Nurses Work System Optimization: Macroergonomics Perspective

Abstract

The hospital work system as a complex sociotechnical system has been an interesting research environment for human factor/ergonomic researchers. In this chapter dimensions of nurses’ work system elements were presented and Macroergonomics approaches were pointed out to optimize the interaction between nurses and other system elements. From Macroergonomics perspectives, human factor researchers would be able to identify and categorize health and performance issues through a systematic approach. Researchers are believed that this approach was not shown positive results initially, therefore a low-hanging fruit strategy is recommended. Decomposing work system elements is a potential opportunity to track the balance in the hospital nurse work system by considering these elements for redesigning work systems and applying appropriate interventions.

1. Introduction

To reap what we sowed, “we should start with the low-hanging fruits”

_{(Michael Porter in 1980).}

Hospital work system as a complex sociotechnical system has been an interesting research environment for the human factor/ergonomic researchers. Among health care workers, nurses have always been considered to be a special group because of the significant physical and mental demands they face at work. Nursing is a physically and psychologically demanding profession with a high prevalence of musculoskeletal disorders (MSDs) as indicated in several studies [1, 2, 3, 4, 5]. MSDs are also often cited as the reason for sickness-related absences and the high turnover of nurses [6, 7].

Nurses’ working conditions usually differ across countries, regions, and hospitals [8, 9]. These differences are attributed mainly to the provision of instruments and the quality of process management in hospitals. For instance, nurses whom working in intensive care units may experiences higher stress levels and more health disorders compared with other wards [10].

There are many factors that can influence on nurses working conditions [11]. Therefore, seeking and attenuating these risk factors (risk factors that affect on nurses’ health and working performance) requires a systematic and comprehensive approach. To deal with and overcome on such ergonomic issues in the complex sociotechnical system, macro ergonomic approaches always have been shown positive and applicable [11].

1.1 Macroergonomic approaches as a solution

As the new millennium unfolds, there is significant evidence that the complexity of organizations is increasing and with this consistent growth comes new considerations for designing, implementing and maintaining work systems. In order to manage this growing complexity and to achieve desired outcomes, in these contexts, numerous approaches have been proposed [12]. Macroergonomics, a sub-discipline of ergonomics, has been a practical response to this growing need and with embracing this innate complexity it aims to improve performance and well-being in work systems [13].

Viewing under the Macroergonomics glasses, enables human factor researchers to identify and categorize health and performance issues through a systematic approach. In this vein, it would be helpful for identifying such factors by taking into account all components of the work system [14]. For instance, Garosi et al., used this approaches to identify influencing factors on nurses workability [15].

Lets back on Michael Porter in 1980 quotation about “piking low hanging fruits” as indicated by H. W. Hendrick and B. Kleiner [14]. This quotation is indicates on doing micro accessible intervention and then performing the macro intervention. Macroergonomics approaches help researcher to find, which work system elements are accessible and can be manipulate at first.

During this book chapter, we do a review on some studies affirmed macroergonomics approaches in similar health scope system and then we decomposed nurses work system elements with focus on their workability using the Systems Engineering Initiative for Patient Safety (SEIPS). Next, relative recommendations were provided to optimize interaction between nurses and work system element.

1.2 Published articles in domain of Macroergonomics

Studies on the level of Macroergonomics were searched over Google Scholar, PubMed, and Science Direct from 2013-2018. The search was conducted using such keywords including: “(Macroergonomics OR Macro-ergonomics)” The inclusion criteria were the article published in English, and all type of study (interventional or questionnaire). The database search showed 72 articles, out of which 40 were excluded because of duplication, repetition and article publication date. Among the remaining articles, a further 7 were removed due to the irrelevant subject. Finally,25 articles were left and selected for extracting the kay-pints. Table 1 shows the article in order of publication date.

Authors	Title	Conclusion
Carayon et al., [11]	Macroergonomics in Healthcare Quality and Patient Safety	Study of job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of Macroergonomics contributions to healthcare quality and patient safety. Macroergonomics models of healthcare quality and patient safety are well-accepted by the healthcare community Hence, the potential impact of Macroergonomics on refining care processes and patient outcomes is important.
Punnett et al., [16]	Participatory Ergonomics as a Model for Integrated Programs to Prevent Chronic Disease	Participatory ergonomics is pertinent to workplace health promotion (WHP) because (1) psychosocial stress backs to individual health behaviors as well as chronic diseases; (2) job stress cannot be spoken without employee envelopment in hazard identification and solutions; (3) the interaction of multiple levels within an organization requires consideration to necessities and limitations at all levels.
Guimarães et al., [17]	Worker evaluation of a Macroergonomics intervention in a Brazilian footwear company	This study showed that problems and resolutions can be recognized through participatory ergonomics, that it is easier to include workers than the managerial staff, and that a Macroergonomics intervention, mainly focusing on work organization, led to positive employees, health and production results, despite management’s opposition to changes multiskilling and teamwork were the foremost changes promoted to increase and improve work and make it more flexible.
Adelt et al., [18]	Governance of complex systems: results of a sociological simulation experiment	Practitioner can have oriented into functioning of complex systems and acquire how to well manage them. Moreover, they can ever measure the performance.
Murphy et al., [19]	The next generation of Macroergonomics: Integrating safety climate	Investigating safety climate with concerns to a systems method is a zone of research that is growing. Whereas safety climate is a principal indicator of safety, it is used more often to measure the level of general safety in an organization and not to determine where safety problems happen. Hence, the concept needs to be complemented with a Macroergonomics approach to design work systems accordingly that we can recognize specific human-technology organization interfaces within an organization that negatively and positively affect the safety consciousness of workers’ in that organization.
Clack et al., [20]	low-hanging fruit for human factors design in infection prevention still too high to reach?	In the progressively sophisticated and complex health care system, future infection prevention success on not only moving from standard operating procedures to engineered solutions but also how well we govern trans- institutional complexity.
Karsh et al., [21]	Crossing levels in systems ergonomics: A framework to support ‘Macroergonomics’ inquiry	“Macroergonomics is defined as an open systems approach to human factors and ergonomics (HFE) theory and research whereby the connection between variables in at least two different system levels is studied, and where the dependent variables are human factors and ergonomic constructs.”
Carayon et al., [22]	Human factors systems approach to healthcare quality and patient safety	Harmonizing the work system and boosting the dynamic and adaptive role of workers are important principles for improving healthcare quality and patient safety.
Carayon et al., [22]	Healthcare workers’ perceptions of lean: A context-sensitive, mixed methods study in three Swedish hospitals	Hospital workers’ perceptions of lean differ by hospital, unit, and role study approves that background problems and sheds some light on how specific lean intervention plans in definite settings influence employees’ primary perceptions of lean.
Village et al., [23]	design for human factors (DfHF): a grounded theory for integrating human factors into production design processes	The DfHF grounded theory delivers empirical evidence that fills a gap by showing ‘how’ HF characteristics can be combined into the production design process to increase worker performance and well-being
Waterson et al., [24]	Defining the methodological challenges and opportunities for an effective science of sociotechnical systems and safety	This article is described sociotechnical systems theory STS methods for workplace safety, as well as outlining a set of six case studies covering the application of these methods to a range of safety contexts
Salas et al., [25]	Measuring Team Cohesion: Observations from the Science	“However long considered a key contributor to team success, cohesion is perhaps more important than ever. As organizations continue to seek competitive advantage, teams are increasingly looked to in the hopes of facilitating knowledge, morale, and creativity.”
Kleiner et al., [26]	Sociotechnical attributes of safe and unsafe work systems	Sociotechnical methodologies to workplace safety highlight the critical importance of design through the sociotechnical field. Given the dramatic progress in complexity of everyday work systems, sociotechnical systems thinking be able to possibly most helpfully be assumed of as providing a set of constructs, objectives and methods to support vital efforts to joint optimization of system element and interactions.
Realyvásquez et al., [27]	Structural Model for the Effects of Environmental Elements on the Psychological Characteristics and Performance of the Employees of Manufacturing Systems	The Macroergonomics compatibility of environmental elements shows a important straight effects on participant psychological characteristics and also direct or indirect effects on the workers’ performance.
Bolis and Sznelwar, [28]	A case study of the implementation of an ergonomics improvement committee in a Brazilian Hospital Challenges and benefits	The findings of this study shows that good consequences require autonomy and support from management, and the adoption of effective methods to increase and legitimize the development committee’s life.
Steege and Dykstra, [29]	A Macroergonomics perspective on fatigue and coping in the hospital nurse work system	“A Macroergonomics approach is valuable for understanding complexities of work system barriers and facilitators to fatigue and coping.”
Azadeh et al., [30]	Optimization of healthcare supply chain in context of macro-ergonomics factors by a unique mathematical programming approach	This is the first study for Macroergonomics optimization of healthcare supply chain. This technique can examine the influence of Macroergonomics factors on supply chain management in healthcare environment. Correspondingly, this technique ranks the pertinent performance efficiencies of each healthcare supply chain. This study by using proposed method, indicates on “teamwork” topic as is a well-known topic in Macroergonomics. Furthermore, this study would help managers to detect the areas of faults in their supply chain management system and fixed them by improvement target plan for the related supply chain management system in healthcare environments.
Yang and Asan, [31]	Designing patient-facing health information technologies for the outpatient settings: a literature review	The designs of patient-facing health information technologies (HITs) in outpatient sites are likely by easing the doctor-patient communication and patient engagement. Conversely, their effectiveness and usefulness need to be additional assessment and improved from a systems viewpoint.
Meshkati et al., [32]	People-Technology-Ecosystem Integration: A Framework to Ensure Regional Interoperability for Safety, Sustainability, and Resilience of Interdependent Energy, Water, and Seafood Sources in the (Persian) Gulf	Based on the emerging realities in the Gulf region, it is concluded that without systematic approach concerning to interdependencies of water and energy sources, sustainability will be just a short-lived dream and success will be a disappearing mirage for millions of people that live in this area.
Thatcher and Yeow, [33]	A sustainable system of systems approach: a new HFE paradigm	This study present a sustainable system of systems model that joins ideas from the ecological sciences, particularly a nested order of systems and a hierarchical time aspect.
Holden et al., [34]	Macroergonomic Factors in the Patient Work System: Examining the Context of Patients with Chronic Illness	After present 3 relevant case findings: proved that not only the importance of setting for patients’ health-related activities but also specific factors to study in future research, design, and policy efforts.
Coelho et al., [35]	Psychosocial and ergonomic survey of office and field jobs in a utility company	For most psychosocial aspects, the organizational design and management system in place and the overall cultural environment in which it works, create a much robust and more critical impact than job-specific factors.
Murphy et al., [36]	A sociotechnical systems approach to enhance safety climate in the trucking industry: Development of a methodology	Tis study proposed a mythology that can be used as a way to recognize gaps in the specific work system, and this data can be used to design interventions to change the safety climate, and finally the culture, of an organization in due to reduce negative safety consequences.
Murphy et al., [37]	A sociotechnical systems approach to enhance safety climate in the trucking industry: Results of an in-depth investigation	The overall goal of this study was to generate a methodology, based on a systems approach that could be used to evaluate an organizational work system as an assessment tool. The findings of this study comprised 19 themes that affect on safety. These themes fluctuated from balancing work and family-personal time, the firm’s strategy vs. practice, respecting the job of the driver, and active listening and meaningful feedback. The most imperative themes were related to the workers internal environment.
Thatcher et al., [38]	State of Science: ergonomics and global issues	This article is showed what has been achieved by the ergonomics profession in relation to the global challenges raised by Moray’s 1993 keynote address to the International Ergonomics Association.

Table 1.

Published articles concern to macroergonomic approaches.

2. Decomposing nurses work system elements

According to the Systems Engineering Initiative for Patient Safety (SEIPS) elements of a work system comprises five components including environment, person, tools and technology, task, and organization, and their interplay determines (the processes), how care is managed and provided to patients leading to desired or undesired outcomes [39]. Following, partial results of a study [15] is presented to emphasize on SEIPS model as a framework for decomposing influencing factors on the nurse’s workability.

2.1 Environmental elements

• The environmental elements are included:

• Layout of work space

• Work space dimensions (ingress and egress)

• Illumination

• Noise and Vibration

• Ventilation and temperature stress

• Esthetics of the workspace design (Furniture design)

Environmental conditions may interfere with nurse’s task. Due to lack of space, people may work in inappropriate postures and poor lighting conditions, which can increase the risk of musculoskeletal disorders [29].

For better perception in work space, applying ornamental artificial flowers and color variations as features for motivating are recommended. However optimal design of the work environment increases the satisfaction of nurses and consequently lead to positive performance results [40].

2.2 Person- related factors (nurses)

• Demographic characteristics

• Ethnicity

• Working experience

• Self-esteem

• Second job

Many studies have examined the relationship between demographic characteristics, ethnicity, and diseases to the nurses work ability. For instance, high body mass index had an inverse relationship with work ability [41]. Generally, as BMI crosses over 25, the working ability of nurses decreased by 2.2 points [42]. Moreover, many studies have showed the relationship between age and work ability. Second job or worked simultaneously in two or more hospitals put nurses under more physical and mental stress, fatigue [43, 44].

2.3 Factors related to tools and technology

Usability of the tools and technology are reported as an important factor, which could increase satisfaction and work ability. In addition, some other factors such as equipment precision (calibration), applicability, equipment safety, computerization are reported important contributors to the nurses work ability [15]. Correspondingly, availability of equipment, proper functioning and effectiveness of tools were identified as measures to prevent nursing fatigue. Moreover, it is reported that electronic reporting and high level technology based tools may prevents nurses fatigue [29]. In this way Samadi and Golmohammadi, showed that there was a negative relationship between work ability and fatigue [45]. It is quit clear that usability of devises are important in every similar sociotechnical systems. Therefore, Lacking usability leading to fatigue and increases the risk of musculoskeletal disorders in nursing job [46]. For instance, a nurses quotation from a qualitative study is considerable “although computers and technology are much quicker and more comfortable to use, in some cases these computers and automation software are so problematic and time wasting, that we decide to do tasks manually” [15].

2.4 Task-related factors

Task-related factors are factors related to the nature of nursing tasks. The most important factors Identified included:

• High mental and physical demanding tasks

• Workload

• Repetitive tasks

• work cycle time/rest

• Work pace

Nursing job stressors such as inappropriate expectations from co-workers, time constraints, response to patient families are reported as other nurses job related factors that have negative effect on nursing work ability [45].

2.5 Organization elements

Danesh et al., 2020 reported that are more effective factor on the nurses work ability [15]. These factors included:

• Supervisor support

• Teamwork

• Staffing work regulation

• Salary and organizational policies

• Participation

• Job involvement

Quality supervisors support was reported among the most important predictors of nurses work ability. In a study by Gharibi et al. [47], which was conducted among a number of employees of different sectors, including industry, bank, and hospital, there was a straight relationship between supervisors support and work ability. Moreover, a strong correlation between supervisor support and work ability was reported [48]. Teamwork and support of colleagues are among other effective factors that influence on nurses work ability. Working under the supervision and in an efficient team and fairly performing tasks, there will be lower fatigue and team performance will be increase [49]. Shift work schedule is a factor that can affect circadian rhythm as, Safari et al. Safari et al. showed a significant relationship between work ability and work shift [50]. Other studies emphasized the role of shift work on nursing work ability, with nurses who had more than 8 hours of work shift were more likely to suffer burnout [51].

Salary and wage are factors that directly related to motivation and work ability. Under Herzberg’s two-factor model, incomes and paybacks are “health” factors, which, if not sufficient, result in dissatisfaction and eventually stress and adverse outcomes [52].

3. Conclusions

Optimizing nurses’ work system requires a holistic approach and the Macroergonomics approach could be helpful in this way. Under Macroergonomics perspectives, human factor researchers would be able to identify and categorize health and performance issues through a systematic approach. Researchers are believed that this approach was not shown positive results initially, therefore a low-hanging fruit strategy is recommended. Decomposing work system elements is a potential opportunity to track the balance in the hospital nurse work system by considering these elements for redesigning work systems and applying appropriate interventions.