Anne Miller

Uni- and Interdisciplinary Effects on Round and Handover Content in Intensive Care Units

Objective: The aim of this study was to explore differences in the verbal content of handovers and rounds conducted in uni- and interdisciplinary social contexts. We expected higher proportions of goals to be articulated during interdisciplinary rounds. Background: Lack of explanatory connections between round improvement initiatives and outcomes suggest insufficient understanding about health care communications, especially the role of social interaction. Methods: The recognition-primed abstract decomposition space (RP-ADS) was used to analyze the information content of nurse handovers and morning rounds in a unidisciplinary- (physicians only) and an interdisciplinary-round intensive care unit (ICU). Data were collected using audio recordings of rounds and handovers for five patients for 5 days each in both ICUs. Results: Hierarchical log-linear analyses show strong associations between events (medical rounds vs. nurses’ shift handovers), type (uni- vs. interdisciplinary), and focus (levels of the RP-ADS) with highly significant combined two-way and higher-order interactions, LRχ2(df = 4) = 30.91, p < .0001. All tests of partial association were also highly significant. Differences among levels of the variables were evaluated using standardized residuals. Conclusion: Nurses focused on RP-ADS data and intervention levels, whereas physicians focused on diagnoses and expectations. Clinical goals that integrate these orientations emerged to a greater extent in interdisciplinary rounds. In addition, social context of rounds appears to influence nurse handovers. Unidisciplinary ICU nurse handovers consisted of a series of data-and intervention-related observations, whereas ICU nurse handovers in interdisciplinary ICUs tended to integrate data, interventions and clinical goals. Application: These results are relevant to the design and implementation of clinical communication improvement initiatives and support tools.

Care Coordination in Intensive Care Units: Communicating Across Information Spaces

Objective: This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs). Background: The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination. Method: Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs). Results: Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, χ2(df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, χ2(df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, χ2(df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals. Conclusion: ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies. Application: The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.

Preface to the Special Section on Methods for the Analysis of Communication

Communication is a ubiquitous behavior of dyads, groups, teams, and organizations. It is one of the primary vehicles for group interaction, and thus, communication data provide a rich record of interaction processes. When the group or team is engaged in a cognitive task (versus a physical one), its communication reveals cognitive processing at the group or team level (Cooke, Gorman, & Rowe, 2009; Cooke, Gorman, & Winner, 2007). In fact, communication can be likened to a group-level think-aloud. However, in this case, the verbal protocol does not have to be elicited; it occurs naturally, “in the wild.” In this special section of Human Factors, the term communication analysis is used broadly to include a number of specific types of analyses that are based on different characteristics of communication (e.g., some are analyses of words; some of voice; and some are analyses of interactions among people). Broadly defined, communication analysis enables us to study cognitive processes that operate at the system level, including sociotechnical systems (e.g., Cooke, Gorman, & Kiekel, 2008). Whereas discrete laboratory trials (e.g., stimulus-process-response methods) may be appropriate for understanding isolated cognitive phenomena, cognitive processes that depend on more complex and distributed human– human, human–machine, and temporal relations (e.g., teams and other divided labor systems) are not directly observable with traditional laboratory measures, such as error rate and response time. Communication analysis fills this gap by allowing us to directly observe cognition as the human–human and human–machine interactions unfold temporally. Data derived from communication studies provide an excellent resource for understanding the propagation of peoples’ reasoning and decision making in complex task environments. Communication analysis, for example, can help uncover “resident pathogens” (Reason, 1990) that may lead to human error in complex environments. Accordingly, communication analysis can produce results that have implications for assessment, training, and the design of complex sociotechnical systems. Although there are social and ethical concerns that need to be addressed in using such analyses in the workplace (McCormack, Duchon, Geyer, & Orvis, 2009), the potential to improve team and organizational performance through the use of such analyses is great. However, to understand how to improve performance, we must first understand what aspects of performance are captured by communication data.

Blood product positive patient identification: comparative simulation-based usability test of two commercial products.

BACKGROUND: The blood product administration process has been subject to various quality improvement initiatives aimed at reducing errors, including blood product labels that are missing, inaccessible, unreadable, or mismatched to orders and/or patients. This article reports the results of a formal simulation‐based usability test of two comparable technologies designed to reduce blood product administration errors.

Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration

Introduction: Human factors workflow analyses in healthcare settings prior to technology implemented are recommended to improve workflow in ambulatory care settings. In this paper we describe how insights from a workflow analysis conducted by NIST were implemented in a software prototype developed for a Veteran’s Health Administration (VHA) VAi2 innovation project and associated lessons learned. Methods: We organize the original recommendations and associated stages and steps visualized in process maps from NIST and the VA’s lessons learned from implementing the recommendations in the VAi2 prototype according to four stages: 1) before the patient visit, 2) during the visit, 3) discharge, and 4) visit documentation. NIST recommendations to improve workflow in ambulatory care (outpatient) settings and process map representations were based on reflective statements collected during one-hour discussions with three physicians. The development of the VAi2 prototype was conducted initially independently from the NIST recommendations, but at a midpoint in the process development, all of the implementation elements were compared with the NIST recommendations and lessons learned were documented. Findings: Story-based displays and templates with default preliminary order sets were used to support scheduling, time-critical notifications, drafting medication orders, and supporting a diagnosis-based workflow. These templates enabled customization to the level of diagnostic uncertainty. Functionality was designed to support cooperative work across interdisciplinary team members, including shared documentation sessions with tracking of text modifications, medication lists, and patient education features. Displays were customized to the role and included access for consultants and site-defined educator teams. Discussion: Workflow, usability, and patient safety can be enhanced through clinician-centered design of electronic health records. The lessons learned from implementing NIST recommendations to improve workflow in ambulatory care using an EHR provide a first step in moving from a billing-centered perspective on how to maintain accurate, comprehensive, and up-to-date information about a group of patients to a clinician-centered perspective. These recommendations point the way towards a “patient visit management system,” which incorporates broader notions of supporting workload management, supporting flexible flow of patients and tasks, enabling accountable distributed work across members of the clinical team, and supporting dynamic tracking of steps in tasks that have longer time distributions.

Discussion panel giving human factors/ergonomics away: How can we bring the benefits of HF/E to nursing?

Patients spend the most time with nurses compared with other health care providers, and patient outcomes are directly related to the quality of nursing care. Unfortunately, nursing work systems are often not designed to accommodate the limits and capabilities of perceptual, cognitive, and physical processes, which can result in errors. The Institute of Medicine estimated that hospital patients experience one medication error each day. Increasingly, technology is relied upon to reduce errors and improve work efficiency. However, new technologies can lead to unintended consequences. Applying principles of human factors and ergonomics (HF/E) to improve nursing work systems and the technologies nurses use has the potential for significant improvements in the quality of patient care. Incorporating HF/E into the nursing domain presents challenges. Conducting research in the nursing environment poses unique logistical issues, and implementing HF/E recommendations requires that nursing personnel accept HF/E as beneficial. The purpose of this panel session is to discuss issues that HF/E professionals encounter when they attempt to incorporate HF/E into the nursing domain. The panelists will summarize the work that they have done with nurses and describe challenges and successes. The panel will invite the audience to discuss ways to address challenges, increase successes, and identify lessons learned in other domains that may benefit nursing.

Work artifacts as a reflection of change in Intensive Care Units

The demands of hospital patients are changing to the extent that adaptive changes in workflow or practice are becoming more evident. This paper presents a set of locally designed paper-based tools that are physical manifestations of responses to change, and that provide suggestions for health information technology design. Fifteen nurses were ‘shadowed’ during their shift handover and during the morning interdisciplinary round. Three paper-based tools with the context and reasons for their use are described as are potential vulnerabilities. Suggestions for improvement are made.