which is determined by safety, time sensitivity, or secondary task medication.17 As one nurse stated, “If the patient calls screaming for pain medications, I will fulfill his request immediately, but if he asks for constipation medication, I feel anger—he can wait for me to finish treating the wound.”19 Ideally, the nurse can foresee the predictable workflow interruption and prevent it by addressing the issue before the need for the request/interruption. On the other hand, unpredictable interruptions, such as a rapid response, require full engagement and immediate cessation of other activities.20 This need for continuous reprioritization leads to nurses reporting difficulty with “keeping on track” due to “task juggling,” “information overload,” and frequently “pausing for consideration.”21 Nursing perspective. Nurses liken these disruptions to “working in a minefield,” where managing the turbulent environment is determined both by organization-specific factors and individually developed strategies.22 When surveyed about reasons for missed nursing care, nurses primarily blamed limited resources, patient acuity, and staff commitment to the organization.6,23,24 Other reasons included the nurse's skill set and ability to think beyond routine care and difficult patients and families who may demoralize caring for that patient. Additional influencers were the perceived importance of the task and whether it's monitored.23 Although social conversations may contribute to the number of interruptions, some of these may be considered acceptable and even productive in the work environment.18 However, barriers to communication and cohesiveness were among the strongest contributors to frustration and associated missed care.19 These factors result in added stress, frustration, and feelings of nonperformance in task incompletion.18,19 As one nurse expressed, “I was in the middle of preparing medication when suddenly the head nurse turned to me and asked, ‘Do you hear the alarms?’ I was angry—I cannot stop drug preparation, so I ignored her.”19 Another nurse stated, “It seems that everyone knows that interruptions are a problem, but no one has any solutions. We tell the management that we have been in a hurry, and we see that there have been mistakes.”22 Overall, nurses expressed a lack of trust in leadership, unreasonable expectations, and little recognition.24 Nurses feel as if they're “the glue that keeps everything together to make the day run smoothly,” but this function comes at a cost, often needing to work through lunch and stay late past their shifts.18,25 Psychological impact of disruptions. Perhaps most significant is the psychological effect of numerous disruptions on the nursing staff. As the number of disruptions get higher, staff perceive an increased workload.26 Disruptions decrease the nurses' situational awareness, which is defined as their cognitive awareness and responsiveness. One study showed that nurses reported a situational awareness of 7.2 for a perceived disruptiveness of 4.21 on a Likert-type scale ranging from 0 (very low) to 10 (very high). This result shows that moderate amounts of disruptions negatively impact the nurse's situational awareness.26 Although 7.2 is a relatively higher score, it's still less than 10, which would indicate perfect cognizance to perform the job. In addition, more mental demands increase the time it takes staff to react to a situation.27 One nurse reflected that “with major interruptions...it takes time to refocus. If I have been away from a task for a longer time, I am exposed to new interruptions on my way back.”22 This sentiment could explain how a higher perceived nurse workload is significantly associated with increased patient mortality.28 These data complement existing knowledge on cognitive load, a concept that encapsulates the limitations of the human mind in memory recall in a given scenario. The three components of cognitive load (intrinsic, extrinsic, and germane) consider the cognitive effort needed to complete the task, manage external input from the working environment, and interpret and translate new information. Excessive cognitive input results in cognitive overload, a regular occurrence in nursing that negatively impacts the nurse's ability to provide seamless and error-free patient care.29 Organizational and patient impact. These disruptions are directly and indirectly responsible for several disturbances, including protocol workarounds, delays in patient care, and compromised patient safety (such as hospital-acquired infections, falls with injury, pressure injuries, and medication errors).7,10,11,30 Nurses have also reported neglecting certain duties, such as discharge teaching, repositioning patients, and hand hygiene.6 These aberrations in care may explain the identified patient safety events, as frequent as every 89 minutes, that are correlated with operational failures.7 The consequences of these disruptions inevitably add to the nurse's stress/burnout, job dissatisfaction, and intent to leave the organization.11 One study found that an increased number of tasks impedes evidence-based practice and the implementation of quality measures.21 In addition, organizations with poor work environments are associated with more operational failures and lower scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey—a national, standardized, publicly reported survey of patients' perspectives of hospital care.11 These poor scores negatively impact the hospital's reputation and reimbursement by Medicare and Medicaid.31 DISCUSSION Literature review summary When questioned about causes for missed nursing care, acute care nurses tend to emphasize areas of staffing, experience, and job turbulence, while apparently unaware of the number of invisible barriers. Figure 1 summarizes the downstream effect of invisible barriers on the nurse, the patient, and the organization. The most identified invisible barriers include staff communication, patient/family communication, supplies, medication availability, staffing, equipment, EHR, and alarms. In addition, subjective invisible barriers include the number and complexity of tasks and time to complete them.FIGURE 1:: Effects of invisible barriersThese invisible barriers reduce the amount of time the nurse has to devote to true nursing tasks, resulting in a “time pressure” theme that often results in workarounds to accomplish those tasks within the time frame of the shift.25 Based on these data, conceptually, if a nurse has 70 minutes of tasks to complete in 1 hour, then there's the risk that 10 minutes of tasks won't be completed or the staff will develop workarounds.6,11 These delays and interruptions, in turn, result in patient safety events, poor HCAHPS scores, and a disengaged staff.11 The data show that nurses experience interruptions at all phases of care, including medication tasks, direct patient care, or documentation. In addition, the number of interruptions is high, significantly contributing to a decreased situational awareness, often unbeknownst to the nurse. Such cognitive impact dampens the nurse's ability to most effectively respond to patient needs.26Box 1 presents a hypothetical, but realistic, scenario of a nurse who was met with various invisible barriers contemporaneously, resulting in a patient fall. This case scenario will be used as the exemplar in formulating the strategies for nurse leaders. Common leadership approach In the traditional setting, a designated team would review an event such as the patient fall in the case scenario and search for potential causes in a root cause analysis (RCA). The team would go through a stepwise process, questioning the parties involved until they determine a root cause.32 However, RCAs are limited by recall bias, fear of blame (despite a and the on a for the nurse in the case he was up in his shift and recall all the at the As a his the that this fall was due to protocol nonadherence, neglecting the of invisible barriers The nurse the disengaged and a approach to negative events, nurse leaders common to such as the for an method for organizational This approach evidence-based strategies that nurse leaders but to these within the of the invisible barriers. for nurse leaders The strategic as in Figure with a Balanced which will be further defined in the The on the Balanced Scorecard then the of the invisible barriers, and the nurse if these barriers are and are preventing successful outcomes. the specific barriers can be difficult because staff often on these of fear or a perceived lack of organizational Nonetheless, using the invisible barriers identified in Figure as a the nurse can underlying challenges in the to invisible barriers aren't by more tasks and the be to reduce and tasks while This can be through Lean Six a that often a team approach among various of leadership and for the of this the nurse contribution will be If no invisible barriers are then the can consider other such as staff and to the task, to that these are Balanced Scorecard The Balanced first by and in the is an effective for nurse managers to organizational A Balanced Scorecard is a that presents with respect to the and method of Figure These often include and the in healthcare are related to the to the as a such as and to which can to team and Balanced with the Balanced Scorecard is that leaders have numerous and could the a will the most on the example, if the numerous but one it may be less to include as a goal. Figure shows a Balanced Scorecard on the case scenario. This Balanced Scorecard includes some traditional but these could for example, the could be with Lean Six Sigma healthcare in Lean Six Sigma has been in medication errors, pressure injuries, and Lean on with respect to time and supplies through a process Figure This process with the or purpose in a given process and then it from to is then by the not directly to the end by a on the the and Finally, is that this new process while of to further it in the Lean and Six Sigma on in organizational processes by the with the problem, or of are and This analysis the for at which those new processes need to be and Lean and Six Sigma together Six has been to improve quality in healthcare by barriers to optimal processes, and may be times when Lean or Six Sigma will be but that will be at the of the nurse the invisible barriers. to the case the nurse could have identified several invisible barriers through the strategic approach in Figure These invisible barriers include the medications, physician communication, staff communication, number of tasks, and of these invisible barriers are within the nurse such as for the and effective team the that the nurse was in room the of his patients were between 1 and was he away to hear the but the also of time to the nurse's in management (such as nurse and patient be to the and of the the and these fall this the first time these events this issue could have been to the department in Finally, the in physician communication new in would to cohesiveness among all where barriers can be expressed and for the purpose of or even if that will enhance timely One in which the nurse could Lean would be the management of direct (such as nurses and unlicensed assistive the would be timely can in one of four electronic in some or communication (such as from the the nurse can then a process deemed and example, can be on a thereby preventing interruptions, and could a to an specific In this the invisible is the time for the staff and barriers The efficacy of this strategic approach is dependent on the and in the The nurse would need to a Balanced Scorecard that to the staff need to feel with their leadership, and a team who their on their will be more to departments need to be on in working together outcomes. 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