Alexa K. Doig

Collaborative learning using nursing student dyads in the clinical setting.

Abstract Formal pairing of student nurses to work collaboratively on one patient assignment is a strategy for improving the quality and efficiency of clinical instruction while better utilizing the limited resources at clinical agencies. The aim of this qualitative study was to explore the student nurse and patient experiences of collaborative learning when peer dyads are used in clinical nursing education. Interviews were conducted with 11 students and 9 patients. Students described the process of collaborative learning as information sharing, cross-checking when making clinical decisions, and group processing when assessing the outcomes of nursing interventions. Positive outcomes reported by students and patients included reduced student anxiety, increased confidence and task efficiency. Students’ primary concern was reduced opportunity to perform hands-on skills which had to be negotiated within each dyad. Meeting the present and future challenges of educating nurses will require innovative models of clinical instruction such as collaborative learning using student peer dyads.

Evaluation of a Configural Vital Signs Display for Intensive Care Unit Nurses

Objective: The objective was to evaluate a configural vital signs (CVS) display designed to support rapid detection and identification of physiological deterioration by graphically presenting patient vital signs data. Background: Current display technology in the intensive care unit (ICU) is not optimized for fast recognition and identification of physiological changes in patients. To support nurses more effectively, graphical or configural vital signs displays need to be developed and evaluated. Method: A CVS display was developed based on findings from studies of the cognitive work of ICU nurses during patient monitoring. A total of 42 ICU nurses interpreted data presented either in a traditional, numerical format (n = 21) or on the CVS display (n = 21). Response time and accuracy in clinical data interpretation (i.e., identification of patient status) were assessed across four scenarios. Results: Data interpretation speed and accuracy improved significantly in the CVS display condition; for example, in one scenario nurses required only half of the time for data interpretation and showed up to 1.9 times higher accuracy in identifying the patient state compared to the numerical display condition. Conclusion: Providing patient information in a configural display with readily visible trends and data variability can improve the speed and accuracy of data interpretation by ICU nurses. Application: Although many studies, including this one, support the use of configural displays, the vast majority of ICU monitoring displays still present clinical data in numerical format. The introduction of configural displays in clinical monitoring has potential to improve patient safety.

Informing the design of hemodynamic monitoring displays

In the ICU, an extensive array of variables from the hemodynamic monitoring display is routinely analyzed. However, the development of new display technologies is proceeding without adequate study of the monitoring tasks and behaviors of a primary user group—critical-care nurses. Semistructured interviews focusing on the cognitive aspects of the hemodynamic monitoring task were conducted with 14 critical-care nurses. A systematic content analysis of qualitative data identified cognitive tasks that had applicability to the design of monitoring displays. The cognitive tasks of hemodynamic monitoring were (1) selective data acquisition, (2) applying meaning to the variables and understanding relationships between parameters, (3) controlling hemodynamics by titrating medications and intravenous fluids, and (4) monitoring complex trends of multiple interacting variables and patient response to interventions. Recommendations include designing the monitoring display to match the mental constructs and cognitive tasks of the user by applying conceptual meaning to the variables, highlighting relationships between variables, and presenting a “big picture” view of the patient’s condition. Monitoring displays must also present integrated trends that illustrate the dynamic relationship between interventions and patient response.

The hazards of using floor mats as a fall protection device at the bedside.

Objectives: In this study, we evaluated the clinical safety of the floor mat, a device intended to reduce severity of injury in falls from the bed or at the bedside. Methods: Fifteen participants with a range of gaits and fall risk were video-recorded as they approached and entered a hospital bed and then as they exited and walked away. For 10 participants, a 1-inch-thick floor mat with a beveled edge was used as a fall protection device at the bedside. The videos were coded and analyzed for the purpose of determining the mechanisms by which the floor mat affected balance and gait while participants ambulated to and from the bed. Permission has been received from all patients. Results: The bedside floor mat caused elderly patients with impaired and normal gaits to lose balance and, in some cases, stumble while ambulating onto the floor mat. Eight of 10 patients had difficulty exiting the bed because they placed their heels on the beveled edge of the mat closest to the bed, which shifted their center of gravity back as they were attempting to stand. Furthermore, walkers and mobile intravenous stands maneuvered onto the floor mat were unbalanced and unstable, further jeopardizing patient safety. Conclusions: The bevel-edged, bedside floor mat is a potential hazard for ambulatory patients, especially those with impaired gaits, using walkers and pushing mobile intravenous stands.

Effects of bed height on the biomechanics of hospital bed entry and egress.

BACKGROUND Although a significant proportion of patient falls in hospitals occur in the vicinity of the hospital bed, little is known about the contribution of bed height to fall risk. OBJECTIVE To compare lower extremity joint torques and angles during hospital bed entry and egress at two bed heights. METHODS Twelve adults (age > 55) were purposively selected and had variety of strength and mobility limitations. Biomechanical data for this pilot study were collected with three digital video cameras and processed to obtain estimates for joint torques and included angles. RESULTS At the low bed height, hip torque for bed entry was significantly higher, and hip, knee, and ankle flexion angles were significantly smaller. The absence of significant differences in knee and ankle torques were the result of a compensation strategy that shifts the center of mass forward by flexing the torso during low bed ingress. Torque data from the egress motion were similar, however 50% of participants were unable to rise from the low bed without assistance. CONCLUSIONS Healthcare providers should be aware that low bed heights pose safety risks to the population for which they were designed-elderly persons at high risk for falling.

Defeating information overload in health surveillance using a metacognitive aid innovation from military combat systems

Modern sensors for health surveillance generate high volumes and rates of data that currently overwhelm operational decision-makers. These data are collected with the intention of enabling front-line clinicians to make effective clinical judgments. Ironically, prior human–systems integration (HSI) studies show that the flood of data degrades rather than aids decision-making performance. Health surveillance operations can focus on aggregate changes to population health or on the status of individual people. In the case of clinical monitoring, medical device alarms currently create an information overload situation for front-line clinical workers, such as hospital nurses. Consequently, alarms are often missed or ignored, and an impending patient adverse event may not be recognized in time to prevent crisis. One innovation used to improve decision making in areas of data-rich environments is the Human Alerting and Interruption Logistics (HAIL) technology, which was originally sponsored by the US Office of Naval Research. HAIL delivers metacognitive HSI services that empower end-users to quickly triage interruptions and dynamically manage their multitasking. HAIL informed our development of an experimental prototype that provides a set of context-enabled alarm notification services (without automated alarm filtering) to support users’ metacognition for information triage. This application is called HAIL Clinical Alarm Triage (HAIL-CAT) and was designed and implemented on a smartwatch to support the mobile multitasking of hospital nurses. An empirical study was conducted in a 20-bed virtual hospital with high-fidelity patient simulators. Four teams of four registered nurses (16 in total) participated in a 180-minute simulated patient care scenario. Each nurse was assigned responsibility to care for five simulated patients and high rates of simulated health surveillance data were available from patient monitors, infusion pumps, and a call light system. Thirty alarms per nurse were generated in each 90-minute segment of the data collection sessions, only three of which were clinically important alarms. The within-subjects experimental design included a treatment condition where the nurses used HAIL-CAT on a smartwatch to triage and manage alarms and a control condition without the smartwatch. The results show that, when using the smartwatch, nurses responded three times faster to clinically important and actionable alarms. An analysis of nurse performance also shows no negative effects on their other duties. Subjective results show favorable opinions about utility, usability, training requirement, and adoptability. These positive findings suggest the potential for the HAIL HSI system to be transferrable to the domain of health surveillance to achieve the currently unrealized potential utility of high-volume data.

Cognitive Factors Associated with Nurses’ Successful Detection of Sepsis Versus Failure to Rescue

The objective of this study was to identify cognitive predictors of failure to rescue among acute care oncology nurses. Fifty-seven oncology nurses were video recorded as they monitored a patient developing a life threatening non-routine event in a high fidelity acute care hospital setting, in the case of this analysis– sepsis. Nurses who had higher levels of level 1 situation awareness (i.e., use limited data from the electronic health record and assessment findings) were more likely to detect sepsis and initiate an appropriate response. In the failure to rescue cases, the majority of errors occurred at the level of perception or level 1 situation awareness. Twenty percent of nurses who identified that the patient was septic, were not able to project the potential severity of the situation and apply appropriate interventions.

The Symbolic Functions of Nurses’ Cognitive Artifacts on a Medical Oncology Unit:

Acute care nurses continue to rely on personally created paper-based tools—their “paper brains”—to support work during a shift, although standardized handoff tools are recommended. This interpretive descriptive study examines the functions these paper brains serve beyond handoff in the medical oncology unit at a cancer specialty hospital. Thirteen medical oncology nurses were each shadowed for a single shift and interviewed afterward using a semistructured technique. Field notes, transcribed interviews, images of nurses’ paper brains, and analytic memos were inductively coded, and analysis revealed paper brains are symbols of patient and nurse identity. Caution is necessary when attempting to standardize nurses’ paper brains as nurses may be resistant to such changes due to their pride in constructing personal artifacts to support themselves and their patients.

Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms

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.

Microbiology Education in Nursing Practice

Nurses must have sufficient education and training in microbiology to perform many roles within clinical nursing practice (e.g., administering antibiotics, collecting specimens, preparing specimens for transport and delivery, educating patients and families, communicating results to the healthcare team, and developing care plans based on results of microbiology studies and patient immunological status). It is unclear whether the current microbiology courses required of nursing students in the United States focus on the topics that are most relevant to nursing practice. To gauge the relevance of current microbiology education to nursing practice, we created a confidential, web-based survey that asked nurses about their past microbiology education, the types of microbiology specimens they collect, their duties that require knowledge of microbiology, and how frequently they encounter infectious diseases in practice. We used the survey responses to develop data-driven recommendations for educators who teach microbiology to pre-nursing and nursing students. Two hundred ninety-six Registered Nurses (RNs) completed the survey. The topics they deemed most relevant to current practice were infection control, hospital-acquired infections, disease transmission, and collection and handling of patient specimens. Topics deemed least relevant were the Gram stain procedure and microscope use. In addition, RNs expressed little interest in molecular testing methods. This may reflect a gap in their understanding of the uses of these tests, which could be bridged in a microbiology course. We now have data in support of anecdotal evidence that nurses are most engaged when learning about microbiology topics that have the greatest impact on patient care. Information from this survey will be used to shift the focus of microbiology courses at our university to topics more relevant to nursing practice. Further, these findings may also support an effort to evolve national recommendations for microbiology education in pre-nursing and nursing curricula.