Nurses' instruction of patients in the use of INR-monitors for self-management of cardio-vascular conditions: Missed instructional opportunities

Using conversation analysis to appraise how novel educational videos impact patient medical education

OBJECTIVE

To determine in what ways, if any, do patients, caregivers, and nurses make videos relevant during in-person education.

METHODS

We applied conversation analysis to analyze interaction in 12 nurse-led education visits (1011 min of audio) in which speakers referred to a supplemental education video.

RESULTS

Patients initiated talk about the video in about half of the clinic visits analyzed, while nurses initiated talk about the video across all clinic visits analyzed. Interactions showed that patients demonstrated knowledge of video content and clarified information concerning their treatment plans by asking questions of nurses. Nurses referenced the video prior to repeating information that they recognized patients had viewed. In all instances analyzed, nurses made references to the videos in ways that re-oriented conversations back toward the content of the informal scripts that they used to deliver patient education.

CONCLUSION

Patients referenced the video in ways that demonstrated that they had viewed it and had gained knowledge concerning treatment plans, and to ask specific questions about these. Nurses referred to the videos by acknowledging patients' prior knowledge of upcoming information.

PRACTICE IMPLICATIONS

Understanding how pre-delivered supplemental videos impact patient involvement in in-person education contributes understanding to how video-based instruction supports patient-centered care.

Relationship Between Efficiency, Effectiveness, and Learnability of Home Connected Medical Device in Ambulatory Surgery

Background: Currently, usability assessments of home connected medical devices do not systematically take into account learnability metrics. In case of the Smart Angel device-designed for monitoring ambulatory surgery patients-users are trained at the hospital and have to use the device at home to monitor their health remotely. Objective: The aim of this study was to better understand the relationships between two metrics of usability-efficiency and effectiveness-and learnability of the Smart Angel device. Materials and Methods: Twenty-eight participants were trained in a simulated hospital (SimUsanté), and then we filmed the participant using the device three times. Between each session, the participant had to complete questionnaires (sociodemographic and health literacy). Results: The results of a between-subject analysis [χ²(2) = 18.969, p < 0.001] and a within-subject analysis [F(2.28) = 13.34, p < 0.001, η² = 0.35] showed that efficiency (manipulation time) significantly improved with learnability (number of sessions). Conversely, effectiveness (number of manipulation errors) stagnated over the three sessions with a between-subject analysis [F(2.75) = 1.628, p = 0.203], while the within-subject analysis revealed that users seemed to significantly correct their errors with the number of sessions [F(2.28) = 6, p = 0.005, η² = 0.19]. By analyzing the errors, we observed that some errors could appear at any time (e.g., moving during the measurement) and others were systematic (e.g., the wrist blood pressure on the right arm). Conclusions: While the "first attempt" at using a home medical device is a major revealing step for the study of manipulation errors, learnability is an equally useful metric to include in usability studies, as well as in the very definition itself of usability.

Effects of User Characteristics on the Usability of a Home-Connected Medical Device (Smart Angel) for Ambulatory Monitoring: Usability Study

Background

The Smart Angel home medical device allows ambulatory surgery patients to monitor their own health by taking their blood pressure and oxygen levels and answering a health questionnaire from home. Currently, this device is a prototype in the design phase, and no usability evaluation has been performed. This preventive device must be usable by patients with different profiles; however, it is important to select patients carefully to ensure their safety when using the device. As such, it would be interesting to know how to select or exclude patients. However, the links between user characteristics and the usability of this home medical device remain unclear.

Objective

This study aims to better understand the links between certain characteristics of potential patients (ie, age, education, technophilia, and health literacy) and the usability (ie, effectiveness, efficiency, and satisfaction) of Smart Angel, as defined by the ISO 9241-11.

Methods

We conducted an experimental study involving 36 participants investigating the effects of 4 patient characteristics (ie, age, education, technophilia, and health literacy) on usability, measured in terms of effectiveness, efficiency, and satisfaction. A mixed methods approach (subjective vs objective) using a variety of standard instruments was adopted (direct observation, video analysis, and questionnaires). First, to help participants project themselves into the real use of the Smart Angel device, they watched a scenario in a video. Second, the participants completed a set of questionnaires to show the extent of their health literacy level (Newest Vital Sign [NVS] and the Health Literacy Survey [HLS]) and then operated Smart Angel devices. Efficiency (ie, handling time) and effectiveness (ie, number of handling errors) measures were collected by video analysis. Satisfaction measures were collected by a questionnaire (System Usability Scale [SUS]). The qualitative observational data were coded using inductive analysis by 2 independent researchers specialized in cognitive psychology and cognitive ergonomics.

Results

The results show a moderate and positive correlation between age and effectiveness (r=0.359; P=.03) and efficiency (r=0.357; P=.03). There is strong correlation between health literacy scored by the NVS and effectiveness (r=0.417; P=.01), efficiency (r=-0.38; P=.02), and satisfaction (r=0.45; P=.006). However, there is a weak correlation between technophilia and usability and no relationship between education level and usability.

Conclusions

Our results show that literacy level and age are 2 important factors to consider when selecting future users of the Smart Angel device to ensure patient safety. This study also serves as an example promoting mixed methodologies in assessments of medical device usability that cannot be performed under real-world conditions.

Impact of the format of user instructions on the handling of a wrist blood pressure monitor

Few studies have focused on procedural documents in the field of home medical devices, although incorrect use and usability problems can have important consequences for the patient's health. In this study, we focused on the procedural learning of a home medical device, a blood pressure monitor. Five formats (unimodal: text, audio, pictures; and multimodal: text/audio with pictures) were tested on 124 novice participants randomly assigned to 5 groups. We judged the quality of the formats on the basis of three metrics: efficiency (i.e., handling errors), effectiveness (i.e., consultation time of the procedure, execution time of the devices) and memorability (i.e., recall task). Results suggest that the audio format was more effective than the other groups but also the least efficient. We consider the audio format to be beneficial for patient safety because this format would oblige participants to use a strategy suited to the situation, namely an atomization of the action corresponding to a segmentation of information less likely to saturate working memory. Results in relation to the other formats did not show a more effective, efficient and memorable format. This lack of difference in user performance is nevertheless important, illustrating the need to adapt each instruction to the context of learning, i.e., according to the users, the environment, the resources and the complexity of the task to be executed.

Using Applied Conversation Analysis in Patient Education

The conversation strategies patients and clinicians use are important in determining patient satisfaction and adherence, and health outcomes following patient education-yet most studies are rife with surveys and interviews which often fail to account for real-time interaction. Conversation analysis (CA) is a powerful but underused sociological and linguistic technique aimed at understanding how interaction is accomplished in real-time. In the current manuscript, we provide a primer to CA in an effort to make the technique accessible to patient education researchers including; The history of CA, identifying and collecting data, transcription conventions, data analysis, and presenting the findings. Ultimately, this article provides an easily digestible demonstration of this analytic technique.

Nurses' elicitation of patient error as a practice in training end-stage renal patients in automated home peritoneal dialysis

As part of a reorganisation of the delivery of health care in Denmark therapies for chronic medical conditions are moved out of hospitals and disease-specific patient education programmes instituted to train patients to assume responsibility for treating their disease at home, that is, perform tasks and functions traditionally done by healthcare professionals. Drawing on video-recordings (90:25h) from a programme for self-management of end-stage renal disease through automated home peritoneal dialysis, the study employs conversation analysis to examine nurses' instructional practices for providing patients with the necessary knowledge, skill and competences. Showing training to rely on an error-based monitoring strategy, the study demonstrates that rather than solely waiting for random errors to emerge, nurses on occasion steer patients towards specific errors to bring about particular instructional opportunities. Surprising given the seriousness of the therapy, this elicitation of error is shown to reflect a deliberate instructional choice; nurses promote select errors to impart patients with an understanding of the procedural logic behind the therapy and medical technology. The study argues that training patients for chronic disease self-management and providing them with a proficiency level, normally associated with certified professionals, necessitates pushing patients beyond what is strictly accurate and exposing them to medically delicate events.