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-related cognitive artifacts used by older adults with heart failure

OBJECTIVE: To use a human factors perspective to examine how older adult patients with heart failure use cognitive artifacts for medication management. METHODS: We performed a secondary analysis of data collected from 30 patients and 14 informal caregivers enrolled in a larger study of heart failure self-care. Data included photographs, observation notes, interviews, video recordings, medical record data, and surveys. These data were analyzed using an iterative content analysis. RESULTS: Findings revealed that medication management was complex, inseparable from other patient activities, distributed across people, time, and place, and complicated by knowledge gaps. We identified fifteen types of cognitive artifacts including medical devices, pillboxes, medication lists, and electronic personal health records used for: 1) measurement/evaluation; 2) tracking/communication; 3) organization/administration; and 4) information/sensemaking. These artifacts were characterized by fit and misfit with the patient's sociotechnical system and demonstrated both advantages and disadvantages. We found that patients often modified or "finished the design" of existing artifacts and relied on "assemblages" of artifacts, routines, and actors to accomplish their self-care goals. CONCLUSIONS: Cognitive artifacts are useful but sometimes are poorly designed or are not used optimally. If appropriately designed for usability and acceptance, paper-based and computer-based information technologies can improve medication management for individuals living with chronic illness. These technologies can be designed for use by patients, caregivers, and clinicians; should support collaboration and communication between these individuals; can be coupled with home-based and wearable sensor technology; and must fit their users' needs, limitations, abilities, tasks, routines, and contexts of use

Program Planning Theory in Service-Learning: A Relational Model

This paper introduces the relationship between program planning theory and service-learning in graduate education and the development of a relational program planning model for service-learning. A case will be made regarding the value of the relational program planning model for guiding and enabling more democratic forms of service-learning practice

Site-Dependent Differences in Artificial Reef Function: Implications for Coral Reef Restoration

There is an increasing use of artificial structure in coral reef restoration (for references, see Spieler et al., this volume). Often artificial reef structures are chosen for a restoration project simply because they were used elsewhere. However, it is questionable whether the results obtained at one restoration site can be extrapolated to another. In recent years, several studies have examined the effect of artificial reef site selection on formation of associated fish, algae, and/or invertebrate assemblages (Alevizon et al., 1985; Blinova et al., 1994; Bombace et al., 1994; Caley and St. John, 1996; Chang, 1985; Haughton and Aiken, 1989; Hixon and Beets, 1989; Jara and Cespedes, 1994; Kruer and Causey, 1992; Lozano-Alvarez et al., 1994; Moffitt et al., 1989; Relini et al., 1994; Sherman et al., 2000; Sherman et al., 1999; Sogard, 1989; Spieler, 1998; Tomascik, 1991). Although not designed specifically as coral reef restoration projects, the results of these studies lend insight into the problems of restoration. This paper is an overview of recent literature on site selection intended for resource managers interested in using artificial reefs in coral reef restoration. To that end, we re-examined the data from several studies comparing similar artificial reef structures at different sites

Artificial Substrate and Coral Reef Restoration: What Do We Need to Know to Know What We Need

To use artificial substrate effectively in coral reef restoration certain basic knowledge is required: (1) what is the artificial substrate expected to accomplish relative to the goals of the restoration effort and (2) what are the expected interactions of the selected substrate’s composition, texture, orientation, and design with the damaged environment and the biota of interest. Whereas the first point is usually clear, at least in general terms, the second is not. In this review, we examine: the functions of artificial substrate in restoration and some of the physical (i.e., composition; surface texture; color and chemistry; and design in terms of profile, shelter, shading, size and configuration, settlement attractants, and stability) and environmental factors (i.e., temperature, light sedimentation, surround biota, hydrodynamics, depth, and temporal effects) affecting these functions. We conclude that until substantial additional research is accomplished, the use of artificial substrate in coral reef restoration will remain a ‘best guess’ endeavor. Areas requiring additional research are identified and some potentially promising lines of inquiry are suggested

Medication Management: The Macrocognitive Workflow of Older Adults With Heart Failure

BACKGROUND: Older adults with chronic disease struggle to manage complex medication regimens. Health information technology has the potential to improve medication management, but only if it is based on a thorough understanding of the complexity of medication management workflow as it occurs in natural settings. Prior research reveals that patient work related to medication management is complex, cognitive, and collaborative. Macrocognitive processes are theorized as how people individually and collaboratively think in complex, adaptive, and messy nonlaboratory settings supported by artifacts. OBJECTIVE: The objective of this research was to describe and analyze the work of medication management by older adults with heart failure, using a macrocognitive workflow framework. METHODS: We interviewed and observed 61 older patients along with 30 informal caregivers about self-care practices including medication management. Descriptive qualitative content analysis methods were used to develop categories, subcategories, and themes about macrocognitive processes used in medication management workflow. RESULTS: We identified 5 high-level macrocognitive processes affecting medication management-sensemaking, planning, coordination, monitoring, and decision making-and 15 subprocesses. Data revealed workflow as occurring in a highly collaborative, fragile system of interacting people, artifacts, time, and space. Process breakdowns were common and patients had little support for macrocognitive workflow from current tools. CONCLUSIONS: Macrocognitive processes affected medication management performance. Describing and analyzing this performance produced recommendations for technology supporting collaboration and sensemaking, decision making and problem detection, and planning and implementation

Design and introduction of a quality of life assessment and practice support system: perspectives from palliative care settings

Background: Quality of life (QOL) assessment instruments, including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs), are increasingly promoted as a means of enabling clinicians to enhance person-centered care. However, integration of these instruments into palliative care clinical practice has been inconsistent. This study focused on the design of an electronic Quality of Life and Practice Support System (QPSS) prototype and its initial use in palliative inpatient and home care settings. Our objectives were to ascertain desired features of a QPSS prototype and the experiences of clinicians, patients, and family caregivers in regard to the initial introduction of a QPSS in palliative care, interpreting them in context. Methods: We applied an integrated knowledge translation approach in two stages by engaging a total of 71 clinicians, 18 patients, and 17 family caregivers in palliative inpatient and home care settings. Data for Stage I were collected via 12 focus groups with clinicians to ascertain desirable features of a QPSS. Stage II involved 5 focus groups and 24 interviews with clinicians and 35 interviews with patients or family caregivers during initial implementation of a QPSS. The focus groups and interviews were recorded, transcribed, and analyzed using the qualitative methodology of interpretive description. Results: Desirable features focused on hardware (lightweight, durable, and easy to disinfect), software (simple, user-friendly interface, multi-linguistic, integration with e-health systems), and choice of assessment instruments that would facilitate a holistic assessment. Although patient and family caregiver participants were predominantly enthusiastic, clinicians expressed a mixture of enthusiasm, receptivity, and concern regarding the use of a QPSS. The analyses revealed important contextual considerations, including: (a) logistical, technical, and aesthetic considerations regarding the QPSS as a technology, (b) diversity in knowledge, skills, and attitudes of clinicians, patients, and family caregivers regarding the integration of electronic QOL assessments in care, and (c) the need to understand organizational context and priorities in using QOL assessment data. Conclusion: The process of designing and integrating a QPSS in palliative care for patients with life-limiting conditions and their family caregivers is complex and requires extensive consultation with clinicians, administrators, patients, and family caregivers to inform successful implementation