Katherine D. Lippa

Everyday Expertise: Cognitive Demands in Diabetes Self-Management

Objective: To assess the relationship between decision making and successful diabetes self-management. Background: Patients with type II diabetes make routine but critical self-management decisions. Method: We conducted cognitive task analysis interviews with 18 patients to examine problem detection, functional relationships, problem-solving strategies, and types of knowledge used to make self-management decisions. We expected that these decision processes would be related to behavioral adherence and glycemic control. Results: Verbal reports displaying problem detection skills, knowledge of functional relationships, and effective problem-solving strategies were all related to better adherence. Problem detection skill was linked to greater glycemic control. Participants differed in declarative and applied knowledge. Conclusion: Diabetes self-management draws on the same cognitive skills found in experts from diverse professional domains. Considering diabetes self-management as a form of expertise may support adherence. Application: Human factors approaches that support professional expertise may be useful for the decision making of patients with diabetes and other chronic diseases.

Type 2 Diabetes Self-Management: Controlling a Dynamic System

People with type 2 diabetes risk disability and early death when they fail to control their blood glucose levels. Despite advances in medicine, pharmacology, human factors, and education, dangerous glucose levels remain endemic. To investigate cognitive barriers to control, we observed American Diabetes Association (ADA) certified training programs; reviewed ADA and National Institute of Health diabetes Web sites; and interviewed patients with type 2 diabetes using a critical decision method. A consistent picture emerged. The prevailing rules and procedures approaches are not preparing patients for the dynamic control task they face. Patients are often unable to understand and use the rules and procedures provided. They are unprepared to detect problems, make sense of dynamic relationships, and manage complex situations. Our results suggest that glucose self-regulation is better conceptualized as a dynamic control challenge requiring complex processes, including problem detection, sensemaking, decision making, and planning/replanning. The mismatch between most patient training and the dynamic demands of glucose regulation helps explain limitations in existing training and poor patient outcomes. We argue that constructs gleaned from naturalistic decision-making research in other complex domains can help many but not all patients develop the cognition necessary for effective blood glucose self-management.

Calling 911: emergency medical services in need of human factors

Emergency medical services (EMS) play an important role in community health care systems. Paramedics provide basic life support, deliver babies, and transport critical patients to the hospital, among other services. We observed EMS units in action to learn about their underlying human factors/ergonomics (HF/E) and found that equipment and organizational systems were often difficult to use or poorly suited to task demands. Although HF/E professionals have the knowledge and tools to improve patient safety and occupational health, HF/E research on EMS is scarce. Our observations provide a systems overview pointing to needed improvements in equipment, decision making, and organizational coordination.

Assuming control after system failure: type II diabetes self-management

Type II diabetes occurs when the body’s natural blood glucose regulatory system breaks down. Elevated blood glucose can lead to disabilities, early deaths, and enormous societal expense. While medical and pharmacological science offers powerful approaches for controlling blood glucose levels and ameliorating dangerous consequences, the patient must make most critical day-to-day decisions. Diabetes self-management education is widespread and typically depends on training rules and procedures. Our research identified a pervasive gap between existing educational programs and the real, dynamic challenges that patients face. While simple, well-defined tasks can be managed with rules and procedures, dynamics ones require much more. We describe glucose level management as analogous to the regulation of other complex systems. Patients must control their diet and exercise to achieve a safe blood glucose level and must use physiological feedback and blood glucose monitoring to make corrections when facing illness, stress, or other difficulties. Our research demonstrated that people who had adopted a control model were more likely to maintain healthy blood glucose levels. They had better understanding of diagnostic tools and were able to use the information provided to maintain healthy blood glucose levels. Patients, like others who must control complex systems, are most resilient when they can detect problems, identify problem sources, monitor and interpret outcomes, and generate plausible management plans. While not all people will be able to use this approach, this study suggests that it can assist many people in managing their Type II diabetes.

Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

How Patients Understand Diabetes Self-Care

Millions of people with diabetes must control their blood glucose system through diet, medication, and exercise. To learn how patients understand this daunting task, we conducted Cognitive Task Analysis interviews with 20 participants with type II diabetes. The interviews queried initial education, experiences with self-care, understanding of the disease, and treatment adherence. Participants who showed greater expertise in their articulation of problem detection strategies, functional relationships, and problem solving strategies were more effective self-managers. Several mental models of diabetes self-management were identified. Human Factors advances that have helped pilots control planes, may also help patients to develop functional models of blood glucose control and cope with the complexities of self-care. These advances may also help people facing other chronic medical conditions and complex life challenges.

Making ‘Human Factors’ Truly Human: Cultural Considerations in Human Factors Research and Practice

Traditionally, human factors research has been conducted in Western nations to answer the questions of Western practitioners. This approach was appropriate in the past and still works well in many situations. However, as the world of work is becoming more international it is important to consider how national differences affect human factors applications. We review recent issues of the Human Factors journal to see how cultural differences are being addressed in research. Five domains where important cultural difference may influence research findings are reviewed. These areas are physical design, visual displays, symbolic communication, information technology and managing complex processes. We present recommendations for incorporating greater cultural variation into Ergonomic and Human Factors work.