Nurse Overload: The Risks to Employee and Patient

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By: Beth Boynton and Doug Hall…

The secret is out. The illusion is exposed. The truth is known:

Hospitals are dangerous places.

Healthcare workers have known this for a long time and tried to tell friends and family but few let the warnings change their long-held image of ideal hospital

care.  Many nurses and other healthcare workers also held onto this illusion of ideal hospital care and thought they were the ones who were failing when faced with sicker patients and fewer staff.

Statistics are now published and mainstream media run stories of the reality of today’s healthcare.

Enter Cognitive Stacking – the nurse’s overloaded brain.

Cognitive means intellectual activity such as thinking, reasoning, remembering, reevaluating, planning, calculating and extrapolating. Stacking is, well, stacking.

Cognitive Stacking is similar but not the same as multi-tasking. Multi-tasking is a term from computer engineering in which processes are completed so fast that they appear to be done at the same time. Studies have disclosed that people do not perform well even with very simple tasks performed at the same time.

Multi-tasking usually involves only a few functions, lasts only a few minutes and usually doesn’t involve making 100% accurate decisions involving the life of another. For example, combing your hair while feeding the dog, putting on a shoe, and answering the phone.

Overload and Cognitive Stacking negatively affects the health and employment satisfaction of healthcare workers. It is a work environment in which nurses are overwhelmed with information, data and distractions that ultimately can result in job dissatisfaction, burn-out and injury to a patient. And this overload is relentlessly present in every minute, hour, and shift.

nurse's station

Raising awareness among healthcare consumers, professionals, advocates, and administrators is an important step towards creating workplaces that support the work RNs do.  The following is a realistic recreation of ten minutes in the life of a Registered Nurse on a busy medical-surgical unit. In addition, add the sounds of I.V. pump alarms, patient vital sign alarms, overhead announcements, phones,  and colleague conversations. Can you imagine yourself as the nurse or  patient on this unit?  How might you feel?   What are your thoughts?


The scene opens at the nurses station! Click To Tweet

0:00 The patient in 314B pulled that Foley catheter out again.

The family in 309A wants to talk to you.

That colostomy bag in 322A needs to be changed soon.

What’s taking so long? My mother is screaming in pain.

Can I borrow an Aldactone from 326A for 307B?

1:00 You have a call holding on line 1.

Is it OK for my brother to eat with a blood sugar of 53?

Did the blood work get done for the patient in 311?

Were there any abnormal labs for my other patients?

Was the physician notified of my nephew’s problem?

Has anyone talked to the patient about surgery being cancelled?

2:00 Which Mr. Smith is getting the blood transfusion?

Mr. Jones says he’s allergic to the new antibiotic ordered.

The pre-op patient in 313 is eating a hamburger.

Did you know The Joint Commission is here today?

Did you hear that Joe Smith in CCU got fired?

Did the emergency surgery patient get prepped?

3:00 Dr. Brown wants Mr. Green’s MRI done tonight.

How do I get to the gift shop? And, do they have daisies?

Can you show me how to use the new PCA pumps?

The patient in 301B has an infected incision. Did you call?

Can you take this call? It’s the daughter of 302A. She’s upset.

Can you give me a quick in-service on these glucometers.

Can you cover my patients while I go to lunch?

4:00 Where’s the X-ray tech for that stat I ordered.

The patient in 310B needs to go to ICU, now!

Did we get the medical records for the patient in 305B.

Is prochlorperazine the same as trifluoperazine?

Is it OK to bolus 2200 units of heparin with a PTT of 45?

Pharmacy is on the phone for you.

Will you call the kitchen? I didn’t get my coffee today.

Do you know if it’s going to rain or snow tomorrow?

P.T. wants to know when 320B got back from surgery.

We’re out of soap at this hand-wash station.

I need a thermometer battery. Where are they?

5:00 Chris just called in sick. Can you work a double?

Can you help me start an I.V. in 320B

Can you co-sign this morphine I’m wasting?

How do I convert micrograms per minute to milligrams per hour?

When can we talk about your yearly evaluation?

And, I want you to work on your time-management skills.

Excuse me, but did you wash your hands?

The patient in 303A is disoriented times 3. Did you call?

6:00 Who’s on-call for Dr. Jones?

Medical Records says we need to document better.

We need housekeeping in 314 do you know their number?

I’m a student. Can I ask you a few questions?

Dietary is on the phone for you.

Your L.P.N. just went to the E.R. with a back strain.

Notify your staff that there is to be no overtime.

Read this memo. Don’t miss the Discharge Planning meeting.

I just got stuck by needle left on a gurney.

7:00 There is no more gauze. Can you call someone?

The new graduate is crying in the stairwell.

Is Vioxx the generic for Zyvox?

Will you get me some vanilla pudding? I got Jello instead of pudding.

Look at these pictures. My dog had puppies.

Your fresh post-op is here and doesn’t look very good.

The patient is 306 just fell in the bathroom. Can you help?

8:00 The I.V. is empty in 302B.

The car repair shop wants to know if you want white wall tires?

The patient in isolation has a potassium of 2.5. What should I do?

I’m new here. I was told to ask you where Billi Rubin works.

The letter G just came off my keyboard.

What is the NPO deficit replacement formula?

Dr. Smith wants to know if 325A has Respiratory Alkalosis.

What are the drops per minute to equal 125 milliliters per hour?

9:00 The lab tech can’t find the patient in 322A.

Ten visitors are in 300A and 300B is complaining.

The patient in 312A says someone stole her get-well gifts.

The computer is slow. Who do we call?

Your kids are on-hold on line 5.

Did you finish charting that code blue from yesterday?

Dr. Jones forgot his password.

The family of 319 is taking him home AMA.

Call the Rapid Response Team for 303B!  His blood pressure is crashing!

10:00 Did you call about my not getting my coffee?  The service here is horrible!

Only 7 hours and 50 minutes to go for this shift.

Oh, I forgot, I may have to do a double…


Raising awareness will help to recognize the complexity of RN work, minimize interruptions, and contribute to effective solutions that involve:

  • Assertiveness training and practice.
  • Adequate staffing.
  • In depth Root Cause Analysis.
  • Safety Engineering.

Learn more: 

Medication Errors:  How Really Smart People Make Really Stupid Mistakes!

Interruption Awareness:  A Nursing Minute for Patient Safety!

Root Cause Analysis Series with Bob Latino

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15 Responses to Nurse Overload: The Risks to Employee and Patient

  1. Anonymous says:

    Excellent article Beth and Doug! A must read for all H/C Executives, especially HR Pro’s…..

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  7. Thank heavens the docs weren’t actually rounding when you recorded this narrative. I hate to think what strange additional garble of mixed messages would have been added to the fray.

    Breathe between tasks and before you answer a question. Breathe to recenter. Because there is really nothing you can do in a work environment this chaotic but breath and continually work to recenter and refocus.

    When you can do that in this environment, you are a true master of mindfulness that formal meditators in the isolation of their quiet rooms and seat cushions can only envy.

    Skilled nursing care is why patients are in the hospital. Keep up the great work.

    Dike Drummond MD

    • Beth_Boynton_RN_MS says:

      Hi Dike,
      Thanks for your comments. Staying centered is good advice. Especially when these periods are intermittent and we have a ‘between’ tasks to do it! Or as you say, are a master in of mindfulness! In some places the workload and chaos is so constant it is like being in flight or flight mode continually. There is no between tasks, rather perpetual overlap…. Maybe you see some stressed out RNs in your practice? I think it can only help if we have physicians who have insight into the complexity and pressure of our work and I am even more appreciative that you took the time to read and respond! Beth

      • The fundamental causes and pathophysiology and effects of burnout are identical in doctors and nurses. I do have nurse clients and the ways out of burnout and techniques to lower your stress are the same too. It always involves a combination of an inner change (who you are being) and an outer change (what you are doing). It really helps to have a supportive and aware administration too. The work conditions you describe above do not have to be the way the front line is organized … right?

        Dike Drummond MD

        • Beth_Boynton_RN_MS says:

          I absolutely agree, Dike. We’ll all evolve regardless of leadership’s role, but a supportive administration (that ensures enough time and staff) is essential for sooner rather than later evolution which will go a long way towards improving safety, burnout, workplace violence. As a specialist in communication and collaboration, I focus on building assertiveness, not only for our patients but for ourselves.(“Doctor, that’s the wrong leg!”, “I need help”, “No, I can’t work a double shift.” all come from the same place. I agree with my colleagues about the value of mindfulness, but it can be tough to practice on a chronically understaffed unit.

  8. Denise Flowers says:

    that about sums up my day or evening! I work in Long term care and nurses are always working extra and doubles. It really does effect patient cre

    • Beth_Boynton_RN_MS says:

      It absolutely affects care. Hope you get some rest Denise. I’ve been exhausted all day from working evenings sat/sun. The pace is unsafe and absurd. Of course the nature of healthcare is to have bursts of clinical priorities that require us to pump adrenaline, but all the time???? Ugh. It is so unhealthy for nurses, nurse assistants, and of course, patients/residents.

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  10. Hi Jim,
    Thanks for your feedback and great point about mindfulness. I anticipate this would be a hard practice to develop in the middle of high stress, and that it would be a great strategy. I can even envision the non verbal education that might ensue and teach patients and other staff that I am taking a ‘Mindfulness Minute”. Beth

  11. Jim Murphy says:

    This is a rich, magnificent post. I wish everyone could read it. After all, ultimately we are all patients!

    I would add mindfulness to the list of remedies for communication overload. Though originally stemming from Buddhism, mindfulness has a medical pedigree. Jon Kabat-Zinn introduced the concept and founded the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School. It has been found successful in stress reduction and there is a growing body of applications, such as mindful eating.

    Mindfulness has also been used in organizational development. Michael Carroll’s The Mindful Leader uses the concept for management development, with explicit Buddhist reference. Resonant Leadership, by Richard Boyatis and Annie McKee, takes a more business school approach.

    Of course there is no one answer to the difficulties you so well describe.Good organizations show awareness and take action so that all employees are involved in identifying and solving such problems.

What are your thoughts?