Heljä Lundgrén-Laine

Think-Aloud Technique and Protocol Analysis in Clinical Decision-Making Research

In this article, we aim to describe the practical aspects of research actions that should be taken into account when two methods—the think-aloud technique for data collection and protocol analysis as an analysis technique—are combined with research of decision making in acute clinical settings. These methods are rarely used together or written about in health care research. In addition, careful consideration of the pros and cons of study sampling, data collection, data management, and analysis techniques or approaches is still lacking when these methods are used in health care research. We discuss the background of the think-aloud technique and protocol analysis and review previous studies that have used these methods. The examples in the article are based on our study, in which we investigated the decision making of critical care experts. We find that the combination of the think-aloud technique and protocol analysis is applicable when investigating complex and overlapping decision-making processes and rapid, ad hoc decisions made by critical care experts.

Managing daily intensive care activities: An observational study concerning ad hoc decision making of charge nurses and intensivists

IntroductionManagement of daily activities in ICUs is challenging. ICU shift leaders, charge nurses and intensivists have to make several immediate ad hoc decisions to enable the fluent flow of ICU activities. Even though the management of ICU activities is quite well delineated by international consensus guidelines, we know only a little about the content of the real clinical decision making of ICU shift leaders.MethodsWe conducted an observational study with the think-aloud technique to describe the ad hoc decision making of ICU shift leaders. The study was performed in two university-affiliated hospital ICUs. Twelve charge nurses and eight intensivists were recruited. Observations were recorded and transcribed for qualitative content analysis using the protocol analysis method. The software program NVivo 7 was used to manage the data. The interrater agreement was assessed with percentages and by Cohens κ.ResultsWe identified 463 ad hoc decisions made by the charge nurses and 444 made by the intensivists. During our data collection time, this breaks down to over 230 immediately made decisions per day (24 hours). We divided the ad hoc decision making of ICU shift leaders into two types: process-focused and situation-focused. Process-focused decision making included more permanent information, such as human resources, know-how and material resources, whereas situation-focused decision making included decisions about single events, such as patient admission. We named eight different categories for ICU ad hoc decision making: (1) adverse events, (2) diagnostics, (3) human resources and know-how, (4) material resources, (5) patient admission, (6) patient discharge, (7) patient information and vital signs and (8) special treatments.ConclusionsICU shift leaders make a great number of complex ad hoc decisions throughout the day. Often this decision making involves both intensivists and charge nurses. It forms a bundle that requires versatile, immediate information for a successful outcome. In the future, we need to investigate which information is crucial for ad hoc decision making. These challenges should also be emphasised when information technology programs for ICU care management are developed.

Characteristics of Finnish and Swedish intensive care nursing narratives: a comparative analysis to support the development of clinical language technologies

BackgroundFree text is helpful for entering information into electronic health records, but reusing it is a challenge. The need for language technology for processing Finnish and Swedish healthcare text is therefore evident; however, Finnish and Swedish are linguistically very dissimilar. In this paper we present a comparison of characteristics in Finnish and Swedish free-text nursing narratives from intensive care. This creates a framework for characterising and comparing clinical text and lays the groundwork for developing clinical language technologies.MethodsOur material included daily nursing narratives from one intensive care unit in Finland and one in Sweden. Inclusion criteria for patients were an inpatient period of least five days and an age of at least 16 years. We performed a comparative analysis as part of a collaborative effort between Finnish- and Swedish-speaking healthcare and language technology professionals that included both qualitative and quantitative aspects. The qualitative analysis addressed the content and structure of three average-sized health records from each country. In the quantitative analysis 514 Finnish and 379 Swedish health records were studied using various language technology tools.ResultsAlthough the two languages are not closely related, nursing narratives in Finland and Sweden had many properties in common. Both made use of specialised jargon and their content was very similar. However, many of these characteristics were challenging regarding development of language technology to support producing and using clinical documentation.ConclusionsThe way Finnish and Swedish intensive care nursing was documented, was not country or language dependent, but shared a common context, principles and structural features and even similar vocabulary elements. Technology solutions are therefore likely to be applicable to a wider range of natural languages, but they need linguistic tailoring.AvailabilityThe Finnish and Swedish data can be found at: http://www.dsv.su.se/hexanord/data/.

National survey focusing on the crucial information needs of intensive care charge nurses and intensivists: same goal, different demands

BackgroundAlthough information technology adequately supports clinical care in many intensive care units (ICUs), it provides much poorer support for the managerial information needed to coordinate multi-professional care. To gain a general view of the most crucial multi-professional information needs of ICU shift leaders a national survey was conducted, focusing on the information needs of charge nurses and intensivists.MethodsBased on our previous observation study an online survey was developed, containing 122 information need statements related to the decision-making of ICU shift leaders. Information need statements were divided into six dimensions: patient admission, organisation and management of work, allocation of staff and material resources, special treatments, and patient discharge. This survey involved all ICU shift leaders (n = 738) who worked in any of the 17 highest level ICUs for adults in university hospitals in Finland during the autumn of 2009. Both charge nurses’ and intensivists’ crucial information needs for care coordination were evaluated.ResultsTwo hundred and fifty-seven (50%) charge nurses and 96 (43%) intensivists responded to the survey. The consistency of the survey was found to be good (Cronbach’s α scores between .87–.97, with a total explanatory power of 64.53%). Altogether, 57 crucial information needs for care coordination were found; 22 of which were shared between shift leaders. The most crucial of these information needs were related to organisation and management, patient admission, and allocation of staff resources. The associations between working experience, or shift leader acting frequencies, and crucial information needs were not statistically significant. However, a statistically significant difference was found between the number of ICU beds and the ICU experience of charge nurses with information needs, under the dimension of organisation and management of work. The information needs of charge nurses and intensivists differed. Charge nurses’ information needs related to care coordination, were more varied, and concerned issues at a unit level, whereas intensivists focused on direct patient care.ConclusionsThe reliability and validity of our survey was found to be good. Our study findings show that care coordination at an ICU is a collaborative process among ICU shift leaders with multiprofessional information needs related to organisation and management, patient admission, and allocation of staff resources. Study findings can be used to identify the most crucial information needs of ICU shift leaders when new information technology is developed to support managerial decision-making during care coordination.

Information utilization in tactical decision making of middle management health managers.

Healthcare is an information-intensive field, as information is needed to make strategic, tactical, and operational decisions. The purpose of this study was to identify the tactical decisions that middle management healthcare managers make, the information that is available, and the necessary information that is missing using the cardiac care process as an example. Data were collected through focused interviews of nurses and physicians who work in middle management in a secondary healthcare field. The interviews were coded and analyzed using the thematic content analysis method. We identified two main categories of tactical decisions: those concerning the process of care and those concerning the resources for the care. We termed the categories “process decisions” and “resource decisions.” The availability of information varied. Much of the necessary information was created and processed manually. Our results show that the collection, mining, and systematic use of information are difficult because of the existence of many types of information systems and their varying abilities to produce and report information. Finally, much of the important information is missing. In conclusion, the information management process in healthcare settings needs to be improved, and a new generation of information system is needed to support tactical decision making in middle management.

Information flow in intensive care narratives

Fluent patient information flow is a prerequisite for clinical decision making. Our purpose is to identify unmet information needs in the flow of Finnish intensive care narratives in order to focus the development of natural language processing methods for this domain. Our data set consists of 516 authentic electronic patient records. First, we assess statistically the amount of narratives. We find that the amount is substantial: elective admission type and high nursing intensity contribute this. Second, we perform a content analysis. We observe that notes relevant for a given topic are scattered over the narratives, headings are inconsistent, and the flow from earlier narratives is fragmented. Consequently, support for gaining topical overviews is needed. Meeting this clinical need holds the promise of making narratives better accessible throughout a patients stay and thereby improving clinical decision making and outcomes of care.

Critical incidents and important information in the care processes of patients with cardiac symptoms

AIM To describe important information in the care processes of patients with cardiac symptoms. BACKGROUND Process-based work-flow models are increasingly being used in healthcare. At the same time, developments in information systems offer the possibility of supporting improvements in process and information management in healthcare. To better utilize these possibilities we need to understand more about important information content and flow during treatment processes. METHOD A qualitative approach involving the critical incident technique was used. Critical incidents were collected using a semi-structured questionnaire (50 respondents) and interviews (n=10). RESULTS Three incident categories of important information were identified: (1) process-related incidents, (2) managerial incidents and (3) clinical incidents. Process-related incidents focused on agreed-care practices and the importance of the care environment. Managerial incidents focused on human and material resources. Clinical incidents focused on medical and nursing care and the importance of patient education. CONCLUSIONS Information content, information flow and the timing of such information should be modelled further in order to improve the management of care processes. IMPLICATIONS FOR NURSING MANAGEMENT Increasing knowledge about essential points of information as part of nursing management is important.

Information Management Efforts in Improving Patient Safety in Critical Care - A Review of the Literature

Patient safety is the responsibility of all professionals involved in the provision of health care services. The risk of harm is increased in the critical care setting due to complex care needs and frequent procedures. Information management is a contributing factor to a large number of incidents in the critical care setting. The aim of this study was to explore the current research of efforts in improving patient safety in the critical care environment. An integrative literature review was conducted and four databases (Cinahl, Pubmed, Scopus, and Web of Science) were searched. A total of 19 articles were included in the review. A theoretical framework of information management in decision-making in hospitals was used to guide the analysis. The results indicate that most research from a patient safety perspective focuses on means to improve information management on clinical level decision-making and that managerial information management remains vaguely explored.

Governance of Managerial Information Needed by Nurse Managers in Hospitals – A Literature Review

Information technology has a great impact on efficiency and effectiveness in health care organizations. Software solutions are used not only to manage organization revenues and expenses but also for managing functions and activities when patient care is coordinated. Managerial decision making may concern strategic, tactical and operational levels. Different kinds of information related to care coordination is needed by the hospital nurse managers every day. A literature review was made to explore information systems used by nurse managers in hospitals for information needed in tactical decision making.

Information Management in the Daily Care Coordination in the Intensive Care Unit

This study aimed to explore intensive care shift leaders’ daily care coordination related information needs and sources of important information. Information needs were explored with a survey and sources of important information were determined through interviews. The survey response rate was 21 % (n = 20) and nine shift leaders were interviewed. The findings are that charge nurses and physicians in charge have different responsibilities and differing information needs, though, some managerial activities and information needs are shared. Shift leaders use numerous sources to obtain necessary information to support decision-making. Sources were categorized into electronic sources, human sources, manual sources and real-time events. Further, information was located within or outside the ICU or based on the shift leader’s knowledge. Information systems should be developed based on shift leaders’ information needs regardless of the source to support daily care coordination related decision-making. Shift leaders could further benefit from a real-time hospital-wide shared situational awareness.