Critically ill patients require intensive nursing care. Intensive care unit (ICU) nurses, who care for these physiologically unstable patients, are continuously occupied with the integration of assessments, monitoring, and interventions that are responsive to a patient's evolving state. Since 2005, numerous evidenced-based clinical protocols have been implemented in the critical care unit. Individually, each may not appear to be burdensome but, collectively, these clinical protocols add to the cognitive work of ICU nurses. While nurses are central to the successful implementation of these protocols, little is written about the cognitive burden imposed on them by the addition of these clinical protocols. This article explores the impact of clinical protocols on the cognitive burden of ICU nurses, using a tight glucose control (TGC) protocol as an exemplar case. Research from management, ergonomics, systems engineering, and nursing is used to build the concept of cognitive burden. Future research can build upon this understanding to facilitate successful implementation of clinical protocols.
Van den BergheGWoutersPWeekersFBruyninckxFSchetzMVlasselaersDFerdinandePLauwersPBouillonR. Intensive insulin therapy in the critically ill patients. N Engl J Med.2001;345 (19): 1359–67.
2.
NICE-SUGAR Study Investigators, FinferSChittockDRSuSYBlairDFosterDDhingraVBellomoRCookDDodekPHendersonWRHébertPCHeritierSHeylandDKMcArthurCMcDonaldEMitchellIMyburghJANortonRPotterJRobinsonBGRoncoJJ. Intensive versus conventional glucose control in critically ill patients. N Engl J Med.2009;360 (13): 1283–97.
GriesdaleDEde SouzaRJvan DamRMHeylandDKCookDJMalhotraADhaliwalRHendersonWRChittockDRFinferSTalmorD. Intensive insulin therapy and mortality among critically ill patients: A meta-analysis including NICE-SUGAR study data. CMAJ.2009;180 (8): 821–7.
5.
Van den BergheGSchetzMVlasselaersDHermansGWilmerABouillonRMesottenD. Clinical review: Intensive insulin therapy in critically ill patients: NICE-SUGAR or Leuven blood glucose target?. J Clin Endocrin Metab.2009;94 (9): 3163–70.
6.
WienerRSWienerDCLarsonRJ. Benefits and risks of tight glucose control in critically ill adults: A meta-analysis. JAMA.2008;300 (8): 933–44.
7.
QaseemAHumphreyLLChouRSnowVShekelleP, Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: A clinical practice guideline from the American College of Physicians. Ann Intern Med.2011;154 (4): 260–7.
8.
VogelzangMZijlstraFNijstenMW. Design and implementation of GRIP: A computerized glucose control system at a surgical intensive care unit. BMC Med Inform Decis Mak.2005;5: 38.
9.
OeyenSGHosteEARoosensCDDecruyenaereJMBlotSI. Adherence to and efficacy and safety of an insulin protocol in the critically ill: A prospective observational study. Am J Crit Care.2007;16 (6): 599–608.
10.
AragonD. Evaluation of nursing work effort and perceptions about blood glucose testing in tight glycemic control. Am J Crit Care.2006;15 (4): 370–7.
11.
MaleskerMAForalPAMcPhillipsACChristensenKJChangJAHillemanDE. An efficiency evaluation of protocols for tight glycemic control in intensive care units. Am J Crit Care.2007;16 (6): 589–98.
12.
MayC. Nursing work, nurses' knowledge, and the subjectification of the patient. Sociology of Health and Illness.1992;14 (4): 472–87.
13.
ElyEWBakerAMDunaganDPBurkeHLSmithACKelleyPTJohnsonMMBrowderRWBowtonDLHaponikEF. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med.1996;335 (25): 1864–9.
14.
KressJPPohlmanASO'ConnorMFHallJB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med.2000;342 (20): 1471–7.
15.
PrasadMChristieJDBellamySLRubenfeldGDKahnJM. The availability of clinical protocols in US teaching intensive care units. J Crit Care.2010;25 (4): 610–9.
16.
DruckerPF. Landmarks of Tomorrow. 1st ed. New York: Harper & Brothers; 1959.
17.
DruckerPF. The Coming of A New Organization. Harv Bus Rev.1988 (Jan-Feb): 45–53.
18.
PretoriusACilliersPJ. Development of a mental workload index: A systems approach. Ergonomics.2007;50 (9): 1503–15.
19.
MegillKA. Thinking for a living: The coming of knowledge work. M?nchen, Germany: K. G. Saur Verlag GmbH; 2004.
20.
MorrisCHLeungYK. Pilot mental workload: How well do pilots really perform?. Ergonomics.2006;49 (15): 1581–96.
21.
BennerPHooper-KyriakidisPStannardD. Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach. CA: Saunders; 1999.
22.
SvenssonEAngelborg-ThanderzMSjobergLOlssonS. Information complexity–mental workload and performance in combat aircraft. Ergonomics.1997;40 (3): 362–80.
23.
GreggAC. Relationship among subjective mental workload, experience, and education of cardiovascular critical care RNs. Nurs Adm Q.1994;19 (1): 89–90.
24.
JexHR. Measuring Mental Workload: Problems, Progress, and Promises. In: HancockPAMeshkatiN, eds. Human Mental Workload. North-Holland: Elsevier Science Publishers; 1988; 5–39.
25.
WinwoodPCLushingtonK. Disentangling the effects of psychological and physical work demands on sleep, recovery and maladaptive chronic stress outcomes within a large sample of Australian nurses. JAN.2006;56 (6): 679–89.
26.
SchultzMJRoyakkersAALeviMMoeniralamHSSpronkPE. Intensive insulin therapy in intensive care: An example of the struggle to implement evidence-based medicine. PLoS Med.2006;3 (12): e456.
27.
ChaseJGAndreassenSJensenKShawGM. Impact of human factors on clinical protocol performance: A proposed assessment framework and case examples. J Diabetes Sci Technol.2008;2 (3): 409–16.
28.
GoldbergPASiegelMDSherwinRSHalickmanJILeeMBaileyVALeeSLDziuraJDInzucchiSE. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care.2004;27 (2): 461–7.
29.
DavidsonPCSteedRDBodeBWHebblewhiteHRPrevostiLCheekatiV. Use of a computerized intravenous insulin algorithm within a nurse-directed protocol for patients undergoing cardiovascular surgery. J Diabetes Sci Technol.2008;2 (3): 369–75.
30.
VogelzangMLoefBGRegtienJGvan der HorstICCvan HassenHZijlstraFNijstenMWN. Computer-assisted glucose control in critically ill patients. Intensive Care Med.2008;34 (8): 1421–7.
31.
ThompsonBTOrmeJFZhengHLuckettPMTruwitJDWillsonDFHiteR DuncanBrowerRGBernardGRCurleyMASteingrubJSSorensonDKSwardKHirshbergEMorrisAH. Reengineering Critical Care Clinical Research Investigators. Multicenter validation of a computer-based clinical decision support tool for glucose control in adult and pediatric intensive care units. J Diabetes Sci Technol.2008;2 (3): 357–68.
32.
BoulkinaLSBraithwaiteSS. Practical aspects of intensive insulinization in the intensive care unit. Curr Opin Clin Nutr Metab Care.2007;10 (2): 197–205.
33.
The Cognition and Technology Group at Vanderbilt. Anchored Instruction and Its Relationship to Situated Cognition. Educational Researcher.1990;19 (6): 2–10.
34.
HarperJ. Glucose control in the intensive care unit: How it is done. Proceedings of the Nutrition Society.2007;66 (3): 362–6.
35.
WeickKESutcliffeKM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001; pg 224.
