Nurse calls via personal wireless devices; some challenges and possible design solutions

1. Nurse calls via personal wireless devices; some challenges and possible design solutions Lill Kristiansen, Dept. of Telematics, ntnu, Norway lillk@item.ntnu.no

2. Content • Introduction to nurse calls in the Norwegian context • Former work from health care and research questions • Methods • Findings • Design proposals • Future work

3. The old nurse call (signal) system (simplified) Manual whiteboard Opt.:’Overhead page’ and/orIntercom-calling Manual presence

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

5. Collective work vs individual phone • Continuity of care vs quickest possible response • Previously: Collective displays • Nurses ’picked up’ a signal and answered • Now: Delivery to individual personal phone • Aim: ”Focus the delivery of the nurse call, which will again benefit the patient”

6. Former work from health care • Interrupts and suboptimal communication is a problem in hospitals • Coiera and Tombs, McGillis Hall, Scholl et al. ++ • Health care workers are highly mobile • Bardram and Bossen, ++ • Redundancy is useful in hospitals • For coordination (Cabitza et al. ) • For reliability • Ref. Accident in Norw. hospital last week, IP-network was down, hospital in ad hoc manner used GSM phones

7. Research questions • Are interrupts caused by nurse calls on the wireless devices (phones) problematic? • If yes, under what circumstances? • What are the implications for design at a detailed level? • Our aim (as technically skilled designers) is that the answer to shall be useful for ICT persons in the hospital handling changes in the existing system as well as for vendors building new nurse call systems.

8. General former work critical to ”smart systems” • Brown and Randell: • Building a ”context sensitive phone” that does not ring during a passionate embrace... • This is a false scenario, it is equivalent to building an intelligent computer • Proposes to use context ’defensively’ • Ackerman: The socio-technical gap • How can a technical system successfully ignore the need for context and nuances

9. Generalized questions for mobile workers in tight teams, local mobility • How does a change from fixed and public to personal and wireless devices impact: • Group awareness and coordination • Including a change in unwanted interrupts and/or the ability to handle the interrupt • How can redundancy of data among various devices be utilized to redunce the impact of the interrupt? • Is ”context-awareness” (adaption inside the technical system) needed? • What are the success criteria for automatic context changes and when should that be avoided and leave the judgement to the humans?

10. Analytical concept: redundancy • Cabitza et al. (2005): • Redundancy of effort (human or computer) • double checking of medication, two computers carrying out independent calculations (more resources, more reliable) • Redundancy of data (human, paper or computer) • The same nurse call is displayed on several fixed and wireless devices. • The same (or related data) on whiteboard and in an ICT system • Several nurses know (in their head) about the same patient • Redundancy of function (humans or computers) • Several entities are capable of carrying out the same function • Basic nursing skills (standardization of education) • Several applications running on the same type of servers • The statistical mechanism ”the law of big numbers”

11. Group Awareness • Definition: The understanding of who is working with you, what they are doing, and how your own actions interact with theirs [Dourish and Bellotti, 1992]. • Group awareness may be totally ’virtual’ (ICT-mediated) • As in distributed open source projects: emails, IM, forum,.. • Co-operation between hospital and GP/prim. Dr. is often this way • Formal sources inside hospital may be: • handover meeting , EPR • Often partly obtained via informal sources • F2F, oral communication, visual line of sight, …

12. Method: Rapid ethnography (Millen) • 3 hours passive observation during telephony training • Document studies • notes on experiences from nurses during phase 1 • Doc. studies of training material • emails • Obsevations at 2 wards (total of 12 hours approx.) • Approved by REK (ethical commitee) • Clarifying questions and talks when clinical status allowed • Interviews with 2 head nurses (2 x 50 min. approx.) • Observations and interviews were focused on redundancy, coordination and interrupts

13. Interviews and observations

14. PC-client to set up the responsibilities per room (i hht bemaningsplan) Ignore / timeout Pasient Reject Accept Patient signal system: animation PC på sengetun Rompanel Anropspanel Våtsone Pasientpanel Pasientterminal Vaktromsapparat

15. St.Olav: Call plan • Redundancy of function is directly related to the call plan ruling the delivery of nurse calls to the phones (Imatis client on a PC in the nurse call station) • Ignore, reject: Who serves as backup nurses? • The tension between quick response and ’continuity of care’ • Obviously also redundancy of data typically via fixed devices contributes to awareness and flexibility in real work (and the building’s floor plan / line of sights matters as well)

16. Bed area / bed court / ”sengetun”(reducing walking distance)

17. Unplanned business/coordination • “The best thing with the system is that I am available everywhere [“when I am following a patient to the X-ray building”] • Useful to receive phone calls when mobile • (Some issues are known by a particular person) • (Not useful to receive nurse calls when mobile ourside the ward) • Nurses need to work collectively: • “The optimal solution is that the primary responsible [nurse] follows up on a nurse call as much as possible, and that the whole group –we are a small group- functions as a backup” • ”Reject” / ”Ignore” + the round robin function in the call plan for nurse calls caters for some types of busy hands

18. Interrupts during communication with patients/relatives • It is interruptive and also rude to the communication partner to receive nurse calls during a phone call • This related to an ongoing phone call interrupted by ringing from a nurse call (signal) • This situation may be automatically detected • Interrupts from nurse calls (or phone calls) when having ”a difficult conversation” with patient or relative • This related to F2F communication interrupted by ringing • Ringing may be phone call or nurse call signal • This involves human judgement (do not automate) • Unlikely that teh system may detect what is ”difficult” and compare the importance of this situation with an unstable patient on the next room

19. Interrupts from nurse calls during phone conversations: Proposal • The most important negative finding highlighted by almost all of the nurses was the following: • It is interruptive and also rude to the communication partner to receive nurse calls during a phone call. Bip! Bip! Bip! • Suggestions: • Automatically avoid the nurse call to be delivered on phone (server side). Or avoid the sound on the ear (on the endpoint) • Use the presence panel for peripheral group awareness

20. Proposal for lunch and ”difficult convenversation” • Allow nurses to use a status field (beyond binary Yes/ -) • Allow other users to see this status L: lunch M: Meeting IPV Etc (use icons)

21. Options on the status fields • One may set timers on these: • Lunch break: • 20 min. pause from nurse calls • May allow or disallow phone calls during the lunch • Many nurses prefer to be available for calls from physicians during the lunch break • ’important visit to patient’: • default 10 min, • or set other time • or maybe (?): ”until manually turned on again”

22. Automatic vs human judgement • Silent/no delivery of nurse call during phone call seems sensible to automate, since the system knows when a phone call is ongoing • When hands are busy / user inside patient room: • Impossible to ’guess’ this for the ICT system • Do not automate this • Do not assume manual updates at all times for all types of status fields • Keep the system ”fitted for all types of contexts” • 3 choices ’accept’, ’reject’ , ’ignore’ at all times during normal yes (ja) status • Remember that the fixed nurse call system is also showing the nurse calls

23. Future work / CoCoCo project • CoCoCo: Communication, coordination and context in hospitals • 1 PostDoc + 1 PhD starting now • Study in more details how the physical layout of the bed areas may impact the coordination / the use of ICT • Study the values expressed by Pontin as ”human centered nursing philosophy” and by hospital architect as ”holistic model” • Values focus on qualitative aspects including • Gode samtaler....med pasient og pårørende

24. More future work • More quantitative and qualitative studies of the existing system • Measure todays response times and quality on the nurse calls, • as seen from the nurses and from the patients • A nurse is doing a master thesis now on this • Create some prototypes and test! • As sketched in this paper • May include location, status ++ • More use of teh fixed system for reduncancy

25. Questions?