Factors Affecting Competent Nursing Practice
Key Points
- Competent practice can be reduced by staffing, scheduling, fatigue, and health status.
- Presenteeism is being physically at work but unable to perform competently due to illness or stress.
- Shift work and fatigue increase concentration and communication failures.
- Higher patient assignment load is associated with increased mortality risk, burnout, and dissatisfaction.
Pathophysiology
Clinical performance depends on sustained cognitive attention, accurate communication, and physical capacity. Workforce and health stressors degrade these functions, creating a pathway to medication error, missed care, falls, and delayed recognition of deterioration.
Classification
- Intrinsic factors: Physical health, mental health, stress burden, and fatigue.
- Work-organization factors: Shift length, schedule rotation, and staffing ratios.
- Performance-state factors: Presenteeism and communication/concentration impairment.
- Outcome impacts: Errors, missed care, injury risk, burnout, and mortality-associated risk.
Nursing Assessment
NCLEX Focus
Priority is identifying when workforce conditions create immediate safety risk requiring escalation or workload adjustment.
- Assess unit workload and assignment intensity at start and during shift.
- Assess for fatigue indicators that can impair judgment and task reliability.
- Assess communication quality during handoff and high-risk interventions.
- Assess for signs of presenteeism affecting safe execution.
- Assess whether current staffing supports required monitoring frequency.
Nursing Interventions
- Escalate unsafe staffing or assignment conditions through leadership pathways.
- Use standardized communication and double-check processes during fatigue-prone periods.
- Prioritize high-risk safety tasks when workload exceeds baseline capacity.
- Document objective safety concerns and mitigation actions in real time.
- Support error-prevention culture through timely reporting and follow-up.
Presenteeism Hazard
Working while too ill, stressed, or fatigued can increase falls, medication errors, and missed care.
Pharmacology
Medication workflows are especially vulnerable to fatigue and interruption. Risk reduction includes strict verification routines, independent checks, and immediate escalation of uncertain orders.
Clinical Judgment Application
Clinical Scenario
A nurse on a prolonged shift reports difficulty concentrating while managing a high-acuity assignment.
Recognize Cues: Fatigue and assignment intensity create elevated error risk. Analyze Cues: Cognitive overload threatens medication and monitoring reliability. Prioritize Hypotheses: Immediate workload adjustment and safety reinforcement are required. Generate Solutions: Rebalance assignments, trigger high-risk double checks, and increase team support. Take Action: Escalate to charge nurse and implement targeted risk controls. Evaluate Outcomes: Critical tasks remain timely and error events are prevented.
Related Concepts
- quality-improvement-nurse-role-and-qapi - Links workforce risk signals to system-level improvement action.
- ana-nursing-documentation-principles - Supports objective documentation of safety concerns and actions.
- medication-error-reporting-and-escalation - Provides workflow for rapid error and near-miss response.
Self-Check
- Why is presenteeism a safety concern even when staffing appears complete?
- How do schedule design and staffing ratios influence patient outcomes?
- What is the first nursing action when fatigue threatens high-risk task reliability?