Nurse Call via personal and public devices; - some usability findings from a CSCW inspired study

1. Nurse Call via personal and public devices; - some usability findings from a CSCW inspired study Lill Kristiansen Telematics, NTNU / NSEP

2. The nurse call system is for patients and nurses • Norwegian: Pasientsignalsystem • But this study is not really about ”the patient as a user” (even though this is the title of this session) • Based on the presentation yesterday (Kaufmann) I may want to draw your attention to an unpublished study from 2004 • http://org.ntnu.no/knappen/ (Norwegian)

3. As Ole Alsos stated yesterday (slightly rewritten): ”When considering a system for patients the nurses matters!” The study reported here focus on the nurses’ side of a nurse call system 2004: ”Knappen””The (enhanced patient) button”

4. Background HCI and CSCW: • The study by Svanæs et al. ‎[10] is reporting that social, physical and bodily aspects influenced the usability. • Several papers (such as ‎[4] and ‎[10]) are pointing out the usability in groupware applications may benefit from methods from CSCW • HCI studies are traditionally often carried out in a controlled lab setting (often 1 person and 1 machine ) • CSCW is traditionally more qualitative oriented

5. Our study: The background • A CSCW-inspired study • Studying interrupts by wireless devices (mobile phones) user for nurse calls • Several former studies (Scholl et al. ‎[9], McGillis Hall et al. ‎[7]) point out that wireless devices may come at the expense of unwanted interrupts. • The study by Harr and Kaptelinin ‎[5] points out that studies of interrupts should ideally be done with real users with real social relations and with real tasks. • Studying the existing system as deployed is the easiest way to obtain this

6. Concepts from CSCW • Cabitza et al. ‎[2] point out that redundancyplay important roles in clinical work. • Dourish and Bellotti ‎[3] points out that group awarenessmay be important in collaborative work. • These two concepts guided our studies • Interviews contains scenarios where redundancy among nurses were important • Pictures showing redundant data sources • Observing during a morning hand-over • Etc.

7. Nurse call plan Receive nurse call/signal Telephony / display The old/ new nurse call system simplified Manuell whiteboard Opt.:’Overhead page’ / Intercom Manual presence

8. WARD-2 (one observational site)Single bedded rooms ’sengetun’, bed courts

9. Method: rapid ethnography • “[A] collection of field methods intended to provide a reasonable understanding of users and their activities given significant time pressures and limited time in the field. • The core elements include limiting or constraining the research focus and scope, • using key informants, • capturing rich field data by using multiple observers and interactive observation techniques, • and collaborative qualitative data analysis.” • (From Millen, [14]).)

10. Plus: Quantitative data collection • We performed a simple test of the time delay in the system in the fall 2010. We tested with a stop watch and combined this with capturing of the screens via a handheld video camera which also included sound recording. • We did only observe the external behavior of the system; hence the tests did not formally require any technical skills.

11. Findings • This paper will report the findings relating to usability/GUI and group work • ”Plain” GUI issues will not be covered • like button is sometimes to the left, sometimes to the right etc. • CSCW issues and interrupts are mostly covered elsewhere (Kristiansen, CBMS, [6])

12. Findings: 1) Interrupt and delay • A nurse call from a toilet was activated, and we (all 3) saw and heard this on the presence panel in the pause room. Ann went to help the patient, while Betty continued to talk to me (the researcher). Sometime later Betty’s phone started to ring. • Talking to her while her phone was ringing for 15 sec. was indeed annoying and interruptive. • Long before Betty’s phone stopped ringing, we both saw (via line of sight) that Ann entered the toilet, and we also saw that the presence panel now showed a green light indicating that this nurse call was now answered, and that a nurse was present in the room (while the phone was still ringing). • Quantitative measures confirmed these delays (30 sec.)

13. Finding 2: Awareness from fixed presence panel • At one occasion we heard a new nurse call, and turned our head to see the number. However, we realized that the new nurse call disappeared before we managed to see it. Instead other (green) signals were shown. • We had to wait for approximately 20 sec. before the (not any longer new) red signal showed up again. • However, the nurses themselves never expressed that the red signal was showing to short time. Instead they complained about the phone ringing too much, and the lack of the displays in the corridor ceiling.

14. Finding 3: On design context • The concept ”design context” is used by Svanæs and Gulliksen, 2008 [11] • Our document studies shows that the system is delivered by 3 vendors (Imatis in Norway, BEST(best.se) and cisco). • The redundancy between the fixed system and the Imatis system is highlighted in the notes from the experience workshop, but is less visible in materials from Imatis.no. This clearly indicates that the various vendors have different business interests.

15. Conclusions relating to methods: • Interrupt and awareness studies should be done in real setting (with real teams, real tasks etc) • Performing our interviews in the hospital (in a room with a presence panel) proved useful • Talking to nurses (in quiet periods) in rooms where the nurse call system was active proved useful (experiencing interrupts from the devices ourselves) • Unstructured, focused observations proved useful, but require consent from the ethical committee.

16. Conclusions (cont’d) • Usability is more that just the GUI, the organization ”at the all ends” matters. • Nurses, patients, relatives • Usability in teams =/= simple usability • Rapid ethnography helped us identify several collaborative issues related to usability • Usability may be studied also after deployment • The design context (commercial partners, existing system) etc. Must be taken into account when proposing (realistic) design changes

17. Hospital challenges • We cannot just deplay a new IKT artefact (prototype) in in the hospital: • Lab settings may prove useful, • The empty bed area at St.Olavs proved useful to us • May be used as an extended ’lab’ in some pretests of a

18. Bigger ”lab” areas

19. References • Bjønness, R. (2007), Forståelse av Klinisk Arbeid gjennom Empiriske Metoder,master thesis ntnu (in Norwegian), http://daim.idi.ntnu.no/masteroppgaver/IME/IDI/2006/1145/masteroppgave.pdf • Cabitza, F., Sarini, M., Simone, C., and Telaro, M. (2005). When once is not enough: the role of redundancy in a hospital ward setting. In Proc. GROUP '05. ACM, New York, NY, 158-167. • Dourish P and Bellotti. V (1992). Awareness and coordination in shared workspaces. In Proc. CSCW '92. ACM, 107-114. • Gennaria,J.H, et al. (2005) Asynchronous communication among clinical researchers:.., International journal of medical informatics, 74(10), 797-807 • Harr, R. and Kaptelinin, V. (2007). Unpacking the Social Dimension of External Interruptions. GROUP’07, 399-408. • Kristiansen, L. (2011), Nurse calls via personal wireless devices; some challenges and possible design solutions. Proc CBMS2011, IEEE (in press)

20. Ref. cont’d • McGillis Hall, L., Pedersen, C. and Fairley, L. (2010), Losing the moment: Understanding interruptions to nurse’s work, JONA, 40(4), pp. 169-176, • Millen, D. R. (2000). Rapid ethnography: time deepening strategies for HCI field research. Proc. DIS '00. ACM, New York, NY, 280-286. • Scholl, J. et al. Managing communication availability and interruptions: a study of mobile communic. (..) , In Pervasive, 2007, pp. 234-250. • Svanæs, D., Alsos, O.A. and Dahl Y.,(2010) Usability testing of mobile ICT for clinical settings: Methodological and practical challenges, International journal of medical informatics [1386-5056]vol:79, e24-e34 • Svanæs D. and Gulliksen J. (2008). Understanding the context of design: towards tactical user centered design. NordiCHI '08, 353-362. • Ukwitegetse, R.S., (2011), Pasientsignalsystemet; - samspill mellom IKT og sengetunsorganisering, (Nurse call system; - imterplay between ICT and bed court organisation), Master thesis, ntnu (In Norw.) url: http://daim.idi.ntnu.no/masteroppgave?id=5917

21. BEST and Imatis working together

22. A general finding on the interview method in hospital • Health care workers availability for interviews may be somewhat limited • It helps to state clearly that of course the may interrupt the interview if urgent matters pops up • This also allow us to observe interrupts in practice • Interrupts from knocking on the door • Allowing us to observe the (fixed) awareness technology in use during the interview

23. Discussion • Bjønness [1] concluded that his lab-simulations (NSEP usability lab) did not capture real collaborative working and interrupts • If assuming that redundancy is important, he might have seen that having 1 nurse and 1 physician was too little • Traditionally HCI has more focus on quantitative data than what CSCW has. • But interpretive, qualitative studies proved usefull also in identifying HCI issue relating to awareness and coordination

24. Interrupts / In a real organization… • Harr&Kaptelinin: Argues that interrupt studies should be carried out ”for real” • in real organizations • with real users • having real social relationsships • performing real tasks • Creating your own working prototype may be done, • but being allowed to run and evaluate it is a real hospital environment is ”somewhat challenging”

25. Adressebok med oppdatert statusEksempel på telefoni/status appl. 1/2 • The 3 social cues are set independently. • In Figure all the 3 different context cues are set for all persons. • JL is currently selected. • A phone call to JL is initiated by selecting ‘Kontakt’, while a text message is initiated by selecting ‘Besked’ (Danish for ‘message’).

26. Adressebok med oppdatert statusEksempel på telefoni/status appl. 2/2 Availability status and personal activity (Y = yellow). Modified from [13] and translated into English