Inefficient Processes and Associated Factors in Primary Care Nursing: System Configuration Analysis (Preprint)

Abstract

BACKGROUND Better understanding the work system for primary care nurses is vital to understanding their needs and informing the design, development, and successful implementation of interventions to support their work. However, published evidence is sparse on primary care nurses’ work systems which takes into account multiple factors such as persons, tasks, tools and technologies, organization, and environment, and how they interact with each other. This has implications for mobile health information technologies (HIT) (e.g., laptops, tablets, and smartphones) designed to aid nurses in completing tasks at the point of care and away from their desk. These mobile HITs are not always available, or may not adequately meet their needs, because they are not well integrated into nurses’ work which may be due to a lack of understanding of the primary care nurses’ work system factors that may lead to process inefficiencies. OBJECTIVE The objective of this study is to characterize nurses’ perceptions of process inefficiencies in the primary care setting. METHODS Guided by the Systems Engineering for Patient Safety (SEIPS) 2.0 model, we conducted a work system analysis with primary care nurses and health technicians. Semi-structured interviews and observations were conducted in two sets of primary care clinics in the Midwestern United States, one set in an urban tertiary care center, and the other in a rural community-based outpatient facility. Participants were asked to identify frequent, redundant, or difficult tasks, related processes, and make recommendations for improvement. We applied SEIPS to analyze the relationships between work system factors that influenced process inefficiencies. RESULTS We interviewed a convenience sample of 20 nurses and two health technicians, averaging approximately 12 years of experience in their current primary care role. Across sites, the processes of managing patient calls and walk-ins were consistently perceived by participants as inefficient, in part due to policies affecting patient flow management. These processes included managing electronic notifications, chart review, and documentation, which were identified as frequent, repetitive, and difficult tasks. During interviews, participants identified potential mobile HIT solutions, including a digital triage system and a mobile application to record patient symptoms. CONCLUSIONS Using SEIPS 2.0, we show that when technology does not properly align with tasks, policies, and other work system factors, care processes and outcomes can be adversely affected. Understanding how the implementation of organizational policies impacts other factors in the work system is required to promote the effectiveness and efficiency of primary care nurse processes Moreover, the design and implementation of mobile HIT interventions should consider influential work system factors and their effects on primary care.