Why Medical Informatics (still) Needs Cognitive and Social Sciences.

International audienceOBJECTIVES: To summarize current excellent medical informatics research in the field of human factors and organizational issues. METHODS: Using PubMed, a total of 3,024 papers were selected from 17 journals. The papers were evaluated on the basis of their title, keywords, and abstract, using several exclusion and inclusion criteria. 15 preselected papers were carefully evaluated by six referees using a standard evaluation grid. RESULTS: Six best papers were selected exemplifying the central role cognitive and social sciences can play in medical informatics research. Among other contributions, those studies: (i) make use of the distributed cognition paradigm to model and understand clinical care situations; (ii) take into account organizational issues to analyse the impact of HIT on information exchange and coordination processes; (iii) illustrate how models and empirical data from cognitive psychology can be used in medical informatics; and (iv) highlight the need of qualitative studies to analyze the unexpected side effects of HIT on cognitive and work processes. CONCLUSION: The selected papers demonstrate that paradigms, methodologies, models, and results from cognitive and social sciences can help to bridge the gap between HIT and end users, and contribute to limit adoption failures that are reported regularly

NURSING INTERRUPTION DYNAMICS: THE IMPACT OF WORK SYSTEM FACTORS

Interruptions occur frequently in healthcare work systems. Hands-free Communication Devices (HCDs) were implemented in healthcare work systems to support the interruption process. However, from a sociotechnical systems perspective, HCDs may introduce new complications and unintended consequences to the work system. Research gaps exist in investigating the complexity of HCD interruptions in the real-world context. This dissertation aims to understand HCD interruption dynamics in the nursing work systems, using qualitative research methods. The first study examined the major differences between face-to-face and HCD-mediated interruptions, based on 30 hours of field observations in the acute care setting. Three major differences included: (1) The available cues to understand interruptee’s interruptibility, (2) The delivery of interruption content, and (3) The options to manage interruptions. The results uncovered facilitators and barriers that appeared to influence nursing work in the interruption process. The second study explored HCD interruption dynamics in more depth. It examined which system factors impact the interruption dynamics and how they influence nurses’ decisions and performance regarding the use of HCDs, based on 15 hours of field observations and 15 in-depth interviews with registered nurses in the pediatric intensive care units. This study was framed by the meso-ergonomics paradigm and activity theory. A descriptive model of HCD interruption dynamics was developed, comprising of five proximal system factors, 17 indicator and moderator system factors, and four distal system factors. These system factors interact and create integrated causal chains to impact interruption dynamics and influence the nurses’ decisions and performance regarding the use of HCDs. Specifically, the proximal system factors immediately impact interruption dynamics, the indicator or moderator system factors provide partial inputs and contextual circumstances of the proximal system factors, and the distal system factors are further down the causal chain. The results of the dissertation provided the basis for improving the design of interruption-mediating tools as well as the nursing work system, to better support the HCD-mediated interruption process, which may ultimately enhance the quality and safety of healthcare work systems

Emergency departments as complex adaptive systems

Introduction Globally, emergency departments (ED) are confronted with yearly rises in visit numbers and an increasingly older and multimorbid patient population. Several work system factors were associated with employee well-being and patient safety in previous literature. This thesis reports results of a mixed-methods intervention study investigating interrelationships between psychosocial ED work system factors, employee well-being and quality of patient care under consideration of the concept of resilient health care and complex adaptive systems (CAS). Methods A before and after study including an interrupted time-series (ITS) design was established in the multidisciplinary ED of a tertiary referral hospital in Southern Germany between 2015 and 2017. Applied methods and data sources included (1) standardized employee surveys, (2) structured work observations, (3) patient surveys, (4) register data, and (5) qualitative interviews. Additional data on employees’ activity and interruption patterns was collected in one US-American ED in 2016. Results Assessment of psychosocial work factors indicated considerable work demands for ED employees before and after the participative intervention comprising ten health circles. Inconsistent longitudinal intervention effects were found for changes in psychosocial work factors and employee mental wellbeing, e.g., increase in job control but decline in job satisfaction. Improvements in patient satisfaction were observed over time. Interviews revealed facilitators (e.g., comprehensive approach, employee participation) and barriers (e.g., understaffing, organizational constraints) for intervention implementation. Further associations between work interruptions and ED patient satisfaction as well as cross-national differences in ED work activity patterns were observed. Conclusions Reasons for inconsistent intervention results stem from the complexity of the ED work system including profession- and institution-specific challenges and individual stress experiences of employees. Studies should further consider employee health as a concurrent determinant as well as outcome in the theoretical concepts of CAS and resilient health care.Einleitung Notaufnahmen (NA) sind mit jährlich steigenden Besuchszahlen und einer älter werdenden und multimorbiden Patientenpopulation konfrontiert. Psychosoziale Arbeitsbedingungen wurden in der Literatur mit der Gesundheit von Beschäftigten und der Qualität der Versorgung assoziiert. Diese Dissertation berichtet die Ergebnisse einer Mixed-Methods-Interventionsstudie, die diese Zusammenhänge unter Berücksichtigung der Theorie komplexer adaptiver Systeme adressiert. Methode In der interdisziplinären NA eines süddeutschen Maximalversorgers wurde zwischen 2015 und 2017 eine Vorher-Nachher-Studie mit einem sog. Interrupted Time-Series Design durchgeführt. Methoden und Datenquellen umfassten (1) standardisierte Mitarbeiterbefragungen, (2) strukturierte Arbeitsbeobachtungen, (3) Patientenbefragungen, (4) Sekundärdaten und (5) qualitative Interviews. Ergänzende Daten zu Arbeitsbedingungen wurden 2016 in einer US-amerikanischen NA erhoben. Ergebnisse Vor und nach der partizipativen Intervention – bestehend aus 10 Gesundheitszirkeln – wurden erhebliche psychosoziale Arbeitsbelastungen für in der NA Beschäftigte identifiziert. Inkonsistente Längsschnitteffekte zeigten Veränderungen in psychosozialen Arbeitsbedingungen und im psychischen Wohlbefinden, z.B. Zunahme der Autonomie jedoch verringerte Arbeitszufriedenheit. Die Patientenzufriedenheit verbesserte sich im Laufe der Zeit. Unterstützende Faktoren für die Implementierung der Intervention waren ihr umfassender Ansatz und die Mitarbeiterbeteiligung wohingegen personelle Unterbesetzung und organisatorische Einschränkungen Barrieren darstellten. Weitere Zusammenhänge zwischen Arbeitsunterbrechungen und der Patientenzufriedenheit sowie länderübergreifende Unterschiede in NA-Arbeitsabläufen wurden beobachtet. Schlussfolgerungen Gründe für inkonsistente Interventionsergebnisse liegen in der Komplexität des NA-Arbeitssystems einschließlich berufs- und institutionsspezifischer Herausforderungen und individueller Beanspruchungserfahrungen der Beschäftigten begründet, welche in zukünftigen Studien zur arbeitsbezogenen Gesundheit im Rahmen der CAS-Theorie berücksichtigt werden sollten

Interrupções de atividades de enfermeiros e a segurança do paciente: revisão integrativa da literatura

OBJETIVOS: identificar características relacionadas a la interrupción que sufren los enfermeros en su práctica profesional, así como evaluar las implicaciones para la seguridad del paciente. MÉTODO: fue realizada una revisión de literatura de tipo integradora, con búsqueda en las bases de datos Pubmed/Medline, LILACS, SciELO y Biblioteca Cochrane, utilizando los descriptores interruptions y patient safety. La fecha inicial no fue limitada y la fecha final fue 31 de diciembre de 2013, se identificaron 29 artículos que atendieran a los criterios de inclusión. RESULTADOS: todos los artículos revisados describieron la interrupción como un factor perjudicial a la seguridad del paciente. El análisis de estos estudios reveló tres categorías relevantes: características de la interrupción, implicaciones de la interrupción para la seguridad del paciente e intervenciones para minimizar las interrupciones. CONCLUSIÓN: la interrupción favorece la ocurrencia de errores en la salud. Así, se notó la necesidad de realizar nuevas investigaciones para comprender ese fenómeno y los efectos del mismo en la práctica clínica.OBJECTIVES: to identify characteristics related to the interruption of nurses in professional practice, as well as to assess the implications of interruptions for patient safety. METHOD: integrative literature review. The following databases were searched: Pubmed/Medline, LILACS, SciELO and Cochrane Library, using the descriptors interruptions and patient safety. An initial date was not established, but the final date was December 31, 2013. A total of 29 papers met the inclusion criteria. RESULTS: all the papers included describe interruptions as a harmful factor for patient safety. Data analysis revealed three relevant categories: characteristics of interruptions, implications for patient safety, and interventions to minimize interruptions. CONCLUSION: interruptions favor the occurrence of errors in the health field. Therefore, there is a need for further studies to understand such a phenomenon and its effects on clinical practice.OBJETIVOS: identificar características relacionadas à interrupção de enfermeiros em sua prática profissional, bem como avaliar as implicações para a segurança do paciente. MÉTODO: foi realizada revisão de literatura do tipo integrativa, com busca nas bases de dados Pubmed/Medline, LILACS, SciELO e Biblioteca Cochrane, utilizando os descritores interruptions e patient safety. A data inicial não foi limitada e a data final foi 31 de dezembro de 2013, identificando-se 29 artigos que atenderam aos critérios de inclusão. RESULTADOS: todos os artigos revisados descreveram a interrupção como fator prejudicial à segurança do paciente. A análise destes estudos revelou três categorias relevantes: características da interrupção, implicações da interrupção para a segurança do paciente e intervenções para minimizar as interrupções. CONCLUSÃO: a interrupção favorece a ocorrência de erros na saúde. Assim, notou-se necessidade de novas pesquisas para compreender tal fenômeno e seus efeitos na prática clínica

Emergency departments as complex adaptive systems

Introduction Globally, emergency departments (ED) are confronted with yearly rises in visit numbers and an increasingly older and multimorbid patient population. Several work system factors were associated with employee well-being and patient safety in previous literature. This thesis reports results of a mixed-methods intervention study investigating interrelationships between psychosocial ED work system factors, employee well-being and quality of patient care under consideration of the concept of resilient health care and complex adaptive systems (CAS). Methods A before and after study including an interrupted time-series (ITS) design was established in the multidisciplinary ED of a tertiary referral hospital in Southern Germany between 2015 and 2017. Applied methods and data sources included (1) standardized employee surveys, (2) structured work observations, (3) patient surveys, (4) register data, and (5) qualitative interviews. Additional data on employees’ activity and interruption patterns was collected in one US-American ED in 2016. Results Assessment of psychosocial work factors indicated considerable work demands for ED employees before and after the participative intervention comprising ten health circles. Inconsistent longitudinal intervention effects were found for changes in psychosocial work factors and employee mental wellbeing, e.g., increase in job control but decline in job satisfaction. Improvements in patient satisfaction were observed over time. Interviews revealed facilitators (e.g., comprehensive approach, employee participation) and barriers (e.g., understaffing, organizational constraints) for intervention implementation. Further associations between work interruptions and ED patient satisfaction as well as cross-national differences in ED work activity patterns were observed. Conclusions Reasons for inconsistent intervention results stem from the complexity of the ED work system including profession- and institution-specific challenges and individual stress experiences of employees. Studies should further consider employee health as a concurrent determinant as well as outcome in the theoretical concepts of CAS and resilient health care.Einleitung Notaufnahmen (NA) sind mit jährlich steigenden Besuchszahlen und einer älter werdenden und multimorbiden Patientenpopulation konfrontiert. Psychosoziale Arbeitsbedingungen wurden in der Literatur mit der Gesundheit von Beschäftigten und der Qualität der Versorgung assoziiert. Diese Dissertation berichtet die Ergebnisse einer Mixed-Methods-Interventionsstudie, die diese Zusammenhänge unter Berücksichtigung der Theorie komplexer adaptiver Systeme adressiert. Methode In der interdisziplinären NA eines süddeutschen Maximalversorgers wurde zwischen 2015 und 2017 eine Vorher-Nachher-Studie mit einem sog. Interrupted Time-Series Design durchgeführt. Methoden und Datenquellen umfassten (1) standardisierte Mitarbeiterbefragungen, (2) strukturierte Arbeitsbeobachtungen, (3) Patientenbefragungen, (4) Sekundärdaten und (5) qualitative Interviews. Ergänzende Daten zu Arbeitsbedingungen wurden 2016 in einer US-amerikanischen NA erhoben. Ergebnisse Vor und nach der partizipativen Intervention – bestehend aus 10 Gesundheitszirkeln – wurden erhebliche psychosoziale Arbeitsbelastungen für in der NA Beschäftigte identifiziert. Inkonsistente Längsschnitteffekte zeigten Veränderungen in psychosozialen Arbeitsbedingungen und im psychischen Wohlbefinden, z.B. Zunahme der Autonomie jedoch verringerte Arbeitszufriedenheit. Die Patientenzufriedenheit verbesserte sich im Laufe der Zeit. Unterstützende Faktoren für die Implementierung der Intervention waren ihr umfassender Ansatz und die Mitarbeiterbeteiligung wohingegen personelle Unterbesetzung und organisatorische Einschränkungen Barrieren darstellten. Weitere Zusammenhänge zwischen Arbeitsunterbrechungen und der Patientenzufriedenheit sowie länderübergreifende Unterschiede in NA-Arbeitsabläufen wurden beobachtet. Schlussfolgerungen Gründe für inkonsistente Interventionsergebnisse liegen in der Komplexität des NA-Arbeitssystems einschließlich berufs- und institutionsspezifischer Herausforderungen und individueller Beanspruchungserfahrungen der Beschäftigten begründet, welche in zukünftigen Studien zur arbeitsbezogenen Gesundheit im Rahmen der CAS-Theorie berücksichtigt werden sollten

Traditions of research into interruptions in healthcare: A conceptual review

Background Researchers from diverse theoretical backgrounds have studied workplace interruptions in healthcare, leading to a complex and conflicting body of literature. Understanding pre-existing viewpoints may advance the field more effectively than attempts to remove bias from investigations. Objective To identify research traditions that have motivated and guided interruptions research, and to note research questions posed, gaps in approach, and possible avenues for future research. Methods A critical review was conducted of research on interruptions in healthcare. Two researchers identified core research communities based on the community’s motivations, philosophical outlook, and methods. Among the characteristics used to categorise papers into research communities were the predominant motivation for studying interruptions, the research questions posed, and key contributions to the body of knowledge on interruptions in healthcare. In cases where a paper approached an equal number of characteristics from two traditions, it was placed in a blended research community. Results A total of 141 papers were identified and categorised; all papers identified were published from 1994 onwards. Four principal research communities emerged: epidemiology, quality improvement, cognitive systems engineering (CSE), and applied cognitive psychology. Blends and areas of mutual influence between the research communities were identified that combine the benefits of individual traditions, but there was a notable lack of blends incorporating quality improvement initiatives. The question most commonly posed by researchers across multiple communities was: what is the impact of interruptions? Impact was measured as a function of task time or risk in the epidemiology tradition, situation awareness in the CSE tradition, or resumption lag (time to resume an interrupted task) in the applied cognitive psychology tradition. No single question about interruptions in healthcare was shared by all four of the core communities. Conclusions Much research on workplace interruptions in healthcare can be described in terms of fundamental values of four distinct research traditions and the communities that bring the values and methods: of those research traditions to their investigations. Blends between communities indicate that mutual influence has occurred as interruptions research has progressed. It is clear from this review that there is no single or privileged perspective to study interruptions. Instead, these findings suggest that researchers investigating interruptions in healthcare would benefit from being more aware of different perspectives from their own, especially when they consider workplace interventions to reduce interruptions

The Role of Patient Room-Type, Interruptions, and Intrapersonal Resources in Nurse Performance and Well-Being

Interruptions create a complex challenge in health care. Because some interruptions are necessary in health care, they cannot be completely eliminated. Thus, their effects must be appropriately mitigated. To better understand predictors and consequences of interruptions, as well as factors that may mitigate their negative effects, I employed Job Demands-Resources (JD-R) theory, supplemented by additional constructs from organizational behavior and psychology to develop a model of predictors and mitigators of interruptions. Twenty registered nurses providing care on a progressive acute care unit with single- and double-occupancy patient rooms volunteered to participate in this study. The study incorporated nurse-level questionnaires, event-level surveys, observation, and medical record review to test a mediated, moderation multi-level model. Double-occupancy rooms were a significant predictor of interruptions. Interruptions mediated the effect of room-type on perceived stress, but not on the other five dependent variables (task completion rate, medication administration errors, positive affect, and negative affect). While the full mediated, moderation models were not supported, the individual nurse characteristic of conscientiousness was found to have a significant moderating effect on the effect of room-type on perceived stress. Other nurse characteristics tested, but not found to have a significant effect, were stress mindset and psychological resilience. This study fills significant gaps in interruption research by using theory to develop a single conceptual model that identifies predictors of interruptions and nurse characteristics that may mitigate their effects. Future applications of this research should expand this approach to support nurse selection and training for working in interruptive patient care environment

Driven to distraction : a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students

Acknowledgments The authors would like to thank The Clinical Skills Managed Educational Network for its financial support, without which this research would not have taken place. Ethics approval Ethics approval for this research study was sought and granted from the University of Aberdeen's College and Ethics Research Board (Application No. CERB/2013/1/837). All participants in the study gave informed written consent before taking part in the research. Data sharing statement The research was carried out as part of a Masters in Medical Education degree. The Masters dissertation includes extensive study data—whereas this article contains the most pertinent quantitative data. The full Masters thesis is available from the University of DundeePeer reviewedPostprin