Objective: To combine human factors engineering techniques with qualitative observation of nurses in practice to analyze the nature of nurses' cognitive work and how environmental factors create disruptions that pose risks for medical errors. Background: Few researchers have examined the nature of nurses' cognitive work while in practice with patients. Researchers have described the broad range of thinking processes required in the acute care work setting, but have failed to examine how such processes are conducted and influenced by the complex care environment. A combined research methodology enables researchers to better understand how the nursing process becomes disrupted and the potential influence of this disruption on the safe and effective care of patients. Methods: An ethnographic study, using mixedmethodological approaches, involved 7 staff registered nurses. The quantitative and qualitative data collection included field observation and summarative interviews. Findings: A high number of cognitive shifts and interruptions, and a nurse's cumulative cognitive load, create the potential for disrupting a nurse's attention focus during care of patients. A majority of interruptions occurred as nurses performed interventions, particularly medication preparation. Conclusion: New attention must be given to how care systems and work processes complement or interfere with nurses' cognitive work.

Health care researchers agree that the acute care hospital environment is filled with numerous distractions. Within this environment, professional nurses make clinical judgments about their patients, whose conditions may change minute by minute. As a result, nurses constantly organize and reorganize the priorities and tasks of care to accommodate patients' fluctuating status. To date, little attention has been given to how interruptions in the workplace influence nurses' ability to anticipate and carry out the actions directed by their clinical judgment. This paper describes an ongoing research study aimed at exploring the effect of interruptions on the cognitive work of nursing. A methodology combining human factors techniques and qualitative observation of nurses in practice has produced a cognitive pathway. The pathway is a unique visual graphic that offers a perspective of the nature of nurses' work and the relationship interruptions and cognitive load may have on omissions and errors in care. The approach to analyzing the cognitive work of nurses has important implications for understanding the origins of medical errors.

Extension of the methods demonstrated here may be useful in guiding efforts to change the work of nursing to better provide quality care and less stressful work environments.

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The work of nursing is nonlinear and involves complex reasoning and clinical decision making. The use of human factors engineering (HFE) as a sole means for analyzing the work of nursing is problematic. Combining HFE analysis with qualitative observation has created a new methodology for mapping the nursing process. A cognitive pathway offers a new perspective for understanding the work of nursing and analyzing how disruptions to the nursing process may contribute to errors in the acute care environment.