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  1. Potter, Patricia PhD, RN
  2. Boxerman, Stuart DSc, CHE
  3. Wolf, Laurie MS, CPE
  4. Marshall, Jessica MS
  5. Grayson, Deborah MSN, RN, COHNS
  6. Sledge, Jennifer MSW
  7. Evanoff, Bradley MD, MPH


The work of nursing is nonlinear and involves complex reasoning and clinical decision making. The use of human factors engineering (HFE) as a sole means for analyzing the work of nursing is problematic. Combining HFE analysis with qualitative observation has created a new methodology for mapping the nursing process. A cognitive pathway offers a new perspective for understanding the work of nursing and analyzing how disruptions to the nursing process may contribute to errors in the acute care environment.


During the past decade, hospitals have attempted to address issues of patients' demands for high-quality, safe care along with payers' demands for lower costs. As a result, many hospitals have examined the work processes involved in patient care in an effort to streamline the processes, gain productivity, reduce costs, and maintain quality. Human factors engineering (HFE) techniques, drawn from the sciences of industrial engineering, ergonomics, and mathematics, have been used successfully to analyze clinical care processes and restructure patient care delivery. HFE has been used as a framework for constructive thinking to help healthcare teams perform patient safety analyses. 1 Use of HFE techniques often resulted in changes in patient care systems, such as medication delivery, supply access, or documentation.


Although HFE has enjoyed success in performance improvement, healthcare administrators must be aware that "traditional HFE or control-based engineering methods for improving performance are not successful in analyzing knowledge and service work such as nursing"2 This lack of success results to a great extent from the nonlinearity of knowledge work such as nursing, which involves complex reasoning and decision making that are part of the nursing process.


The nursing process is aimed at identifying, diagnosing, and treating actual or potential human responses to health and illness. 3 The cognitive work of delivering nursing care is not easily observed and recorded using HFE methodology. Drawing conclusions and making process changes in the nursing care system based on HFE studies can be problematic. For example, system changes resulting from HFE analysis may benefit the environmental design on a patient care unit but not provide the solutions needed to change those processes that support a nurse's clinical reasoning. To date, few attempts have been made to analyze how the cognitive work of the nursing process is conducted in practice and how it is influenced by acute care working conditions.


This article describes an observational investigation of a single registered nurse (RN) and patient care technician (PCT) dyad, in which a new methodology for mapping the nursing process, described here as a cognitive pathway, was developed. The pathway offers a new perspective for understanding the work of nursing and provides an analytical tool for examining how disruptions to the nursing process may contribute to errors within the acute care environment.