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  1. Ebright, Patricia R. DNS, RN
  2. Patterson, Emily S. PhD
  3. Chalko, Barbara A. MSN, RN
  4. Render, Marta L. MD


Nursing shortages and patient safety mandates require nursing managers and administrators to consider new ways of understanding the complexity of healthcare provider work in actual situations. The authors report findings from a study guided by an innovative research approach to explore factors affecting registered nurse performance during real work on acute care medical-surgical units. Our findings suggest beginning targets for interventions to improve patient safety, as well as recruitment and retention, through support for registered nurse work.


Predictions of significant nursing staff shortages during the next 20 years complicates the mandate for increasing patient safety. 1 In light of the predicted registered nurse (RN) shortages, renewed calls have begun for redesigns in the workplace to recruit and retain nurses. Redesign efforts implemented in the 1990s were criticized for decreasing RN-patient ratios, relying too heavily on nurse extenders, 2 and leading to difficult working conditions. However, those conditions are not understood and, more importantly, whether they also might affect patient safety.


NurseWeek and the American Organization of Nurse Executives reported findings from surveys completed by 4,108 RNs about their perceptions of the nursing shortage, its impact, their career plans, and their work environment. 3 Eighty-three percent of the RNs agreed that improved working environments would help solve the nursing shortage. Respondents reported that the nursing shortage was a problem factor in nurses' ability to maintain patient safety, detect patient complications, carry out physician orders in a timely manner, and collaborate with other team members.


The expertise of human performance and safety experts and their research in non-healthcare industries, such as the military, nuclear power plants, and space mission control, 4 can help us to understand the complexity of the work environment. According to human performance experts, performance in complex work environments is influenced by human and environmental factors, such as types of information available, worker experience, ambiguity, unpredictability, conflicting goals, and time pressures. 5 Improving patient safety depends on understanding that such work environments require worker flexibility in adapting to variation in patient needs and environmental factors. 6,7 Indeed, research has demonstrated that healthcare workers create safety daily in the presence of multiple "latent failures" and are the resilient factor for preventing accidents in complex systems. 8 A latent failure is a flaw in a system that does not immediately lead to an accident but establishes a situation in which a triggering event leads to failure despite defenses that were built to protect against the failure. 9