'Cognitive load' increasing for health care workers

It's 'brain flow,' not work flow

Something called "cognitive load" or "cognitive work" is the centerpoint of some of the latest thinking on the way people process information and do their jobs.

That research — by Patricia Potter, a nurse scientist at Barnes-Jewish Hospital in St. Louis who co-wrote the textbook "Fundamentals of Nursing" — concerns nurses, but can be extrapolated to case managers and other health care professionals, notes Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA.

"Pat is doing research with an industrial engineer," Zander says. "He is looking at work flow, but she is studying 'brain flow.' In clinical work, sometimes your body and mind are not in the same place."

The engineer measures when and where the nurses go, how much time they spend in each patient room, and whether they are charting or performing another task, she explains. Meanwhile, Potter is studying what's going on in their brains, what they are filled with as they go from place to place or while in one place, Zander adds.

"The idea is that you hold a lot in your head," she says, "and it's different from multi-tasking, which is eating a sandwich, talking on the phone, and reading something on your computer screen at the same time."

Cognitive load is about how many activities and distinct pieces of information a person holds in his or her head at any one time, Zander continues. "It's the thinking that goes into the doing, the assessment, and judgment that comprise critical thinking."

In "regular life," the cognitive load may have to do with thinking about how much food is in the refrigerator and an errand that needs to be done and being interrupted by a phone call, she says. "In health care, it's high-level stuff."

As part of her research, Potter tracks the number of shifts people makes in their cognitive work as they go through the day, Zander says. "She's looking at how a nurse shifts from one to the other of four things: assessing, planning, implementing, and evaluating."

The findings were that a nurse had 82 shifts in thinking in eight hours, she notes. "When the nurse is in a room with a patient, and the patient is telling her about a pain in his side and she is asking questions, that's assessing. If she's starting to say things like, 'If you take deep breaths it might get better,' or 'I'll get you a pill,' that's implementing."

If the nurse goes back later and says, "Are you feeling better?" and "Can you walk now?" that's evaluating, Zander says. "If she says to another nurse, 'This seemed to work this time, but you might want to try another approach on the evening shift,' that would be planning."

In addition to the 82 shifts in thinking in eight hours, there were 42 interruptions, she says, after which the nurse had to return to her work. "That was a nurse with maybe five patients," Zander adds. "A case manager might have 15 or 20."

The industrial engineer concluded that the nurses spent an average of 30.9 minutes per patient room, she notes, but Potter found the cognitive work took another 15.7 minutes per patient, for a total of 46.6 minutes.

"[The cognitive work] is invisible to the eye, but it is the stress of what the work is," Zander says. "If that breaks down, if the person just can't carry all that in her head or can't get interrupted and go back, and loses focus, that's a safety issue."

Among the questions being addressed with the research, she says, are, "How do you restructure work, so there are fewer interruptions? Can something be reorganized so you can handle the load?"

After learning about this research, she has given more respect and attention to how much thinking case managers are doing about a case, Zander says, and has "gotten much less respectful of productivity studies. They don't prove anything about what's really going on with professional people and their work. That's not how we should be looking at the productivity of a professional person."

An appropriate question for those in leadership positions, she says, is "How can we cut down the variables for case managers, who are more mobile and have more patients than nurses?"

The popular book "Blink," by Malcolm Gladwell, says that the more experience you have, the faster you make your decisions, Zander points out. "Why fill out pages and pages of forms, when an experienced case manager can make a decision in an instant?

"Can we simplify the documentation and the forms we fill out, and yet know we are looking thoroughly at a situation? How do we find a balance and move forward without all the bureaucracy?"