Emily S. Patterson

Understanding the complexity of registered nurse work in acute care settings.

Nursing shortages and patient safety mandates require nursing managers and administrators to consider new ways of understanding the complexity of healthcare provider work in actual situations. The authors report findings from a study guided by an innovative research approach to explore factors affecting registered nurse performance during real work on acute care medical-surgical units. Our findings suggest beginning targets for interventions to improve patient safety, as well as recruitment and retention, through support for registered nurse work.

Exploring Barriers and Facilitators to the Use of Computerized Clinical Reminders

OBJECTIVE Evidence-based practices in preventive care and chronic disease management are inconsistently implemented. Computerized clinical reminders (CRs) can improve compliance with these practices in outpatient settings. However, since clinician adherence to CR recommendations is quite variable and declines over time, we conducted observations to determine barriers and facilitators to the effective use of CRs. DESIGN We conducted an observational study of nurses and providers interacting with CRs in outpatient primary care clinics for two days in each of four geographically distributed Veterans Administration (VA) medical centers. MEASUREMENTS Three observers recorded interactions of 35 nurses and 55 physicians and mid-level practitioners with the CRs, which function as part of an electronic medical record. Field notes were typed, coded in a spreadsheet, and then sorted into logical categories. We then integrated findings across observations into meaningful patterns and abstracted the data into themes, such as recurrent strategies. Several of these themes translated directly to barriers and facilitators to effective CR use. RESULTS Optimally using the CR system for its intended purpose was impeded by (1) lack of coordination between nurses and providers; (2) using the reminders while not with the patient, impairing data acquisition and/or implementation of recommended actions; (3) workload; (4) lack of CR flexibility; and (5) poor interface usability. Facilitators included (1) limiting the number of reminders at a site; (2) strategic location of the computer workstations; (3) integration of reminders into workflow; and (4) the ability to document system problems and receive prompt administrator feedback. CONCLUSION We identified barriers that might explain some of the variability in the use of CRs. Although these barriers may be difficult to overcome, some strategies may increase user acceptance and therefore the effectiveness of the CRs. These include explicitly assigning responsibility for each CR to nurses or providers, improving visibility of positive results from CRs in the electronic medical record, creating a feedback mechanism about CR use, and limiting the overall number of CRs.

Can we ever escape from data overload? A cognitive systems diagnosis

Abstract: Data overload is a generic and tremendously difficult problem that has only grown with each new wave of technological capabilities. As a generic and persistent problem, three observations are in need of explanation: Why is data overload so difficult to address? Why has each wave of technology exacerbated, rather than resolved, data overload? How are people, as adaptive responsible agents in context, able to cope with the challenge of data overload? In this paper, first we examine three different characterisations that have been offered to capture the nature of the data overload problem and how they lead to different proposed solutions. As a result, we propose that (a) data overload is difficult because of the context sensitivity problem – meaning lies, not in data, but in relationships of data to interests and expectations and (b) new waves of technology exacerbate data overload when they ignore or try to finesse context sensitivity. The paper then summarises the mechanisms of human perception and cognition that enable people to focus on the relevant subset of the available data despite the fact that what is interesting depends on context. By focusing attention on the root issues that make data overload a difficult problem and on people’s fundamental competence, we have identified a set of constraints that all potential solutions must meet. Notable among these constraints is the idea that organisation precedes selectivity. These constraints point toward regions of the solution space that have been little explored. In order to place data in context, designers need to display data in a conceptual space that depicts the relationships, events and contrasts that are informative in a field of practice.

Improving Handoffs in the Emergency Department

Patient handoffs at shift change are a ubiquitous and potentially hazardous process in emergency care. As crowding and lengthy evaluations become the standard for an increasing proportion of emergency departments (EDs), the number of patients handed off will likely increase. It is critical now more than ever before to ensure that handoffs supply valid and useful shared understandings between providers at transitions of care. The purpose of this article is to provide the most up-to-date evidence and collective thinking about the process and safety of handoffs between physicians in the ED. It offers perspectives from other disciplines, provides a conceptual framework for handoffs, and categorizes models of existing practices. Legal and risk management issues are also addressed. A proposal for the development of handoff quality measures is outlined. Practical strategies are suggested to improve ED handoffs. Finally, a research agenda is proposed to provide a roadmap to future work that may increase knowledge in this area.

Themes Surrounding Novice Nurse Near- Miss and Adverse-Event Situations

Objective: The study purpose was to identify human performance factors that characterized novice nurse near-miss/adverse-event situations in acute-care settings. Background: Increased focus on recruitment and retention of newly graduated registered nurses (RNs) in light of patient safety improvement goals will challenge healthcare educators and administrators. What we are beginning to learn about human performance issues during real work situations from patient safety research provides information related to human performance in complex environments that may guide education and system supports for novice RNs. Methods: Data collected during 8 retrospective interviews of novice RNs about details surrounding their individual near-miss or adverse event were analyzed for common themes. Results: Nine themes were identified. Seven themes were present in at least 7 of the 8 cases and included environmental and social issues, as well as novice lack of expertise. Conclusions: Findings suggest that support for novice nurses in acute care environments requires attention to the following: consistent availability of expertise in light of workload unpredictability, the social climate regarding expectations of novice performers, realistic expectations of novice decision-making ability during complex situations even up to a year after graduation, and strategies to recognize and intervene when novices are at risk for error.

Compliance With Intended Use of Bar Code Medication Administration in Acute and Long-Term Care: An Observational Study

Objective: To identify the types and extent of workaround strategies with the use of Bar Code Medication Administration (BCMA) in acute care and long-term care settings. Background: Medication errors are the most commonly documented cause of adverse events in hospital settings. Scanning of bar codes to verify patient and medication information may reduce medication errors. Method: A prospective ethnographic study was conducted using targeted observation. Fifteen acute care and 13 long-term care nurses were directly observed during medication administration at small, medium, and large Veterans Administration hospitals to detect workaround strategies. Results: Noncompliance with recommended practices was observed in all settings and facilities. A larger proportion of acute care nurses than long-term care nurses scanned bar-coded wristbands to identify patients (53% vs. 8%, p = .016). A larger proportion of acute care nurses than long-term care nurses administered barcoded medications immediately after scanning (93% vs. 23%, p < .001). Conclusion: Workaround strategies were employed with BCMA that increased efficiency but created new potential paths to adverse events. There was a significant difference in the rate of use of workaround strategies between acute and long-term care. Application: The extent of workaround strategies varied by care setting and facility. BCMA should be tailored to the long-term care setting, including increasing the efficiency of use. Hospitals implementing bar coding should facilitate the intended use through equipment procurement, implementation, and quality improvement strategies.

Voice Loops as Coordination Aids in Space ShuttleMission Control

Voice loops, an auditory groupware technology, are essential coordination support tools for experienced practitioners in domains such as air traffic management, aircraft carrier operations and space shuttle mission control. They support synchronous communication on multiple channels among groups of people who are spatially distributed. In this paper, we suggest reasons for why the voice loop system is a successful medium for supporting coordination in space shuttle mission control based on over 130 hours of direct observation. Voice loops allow practitioners to listen in on relevant communications without disrupting their own activities or the activities of others. In addition, the voice loop system is structured around the mission control organization, and therefore directly supports the demands of the domain. By understanding how voice loops meet the particular demands of the mission control environment, insight can be gained for the design of groupware tools to support cooperative activity in other event-driven domains.

Human Factors Barriers to the Effective Use of Ten HIV Clinical Reminders

OBJECTIVE Substantial variations in adherence to guidelines for human immunodeficiency virus (HIV) care have been documented. To evaluate their effectiveness in improving quality of care, ten computerized clinical reminders (CRs) were implemented at two pilot and eight study sites. The aim of this study was to identify human factors barriers to the use of these CRs. DESIGN Observational study was conducted of CRs in use at eight outpatient clinics for one day each and semistructured interviews were conducted with physicians, pharmacists, nurses, and case managers. MEASUREMENTS Detailed handwritten field notes of interpretations and actions using the CRs and responses to interview questions were used for measurement. RESULTS Barriers present at more than one site were (1) workload during patient visits (8 of 8 sites), (2) time to document when a CR was not clinically relevant (8 of 8 sites), (3) inapplicability of the CR due to context-specific reasons (9 of 26 patients), (4) limited training on how to use the CR software for rotating staff (5 of 8 sites) and permanent staff (3 of 8 sites), (5) perceived reduction of quality of provider-patient interaction (3 of 23 permanent staff), and (6) the decision to use paper forms to enable review of resident physician orders prior to order entry (2 of 8 sites). CONCLUSION Six human factors barriers to the use of HIV CRs were identified. Reducing these barriers has the potential to increase use of the CRs and thereby improve the quality of HIV care.

Collaborative cross-checking to enhance resilience

Resilience, the ability to adapt or absorb disturbance, disruption, and change, may be increased by team processes in a complex, socio-technical system. In particular, collaborative cross-checking is a strategy where at least two individuals or groups with different perspectives examine the others’ assumptions and/or actions to assess validity or accuracy. With this strategy, erroneous assessments or actions can be detected quickly enough to mitigate or eliminate negative consequences. In this paper, we seek to add to the understanding of the elements that are needed in effective cross-checking and the limitations of the strategy. We define collaborative cross-checking, describe in detail three healthcare incidents where collaborative cross-checks played a key role, and discuss the implications of emerging patterns.

Predicting Vulnerabilities in Computer- Supported Inferential Analysis under Data Overload

Abstract: Data overload is a condition where a practitioner, supported by artefacts and other practitioners, finds it extremely challenging to focus in on, assemble and synthesise the significant subset of data for the problem context into a coherent situation assessment, where the subset is a small portion of a vast data field. In order to predict vulnerabilities in intelligence analysis that might arise when traditional strategies for coping with data overload are undermined, we conducted an observational study in a simulated setting. Ten professional intelligence analysts analysed the causes and impacts of the Ariane 501 accident. When study participants performed a time-pressured analysis outside their base of expertise based on sampling reports from a large set, some made inaccurate statements in verbal briefings. Participants that made no inaccurate statements spent more time during the analysis, read more documents, and relied on higher-quality documents than participants who made inaccurate statements. All participants missed potentially available relevant information and had difficulty detecting and resolving data conflicts. Sources of inaccurate statements were: (1) relying upon default assumptions, (2) incorporating inaccurate information and (3) incorporating information that was considered accurate at one point in time. These findings have design implications and point to evaluation criteria for systems designed to address the data overload problem in intelligence analysis.