Changes in nurses’ work associated with computerised information systems: Opportunities for international comparative studies using the revised Work Observation Method by Activity Timing (WOMBAT)

An important step in advancing global health through informatics is to understand how systems support health professionals to deliver improved services to patients. Studies in several countries have highlighted the potential for clinical information systems to change patterns of work and communication, and in particular have raised concerns that they reduce nurses’ time in direct care. However measuring the effects of systems on work is challenging and comparisons across studies have been hindered by a lack of standardised definitions and measurement tools. This paper describes the Work Observation Method by Activity Time (WOMBAT) technique version 1.0 and the ways in which the data generated can describe different aspects of health professionals’ work. In 2011 a revised WOMBAT version 2.0 was developed specifically to facilitate its use by research teams in different countries. The new features provide opportunities for international comparative studies of nurses’ work to be conducted

Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study

Background Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals’ task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied. Objective To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors. Methods 36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians’ working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep. Results Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates. Conclusion Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments

Use of information and communication technologies to support effective work practice innovation in the health sector: a multi-site study

<p>Abstract</p> <p>Background</p> <p>Widespread adoption of information and communication technologies (ICT) is a key strategy to meet the challenges facing health systems internationally of increasing demands, rising costs, limited resources and workforce shortages. Despite the rapid increase in ICT investment, uptake and acceptance has been slow and the benefits fewer than expected. Absent from the research literature has been a multi-site investigation of how ICT can support and drive innovative work practice. This Australian-based project will assess the factors that allow health service organisations to harness ICT, and the extent to which such systems drive the creation of new sustainable models of service delivery which increase capacity and provide rapid, safe, effective, affordable and sustainable health care.</p> <p>Design</p> <p>A multi-method approach will measure current ICT impact on workforce practices and develop and test new models of ICT use which support innovations in work practice. The research will focus on three large-scale commercial ICT systems being adopted in Australia and other countries: computerised ordering systems, ambulatory electronic medical record systems, and emergency medicine information systems. We will measure and analyse each system's role in supporting five key attributes of work practice innovation: changes in professionals' roles and responsibilities; integration of best practice into routine care; safe care practices; team-based care delivery; and active involvement of consumers in care.</p> <p>Discussion</p> <p>A socio-technical approach to the use of ICT will be adopted to examine and interpret the workforce and organisational complexities of the health sector. The project will also focus on ICT as a potentially <it>disruptive innovation </it>that challenges the way in which health care is delivered and consequently leads some health professionals to view it as a threat to traditional roles and responsibilities and a risk to existing models of care delivery. Such views have stifled debate as well as wider explorations of ICT's potential benefits, yet firm evidence of the effects of role changes on health service outcomes is limited. This project will provide important evidence about the role of ICT in supporting new models of care delivery across multiple healthcare organizations and about the ways in which innovative work practice change is diffused.</p

How much time do nurses have for patients? a longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals

<p>Abstract</p> <p>Background</p> <p>Time nurses spend with patients is associated with improved patient outcomes, reduced errors, and patient and nurse satisfaction. Few studies have measured how nurses distribute their time across tasks. We aimed to quantify how nurses distribute their time across tasks, with patients, in individual tasks, and engagement with other health care providers; and how work patterns changed over a two year period.</p> <p>Methods</p> <p>Prospective observational study of 57 nurses for 191.3 hours (109.8 hours in 2005/2006 and 81.5 in 2008), on two wards in a teaching hospital in Australia. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied. Proportions of time in 10 categories of work, average time per task, time with patients and others, information tools used, and rates of interruptions and multi-tasking were calculated.</p> <p>Results</p> <p>Nurses spent 37.0%[95%CI: 34.5, 39.3] of their time with patients, which did not change in year 3 [35.7%; 95%CI: 33.3, 38.0]. Direct care, indirect care, medication tasks and professional communication together consumed 76.4% of nurses' time in year 1 and 81.0% in year 3. Time on direct and indirect care increased significantly (respectively 20.4% to 24.8%, P < 0.01;13.0% to 16.1%, P < 0.01). Proportion of time on medication tasks (19.0%) did not change. Time in professional communication declined (24.0% to 19.2%, P < 0.05). Nurses completed an average of 72.3 tasks per hour, with a mean task length of 55 seconds. Interruptions arose at an average rate of two per hour, but medication tasks incurred 27% of all interruptions. In 25% of medication tasks nurses multi-tasked. Between years 1 and 3 nurses spent more time alone, from 27.5%[95%CI 24.5, 30.6] to 39.4%[34.9, 43.9]. Time with health professionals other than nurses was low and did not change.</p> <p>Conclusions</p> <p>Nurses spent around 37% of their time with patients which did not change. Work patterns were increasingly fragmented with rapid changes between tasks of short length. Interruptions were modest but their substantial over-representation among medication tasks raises potential safety concerns. There was no evidence of an increase in team-based, multi-disciplinary care. Over time nurses spent significantly less time talking with colleagues and more time alone.</p

Validation of the Work Observation Method By Activity Timing (WOMBAT) method of conducting time-motion observations in critical care settings: an observational study

<p>Abstract</p> <p>Background</p> <p>Electronic documentation handling may facilitate information flows in health care settings to support better coordination of care among Health Care Providers (HCPs), but evidence is limited. Methods that accurately depict changes to the workflows of HCPs are needed to assess whether the introduction of a Critical Care clinical Information System (CCIS) to two Intensive Care Units (ICUs) represents a positive step for patient care. To evaluate a previously described method of quantifying amounts of time spent and interruptions encountered by HCPs working in two ICUs.</p> <p>Methods</p> <p>Observers used PDAs running the Work Observation Method By Activity Timing (WOMBAT) software to record the tasks performed by HCPs in advance of the introduction of a Critical Care clinical Information System (CCIS) to quantify amounts of time spent on tasks and interruptions encountered by HCPs in ICUs.</p> <p>Results</p> <p>We report the percentages of time spent on each task category, and the rates of interruptions observed for physicians, nurses, respiratory therapists, and unit clerks. Compared with previously published data from Australian hospital wards, interdisciplinary information sharing and communication in ICUs explain higher proportions of time spent on professional communication and documentation by nurses and physicians, as well as more frequent interruptions which are often followed by professional communication tasks.</p> <p>Conclusions</p> <p>Critical care workloads include requirements for timely information sharing and communication and explain the differences we observed between the two datasets. The data presented here further validate the WOMBAT method, and support plans to compare workflows before and after the introduction of electronic documentation methods in ICUs.</p

INSTITUTIONAL CONTACT RATES AS A DRIVER OF INFECTIOUS DISEASES

For many infectious diseases, pathogen transmission requires close contact between infectious and susceptible hosts. Contact rates- the number of close contacts per infected individual- are influenced by demographics, behaviors, and contextual elements such as occupation and cultural practices. Workplaces are significant areas for disease transmission, due to frequent interactions among employees or between them and their clients. Moreover, cultural norms within workplaces can shape contact patterns, further influencing disease spread. Context-specific data enables a comprehensive understanding of contact rates and networks, facilitating targeted interventions. Amid COVID-19, university policies altered attendance rules, prompting our investigation into policy impacts on employee social contacts. Participants, consisting of university employees, engaged in two surveys conducted during periods of virtual and in-person classes. Results revealed a notable increase in contacts from the first to the second survey (median of 3 contacts to 7), accompanied by a shift from family members towards interactions with strangers and students. Such findings emphasize the importance of considering employees in pandemic planning efforts and implementing targeted precautionary measures.We created a simulation-based study that explored how staffing levels affect methicillin-resistant Staphylococcus aureus (MRSA) acquisition in intensive care units (ICUs). Utilizing compartmental modeling, scenarios with infinite and finite workload conceptualizations and differing nurse-to-patient ratios and intensivist staffing levels were explored. Under baseline conditions, our model had a median of 8.2 MRSA acquisitions per year. The large differential in MRSA acquisition dependent on workload conceptualization underscores the need for tailored staffing strategies in hospital infection control.Veterinary hospitals present unique challenges in managing infectious diseases, particularly due to elevated risks of zoonotic infections among veterinary staff. We created a direct observation pilot study to assess time use and activity patterns among different staff types and departments within a veterinary teaching hospital. Analysis of 12,079 tasks highlighted significant variations between staff types and departments, underscoring the necessity for tailored occupational health interventions.This research highlights the crucial role of institutional policies in shaping contact patterns and disease transmission, especially in workplaces. By combining surveys, models, and observations, researchers can gauge policy impacts and devise effective infection prevention strategies

Tasks, multitasking and interruptions among the surgical team in an operating room: a prospective observational study

Objectives: The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR.Design: Prospective observational study using the Work Observation Method By Activity Timing tool.Setting: An OR department at a county hospital in Sweden.Participants: OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9).Results: The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons’ and ORNs’ intraoperative time, while in RNAs’ work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs’ and surgeons’ work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication.Conclusions: The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system.</p

How can we better prepare new doctors for the tasks and challenges of ward rounds?:An observational study of junior doctors' experiences

Founding: Economic and Social Research Council Open access via T&F agreement Acknowledgements The authors would like to thank participating FY1 doctors and the senior staff who made this study possible. Funding The study was funded by the ESRC via a Doctoral Studentship awarded to CB.Peer reviewedPublisher PD

NAVIGATING THE INTERPLAY OF HOSPITAL INFECTION CONTROL MEASURES AND EMERGING INFECTIOUS DISEASES IN HEALTHCARE SETTINGS

Emerging pathogens pose significant public health risks worldwide, particularly evident amidst the ongoing pandemic for which the full impact on hospitals and healthcare workers remains to be fully understood. Surface contamination within healthcare facilities plays a pivotal role in transmitting nosocomial pathogens and contributing to healthcare-associated infections (HAIs). Understanding the activity patterns of healthcare workers is essential for elucidating pathogen transmission dynamics within hospitals, alongside the use of mathematical models for comprehending the complexities of infectious disease transmission in healthcare settings. The pandemic has presented hospitals with unique challenges, particularly in addressing Personal Protective Equipment (PPE) shortages. Consequently, hospitals have turned to 3D printing. Therefore, we assessed the contamination and disinfection of 3D-printed materials. Results revealed substantial bacterial contamination on standard and antimicrobial materials. Bacterial population levels returned hours after disinfectant application, underscoring the critical need for continuous and thorough disinfection protocols and material selection in healthcare settings. Activity patterns of healthcare workers play a crucial role in hospitals' patient-care mission and outcomes— aiding in understanding patient contact times and interactions, and nosocomial transmission. We explored the use of medical dramas for observer training when direct clinical observation is impractical. Intraclass correlation coefficients demonstrate the reliability of using medical dramas as substitutes for in-person observations, offering a flexible and accessible training method for researchers. However, one should be mindful that inaccuracies in the representation of clinical activity patterns are present and underscore the need for a cautious interpretation of results. Additionally, we investigated nosocomial amplification, the phenomenon wherein infectious diseases escalate within healthcare facilities. We developed a general framework model to elucidate the interconnectedness of hospital and community transmission dynamics, highlighting how hospital-level parameters significantly impact the community. The findings underscore the importance of integrated strategies to mitigate disease spread, emphasizing the reciprocal influence between hospital and community transmission. Our research provides valuable knowledge about infection control measures, observer training methodologies, and an understanding of the complex interplay between hospital and community transmission dynamics. They are pivotal for devising effective strategies to manage current and future infectious disease challenges, thereby safeguarding both healthcare facilities and the broader community

Optimising drug therapy in older patients. Exploring different approaches across the patient pathway

Background - Drug therapy contributes to healthy aging but has a key duality: It prolongs and can improve quality of life, but drugs can also cause serious harm. Harm from drugs include falls, cognitive decline, lowered quality of life, hospitalisation, and death. Older patients are especially at risk for harm from drug therapy, therefore optimising drug therapy is imperative for this group. Aim - To generate new knowledge of drug therapy optimisation for older patients by exploring the impact of drug burden and investigating different approaches to optimise drug therapy across the patient pathway. Methods - This thesis used data from The Norwegian patient registry, The Norwegian Prescription Database and data collected in a randomised controlled trial (RCT). Observational data of the delivery of the RCT-intervention was included. In Paper I the association between anticholinergic (AC) and sedative (SED) drug burden and post-discharge institutionalisation (PDI) was assessed using multiple regression. Paper II described an RCT investigating the effect of an in-hospital pharmacist intervention. Paper III presented the fidelity and process outcomes of the intervention (Paper II). In Paper IV, an observational tool was developed and time distribution for the pharmacists running the RCT examined. Results - Number of drugs used before hospitalisation was mean 7.11 (SD 4.09) and at hospitalisation median 6.0 (range 4-9). Prevalence of AC/SED drugs was 45.5%. All measures of AC/SED drug burden was significantly associated with PDI. The number of AC drugs were most sensitive (OR 1.13, per AC drug), and the DBI most challenging to apply. The clinical pharmacist contributed to identify and solve discrepancies for 72% of the patients (median 1) and DRPs for 94.6% of the patients (median 4), and the acceptance rate was 67%. Intervention fidelity at admission was 100%, and 57% overall. The pharmacists advanced communication of drug therapy across the patient pathway. About 41% of pharmacist time was spent on administrative RCT-tasks and the estimated intervention time was >3.5 hours/patient. Conclusions - The drug burden is high in older patients acutely admitted to hospital in Norway and assessing AC/SED drug use can reduce the risk of PDI. The in-hospital pharmacist intervention contributed to drug therapy optimisation and facilitated communication across the patient pathway. These measures can contribute to optimisation of drug therapy but are time consuming and costly. It is essential to establish models for drug therapy optimisation across the pathway, including primary care