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New type of nurse message from patientto manage interruptions (forstyrrelser):

Feedback from nurses

NoKoBit2012, Bodø, Norway

Av Maja Selseth,Tor Erik Evjemo og Lill Kristiansen(basert på masteroppg. til M.S. )

Presentert av: Lill Kristiansen, telematikk, ntnu, lillk@item.ntnu.no

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Content

Former work

The case description nurse calls / pasientsignal (existing) nurse message / pasientmelding (new)

Method

Findings and discussion

Conclusion

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Definisjon av ”forstyrrelse”

Begrepene forstyrrelse og avbrytelse kan brukes nesten synonymt.

Bokmålsordboka definerer begge begrepene som avbrudd samtidig som forstyrrelser også kan bety uro, støy og/eller uorden.

Vi ser på grenselandet mellom støy og avbrudd

Vi finner ordet forstyrrelse å være mest dekkende. Vi legger ikke noe negativt i ordet forstyrrelse i seg selv

En forstyrrelse og et avbrudd kan være uønsket, ønsket eller livsnødvendig (akutt hjertestans) Saken kan også se forskjellig ut fra den som forstyrrer og

den / de som mottar forstyrrelsen

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Former work on (external) interruptions

”[A]n understanding of an interruption event in the context of an interpersonal relation between the interrupter and interruptee can only be achieved by taking into account the past and the potential future of the relation”. (Harr og Kaptelinin 2007:404). Dette indikerer at studier om forstyrrelser bør skje i ekte

sosiale relasjoner (f.esk. kolleger som regelmessig jobber sammen)

De påpeker også at ekte arbeidsoppgaver er ønskelig Dette kan være utfordrende i sykehus (pasientrisiko!)

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Former work from hospitals

Minnick, Pischke-Winn og Sterk (1994) ser på trådløs kommunikasjon for pleiere, og beskriver at pleierne kan ha behov for å ”go off system” Altså kunne fokusere på den pågående arbeidsoppgaven

uten forstyrrelser fra trådløst kommunikasjonssystem

Dagens trådløse telefon fører til forstyrrelser av negativ art

Scholl et al. 2007 (om uønskede forstyrr. sett fra legen) Kristiansen 2011 (pleiere om uønsket og unødvendige

forstyrr. )

Mayo og Duncan (2004) indikerer at forstyrrelser er en av hovedårsakene til medisineringsfeil.

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What is the single most important need? (As seen from patients and nurses)

Needs Patients (n=69) (%)

Nurses (n=89) (%)

Average

Competentcaregivers

26 38 33

Communication 25 11 18

(other factors)

Treatment by health care staff

10 18 14

Contact with relatives

9 0 4,5

Continuity of care

7 0 3,5

The single most important need as seen by patents and nurses resp. Modied from Hallstrøm and Elander (2001).

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Primary nursing (PN) vs team nursing (TN) vs functional nursing (FN) (Pontin)

PN is considered good in order to ”see the whole patient” Meaning 1: A responsible nurse for the whole stay, which should

as much as possible also participate in the morning round (visitten) and in daily nursing

Meaning 2: One responsible nurse for each shift (which is supposed to respond to nurse calls from this patient if possible)

Other variants of PN

But collaborative work is needed also with all sorts of PN, if the primary is busy, someone else may need to visit the patient in due time (Kristiansen, 2011), (some mix with TN)

Continuity of care may be supported by more visits by same primary nurse, if nurse can know that the issue is less urgent (our design idea)

FN: One gives medicine, one handles food (for many patients) TN and FN are considered to give more complex

communication, and may need more coordination between nurses

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Content

Former work

The case description nurse calls / pasientsignal (existing) nurse message / pasientmelding (new)

Method

Findings and discussion

Conclusion

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Existing system with nurse call first to primary listed nurse’s wireless phone

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Nurse call today (pasientsignal)

…with new functionality (nurse message / pasientmelding)

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Sketch: Nurse message received ”as an SMS” (less sound, asynchr.)

Designet med sikte på redusert forstyrrelse Basert på obsevasjon /intervjuer rapportert i Kristiansen

(2011), detaljer i Selseth (2011) Merk tidslinje med mulig avstand i tid mellom t2 og t3

Pasientens skjerm (t1)

Pleierens skjerm (t2)

Pasientens skjerm (t4)

Pleierens skjerm (t3)

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Content

Former work

The case description nurse calls / pasientsignal (existing) nurse message / pasientmelding (new)

Method

Findings and discussion

Conclusion

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Research strategies

(Based on McGrath (1995) as shown in Alsos (2011))

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Workshop pictures (low-fi)

Pasientterminal (grå plate)Trådløs telefon (grå plate)

”Søsterklokke” (grå plate)Personsøker (grå plate)

Rompanel /Tilstedepanel(grå plate)

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Workshop each of 3 hours

Step 1 (15 min) Information

Step 2 Scenarioes (1h 45 min) Todays practice around morning meeting and the call plan Scenarioes involving todays system (in bed room)

Receiving odays tphone call and nurse call (while ”busy”)

Scenarioes involving the new functionality (in bed room) Receiving new patient messages

I need help I have pain I want something to drink

Step 3 Focus group discussion (50 min)

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Content

Former work

The case description (existing functionality) nurse calls / pasientsignal

The case description (sketch of new functionality) patient message / pasientmelding In addition to existing nurse call system

Method

Findings and discussion

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Findings (differences between ward units)

In the use of today’s wireless nurse call system A1 hardly use the wireless part of existing nurse call sys. In the medical conditions of the patients, and the use of

isolation rooms, and hence in the response times before visit to the

patients room (from 20-40 sec. to 2-4 min on average)

In how the interruptive factors of todays nurse call is perceived This difference is larger between the wards, than between

the individual nurses Those using the wireless phone the least find it most

noisy / disturbing (chicken or hen?)

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Findings about 2 ”patient types”

The nurses describe 2 types of patients today The ”over-consumers” (wolf, wolf!) The ”under-consumers” (ikke så farlig med meg….)

Nurses believe that patient message may help the under-consumers to iniate help (via new nurse message)

Nurses are sceptical to overconsumers in the new system: Will they still use the more urgent button also when in need of a

cup of coffee?

IMPORTANT: Some patients cannot be expected to use the new system: Must be a GUI for nurses to deactivate this new function (and use

only existing nurse call system) –per patient

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New message/ new sound”En forstyrrelse av verdi”

SP-F (A3): “Å få slike beskjeder mens man står med alt alvorligere ting da, det er jo forstyrrende. (..) du er kanskje inne i en sånn samtale som er litt viktig da også er det noen som vil ha en kopp kaffe og du blir jo da satt ut litt sånn ett halvt sekund uansett, liksom”

Forsker: “Hvis du sammenligner det med å få en melding ‘Jeg vil ha en kopp kaffe’ mot det at du får et pasientsignal på den tradisjonelle måten av en pasient som dere er på en måte litt usikker på tilstanden på, om det da kan være bedre å få en slik melding (…)”

SP-F (A3): “Ja, det er et poeng det altså. Du får jo kanskje signalet og blir forstyrret uansett, men da vet du hva det er [ved pasientmelding]. Det er bra ”

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Findings about redundancy between the nurses (if primary is busy)

”…at det bare er jeg som får den meldingen, det syns jeg er veldig skummelt (….) [Det ] blir veldig ansvarsfullt på en måte å ha den meldingen alene”

”Det er et pluss med konkret info om hva pasienten ønsker, for da kan terskelen for å be andre om å gjøre det bli lavere”

Videresending mellom pleiere som en manuell prosedyre er ønsket

Dette anses som viktig ny funksjonalitet for koordinering og overlapp mellom pleiere (funksjonell redundans)

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Findings/discussion: GUI for nurse

Proposal to utilize other devices since the phone is in the pocket (and hence invisible, even sometimes untouchable due to contamination issues) Patient terminal Digital nurse watch The room panel (in coded form)

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Help 5-10 min

Urgent (haster)

Question (spørsmål)

Note: Left: Urgent = todays normal nurse call in the same GUI

GUI for patients: Two proposals

Kaffekopp

Info (spørsmål)

WC

Smerte (/smerte i kne)

Note:Shows only the new nurse messages,

Nurse call is in separate GUI by using the draw string

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How much integration and redundancy?

Full integration with fixed nurse call system: Patient messages may be displayed on fixed displays such as room panel inside each room (with code) Plus: More redundancy Minus: Too much interrupts / warnings to all of ”low prio”

messages aimed for the primary nurse

No integration:As our proposal, but add functionality to forward message to colleage + a snooze function

Medium solution: Integrate patient message with fixed IP-based devices (sengetunsPC / new e-whiteboard) located in work area (but not with fixed nurse call system)

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Need for a hands free solution

The idea is that a nurse may respond later for ”less urgent matters”

If this depend on patient-ID (room number), nurses need some ”at a glance function” because They are busy with their hands Easier to look at (shorter interrupt before ignore, less

negative impact can be assumed) Contamination issues (isolation rooms)

Some at a glance function is probably useful in all cases, also in cases when the nurse can trust the judgement of the patient

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Conclusions

Workshops with nurses introduced new requirements for the new patient message: forward and snooze

Need for hands free operation was confirmed

Patient’s GUI need more research (involving patients as well)

Contextual issues: Practical (Hands busy), different patient ”types”, different

medical conditions, different layout of the ward, different role of the management, interrupt and ”helping

out for a collegue” are socially/culturally dependent All this calls for realistic testing in a real environment

(field experiement) in a later phase

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Future work

Analyse more findings from the workshops, of current articulation work, about methodological issues.

+ Build more prototypes (using the arctis tool for model driven design and quick prototyping)

More workshop testing, later a field experiement testing (after REK approval)

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Questions?

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Patient safety: Testing in later phases of the project, Selseth(2011) Possible to test with ”double systems” as a field

experiment with good realism of most aspects