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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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Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: An integrative review. J Am Med Inform Assoc 2020; 27:1149-1165. [PMID: 32651588 PMCID: PMC7647365 DOI: 10.1093/jamia/ocaa050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/29/2020] [Accepted: 04/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study sought to synthesize published literature on direct care nurses' use of workarounds related to the electronic health record. MATERIALS AND METHODS We conducted an integrative review of qualitative and quantitative peer-reviewed research through a structured search of Academic Search Complete, EBSCO Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Engineering Village, Ovid Medline, Scopus, and Web of Science. We systematically applied exclusion rules at the title, abstract, and full article stages and extracted and synthesized their research methods, workaround classifications, and probable causes from articles meeting inclusion criteria. RESULTS Our search yielded 5221 results. After removing duplicates and applying rules, 33 results met inclusion criteria. A total of 22 articles used qualitative approaches, 10 used mixed methods, and 1 used quantitative methods. While researchers may classify workarounds differently, they generally fit 1 of 3 broad categories: omission of process steps, steps performed out of sequence, and unauthorized process steps. Each study identified probable causes, which included technology, task, organizational, patient, environmental, and usability factors. CONCLUSIONS Extensive study of nurse workarounds in acute settings highlights the gap in ambulatory care research. Despite decades of electronic health record development, poor usability remains a key concern for nurses and other members of care team. The widespread use of workarounds by the largest group of healthcare providers subverts quality health care at every level of the healthcare system. Research is needed to explore the gaps in our understanding of and identify strategies to reduce workaround behaviors.
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Affiliation(s)
- Dan Fraczkowski
- Information Services, UI Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeffrey Matson
- Department of Anesthesia, Northwestern Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Karen Dunn Lopez
- Center for Nursing Classification & Clinical Effectiveness, College of Nursing, The University of Iowa, Iowa City, Iowa, USA
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Unertl KM, Novak LL, Van Houten C, Brooks J, Smith AO, Webb Harris J, Avery T, Simpson C, Lorenzi NM. Organizational diagnostics: a systematic approach to identifying technology and workflow issues in clinical settings. JAMIA Open 2020; 3:269-280. [PMID: 32734168 PMCID: PMC7382633 DOI: 10.1093/jamiaopen/ooaa013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 03/01/2020] [Accepted: 04/22/2020] [Indexed: 01/05/2023] Open
Abstract
Objectives Healthcare organizations need to rapidly adapt to new technology, policy changes, evolving payment strategies, and other environmental changes. We report on the development and application of a structured methodology to support technology and process improvement in healthcare organizations, Systematic Iterative Organizational Diagnostics (SIOD). SIOD was designed to evaluate clinical work practices, diagnose technology and workflow issues, and recommend potential solutions. Materials and Methods SIOD consists of five stages: (1) Background Scan, (2) Engagement Building, (3) Data Acquisition, (4) Data Analysis, and (5) Reporting and Debriefing. Our team applied the SIOD approach in two ambulatory clinics and an integrated ambulatory care center and used SIOD components during an evaluation of a large-scale health information technology transition. Results During the initial SIOD application in two ambulatory clinics, five major analysis themes were identified, grounded in the data: putting patients first, reducing the chaos, matching space to function, technology making work harder, and staffing is more than numbers. Additional themes were identified based on SIOD application to a multidisciplinary clinical center. The team also developed contextually grounded recommendations to address issues identified through applying SIOD. Discussion The SIOD methodology fills a problem identification gap in existing process improvement systems through an emphasis on issue discovery, holistic clinic functionality, and inclusion of diverse perspectives. SIOD can diagnose issues where approaches as Lean, Six Sigma, and other organizational interventions can be applied. Conclusion The complex structure of work and technology in healthcare requires specialized diagnostic strategies to identify and resolve issues, and SIOD fills this need.
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Affiliation(s)
- Kim M Unertl
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laurie Lovett Novak
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Courtney Van Houten
- Center for AI Research and Evaluation, IBM Watson Health, Cambridge, Massachusetts, USA
| | - JoAnn Brooks
- Independent Scholar, Cambridge, Massachusetts, USA
| | - Andrew O Smith
- Operations Improvement, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joyce Webb Harris
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Taylor Avery
- Strategy and Innovation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Simpson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy M Lorenzi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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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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McFarlane DC, Doig AK, Agutter JA, Brewer LM, Syroid ND, Mittu R. Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms. PLoS One 2018; 13:e0197157. [PMID: 29768477 PMCID: PMC5955574 DOI: 10.1371/journal.pone.0197157] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/27/2018] [Indexed: 11/18/2022] Open
Abstract
Objective This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs. Materials and methods A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts. Results Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001). Discussion and conclusion Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.
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Affiliation(s)
- Daniel C. McFarlane
- Patient Care & Monitoring Solutions, Innovation Office, Royal Philips, Andover, Massachusetts, United States of America
- * E-mail:
| | - Alexa K. Doig
- College of Nursing, University of Utah, Salt Lake City, Utah, United States of America
| | - James A. Agutter
- College of Architecture & Planning, University of Utah, Salt Lake City, Utah, United States of America
- Applied Medical Visualizations (Medvis), Salt Lake City, Utah, United States of America
| | - Lara M. Brewer
- Department of Anesthesiology, University of Utah Health Sciences Center, Salt Lake City, Utah, United States of America
| | - Noah D. Syroid
- Applied Medical Visualizations (Medvis), Salt Lake City, Utah, United States of America
- Anesthesiology Center for Patient Simulation, University of Utah, Salt Lake City, Utah, United States of America
| | - Ranjeev Mittu
- Information Technology Division, Information Management and Decision Architectures Branch, United States Naval Research Laboratory, Washington, District of Columbia, United States of America
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Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of the Human Factors Engineering Literature. HUMAN FACTORS 2018; 60:281-292. [PMID: 29533682 DOI: 10.1177/0018720818762546] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Objective To integrate and synthesize insights from recent studies of workarounds to the intended use of health information technology (HIT) by health care professionals. Background Systems are safest when the documentation of how work is done in policies and procedures closely matches what people actually do when they are working. Proactively identifying and managing workarounds to the intended use of technology, including deviations from expected workflows, can improve system safety. Method A narrative review of studies of workarounds with HIT was conducted to identify themes in the literature. Results Three themes were identified: (1) Users circumvented new additional steps in the workflow when using HIT, (2) interdisciplinary team members communicated via HIT in text fields that were intended for other purposes, and (3) locally developed paper-based and manual whiteboard systems were used instead of HIT to support situation awareness of individuals and groups; an example of a locally developed system was handwritten notes about a patient on a piece of paper folded up and carried in a nurse's pocket. Conclusion Workarounds were employed to avoid changes to workflow, enable interdisciplinary communication, coordinate activities, and have real-time portable access to summarized and synthesized information. Application Implications for practice include providing summary overview displays, explicitly supporting role-based communication and coordination through HIT, and reducing the risk to reputation due to electronic monitoring of individual performance.
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Bristol AA, Nibbelink CW, Gephart SM, Carrington JM. Nurses' Use of Positive Deviance When Encountering Electronic Health Records-Related Unintended Consequences. Nurs Adm Q 2018; 42:E1-E11. [PMID: 29194338 DOI: 10.1097/naq.0000000000000264] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
As organizations adopt electronic health records (EHRs), nurses frequently encounter system barriers and difficulty performing role expectations. This article describes nurses' experiences with unintended consequences emerging from the use of an EHR. In some situations, nurses were positively deviant when encountering unintended consequences relating to EHRs to accomplish patient care or protect patient safety. Nurses engaged in work-arounds to provide patient care when the EHR did not meet their needs, sometimes in positively deviant ways. Qualitative data were collected from 5 open-ended questions at the end of a quantitative survey. Analysis included coding of responses and organization of processes in line with the triangle model, a human factors framework, to identify overarching themes. Five themes emerged: (1) User support after implementation of EHR; (2) User satisfaction with EHR; (3) Communication for patient care, quality, and safety; (4) Effort to complete tasks; and (5) Areas for improvement. Nurses' ability to adopt positive deviance as they experience unintended consequences offers opportunities for organizations to engage nursing perspectives in improving the EHR and engineer it to be more resilient to nursing work.
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Affiliation(s)
- Alycia A Bristol
- School of Nursing, Loma Linda University, Loma Linda, California (Dr Bristol); and College of Nursing, The University of Arizona, Tucson (Drs Nibbelink, Gephart, and Carrington)
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