Robin S. Mickelson

Performance barriers among elderly chronic heart failure patients An application of patient-engaged human factors and ergonomics

Applications of the human factors and ergonomics (HFE) approach in the healthcare domain have largely targeted the work of healthcare professionals. Here, we argue for the importance of targeting the work of patients and their lay caregivers, a relatively underdeveloped approach we call patient-engaged HFE. A multi-method study of the barriers to the self-care work of elderly chronic heart failure patients (N=27) and caregivers (N=11) illustrates the approach. Analyses of interview data using a macroergonomic Work System framework revealed a large variety of barriers unique to patient work as well as to CHF self-care. The most common person-related barriers were physical limitations and knowledge gaps. Task-related barriers included medication complexity and side-effects. Tool and technology barriers included lack of or overdependence on aids. Context barriers were organizational (e.g., no indoor gyms), social (e.g., sodiumrich food culture), and physical-environmental (e.g., stairs). Findings motivate further applying HFE concepts and methods (e.g., workload, decision support, distributed cognition, resilience) to patient work.

Assessing the distributed nature of home-based heart failure medication management in older adults

Non-adherence to medications in older adult chronic heart failure (CHF) patients suggests the difficulty these patients experience with medication management tasks. This qualitative study explored home-based medication management and how activities were distributed across persons, artifacts, time and space using a distributed cognition framework. Interviews with CHF patients (N = 27) and their informal caregivers (N=11) were content analyzed for cross-cutting themes about distributed task performance. Results illustrated problem areas within this distributed system such as representational discordance, communication difficulties, and lack of portability of information across environments. Implications for future design of interventions include the need for portability and exchange of information, portability of medications and reminder devices, and improved communication across the distributed system.

Patient Work as a Maturing Approach Within HF/E Moving Beyond Traditional Self-Management Applications

Over the last five years, human factors and ergonomics (HF/E) applications in healthcare have expanded beyond the institution to encompass the homes and communities of patients. The patient work approach has been developed as a means of formalizing the theoretical and methodological foundations of applying HF/E within this new domain. Early applications of the patient work approach were confined to studies of relatively straightforward self-management tasks. As the patient work approach matures, however, its application is spreading to more complex subdomains of health management in home and community settings. This panel will focus on cutting edge application and methodological areas of patient work. Each panelist will introduce their work, present challenges related to expanding the patient work approach in a new direction, and engage with audience members to address these challenges and brainstorm ways in which the patient work approach can be further adapted to more intricate healthcare challenges.

Mind the gulfs An analysis of medication-related cognitive artifacts used by older adults with heart failure

Medication management is a patient health-related activity characterized by poor performance in older adults with chronic disease. Interventions focus on educating and motivating the patient with limited long-term effects. Cognitive artifacts facilitate cognitive tasks by making them easier, faster, and more effective and can potentially improve medication management performance. This study examined how older adult patients with heart failure use cognitive artifacts and how representational structure and physical properties facilitated or impeded medication-related tasks and processes. Interview, observation, medical record, and photographic data of and about older patients with heart failure (N = 30) and their informal caregivers (N=14) were content analyzed for cross-cutting themes about patient goals, representations, and actions. Results illustrated patient artifacts designed from a clinical rather than patient perspective, disparate internal and external representations threatening safety, and incomplete information exchange between patients and clinicians. Implications for design were the need for bridging artifacts, automatic information transfer, and cognitive artifacts designed from the perspective of the patient.

Medication management strategies used by older adults with heart failure: A systems-based analysis

Background: Older adults with heart failure use strategies to cope with the constraining barriers impeding medication management. Strategies are behavioral adaptations that allow goal achievement despite these constraining conditions. When strategies do not exist, are ineffective or maladaptive, medication performance and health outcomes are at risk. While constraints to medication adherence are described in literature, strategies used by patients to manage medications are less well-described or understood. Aim: Guided by cognitive engineering concepts, the aim of this study was to describe and analyze the strategies used by older adults with heart failure to achieve their medication management goals. Methods: This mixed methods study employed an empirical strategies analysis method to elicit medication management strategies used by older adults with heart failure. Observation and interview data collected from 61 older adults with heart failure and 31 caregivers were analyzed using qualitative content analysis to derive categories, patterns and themes within and across cases. Results: Data derived thematic sub-categories described planned and ad hoc methods of strategic adaptations. Stable strategies proactively adjusted the medication management process, environment, or the patients themselves. Patients applied situational strategies (planned or ad hoc) to irregular or unexpected situations. Medication non-adherence was a strategy employed when life goals conflicted with medication adherence. The health system was a source of constraints without providing commensurate strategies. Conclusions: Patients strived to control their medication system and achieve goals using adaptive strategies. Future patient self-mangement research can benefit from methods and theories used to study professional work, such as strategies analysis.

Capturing the Medication Management Work System of Older Adults Using a Digital Diary Method

Human Factors and Ergonomics (HFE) has the potential to transform the lives of older adults by helping them better manage their health and disease. Older adults are often beset with multiple chronic illnesses and struggle to manage complex medication regimens. Non-adherence, errors, and poor outcomes are common. New research shows that patients’ health-related activities constitute an effortful, goal-driven type of work called patient work. HFE can play a major role in the study and improvement of patient work performance but current HFE methods are not fully suitable. This is in part because patient work is variable and takes place in home and community settings dissimilar to those commonly studied by healthcare HFE researchers. The objective of this study was to perform a work systems analysis of the medication management work of older adults with heart failure by adapting a method more suitable for the study of patient work. This qualitative longitudinal study used an innovative digital diary data collection method. Fifteen older adults with heart failure made medication-related multimedia recordings over a one-week period followed by an interview. These data were content analyzed according to the Patient Work System model. Results identified 6 organizational (70 instances), 7 task (45 instances), 7 tool (31 instances), 6 patient (31 instances), 4 social (21 instances), and 2 physical work system factors (10 instances). Patient medication performance suffered from a lack of care coordination and integration. Organizational tools such as mail order delivery facilitated access, but many patients devised tools and strategies to address other barriers. The study concluded that there is a need to design task-relevant tools to support and optimize the patients’ medication management work systems.