1. Ebright, Patricia DNS, CNS, RN
  2. Saleem, Jason PhD
  3. Patterson, Emily PhD

Article Content


Stacking is a registered nurse (RN) decision-making and workload management activity for safe and efficient care delivery. The purpose of our study was to identify critical attributes of stacking consistent across settings and unique to levels of RN experience. Our specific aims were to describe (a) activities stacked by RNs in the context of real-life care situations, (b) factors that contribute to RN decisions surrounding stacking. and (c) strategies used to manage the stack.



Given the increasingly higher acuity of patients and complexity of healthcare systems, understanding and supporting critical features of RN work regarding organization and prioritization in delivering care will affect patient care safety and quality.



We used a multimethod ethnographic approach that included direct observations and interviews of RNs with varied experience and in multiple healthcare settings.



We followed each observation of 30 RNs with an unstructured taped interview to collect detailed data about factors that influenced decision making about stacking. We conducted RN focus groups for each of 3 levels of RN experience (<1, 1-5, and >5 years). Through repeated iterative discussions about data transcripts, the primary author and 2 independent reviewers reached consensus on the list of activities stacked, themes characterizing factors that influenced decision making, and failure-sensitive strategies to reduce error.



We identified the following across RNs and settings: (a) a hierarchy of work activities demonstrating factors that influence ordering of work, (b) 7 stacking management strategies, (c) variation in flexibility and use of strategies across experience levels, and (d) constraints leading to use of strategies.



Our study findings include specific attributes of RN work related to stacking and delivering care in actual care situations common across settings and differing across RN experience levels.


Implications for Practice:

Findings provide information to guide CNSs in the following: (a) mentoring of novice RNs, (b) educating experienced RNs on effective support of novice RNs, and (c) leading redesign of processes and systems to support novice RN capabilities and impact on patient care safety and quality.


Section Description

The 2009 NACNS National Conference will be held in St Louis, Missouri, on March 5 to 7. More than 350 clinical nurse specialists (CNSs), graduate faculty, nurse administrators, nurse researchers, and graduate students are registered. This year's theme, "Clinical Nurse Specialists: Vision, Value, Voice," demonstrates the essential leadership skills of the CNS as well as the CNS role in implementing evidence-based practice.


Seventy abstracts were selected for either podium or poster presentations. Again, this year, there is a CNS student poster session. The abstracts addressed CNS practice in 3 practice domains (spheres of influence), emphasizing patient safety and quality care outcomes, leadership, evidence-based practice, and new ways to shape CNS practice. Topics include CNS work activities incorporated into 3 spheres of influence-patients, nursing practice, organization/system-including the development of clinical inquiry skills among staff nurses, use of simulation technology, strategies to maintain clinical excellence, CNS practice in end-of-life care decisions, and many new and thoughtful ideas to support CNS education, practice, and research. Collectively, the abstracts represent the breadth, depth, and richness of the CNSs' contribution to the well-being of individuals, families, communities, as well as to the advancement of the nursing profession.


The conference abstracts were published here to facilitate sharing this emerging new knowledge with those who were unable to attend the conference. As you read each abstract, appreciate the intellectual talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to the health of society through improved outcomes for patients and healthcare organizations. We encourage you to contact individual presenters to network, collaborate, consult, or share your thoughts and ideas on the conference topics. Watch out for next year's call for abstracts and consider submitting for presentation at NACNS' next annual conference in Portland, Oregon, on March 4 to 6, 2010.