NoKoBit2012, Bodø, Norway

1. 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

2. Content • Former work • The case description • nurse calls / pasientsignal (existing) • nurse message / pasientmelding (new) • Method • Findings and discussion • Conclusion

3. Definisjon av ”forstyrrelse” • Begrepene forstyrrelseogavbrytelsekan 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

4. 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!)

5. 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.

6. What is the single most important need? (As seen from patients and nurses) The single most important need as seen by patents and nurses resp. Modied from Hallstrøm and Elander (2001).

7. 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

8. Content Former work The case description nurse calls / pasientsignal (existing) nurse message / pasientmelding (new) Method Findings and discussion Conclusion

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

10. Nurse call today (pasientsignal) …with new functionality (nurse message / pasientmelding)

11. 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) Pleierens skjerm (t3) Pasientens skjerm (t4)

12. Content • Former work • The case description • nurse calls / pasientsignal (existing) • nurse message / pasientmelding (new) • Method • Findings and discussion • Conclusion

13. Research strategies (Based on McGrath (1995) as shown in Alsos (2011))

14. Workshop pictures (low-fi) Rompanel /Tilstedepanel(grå plate) Pasientterminal (grå plate) Trådløs telefon (grå plate) ”Søsterklokke” (grå plate) Personsøker (grå plate)

15. 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)

16. 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

17. 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?)

18. 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

19. 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 ”

20. 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)

21. 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)

22. Kaffekopp Info (spørsmål) WC Smerte (/smerte i kne) GUI for patients: Two proposals • Help 5-10 min • Urgent (haster) • Question (spørsmål) Note: Left: Urgent = todays normal nurse call in the same GUI Note:Shows only the new nurse messages, Nurse call is in separate GUI by using the draw string

23. 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)

24. 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

25. 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

26. 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)

27. Questions?

28. 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