Doctor of Philosophy

dissertationPreventable adverse events are one of the leading causes of hospitalized patient deaths. Many of these adverse events occur in Intensive Care Units (ICUs) where nurses often work under cognitive, perceptual, and physical overloads. Contributing to these overloads are spatially separated devices which display treatment relevant information such as orders, monitoring information, and equipment status on numerous displays. If essential information of these separate devices was integrated into a single display at the bedside, nurses could potentially reduce their workload and improve their awareness of the patients' treatment plans and physiological status. We conducted a set of three studies for the purpose of designing an efficient and effective ICU display. We observed ICU nurses during their shifts and found that task-relevant information was often presented in the wrong format, unavailable at the point of care or laborious to obtain. Additionally, nurses were sometimes unaware of significant changes in their patient's status and equipment operation. Based on nurses' feedback, we designed an integrated information display that presents all of the information that nurses need at the patient bedside. Nurses selected a display based on the information organization of existing patient monitors, with added medication management and team communication features. The evaluation of paper-based prototypes of both the integrated display and existing ICU displays showed that nurses could answer questions about the patient's status and treatment faster (p<<0.05) and more accurately (p<<0.05) using the integrated display. The number of adverse events in the ICU could potentially be reduced by integrated displays, but to implement them into clinical practice will require significant engineering efforts

Potential uses of AI for perioperative nursing handoffs: A qualitative study

OBJECTIVE: Situational awareness and anticipatory guidance for nurses receiving a patient after surgery are keys to patient safety. Little work has defined the role of artificial intelligence (AI) to support these functions during nursing handoff communication or patient assessment. We used interviews to better understand how AI could work in this context. MATERIALS AND METHODS: Eleven nurses participated in semistructured interviews. Mixed inductive-deductive thematic analysis was used to extract major themes and subthemes around roles for AI supporting postoperative nursing. RESULTS: Five themes were generated from the interviews: (1) nurse understanding of patient condition guides care decisions, (2) handoffs are important to nurse situational awareness, but multiple barriers reduce their effectiveness, (3) AI may address barriers to handoff effectiveness, (4) AI may augment nurse care decision making and team communication outside of handoff, and (5) user experience in the electronic health record and information overload are likely barriers to using AI. Important subthemes included that AI-identified problems would be discussed at handoff and team communications, that AI-estimated elevated risks would trigger patient re-evaluation, and that AI-identified important data may be a valuable addition to nursing assessment. DISCUSSION AND CONCLUSION: Most research on postoperative handoff communication relies on structured checklists. Our results suggest that properly designed AI tools might facilitate postoperative handoff communication for nurses by identifying specific elevated risks faced by a patient, triggering discussion on those topics. Limitations include a single center, many participants lacking of applied experience with AI, and limited participation rate

Doctor of Philosophy

dissertationMedical error causes preventable death in nearly 100,000 patients per year in the US alone. Common sources for error include medication related problems, technical equipment failure, interruptions, complicated and error-prone devices, information overload (providing too much patient data for one person to process effectively), and environmental problems like inadequate lighting or distracting ambient noise. Intensive care units are one of the riskiest locations in a hospital, with up to 9 reported events per 100 patient days. This risk is in large contrast to anesthesia in the operating rooms. Here much advancement in the area of patient safety has been made in the past, dropping the average risk for anesthesia related death to less than 1 in 200,000 anesthetics-an improvement by a factor of 20 in the past 30 years. Improvements in technology and other innovations contributing to this success now need to be adapted for and implemented in the intensive care unit setting. Nurses are increasingly regarded as key decision makers within the healthcare team, as they outnumber physicians 4:1. Reducing nurses' workload and improving medical decision making by providing decision support tools can have a significant impact in reducing the chances of medical errors. This dissertation consists of four manuscripts: 1) a review of previous medical display evaluations, providing insight into solutions that have worked in the past; 2) a study on reducing false alarms and increasing the usefulness of the remaining alarms by introducing alarm delays and detecting alarm context;, such as suctioning automatically silencing ventilator alarms; 3) a study of simplifying the frequent but complicated task of titrating vasoactive medications by providing a titration support tool that predicts blood pressure changes 5 minutes into the future; and 4) a study on supporting the triage of unfamiliar patients by introducing a far-view display that incorporates information from previously disparate devices and presents trend and alarm information at one easy to scan and interpret location

Identifying Transfer of Care Gaps: Electronic Health Record Capture of Perioperative Handoff Communications

Transitions in patient care are held together by interdisciplinary handoff communications intended to coordinate the patient\u27s ongoing care requirements. Patients with complexity in care encumber the transfer of care process requiring a higher level of care coordination between the interdisciplinary team (Coleman, 2003; Naylor et al., 2004). While the literature is abundant on the characteristics and quality of handoff communications, it is limited on the requirements of what data is necessary for ongoing care following transfer communications (Galatzan & Carrington, 2018). This dissertation explores the verbal information transferred during Operating Room (OR) to Post Anesthesia Care Unit (PACU) nursing handoff communications and whether the data is captured in the electronic health record (EHR) to represent the information critical to ongoing patient care and care planning. the study builds on the Kennedy Integrated Theoretical Framework (KITF) (Kennedy, 2012) integrating cognition theory, patterns of knowledge theory, and clinical communication space theory to support the human-technology characteristics within perioperative handoffs. Evidence of wisdom was present in the KITF in addition to elements of non-verbal communication patterns emerging from shared common ground contributed to the framework\u27s expansion. to understand the contributions of the perioperative nursing interface terminology, the Perioperative Nursing Data Set (PNDS), makes to postsurgical care transitions, the study examines nursing diagnoses, interventions, interim outcomes and goals relationships to the handoff data communicated between OR and PACU Registered Nurses. Study findings revealed a complex fragmented process of verbal communications and electronic documentation for the handoff process. While the EHR is prominent in data procurement for the handoff process, the design of handoff artifacts (e.g., paper, electronic) significantly impact the value of information received. Incomplete handoff tools or missing EHR data adds to a cycle of information decay while contributing to increase cognitive load and potentiating opportunities for information and knowledge loss. the absence of nursing diagnoses in the automation of the PNDS challenges the integrity of the language within the documentation platform and raises considerations for hierarchical representation within interface terminologies. This study reinforces literature to reconsider user requirements in the design and functionality of healthcare information technology (HIT) to enable data and information flow and preserve knowledge development. the inclusion of mobile technology, cognitive support aids including clinical decision support tools, and other HIT will further enable the effectiveness of transfer communication, knowledge development, and the safety of ongoing patient care

A Team-Based Approach to Studying Complex Healthcare Processes

Communication is a critical aspect of clinical work. In 2010, the Joint Commission (JC) found that gaps in communication were among leading factors contributing to medical errors. Healthcare processes, such as patient discharge, depend on interdisciplinary communication to be successful. Electronic health records (EHRs) have the potential to facilitate communication and information sharing between interdisciplinary care team members; however, challenges remain in designing tools for team-based care and questions remain in understanding how EHRs impact interdisciplinary team communication. This dissertation focuses on understanding how EHRs can be designed to support communication and information sharing within interdisciplinary patient care teams. The first aim of the dissertation investigated how EHRs impact interdisciplinary clinical teams’ communication, shared mental models, and information sharing activities. The results showed that implementing new EHR tools appeared to have little impact on communication and shared mental models, but new information sharing activities mediated by EHR developed. These changes and lack thereof suggest that new EHR tools will be specifically needed to facilitate interdisciplinary team information sharing activities. The second aim of the dissertation investigates the information sharing activities and information needs of interdisciplinary team members during patient discharge. The results showed that the information clinicians sought out during discharge depended on the roles that person played as well as the progress of the discharge process. Future EHR tools should be aware of how patient care teams are progressing through the patient discharge process in order to provide information contextualized to their current tasks. In conclusion, interdisciplinary team communication and information sharing remain poorly supported by current EHRs and new tools designed specifically for interdisciplinary teams should provide information based on the completion of team activities

Clinician-Driven Design of VitalPAD–An Intelligent Monitoring and Communication Device to Improve Patient Safety in the Intensive Care Unit

The pediatric intensive care unit (ICU) is a complex environment, in which a multidisciplinary team of clinicians (registered nurses, respiratory therapists, and physicians) continually observe and evaluate patient information. Data are provided by multiple, and often physically separated sources, cognitive workload is high, and team communication can be challenging. Our aim is to combine information from multiple monitoring and therapeutic devices in a mobile application, the VitalPAD, to improve the efficiency of clinical decision-making, communication, and thereby patient safety. We observed individual ICU clinicians, multidisciplinary rounds, and handover procedures for 54 h to identify data needs, workflow, and existing cognitive aid use and limitations. A prototype was developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from 15 clinicians. Features included map overviews of the ICU showing clinician assignment, patient status, and respiratory support; patient vital signs; a photo-documentation option for arterial blood gas results; and team communication and reminder functions. Clinicians reported the prototype to be an intuitive display of vital parameters and relevant alerts and reminders, as well as a user-friendly communication tool. Future work includes implementation of a prototype, which will be evaluated under simulation and real-world conditions, with the aim of providing ICU staff with a monitoring device that will improve their daily work, communication, and decision-making capacity. Mobile monitoring of vital signs and therapy parameters might help improve patient safety in wards with single-patient rooms and likely has applications in many acute and critical care settings.This work was supported by the Canadian Institutes of Health Research under Grant PJT-149042

Assessing Post Operative Information Transfers: Evaluation of Patient Outcomes

Purpose: The purpose of this dissertation research was to study postoperative handover information transfers (PITS) and to ultimately improve patient safety and patient outcomes. One of the goals was to identify deficits in PITS by exploring information needs and processes related to PITS. Grounded by the social ecological model (SEM), a scoping review of extant literature was conducted to identify individual, interpersonal, organizational environmental and organizational policy level factors that influence the quality and processes of post-operative information transfers (PITS). An integrative review of extant literature was conducted to describe how PITS have been studied and to describe instruments that have been developed to improve PITS. Using participatory action research, a sequential mixed-methods study was undertaken to assess the feasibility of and pilot test the electronic post-operative information transfer instrument (EPITI). Problem: PITS have been described as fraught with errors and prone to information omissions (Catchpole, Sellers, Goldman, McCulloch, & Hignett, 2010; Segall et al., 2012, 2012). Information transfers between anesthesia providers and post anesthesia care unit nurses take place among a myriad of other patient care activities including re-establishing monitoring technology while communicating the verbal report (Smith, Pope, Goodwin, & Mort, 2008). Deficits in PITS have been associated with delays in medical treatment, and increased morbidity and mortality (Nagpal et al., 2013; Rose & Newman, 2016; van der Walt & Joubern, 2014). Previous research has shown that standardization of PITS increases the amount of information transferred (Potestio, Mottla, Kelley, & DeGroot, 2015; Salzwedel et al., 2013; Siddiqui et al., 2012) One way PITS have been standardized is by including post-operative information transfer forms within anesthesia information management systems (AIMS). Research is needed to assess the feasibility of implementing AIMS, including the EPITI by gaining insight from key stakeholders, defined as anesthesia providers (AP) and PACU nurses. Additional research is needed that describes the development, implementation and evaluation of electronic PIT instruments. The purposes of the manuscripts included in this dissertation were: Manuscript I Scoping Review: To identify factors at each level of the Social Ecological Model that influence PITS Manuscript II Integrative Review: To describe and synthesize instruments developed to improve PITS and to describe how PITS have been studied Manuscript III Pilot and Feasibility Study: To report on pilot testing and evaluation of the feasibility of the electronic post-operative information transfer instrument (EPITI) Design: Sequential mixed methods using a participatory action approach Findings: Individual, interpersonal, organizational and environmental factors influence PITS. Efforts including standardization of PITS have been undertaken to decrease information omissions and to improve interpersonal communication. After pilot testing the EPITI, results of qualitative and quantitative data analysis showed the EPITI was feasible, acceptable and integrated well into clinical practice when pilot tested by AP and PACU nurses. Conclusion: Additional research is needed to implement and assess the effect of electronic postoperative handover instruments on patient specific outcomes

Only connect: addressing the emotional needs of Scotland's children and young people

A report on the SNAP (Scottish Needs Assessment Programme) Child and Adolescent Mental Health Phase Two survey. It describes a survey of a wide range of professionals working with children and young people in Scotland, and deals with professional perspectives on emotional, behavioural and psychological problems. Conclusions and recommendations are presented

De-escalation of aggressive behaviour in healthcare settings:concept analysis

BACKGROUND: De-escalation is the recommended first-line response to potential violence and aggression in healthcare settings. Related scholarly activity has increased exponentially since the 1980s, but there is scant research about its efficacy and no guidance on what constitutes the gold standard for practice.OBJECTIVES: To clarify the concept of de-escalation of violence and aggression as described within the healthcare literature.DESIGN: Concept analysis guided by Rodgers' evolutionary approach.DATA SOURCES: Multiple nursing and healthcare databases were searched using relevant terms.REVIEW METHODS: High quality and/or highly cited, or otherwise relevant published empirical or theoretical English language literature was included. Information about surrogate terms, antecedents, attributes, consequences, and the temporal, environmental, disciplinary, and theoretical contexts of use were extracted and synthesised. Information about the specific attributes of de-escalation were subject to thematic analysis. Proposed theories or models of de-escalation were assessed against quality criteria.RESULTS: N=79 studies were included. Mental health settings were the most commonly reported environment in which de-escalation occurs, and nursing the disciplinary group most commonly discussed. Five theories of de-escalation were proposed; while each was adequate in some respects, all lacked empirical support. Based on our analysis the resulting theoretical definition of de-escalation in healthcare is "a collective term for a range of interwoven staff-delivered components comprising communication, self-regulation, assessment, actions, and safety maintenance which aims to extinguish or reduce patient aggression/agitation irrespective of its cause, and improve staff-patient relationships while eliminating or minimising coercion or restriction".CONCLUSIONS: While a number of theoretical models have been proposed, the lack of advances made in developing a robust evidence-base for the efficacy of de-escalation is striking and must, at least in part, be credited to the lack of a clear conceptualisation of the term. This concept analysis provides a framework for researchers to identify the theoretical model that they purport to use, the antecedents that their de-escalation intervention is targeting, its key attributes, and the key negative and positive consequences that are to be avoided or encouraged.</p

An exploration of nurse preceptors’ perspectives of a pre-registration nursing clinical preceptorship programme in an acute hospital context in Egypt: A constructivist grounded theory approach

Background: The proposed reforms of Egyptian nursing education are based on competencies to achieve well-educated nurse graduates. There is a shortage of clinical faculty and increasing demands for nurse preceptors to act as clinical instructors. There is no national framework to prepare nurse preceptors or clinical instructors, nor a clear framework for implementation of an evidence-based competency-based pre-licensure internship. Research is needed to explore factors influencing the preparation of preceptors and preceptorship programme priorities in the nursing context in Egypt. Aim: To explore preceptors’ perspective of their previous preceptorship experiences and the factors that influence their professional role and development while introducing competency-based internship in an acute critical care hospital in Egypt. Purpose: To develop a contextual preceptorship model to help prepare professional nurse preceptors as clinical leaders within their organizations. Methodology: A qualitative inquiry approach was used with two phases of spiral Constructivist Grounded Theory to develop the proposed theoretical themes. The first study phase engaged semi-structured interviews and comparative analysis of data to construct initial codes. The second phase shared theoretical sampling with participant focus groups. Further data verified initial codes and analysis continued until theoretical themes emerged. Results: The concepts of self-awareness and self-esteem become first steps in an over-arching theme of developing preceptors as lifelong learners. These concepts emerged from the core themes of, ‘Education misalignment issues’, ‘Preceptor selection criteria’ and ‘Developing preceptors as lifelong learners. Discussion: The study analyzed findings with comparison to relevant research literature. A contextualized developmental model of competency-based preceptorship programme is proposed as based on four key phases ‘Discovery’, ‘Selection’, ‘Socialization’ and ‘Development’. Conclusion: A critical component of the conceptual model is improving self-esteem through promoting self-awareness. The proposed program can help academic and hospital leaders to sustain the competency-based internship, orientation and preceptorship to improve the quality of nursing care