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Poots J, Morgan J, Woolf J, Curcuruto M. Identifying system adaptations to overcome technology-based workflow challenges in a telephone triage organization. APPLIED ERGONOMICS 2024; 121:104365. [PMID: 39098206 DOI: 10.1016/j.apergo.2024.104365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 07/29/2024] [Accepted: 08/01/2024] [Indexed: 08/06/2024]
Abstract
Call-center-based telephone triage is an example of a complex sociotechnical system relying on successful interactions between patients, callers, and the integration of many digital technologies. Digital technologies such as computer decision support systems are used to standardize triage outcomes with little consideration of how these unique healthcare systems adapt to maintain functionality in response to real-world operating challenges. Using structured observations of call handlers in two call centers and guided by usability heuristics and the concept of 'workarounds', this paper aims to investigate the effects of technology design on workflow and system adaptations. Opportunities for improvement are highlighted, particularly, assessment prompts, and updating software to reflect dynamic real-world situations. Interactions between system components, especially technological and organizational processes affected workflow, making adaptations at the individual and organizational levels necessary to ensure callers could be triaged safely. System designers could consider these findings to improve systems and procedures during challenging periods.
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Affiliation(s)
- Jill Poots
- Leeds Beckett University, Leeds, England, Uk; Integrated Care 24, Ashford, Kent, England, Uk; Trinity College Dublin, Ireland.
| | - Jim Morgan
- Leeds Beckett University, Leeds, England, Uk
| | - Julie Woolf
- Integrated Care 24, Ashford, Kent, England, Uk
| | - Matteo Curcuruto
- Leeds Beckett University, Leeds, England, Uk; The European University of Rome, Italy
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Anderson E, Moldestad M, Brunner J, Ball S, Helfrich C, Orlander J, Rinne S, Sayre G. User Experiences of Transitioning From a Homegrown Electronic Health Record to a Vendor-Based Product in the Department of Veterans Affairs: Qualitative Findings From a Mixed Methods Evaluation. JMIR Form Res 2024; 8:e46901. [PMID: 39255006 PMCID: PMC11422731 DOI: 10.2196/46901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 11/24/2023] [Accepted: 06/26/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND The Department of Veterans Affairs (VA), the largest nationally integrated health system in the United States, is transitioning from its homegrown electronic health record (EHR) to a new vendor-based EHR, Oracle Cerner. Experiences of the first VA site to transition have been widely discussed in the media, but in-depth accounts based on rigorous research are lacking. OBJECTIVE We sought to explore employee perspectives on the rationale for, and value of, transitioning from a VA-tailored EHR to a vendor-based product. METHODS As part of a larger mixed methods, multisite, formative evaluation of VA clinician and staff experiences with the EHR transition, we conducted semistructured interviews at the Mann-Grandstaff VA Medical Center before, during, and after going live in October 2020. In total, we completed 122 interviews with 26 participants across multiple departments. RESULTS Before the new vendor-based EHR went live, participants initially expressed cautious optimism about the transition. However, in subsequent interviews following the go-live, participants increasingly critiqued the vendor's understanding of VA's needs, values, and workflows, as well as what they perceived as an inadequate fit between the functionalities of the new vendor-based EHR system and VA's characteristic approach to care. As much as a year after going live, participants reiterated these concerns while also expressing a desire for substantive changes to the transition process, with some questioning the value of continuing with the transition. CONCLUSIONS VA's transition from a homegrown EHR to a vendor-based EHR system has presented substantial challenges, both practical and cultural in nature. Consequently, it is a valuable case study for understanding the sociotechnical dimension of EHR-to-EHR transitions. These findings have implications for both VA leadership and the broader community of policy makers, vendors, informaticists, and others involved in large-scale health information technology implementations.
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Affiliation(s)
- Ekaterina Anderson
- Center for Health Optimization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Megan Moldestad
- Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Julian Brunner
- Veterans Affairs Center for the Study of Healthcare Innovation, Implementation & Policy, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, United States
| | - Sherry Ball
- Veterans Affairs Northeast Ohio Healthcare System, Cleveland, OH, United States
| | - Christian Helfrich
- Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
- School of Public Health, University of Washington, Seattle, WA, United States
| | - Jay Orlander
- Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
- Veterans Affairs Boston Healthcare System, Boston, MA, United States
| | - Seppo Rinne
- Center for Health Optimization and Implementation Research, Veterans Affairs Bedford Healthcare System, Bedford, MA, United States
- The Pulmonary Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
| | - George Sayre
- Veterans Affairs Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
- School of Public Health, University of Washington, Seattle, WA, United States
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Saurin TA, Patriarca R, Hegde S, Rayo M. The influence of digital technologies on resilient performance: Contributions, drawbacks, and a research agenda. APPLIED ERGONOMICS 2024; 118:104290. [PMID: 38657384 DOI: 10.1016/j.apergo.2024.104290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/22/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024]
Abstract
The growing use of digital technologies (DTs) has a myriad of implications to socio-technical systems, which are not yet fully recognised. This paper investigates the contributions and drawbacks of DTs to resilient performance (RP), an aspect that so far has received less attention in comparison to others such as efficiency. To this end, a survey questionnaire was applied to 79 academics and practitioners linked to resilience engineering. Data analysis involved descriptive statistics and a thematic analysis of the open-text responses to the survey. Mixed impacts were identified, with 10 themes related to contributions and 16 to drawbacks. Regarding the contributions, the results highlighted the use of DTs for monitoring and anticipating system performance. Machine learning seems to be the most promising approach for this purpose. A key drawback is the need for developing new skills across the workforce so that they can make sense of the outputs of DTs and are aware of their strengths and weaknesses. The human role is expected to remain crucial for RP, which makes the current coordination difficulties with DTs even more important to address. A research agenda composed of five topics is proposed, encompassing description, prescription, and assessment. The agenda emphasizes the need for mapping the attributes or functionalities of DTs onto resilience concepts, models, and frameworks.
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Affiliation(s)
- Tarcisio Abreu Saurin
- Industrial Engineering Post-Graduate Program, Universidade Federal Do Rio Grande Do Sul, Av. Osvaldo Aranha, 99, Porto Alegre, RS, CEP 90035-190, Brazil.
| | - Riccardo Patriarca
- Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Via Eudossiana 18, 00184, Rome, Italy.
| | - Sudeep Hegde
- Industrial Engineering, College of Engineering, Computing, and Applied Sciences, Clemson University, 272 Freeman Hall, Clemson, SC, 29634, United States.
| | - Mike Rayo
- Integrated Systems Engineering, The Ohio State University, Ker System Building 1971, Neil Ave Room 210, Columbus, United States.
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Mörike F, Spiehl HL, Feufel MA. Workarounds in the Shadow System: An Ethnographic Study of Requirements for Documentation and Cooperation in a Clinical Advisory Center. HUMAN FACTORS 2024; 66:636-646. [PMID: 35471848 DOI: 10.1177/00187208221087013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Hospital information systems (HIS) are meant to manage complex work processes across healthcare organizations. We describe limitations of HIS to address local information requirements and how they are circumvented at different organizational levels. Results can be used to better support collaboration in socio-technical systems. BACKGROUND Workarounds describe a mismatch between a technology's purpose and its actual use, whereas shadow systems are unofficial IT systems circumventing limitations of official systems to support workflows. Boundary infrastructures are conceptualized as the entirety of all (in)formal digital and analog systems connecting different communities of practice in a socio-technical system. METHODS An ethnographic study with observations and semi-structured interviews was conducted and analyzed through categorization and iterative coding. RESULTS Several digital-analog workarounds are employed for documentation and a shared server functions as a shadow system to support workflows in ways the HIS cannot. For collaborative documentation, all (official and informal) information sources were used simultaneously as part of an interconnected boundary infrastructure. CONCLUSION Formal and informal IT systems are interconnected across different organizational levels and provide insights into unmet information requirements, effective and problematic work practices, and how to address them to improve system functioning. An integrated perspective on boundary infrastructures, workarounds, and shadow systems may advance system analysis, providing a more comprehensive picture of IT requirements than any concept alone. APPLICATION Workarounds and shadow systems highlight that HIS should support systemic and local needs. Customized interfaces in HIS to support search, access, and exchange of relevant data might help to mitigate current shortcomings.
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Affiliation(s)
- Frauke Mörike
- Technische Universität Berlin, Department of Psychology and Ergonomics (IPA), Division of Ergonomics, Berlin, Germany
| | - Hannah L Spiehl
- Technische Universität Berlin, Department of Psychology and Ergonomics (IPA), Division of Ergonomics, Berlin, Germany
| | - Markus A Feufel
- Technische Universität Berlin, Department of Psychology and Ergonomics (IPA), Division of Ergonomics, Berlin, Germany
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Tedone AM, Lanz JJ. Staying silent during a crisis: How workplace factors influence safety decisions in U.S. nurses. Soc Sci Med 2024; 341:116548. [PMID: 38171213 DOI: 10.1016/j.socscimed.2023.116548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/16/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024]
Abstract
RATIONALE It is critical for healthcare organizations to promote upward communication of safety information to ensure safety issues experienced on the work floor are promptly identified and addressed, especially during crisis events. OBJECTIVE This study investigates mechanisms through which workplace factors affect nurses' motivation to speak up about safety issues, and ultimately their safety behaviors, in a pandemic work environment. METHOD The work experiences of 152 frontline U.S. nurses were captured across three time-points during the height of a global pandemic. RESULTS Findings indicate that nurses who experienced a greater frequency of pandemic-related demands and/or perceived a greater social risk associated with voicing concerns were more likely to remain silent about safety issues due to job-related constraints or a fear of negatively impacting their reputation, respectively. As a consequence, nurses were more likely to bypass safety protocols while completing work tasks, especially those who had a lower risk propensity. CONCLUSION These findings advance the literature on workplace safety by investigating factors that affect employee communication and ultimately safety workarounds in nurses within the context of a global pandemic.
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Affiliation(s)
| | - Julie J Lanz
- Department of Psychology, University of Nebraska at Kearney, USA
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Jacobson JO, Zerillo JA, Doolin J, Stuver SO, Revette A, Mulvey T. Uncovering the Risks of Anticancer Therapy Through Incident Report Analysis Using a Newly Developed Medical Oncology Incident Taxonomy. J Patient Saf 2023; 19:580-586. [PMID: 37922223 PMCID: PMC10662608 DOI: 10.1097/pts.0000000000001169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
BACKGROUND Incident reporting systems were developed to identify possible and actual harm in healthcare facilities. They have the potential to capture important safety trends and to enable improvements that can mitigate the risk of future patient harm and suffering. We recently developed and validated a taxonomy specific for medical oncology designed to enhance the identification, tracking, and trending of incidents that may lead to patient harm. The current project was designed to test the ability of such a taxonomy to be applied across different organizations delivering medical oncology care and to identify specific risks that could result in future harm. METHODS We analyzed 309 randomly selected medical oncology-related incident reports from 3 different cancer centers that had been posted between January 2019 and December 2020. Each report was assigned up to 2 incident categories. We used a 2-step process to reconcile reviewer discrepancies. In a secondary analysis, each of the incidents was reviewed and recoded to identify events which may result in major or catastrophic harm. RESULTS Three hundred four incidents met criteria for inclusion. Three hundred incidents (98.7%) were successfully coded. Sixty-seven percent of incidents were encompassed by the following 4 of 21 categories: prescriber ordering (22%), nursing care (15%), pharmacy (14%), and relational/communication issues (15%). Of 297 evaluable incidents, 47% did not reach the patient, 44.7% reached the patient without harm, 7.7% caused minor injury, and 0.7% caused severe injury or death. Submission rates by physicians varied between the 3 sites accounting for 1.7%, 10.7%, and 16.1% of reports. Secondary analysis identified 9 distinct scenarios that may result in major or catastrophic patient harm. CONCLUSIONS A medical oncology-specific incident reporting taxonomy has the potential to increase our understanding of inherent risks and may lead to process improvements that improve patient safety.
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Affiliation(s)
| | | | - James Doolin
- Harvard Medical School
- Beth Israel Deaconess Medical Center
| | - Sherri O. Stuver
- From the Dana-Farber Cancer Institute
- Boston University School of Public Health
| | - Anna Revette
- From the Dana-Farber Cancer Institute
- Harvard T.H. Chan School of Public Health
| | - Therese Mulvey
- Harvard Medical School
- Mass General Cancer Center, Boston, Massachusetts
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Campbell IM, Karavite DJ, Mcmanus ML, Cusick FC, Junod DC, Sheppard SE, Lourie EM, Shelov ED, Hakonarson H, Luberti AA, Muthu N, Grundmeier RW. Clinical decision support with a comprehensive in-EHR patient tracking system improves genetic testing follow up. J Am Med Inform Assoc 2023; 30:1274-1283. [PMID: 37080563 PMCID: PMC10280356 DOI: 10.1093/jamia/ocad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/10/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE We sought to develop and evaluate an electronic health record (EHR) genetic testing tracking system to address the barriers and limitations of existing spreadsheet-based workarounds. MATERIALS AND METHODS We evaluated the spreadsheet-based system using mixed effects logistic regression to identify factors associated with delayed follow up. These factors informed the design of an EHR-integrated genetic testing tracking system. After deployment, we assessed the system in 2 ways. We analyzed EHR access logs and note data to assess patient outcomes and performed semistructured interviews with users to identify impact of the system on work. RESULTS We found that patient-reported race was a significant predictor of documented genetic testing follow up, indicating a possible inequity in care. We implemented a CDS system including a patient data capture form and management dashboard to facilitate important care tasks. The system significantly sped review of results and significantly increased documentation of follow-up recommendations. Interviews with key system users identified a range of sociotechnical factors (ie, tools, tasks, collaboration) that contribute to safer and more efficient care. DISCUSSION Our new tracking system ended decades of workarounds for identifying and communicating test results and improved clinical workflows. Interview participants related that the system decreased cognitive and time burden which allowed them to focus on direct patient interaction. CONCLUSION By assembling a multidisciplinary team, we designed a novel patient tracking system that improves genetic testing follow up. Similar approaches may be effective in other clinical settings.
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Affiliation(s)
- Ian M Campbell
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Clinical Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan L Mcmanus
- Division of Clinical Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Fred C Cusick
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David C Junod
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah E Sheppard
- Division of Clinical Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eli M Lourie
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Eric D Shelov
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hakon Hakonarson
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anthony A Luberti
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Pruitt ZM, Kazi S, Weir C, Taft T, Busog DN, Ratwani R, Hettinger AZ. A Systematic Review of Quantitative Methods for Evaluating Electronic Medication Administration Record and Bar-Coded Medication Administration Usability. Appl Clin Inform 2023; 14:185-198. [PMID: 36889339 PMCID: PMC9995218 DOI: 10.1055/s-0043-1761435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/20/2022] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Although electronic medication administration records (eMARs) and bar-coded medication administration (BCMA) have improved medication safety, poor usability of these technologies can increase patient safety risks. OBJECTIVES The objective of our systematic review was to identify the impact of eMAR and BCMA design on usability, operationalized as efficiency, effectiveness, and satisfaction. METHODS We retrieved peer-reviewed journal articles on BCMA and eMAR quantitative usability measures from PsycInfo and MEDLINE (1946-August 20, 2019), and EMBASE (1976-October 23, 2019). Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we screened articles, extracted and categorized data into the usability categories of effectiveness, efficiency, and satisfaction, and evaluated article quality. RESULTS We identified 1,922 articles and extracted data from 41 articles. Twenty-four articles (58.5%) investigated BCMA only, 10 (24.4%) eMAR only, and seven (17.1%) both BCMA and eMAR. Twenty-four articles (58.5%) measured effectiveness, 8 (19.5%) efficiency, and 17 (41.5%) satisfaction. Study designs included randomized controlled trial (n = 1; 2.4%), interrupted time series (n = 1; 2.4%), pretest/posttest (n = 21; 51.2%), posttest only (n = 14; 34.1%), and pretest/posttest and posttest only for different dependent variables (n = 4; 9.8%). Data collection occurred through observations (n = 19, 46.3%), surveys (n = 17, 41.5%), patient safety event reports (n = 9, 22.0%), surveillance (n = 6, 14.6%), and audits (n = 3, 7.3%). CONCLUSION Of the 100 measures across the 41 articles, implementing BCMA and/or eMAR broadly resulted in an increase in measures of effectiveness (n = 23, 52.3%) and satisfaction (n = 28, 62.2%) compared to measures of efficiency (n = 3, 27.3%). Future research should focus on eMAR efficiency measures, utilize rigorous study designs, and generate specific design requirements.
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Affiliation(s)
- Zoe M. Pruitt
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
| | - Sadaf Kazi
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Teresa Taft
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Deanna-Nicole Busog
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
| | - Raj Ratwani
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
| | - Aaron Z. Hettinger
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States
- Department of Emergency Medicine, Georgetown University School of Medicine, Washington, District of Columbia, United States
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A Systematic Review of Nursing Practice Workarounds. Dimens Crit Care Nurs 2022; 41:347-356. [PMID: 36179314 DOI: 10.1097/dcc.0000000000000549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Nursing practice workarounds (NPWs) are a significant problem for health care organizations. Identified NPWs serve as a catalyst for innovation to improve efficiency, patient safety, and system design. To date, a systematic review of NPW literature has not been performed. OBJECTIVES The aim of this systematic review was to synthesize evidence of NPW definitions, context, and prevention strategies, utilizing previous research to develop a framework that examines the current state of this phenomenon and implications for clinical practice, while highlighting the need for future research. METHODS A systematic review of the literature was conducted using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Academic Search, Ovid MEDLINE, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar databases were reviewed for eligible studies from 2013 to 2020. Results were further screened and sorted by relevance and scored for quality. RESULTS Thirteen studies were included. Studies lacked the use of theory, and NPW definitions were varied. Nursing workarounds occurred most frequently when implementing new technology (46%) and when administering medications (31%). Contributing factors were workplace stressors and obstructions in workflow environment. Workaround prevention strategies include open communication and a proactive approach addressing conditions, situations, and processes. Overall study quality was low. DISCUSSION This systematic review provides valuable information for critical care nurses and administrators regarding NPW. Implications for practice include the need for proactive and open communication between nurses and administrators when new technology and/or patient care processes require NPW. Administrative considerations include process and environmental improvement strategies to remove perceived workflow barriers. Future research to examine causes and consequences of NPW is needed to identify interventions for NPW prevention. Specific nursing considerations include workload, staffing and time constraints, and impacts of work-related stress levels. Critical care nursing processes should be examined for common NPW challenges. Interventions developed to address these challenges should then be tested to further advance evidence-based critical care nursing care.
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Lyng HB, Macrae C, Guise V, Haraldseid-Driftland C, Fagerdal B, Schibevaag L, Alsvik JG, Wiig S. Exploring the nature of adaptive capacity for resilience in healthcare across different healthcare contexts; a metasynthesis of narratives. APPLIED ERGONOMICS 2022; 104:103810. [PMID: 35635941 DOI: 10.1016/j.apergo.2022.103810] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 05/19/2022] [Accepted: 05/22/2022] [Indexed: 06/15/2023]
Abstract
Adaptive capacity has been described as instrumental for the development of resilience in healthcare. Yet, our theoretical understanding of adaptive capacity remains relatively underdeveloped. This research therefore aims at developing a new understanding of the nature of adaptive capacity by exploring the following research questions: 1. What constitutes adaptive capacity across different healthcare contexts? and 2. What type of enabling factors support adaptive capacity across different healthcare contexts? The study used a novel combination of qualitative methods featuring a metasynthesis of narratives based on empirical research to contribute understanding of adaptive capacity across different healthcare contexts. The findings show that adaptive capacity was found to include four forms: reframing, aligning, coping, and innovating. A framework illustrating the relatedness between the identified forms, in terms of resources, change and enablers, is provided. Based on these findings, a new definition of adaptive capacity for resilience in healthcare is proposed.
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Affiliation(s)
- Hilda Bø Lyng
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway.
| | - Carl Macrae
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway; Nottingham University Business School, University of Nottingham, UK
| | - Veslemøy Guise
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
| | - Cecilie Haraldseid-Driftland
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
| | - Birte Fagerdal
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
| | - Lene Schibevaag
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
| | - Janne Gro Alsvik
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
| | - Siri Wiig
- SHARE - Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, N-4036, Stavanger, Norway
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O’Neill T, McNeese N, Barron A, Schelble B. Human-Autonomy Teaming: A Review and Analysis of the Empirical Literature. HUMAN FACTORS 2022; 64:904-938. [PMID: 33092417 PMCID: PMC9284085 DOI: 10.1177/0018720820960865] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE We define human-autonomy teaming and offer a synthesis of the existing empirical research on the topic. Specifically, we identify the research environments, dependent variables, themes representing the key findings, and critical future research directions. BACKGROUND Whereas a burgeoning literature on high-performance teamwork identifies the factors critical to success, much less is known about how human-autonomy teams (HATs) achieve success. Human-autonomy teamwork involves humans working interdependently toward a common goal along with autonomous agents. Autonomous agents involve a degree of self-government and self-directed behavior (agency), and autonomous agents take on a unique role or set of tasks and work interdependently with human team members to achieve a shared objective. METHOD We searched the literature on human-autonomy teaming. To meet our criteria for inclusion, the paper needed to involve empirical research and meet our definition of human-autonomy teaming. We found 76 articles that met our criteria for inclusion. RESULTS We report on research environments and we find that the key independent variables involve autonomous agent characteristics, team composition, task characteristics, human individual differences, training, and communication. We identify themes for each of these and discuss the future research needs. CONCLUSION There are areas where research findings are clear and consistent, but there are many opportunities for future research. Particularly important will be research that identifies mechanisms linking team input to team output variables.
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Affiliation(s)
- Thomas O’Neill
- University of Calgary, Calgary, AB, Canada
- Curtin University, WA, Australia
- Thomas O’Neill, Department of Psychology, University
of Calgary, AB, T2N 1N4, Canada;
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Baysari MT, Wells J, Ekpo E, Makeham M, Penm J, Alexander N, Holden A, Ubeja R, McAllister S. An Exploratory Study of Allied Health Students' Experiences of Electronic Medical Records During Placements. Appl Clin Inform 2022; 13:410-418. [PMID: 35388446 PMCID: PMC8986461 DOI: 10.1055/s-0042-1744550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Allowing students to access and document in electronic medical records (eMRs) during clinical placements is viewed as critical for ensuring that graduates have a high level of digital proficiency prior to entering the workforce. Limited studies have explored student access to eMRs in health disciplines outside of medicine and nursing. OBJECTIVE Our main objective was to examine allied health students' experiences and perceptions of the opportunity to develop eMR competencies during their placement, across a range of allied health disciplines and placement settings. METHODS An explanatory sequential design was used, comprising a quantitative survey (n = 102) followed by qualitative semi-structured interviews (n = 6) with senior allied health students to explore their experiences and perceptions of eMR access during placements. RESULTS Of the 93 students who responded to the question about their placement eMR, nine (10%) reported their placement site did not use an eMR and four students reported that they were not allowed to access the eMR during their placement. Most students (64%, 54 out of 84) accessed the system using their own credentials, but 31% (26 out of 84) used someone else's log-in and password. Students were satisfied with the eMR training and support received while on placement, but there was significant variability across sites on the level of training and support provided. All students believed that eMR access was beneficial for learning and preparation for work, improved delivery of care, taking ownership of work, and feeling responsible for patient care. CONCLUSION Providing students with access to eMRs during placements is fundamental to the development of a student's professional identity and to recognizing their role in the delivery of interprofessional patient care. For graduates to be equipped to effectively contribute to multi-disciplinary care in a digital health environment, universities need to work with practice partners to standardize and formalize eMR access, registration, training, and support, and to provide students with early exposure and training on eMRs in university courses.
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Affiliation(s)
- Melissa Therese Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jacqueline Wells
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ernest Ekpo
- Medical Image Optimisation and Perception Group (MIOPeG), Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Meredith Makeham
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Pharmacy, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Nathaniel Alexander
- Clinical Governance Unit, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Alexander Holden
- The University of Sydney Dental School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Raj Ubeja
- Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Sue McAllister
- Work Integrated Learning, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,College of Nursing and Health Sciences, Flinders University of South Australia, Adelaide, Australia
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Patterson ES, Rayo MF, Edworthy JR, Moffatt-Bruce SD. Applying Human Factors Engineering to Address the Telemetry Alarm Problem in a Large Medical Center. HUMAN FACTORS 2022; 64:126-142. [PMID: 34011195 DOI: 10.1177/00187208211018883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Address the alarm problem by redesigning, reorganizing, and reprioritizing to better discriminate alarm sounds and displays in a hospital. BACKGROUND Alarms in hospitals are frequently misunderstood, disregarded, and overridden. METHOD Discovery-oriented, intervention, and translational studies were conducted. Study objectives and measures varied, but had the shared goals of increasing positive predictive value (PPV) of critical alarms by reducing low-PPV alarms in the background, prioritizing alarms, redesigning alarm sounds to increase information content, and transparently conveying who initiated alarms. An alarm ontology was iteratively generated and refined until consensus was achieved. RESULTS The ontology distinguishes five levels of urgency that incorporate likely PPV, three categories for who initiates the alarm (hospital staff, patient, or machine), whether it is clinical or technical, and clinical functions. CONCLUSION This unique collaboration allowed us to make progress on the alarm problem by making unintuitive leaps, avoiding common missteps, and refuting conventional healthcare approaches. APPLICATION Hospitals can consistently redesign, reorganize, reprioritize, and better discriminate alarms by priority, PPV, and content to reduce nurse response times.
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14
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Williams R, Aldakhil R, Blandford A, Jani Y. Interdisciplinary systematic review: does alignment between system and design shape adoption and use of barcode medication administration technology? BMJ Open 2021; 11:e044419. [PMID: 34210721 PMCID: PMC8252881 DOI: 10.1136/bmjopen-2020-044419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND In order to reduce safety risks associated with medication administrations, technologies such as barcode medication administration (BCMA) are increasingly used. Examining how human factors influence adoption and usability of this technology can potentially highlight areas for improvement in design and implementation. OBJECTIVE To describe how human factors related determinants for BCMA have been researched and reported by healthcare and human-computer interaction disciplines. DATA SOURCES The Cumulative Index of Nursing, and Allied Health Literature, PubMed, OVID MEDLINE and Google Scholar. STUDY ELIGIBILITY CRITERIA Primary research published from April 2000 to April 2020, search terms developed to identity different disciplinary research perspectives that examined BCMA use, used a human factors lens and were published in English. SYNTHESIS METHODS Computerised systematic searches were conducted in four databases. Eligible papers were systematically analysed for themes. Themes were discussed with a second reviewer and supervisors to ensure they were representative of content. RESULTS Of 3707 papers screened, 11 were included. Studies did not fit neatly into a clinical or human-computer interaction perspective but instead uncovered a range of overlapping narratives, demonstrating consensus on the key themes despite differing research approaches. Prevalent themes were misaligned design and workflow, adaptation and workarounds, mediating factors, safety, users' perceptions and design and usability. Inadequate design frequently led to workarounds, which jeopardised safety. Reported mediating factors included clarity of user needs, pre/post implementation evaluations, analysis of existing workarounds and appropriate technology, infrastructure and staffing. LIMITATIONS Most studies were relatively small and qualitative, making it difficult to generalise findings. CONCLUSION Evaluating interdisciplinary perspectives including human factors approaches identified similar and complementary enablers and barriers to successful technology use. Often, mediating factors were developed to compensate for unsuitable design; a collaborative approach between system designer and end users is necessary for BCMA to achieve its true safety potential.
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Affiliation(s)
- Rachel Williams
- Centre for Medicines Optimisation Research and Education, University College London NHS Foundation Trust, London, UK
| | - Reham Aldakhil
- Clinical and Research Informatics Unit, UCL Institution of Health informatics, University College London, London, UK
| | - Ann Blandford
- UCL Institute of Healthcare Engineering, University College London, London, UK
| | - Yogini Jani
- Centre for Medicines Optimisation Research and Education, University College London NHS Foundation Trust, London, UK
- UCL School of Pharmacy, University College London, London, UK
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15
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Boonstra A, Jonker TL, van Offenbeek MAG, Vos JFJ. Persisting workarounds in Electronic Health Record System use: types, risks and benefits. BMC Med Inform Decis Mak 2021; 21:183. [PMID: 34103041 PMCID: PMC8186102 DOI: 10.1186/s12911-021-01548-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/31/2021] [Indexed: 11/18/2022] Open
Abstract
Background Electronic Health Records (EHRs) are now widely used to create a single, shared, and reliable source of patient data throughout healthcare organizations. However, health professionals continue to experience mismatches between their working practices and what the EHR allows or directs them to do. Health professionals adopt working practices other than those imposed by the EHR to overcome such mismatches, known as workarounds. Our study aims to inductively develop a typology of enduring EHR workarounds and explore their consequences by answering the question: What types of EHR workarounds persist, and what are the user-perceived consequences? Methods This single case study was conducted within the Internal Medicine department of a Dutch hospital that had implemented an organization-wide, commercial EHR system over two years ago. Data were collected through observations of six EHR users (see Additional file 1, observation scheme) and 17 semi-structured interviews with physicians, nurses, administrators, and EHR support staff members. Documents were analysed to contextualize these data (see Additional file 2, interview protocol). Results Through a qualitative analysis, 11 workarounds were identified, predominantly performed by physicians. These workarounds are categorized into three types either performed while working with the system (in-system workflow sequence workarounds and in-system data entry workarounds) or bypassing the system (out-system workarounds). While these workarounds seem to offer short-term benefits for the performer, they often create threats for the user, the patient, the overall healthcare organization, and the system. Conclusion This study increases our understanding of the enduring phenomenon of working around Electronic Health Records by presenting a typology of those workarounds that persist after adoption and by reflecting on the user-perceived risks and benefits. The typology helps EHR users and their managers to identify enduring types of workarounds and differentiate between the harmful and less harmful ones. This distinction can inform their decisions to discourage or obviate the need for certain workarounds, while legitimating others. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01548-0.
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Affiliation(s)
- Albert Boonstra
- Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands.
| | - Tess L Jonker
- Customer Service ERP, AFAS Software, Leusden, The Netherlands
| | | | - Janita F J Vos
- Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
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16
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Hutchings OR, Dearing C, Jagers D, Shaw MJ, Raffan F, Jones A, Taggart R, Sinclair T, Anderson T, Ritchie AG. Virtual Health Care for Community Management of Patients With COVID-19 in Australia: Observational Cohort Study. J Med Internet Res 2021; 23:e21064. [PMID: 33687341 PMCID: PMC7945978 DOI: 10.2196/21064] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/17/2020] [Accepted: 03/01/2021] [Indexed: 01/14/2023] Open
Abstract
Background Australia has successfully controlled the COVID-19 pandemic. Similar to other high-income countries, Australia has extensively used telehealth services. Virtual health care, including telemedicine in combination with remote patient monitoring, has been implemented in certain settings as part of new models of care that are aimed at managing patients with COVID-19 outside the hospital setting. Objective This study aimed to describe the implementation of and early experience with virtual health care for community management of patients with COVID-19. Methods This observational cohort study was conducted with patients with COVID-19 who availed of a large Australian metropolitan health service with an established virtual health care program capable of monitoring patients remotely. We included patients with COVID-19 who received the health service, could self-isolate safely, did not require immediate admission to an in-patient setting, had no major active comorbid illness, and could be managed at home or at other suitable sites. Skin temperature, pulse rate, and blood oxygen saturation were remotely monitored. The primary outcome measures were care escalation rates, including emergency department presentation, and hospital admission. Results During March 11-29, 2020, a total of 162 of 173 (93.6%) patients with COVID-19 (median age 38 years, range 11-79 years), who were diagnosed locally, were enrolled in the virtual health care program. For 62 of 162 (38.3%) patients discharged during this period, the median length of stay was 8 (range 1-17) days. The peak of 100 prevalent patients equated to approximately 25 patients per registered nurse per shift. Patients were contacted a median of 16 (range 1-30) times during this period. Video consultations (n=1902, 66.3%) comprised most of the patient contacts, and 132 (81.5%) patients were monitored remotely. Care escalation rates were low, with an ambulance attendance rate of 3% (n=5), emergency department attendance rate of 2.5% (n=4), and hospital admission rate of 1.9% (n=3). No deaths were recorded. Conclusions Community-based virtual health care is safe for managing most patients with COVID-19 and can be rapidly implemented in an urban Australian setting for pandemic management. Health services implementing virtual health care should anticipate challenges associated with rapid technology deployments and provide adequate support to resolve them, including strategies to support the use of health information technologies among consumers.
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Affiliation(s)
- Owen Rhys Hutchings
- Royal Prince Alfred Virtual Hospital, Sydney Local Health District, Camperdown, Australia
| | - Cassandra Dearing
- Royal Prince Alfred Virtual Hospital, Sydney Local Health District, Camperdown, Australia
| | - Dianna Jagers
- Royal Prince Alfred Virtual Hospital, Sydney Local Health District, Camperdown, Australia
| | - Miranda Jane Shaw
- Royal Prince Alfred Virtual Hospital, Sydney Local Health District, Camperdown, Australia
| | - Freya Raffan
- Royal Prince Alfred Virtual Hospital, Sydney Local Health District, Camperdown, Australia
| | - Aaron Jones
- Sydney Local Health District, Camperdown, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Tim Sinclair
- Sydney Local Health District, Camperdown, Australia
| | | | - Angus Graham Ritchie
- Sydney Local Health District, Camperdown, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
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17
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Lee S, Lee MS. Nurses' Electronic Medical Record Workarounds in a Tertiary Teaching Hospital. Comput Inform Nurs 2021; 39:367-374. [PMID: 33675300 DOI: 10.1097/cin.0000000000000692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The objective of this study was to identify nurses' workarounds related to the use of electronic medical records in a tertiary teaching hospital. A total of 106 nurses (84.8%) using the electronic medical records completed 10-item questionnaires scored on a Likert scale and five open-ended questions with written responses. The numerical data were analyzed by descriptive statistics, and the written descriptions were categorized by meaning. The mean of the scored items ranged from 3.29 to 3.74. Approximately 38% to 50% of the participants reported (very) frequent workflow delays due to the use of the electronic medical records, and 46% to 64% reported (very) frequently using workarounds. Twenty-nine workarounds of the electronic medical records were due to electronic documentation, difficulty accessing the electronic medical records, medication administration, covering physician responsibilities, electronic communication with the physicians, respondents and physicians not skilled in using the electronic medical records, and connection failures between devices or machines and the electronic medical records. Although none of these identified workarounds were intended to be harmful, and certain workarounds were efficient for patient care and workflow, whether patient safety can be jeopardized by workarounds should be considered. This study contributes to the understanding of why and how workarounds occur in the hospital. It will be useful for achieving greater alignment between work contexts and the electronic medical record in the future.
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Affiliation(s)
- Seonah Lee
- Author Affiliations: College of Nursing, Chonnam National University (Dr S. Lee); and Department of Nursing, Nambu University (Ms M-S. Lee), Gwangju, South Korea
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18
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Valvona SN, Rayo MF, Abdel-Rasoul M, Locke LJ, Rizer MK, Moffatt-Bruce SD, Patterson ES. Comparative Effectiveness of Best Practice Alerts with Active and Passive Presentations: A Retrospective Study. ACTA ACUST UNITED AC 2020. [DOI: 10.1177/2327857920091023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We assess the relationship of active or passive presentation of Best Practice Advisories (BPAs) for hospital clinicians with compliance rates of recommended actions. We identify the design characteristics of alerts that can be used to assess the effectiveness of design choices with superior usability. Alerts in Electronic Health Records (EHRs) are frequently overridden by healthcare providers. Identifying characteristics of effective alerts can increase the frequency that actions recommended in evidence-based care guidelines are done, reduce user frustration, and improve interface usability along with the willingness to use alerts. We conducted a retrospective analysis of data for 11 BPAs between June 2014 and May 2015. The outcome measure was the percent correspondence with recommended actions. A repeated measures regression model was used for the correlation of the BPA presentation type with the outcome measure. The BPA presentation type was significant such that the odds are 7.7 times greater that a recommended action would be taken by a provider with an active BPA presentation type after adjusting for whether an action was required. Active presentation alerts achieve higher compliance rates. CDS alerts that actively interrupted the provider’s workflow were associated with a higher compliance rate with recommended actions.
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Affiliation(s)
| | - Michael F. Rayo
- Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH
| | - Linda J. Locke
- Ohio State University Wexner Medical Center, Columbus, OH
| | - Milisa K. Rizer
- Ohio State University Wexner Medical Center, Columbus, OH
- Departments of Family Medicine and Biomedical Informatics, The Ohio State University, Columbus, OH
| | - Susan D. Moffatt-Bruce
- Ohio State University Wexner Medical Center, Columbus, OH
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Emily S. Patterson
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus OH
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19
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Mount-Campbell AF, Evans KD, Woods DD, Chipps E, Moffatt-Bruce SD, Patel K, Patterson ES. Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System. Front Digit Health 2020; 2:12. [PMID: 34713025 PMCID: PMC8521873 DOI: 10.3389/fdgth.2020.00012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/30/2020] [Indexed: 11/25/2022] Open
Abstract
We identify useful functions and usability characteristics of a historical cognitive artifact used by nurses working in a hospital unit, the Kardex. By identifying aspects of a widely used artifact, we uncover opportunities to improve the usefulness of current systems for hospital nurses. We conducted semi-structured interviews with registered nurses about their prior experience with the Kardex. Questions included what elements of the Kardex are missing from their current electronic support. Memos were generated iteratively from interview transcript data and grouped into themes. Eighteen nurses from multiple clinical areas participated and had a median of 25–29 years of nursing experience. The themes were: (1) a status at a glance summary for each patient, (2) a prospective memory aid, (3) efficiency and ease of use, (4) updating information required to maintain value, (5) activity management, (6) verbal handover during shift-to-shift report, (7) narrative charting and personalized care, and (8) non-clinical care communication. Implications for digital support are to provide immediate, portable access to a standardized patient summary, support for nurses to manage their planned activities during a series of shifts, provide unstructured text fields for narrative charting, and to support adding informal notes for personalized care.
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Affiliation(s)
| | - Kevin D Evans
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - David D Woods
- Department of Integrated Systems Engineering, The Ohio State University, Columbus, OH, United States
| | - Esther Chipps
- College of Nursing, The Ohio State University, Columbus, OH, United States.,Wexner Ohio State University Medical Center, Columbus, OH, United States
| | - Susan D Moffatt-Bruce
- Wexner Ohio State University Medical Center, Columbus, OH, United States.,Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Kashvi Patel
- Royal College of Physicians and Surgeons of Canada, Ottawa, ON, Canada.,College of Business, The Ohio State University, Columbus, OH, United States
| | - Emily S Patterson
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, United States
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20
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Cohen DJ, Wyte-Lake T, Dorr DA, Gold R, Holden RJ, Koopman RJ, Colasurdo J, Warren N. Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs. J Am Med Inform Assoc 2020; 27:690-699. [PMID: 32134456 PMCID: PMC7647291 DOI: 10.1093/jamia/ocaa010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/06/2020] [Accepted: 01/16/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To identify the unmet information needs of clinical teams delivering care to patients with complex medical, social, and economic needs; and to propose principles for redesigning electronic health records (EHR) to address these needs. MATERIALS AND METHODS In this observational study, we interviewed and observed care teams in 9 community health centers in Oregon and Washington to understand their use of the EHR when caring for patients with complex medical and socioeconomic needs. Data were analyzed using a comparative approach to identify EHR users' information needs, which were then used to produce EHR design principles. RESULTS Analyses of > 300 hours of observations and 51 interviews identified 4 major categories of information needs related to: consistency of social determinants of health (SDH) documentation; SDH information prioritization and changes to this prioritization; initiation and follow-up of community resource referrals; and timely communication of SDH information. Within these categories were 10 unmet information needs to be addressed by EHR designers. We propose the following EHR design principles to address these needs: enhance the flexibility of EHR documentation workflows; expand the ability to exchange information within teams and between systems; balance innovation and standardization of health information technology systems; organize and simplify information displays; and prioritize and reduce information. CONCLUSION Developing EHR tools that are simple, accessible, easy to use, and able to be updated by a range of professionals is critical. The identified information needs and design principles should inform developers and implementers working in community health centers and other settings where complex patients receive care.
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Affiliation(s)
- Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
| | - Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David A Dorr
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
| | - Rachel Gold
- Center for Health Research, Kaiser Permanente, Portland, Oregon, USA
- Department of Research, OCHIN Inc, Portland, Oregon, USA
| | - Richard J Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richelle J Koopman
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, USA
| | - Joshua Colasurdo
- Department of Medical Informatics and Clinical Epidemiology, OregonHealth and Science University, Portland, Oregon, USA
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21
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van der Veen W, Taxis K, Wouters H, Vermeulen H, Bates DW, van den Bemt PMLA. Factors associated with workarounds in barcode-assisted medication administration in hospitals. J Clin Nurs 2020; 29:2239-2250. [PMID: 32043705 PMCID: PMC7328795 DOI: 10.1111/jocn.15217] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/11/2020] [Accepted: 02/03/2020] [Indexed: 01/25/2023]
Abstract
Aims and objectives To identify that workarounds (defined as “informal temporary practices for handling exceptions to normal procedures or workflow”) by nurses using information technology potentially compromise medication safety. Therefore, we aimed to identify potential risk factors associated with workarounds performed by nurses in Barcode‐assisted Medication Administration in hospitals. Background Medication errors occur during the prescribing, distribution and administration of medication. Errors could harm patients and be a tragedy for both nurses and medical doctors involved. Interventions to prevent errors have been developed, including those based on information technology. To cope with shortcomings in information technology‐based interventions as Barcode‐assisted Medication Administration, nurses perform workarounds. Identification of workarounds in information technology is essential to implement better‐designed software and processes which fit the nurse workflow. Design We used the data from our previous prospective observational study, performed in four general hospitals in the Netherlands using Barcode techniques, to administer medication to inpatients. Methods Data were collected from 2014–2016. The disguised observation was used to gather information on potential risk factors and workarounds. The outcome was a medication administration with one or more workarounds. Logistic mixed models were used to determine the association between potential risk factors and workarounds. The STROBE checklist was used for reporting our data. Results We included 5,793 medication administrations among 1,230 patients given by 272 nurses. In 3,633 (62.7%) of the administrations, one or more workarounds were observed. In the multivariate analysis, factors significantly associated with workarounds were the medication round at 02 p.m.–06 p.m. (adjusted odds ratio [OR]: 1.60, 95% CI: 1.05–2.45) and 06 p.m.–10 p.m. (adjusted OR: 3.60, 95% CI: 2.11–6.14) versus the morning shift 06 a.m.–10 a.m., the workdays Monday (adjusted OR: 2.59, 95% CI: 1.51–4.44), Wednesday (adjusted OR: 1.92, 95% CI: 1.2–3.07) and Saturday (adjusted OR: 2.24, 95% CI: 1.31–3.84) versus Sunday, the route of medication, nonoral (adjusted OR: 1.28, 95% CI: 1.05–1.57) versus the oral route of drug administration, the Anatomic Therapeutic Chemical classification‐coded medication “other” (consisting of the irregularly used Anatomic Therapeutic Chemical classes [D, G, H, L, P, V, Y, Z]) (adjusted OR: 1.49, 95% CI: 1.05–2.11) versus Anatomic Therapeutic Chemical class A (alimentary tract and metabolism), and the patient–nurse ratio ≥6–1 (adjusted OR: 5.61, 95% CI: 2.9–10.83) versus ≤5–1. Conclusions We identified several potential risk factors associated with workarounds performed by nurses that could be used to target future improvement efforts in Barcode‐assisted Medication Administration. Relevance to clinical practice Nurses administering medication in hospitals using Barcode‐assisted Medication Administration frequently perform workarounds, which may compromise medication safety. In particular, nurse workload and the patient–nurse ratio could be the focus for improvement measures as these are the most clearly modifiable factors identified in this study.
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Affiliation(s)
- Willem van der Veen
- Unit PharmacoTherapy, Epidemiology & Economics, Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- Unit PharmacoTherapy, Epidemiology & Economics, Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
| | - Hans Wouters
- General Practitioners Research Institute, University of Groningen, Groningen, The Netherlands
| | - Hester Vermeulen
- Department of IQ Healthcare, Scientific Center for Quality of Healthcare, Radboud Institute of Health Sciences, Nijmegen, The Netherlands
| | - David W Bates
- Harvard Medical School and Brigham and Woman's Hospital, Boston, MA, USA
| | - Patricia M L A van den Bemt
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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22
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Patterson ES, Su G, Sarkar U. Reducing delays to diagnosis in ambulatory care settings: A macrocognition perspective. APPLIED ERGONOMICS 2020; 82:102965. [PMID: 31605828 PMCID: PMC7757423 DOI: 10.1016/j.apergo.2019.102965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/30/2019] [Accepted: 09/25/2019] [Indexed: 05/13/2023]
Abstract
We aim to use a macrocognition theoretical perspective to characterize contributors to diagnostic delays by physicians that can be mitigated by work system redesign. As experienced with other complex, sociotechnical domains, system redesign is anticipated to be more effective at improving safety than training-based solutions. In the outpatient care setting, complex tasks, conducted by a primary care provider, are provided for five macrocognition functions: sensemaking, re-planning, detecting problems, deciding, and coordinating. Redesigning systems could reduce delays to diagnosis by helping users to avoid missed symptoms, forgotten follow-up activities, and delayed actions. Health information technology could support resilience strategies by offloading documentation burdens, recording working diagnoses, displaying planned follow-up activities at the correct time interval, and supporting recognition of patterns in patient care. These insights suggest a path forward for future research on system design innovations to reduce diagnostic delays, and ultimately, reduce patient harm.
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Affiliation(s)
- Emily S Patterson
- The Ohio State University, Division of Health Information Management and Systems, School of Health and Rehabilitation Sciences, College of Medicine, USA.
| | - George Su
- University of California San Francisco, Division of General Internal Medicine, UCSF Center for Vulnerable Populations, USA
| | - Urmimala Sarkar
- University of California San Francisco, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, USA
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Lee BY, Wedlock PT, Mitgang EA, Cox SN, Haidari LA, Das MK, Dutta S, Kapuria B, Brown ST. How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India. BMJ Glob Health 2019; 4:e001609. [PMID: 31565408 PMCID: PMC6747917 DOI: 10.1136/bmjgh-2019-001609] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping. Methods We developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping. Results Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08. Conclusion Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.
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Affiliation(s)
- Bruce Y Lee
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Patrick T Wedlock
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Elizabeth A Mitgang
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Sarah N Cox
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Leila A Haidari
- Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA.,HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA
| | | | | | | | - Shawn T Brown
- HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA.,McGill Center for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada
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Carayon P, Hundt AS, Hoonakker P. Technology barriers and strategies in coordinating care for chronically ill patients. APPLIED ERGONOMICS 2019; 78:240-247. [PMID: 31046955 PMCID: PMC6529186 DOI: 10.1016/j.apergo.2019.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 03/18/2019] [Accepted: 03/22/2019] [Indexed: 05/18/2023]
Abstract
Care managers who coordinate care for chronically ill patients in hospitals and outpatient settings use multiple health information technologies for accessing, processing, documenting, and communicating patient-related information. Using a combination of 41 interviews and observations of 15 care managers, we identified a range of technology-related barriers experienced by care managers (total of 163 occurrences). The barriers are related to (lack of) access to information, inadequate information, limited usefulness and usability of the technologies, challenges associated with using multiple health IT, and technical problems. In 43% of the occurrences, care managers describe strategies to deal with the technology barriers; these fit in three categories: nothing/delay (9 occurrences), work-arounds (32 occurrences), and direct action at the individual, team, and organization levels (29 occurrences). Our data show the adaptive capacity of care managers who develop various strategies to deal with technology barriers and are, therefore, able to care for chronically ill patients. This information can be used as input to work system redesigns.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial & Systems Engineering, University of Wisconsin-Madison, USA; Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA.
| | - Ann Schoofs Hundt
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA
| | - Peter Hoonakker
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, USA
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Health care innovations across practice and academia: A theoretical framework. Nurs Outlook 2019; 67:596-604. [PMID: 31230741 DOI: 10.1016/j.outlook.2019.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 04/23/2019] [Accepted: 05/15/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND An innovation scholarly interest group used the Jobs to Be Done Theory from the business literature to provide insight into the solution-focused progress that nurses are trying to make in challenging situations. PURPOSE This article presents a theoretical framework for understanding the progress nurses are trying to make through health care innovations across both practice and academic environments. METHOD This was a qualitative descriptive study using directed content analysis. We used the Jobs to Be Done Theory to guide the development of the semistructured questionnaire and the interpretation of findings. FINDINGS A theoretical framework of nursing innovations was derived to summarize and visually display the pathways and linkages of challenges, innovations, and impact domains of nursing innovations. Situations and opportunities arise within the context of interconnectedness and can lead to health care innovations in care delivery, patient care interventions, role transitions, research and translational methods, communication and collaboration, technology and data, teaching methods, and processes to improve care. DISCUSSION This theoretical framework offers insight into the dynamic interactions of academic-practice partnerships for innovation. Workplace situations are interconnected and can result in needed innovations designed to impact care delivery.
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Ibrahim S, Donelle L, Regan S, Sidani S. A Qualitative Content Analysis of Nurses' Comfort and Employment of Workarounds With Electronic Documentation Systems in Home Care Practice. Can J Nurs Res 2019; 52:31-44. [PMID: 31200603 DOI: 10.1177/0844562119855509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Electronic documentation systems have the potential to assist registered nurses with timely access to patient health- and care-related information. Registered nurses are the largest users of electronic documentation systems; however, limited evidence exists about their comfort with electronic documentation system usage and the types of workarounds developed within the context of home care. Aim To explore home care registered nurses’ comfort with electronic documentation system usage and identify the types and reasons for the development and implementation of workarounds. Methods A cross-sectional survey design was employed to collect quantitative and qualitative data. A total of 217 home care registered nurses participated in the survey. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using inductive content analysis. Findings: Individual (e.g., registered nurses’ technology-related experience), technological (e.g., electronic documentation system design) and organizational (e.g. training) characteristics influenced registered nurses’ comfort with electronic documentation system usage. Furthermore, workarounds stemmed from the technological characteristics of the electronic documentation system. Conclusion Findings highlight the need for assessing registered nurses’ level of comfort with electronic documentation system usage to inform training initiatives. Including registered nurses in the system design is advocated to ensure electronic documentation systems fit with the complexity of nursing practice, potentially enhancing registered nurses’ level of comfort and mitigating the development and employment of workarounds during system usage.
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Affiliation(s)
- Sarah Ibrahim
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Lorie Donelle
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Sandra Regan
- Arthur Labatt Family School of Nursing, Western University, London, Ontario, Canada
| | - Souraya Sidani
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
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Mount-Campbell AF, Evans KD, Woods DD, Chipps EM, Moffatt-Bruce SD, Patterson ES. Value and Usage of a Workaround Artifact: A Cognitive Work Analysis of "Brains" Use by Hospital Nurses. JOURNAL OF COGNITIVE ENGINEERING AND DECISION MAKING 2019; 13:67-80. [PMID: 33024425 PMCID: PMC7535084 DOI: 10.1177/1555343418825429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
We identify the value and usage of a cognitive artifact used by hospital nurses. By analyzing the value and usage of workaround artifacts, unmet needs using intended systems can be uncovered. A descriptive study employed direct observations of registered nurses at two hospitals using a paper workaround ("brains") and the Electronic Health Record. Field notes and photographs were taken; the format, size, layout, permanence, and content of the artifact were analyzed. Thirty-nine observations, spanning 156 hr, were conducted with 20 nurses across four clinical units. A total of 322 photographs of paper-based artifacts for 161 patients were collected. All participants used and updated "brains" during report, and throughout the shift, most were self-generated. These artifacts contained patient identifiers in a header with room number, last name, age, code status, and physician; clinical data were recorded in the body with historical chronic issues, detailed assessment information, and planned activities for the shift. Updates continuously made during the shift highlighted important information, updated values, and tracked the completion of activities. The primary functional uses of "brains" are to support nurses' needs for clinical immediacy through personally generated snapshot overviews for clinical summaries and updates to the status of planned activities.
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