Evaluating Bar Coding‐Aided Medication Administration through Identification of Nursing Work Deficiencies

Health care information technology (IT) systems manage administrative and clinical processes more accurately and efficiently. However, their effects on clinical work flow are still not fully understood. In this article, we investigate the bar‐coded medication administration (BCMA) system for its effect on nurses working in inpatient departments. Evaluation is applied by examining work deficiencies before and after the IT system implementation based on a proposed nursing work model. A list of nurse‐perceived risks of work deficiencies related to the current BCMA system has been identified. Results show five main deficiencies that are mainly related to aspects of the IT environment and work schedule/process, including increased workload, IT systems downtime, unclear orders/task schedules, reduced time for patient‐care tasks, and redundant documentation. This study emphasizes the importance of understanding the reciprocal relationship between IT implementation and health care work system. © 2012 Wiley Periodicals, Inc.     

That's nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care

Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses’ perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses’ perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA.

Relevance to industry

By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.     

Effects of different physical workload parameters on mental workload and performance

The design and evaluation of an occupational task should include an assessment of mental workload, since excessive levels of mental workload can cause errors or delayed information processing. Physically demanding work that is performed concurrently with a cognitive task may impact mental workload by impairing mental processing or decreasing performance. The primary objective of this study was to determine whether there is a differential effect of various types of physical activity on both mental workload and cognitive performance. Objective and subjective assessment tools (heart rate variability and visual analog scale) were used as indicators of mental workload, while correct responses during an arithmetic task reflected levels of performance. Thirty participants (ages 18-24 years) performed a combination of tasks inducing both physical and mental workload. Type of physical effort, frequency of movement, and force exertion level were manipulated to alter the workload associated with the physical activity. Changes in subjective ratings generally corresponded to changes in both performance on the arithmetic task and objective mental workload assessment. Some discrepancies occurred at the highest physical force exertion level as participants perceived an increase in effort to maintain the same level of performance. Further research is needed to determine the force exertion threshold, beyond which the physical effort required interferes with mental workload and/or cognitive performance.

Relevance to industry

Technological advancements have increased the requirement for many workers to execute cognitive tasks concurrently with physical activity. When designing and evaluating such situations it is important to determine the interactive effects of these activities. A simple, uni-dimensional tool is suggested as a screening tool to identify situations requiring excessive or increased mental workload that many degrade performance or place additional stress on the individual.     

Sensitivity and diagnosticity of the 0.1-Hz component of heart rate variability as an indicator of mental workload

We investigated whether the 0.1-Hz component of heart rate variability (HRV) allows one to discriminate among levels of mental work stress induced by different types of tasks (diagnosticity) as well as among those induced by different levels of difficulty (sensitivity). Our 14 participants were presented 14 tasks of the Advisory Group for Aerospace Research and Development Standardized Tests for Research with Environmental Stressors battery in a repeated-measures design. Sufficient sensitivity was obtained for a discrimination between work and rest, but we found no support for a more fine-grained sensitivity. Concerning diagnosticity, only the grammatical reasoning task could be discriminated from all other tasks, indicating for this task a level of mental strain comparable to rest, which was in contrast with the results both for perceived difficulty and performance. We propose that HRV is an indicator for time pressure or emotional strain, not for mental workload, given that it seems to allow discrimination between tasks with and without pacing. Application of this research argues against using HRV as a measure of mental and especially cognitive workload, particularly where system safety or occupational risks may be at stake (e.g., when evaluating operator tasks or interface design in control room operations).     

Evaluating the effect of perceived mental workload on work body postures

Mental workload is a multidimensional construct that involves the characteristics of the task, individual factors, and the environment where the task is performed. Responses to tasks that are perceived as mentally demanding can exacerbate ergonomics risk factors affecting employee behavior and attitude, leading to risky actions such as awkward body postures, and consequently increasing physiological susceptibility to work-related musculoskeletal disorders. The present study looked to establish if the perception of mental workload can be affected by psychosocial work factors that generate changes in the environment in which humans must perform the tasks. The study also looked to determine if changes in perceived mental workload generated changes in the body postures undertaken to perform an activity to lay the foundation for future exploration into the influence of perceived mental workload over physical demands. The results of this study indicate, that an increase in the perception of mental workload is associated with worse body postures. This study is novel and contributes to overcoming an important shortcoming in the field of mental workload by considering the influence of psychosocial factors, keeping the physical load constant, on the perception of mental workload and its influence on body postures. This interaction between perceived mental workload and its effects on physical risk should be considered in occupational settings since often, employees are exposed to concurrent physical and mental demands that increase the likelihood of developing WMSDs.     

Putting the brain to work: neuroergonomics past, present, and future

OBJECTIVE: The authors describe research and applications in prominent areas of neuroergonomics. BACKGROUND: Because human factors/ergonomics examines behavior and mind at work, it should include the study of brain mechanisms underlying human performance. METHODS: Neuroergonomic studies are reviewed in four areas: workload and vigilance, adaptive automation, neuroengineering, and molecular genetics and individual differences. RESULTS: Neuroimaging studies have helped identify the components of mental workload, workload assessment in complex tasks, and resource depletion in vigilance. Furthermore, real-time neurocognitive assessment of workload can trigger adaptive automation. Neural measures can also drive brain-computer interfaces to provide disabled users new communication channels. Finally, variants of particular genes can be associated with individual differences in specific cognitive functions. CONCLUSIONS: Neuroergonomics shows that considering what makes work possible - the human brain - can enrich understanding of the use of technology by humans and can inform technological design. APPLICATION: Applications of neuroergonomics include the assessment of operator workload and vigilance, implementation of real-time adaptive automation, neuroengineering for people with disabilities, and design of selection and training methods.     

Integration of task networks and cognitive user models using coloured Petri nets and its application to job design for safety and productivity

Changes of task demands due to unforeseen events and technological changes can cause variations in job design such as modifications to job procedures and task allocation. Failure to adapt to job design variations can lead to human errors that may have severe consequences for system safety. Existing techniques for task modelling cannot adequately model how task networks can be adapted to changing work conditions and task demands. Therefore, there is a need to integrate task networks with cognitive user models that indicate how operators process information, make decisions, or cope with suspended tasks and errors. The work described here presents a tool for integrating task and cognitive models using coloured Petri nets. The cognitive user model comprises two modules of attention management (selective and divided attention), a module of memory management of suspended tasks and a module of work organization. Performance Shaping Factors (e.g., workload, fatigue and mental-tracking load) are calculated at any point in time to take into account the context of work (e.g., competing activities, errors and suspended tasks). Different types of human error can be modelled for rule-based behaviours required in proceduralized work environments. Simulation analysis and formal analysis techniques can be applied to process control tasks to verify job procedures, workload management strategies and task allocation schemes in response to technological changes and unfamiliar events.     

Mediating the intersections of organizational routines during the introduction of a health IT system

Public interest in the quality and safety of health care has spurred examination of specific organizational routines believed to yield risk in health care work. Medication administration routines, in particular, have been the subject of numerous improvement projects involving information technology development, and other forms of research and regulation. This study draws from ethnographic observation to examine how the common routine of medication administration intersects with other organizational routines, and why understanding such intersections is important. We present three cases describing intersections between medication administration and other routines, including a pharmacy routine, medication administration on the next shift and management reporting. We found that each intersection had ostensive and performative dimensions; and furthermore, that IT-enabled changes to one routine led to unintended consequences in its intersection with others, resulting in misalignment of ostensive and performative aspects of the intersection. Our analysis focused on the activities of a group of nurses who provide technology use mediation (TUM) before and after the rollout of a new health IT system. This research offers new insights on the intersection of organizational routines, demonstrates the value of analyzing TUM activities to better understand the relationship between IT introduction and changes in routines, and has practical implications for the implementation of technology in complex practice settings.     

Workload perception in drone flight training simulators

Workload perception was measured in a drone flight training Simulator computerized situation. There has been increasing research in recent years on the topic of Remotely piloted aircrafts (RPA). Eleven participants were tested for workload perception during a drone flight simulator training. Reliability, sensitivity and correlations were studied for the workload scale and its relationship with the simulator training tasks. Overall, there were clear effects of mental demand as showed in the workload perception during the training tasks. Reliability for the workload scale showed good score and sensitivity showed mental demand as the most important factor compared to the other parameters measured obtaining highest correlations with landing tasks and number of errors. In our results, we have seen how the AWT (adapted from NASA-TLX) showed good sensitivity in assessing the mental burden of participants. In our research, participants scoring higher in the mental demand subscale showed greater difficulty finishing training tasks, and also showed longer time delays in performing both training sections of the simulation. These types of tools measuring workload perception and virtual training systems can be used in future research, to see how this cognitive aspect affects piloting skills and its possible safety and training implications.     

Micromovements and discomfort associated with flight mission with helmet operation tasks with different levels of cognitive workload

When performing stationary tasks under elevated cognitive workload, individuals must perform continual muscle contractions to maintain stability of the body, resulting in fatigue of the postural muscles. When the muscles perform these contractions in a prolonged manner, the body potentially responds through small changes in body movements—micromovements that may lead to discomfort. The study purpose was to evaluate impact of cognitive load on micromovements. The micromovements were measured during three different cognitive workloads; low, medium, and high. The NASA-TLX score was used to evaluate the perceived mental workload and discomfort was assessed by visual analog scale. In total, 60 subjects (30 males and 30 females) were recruited and performed cognitive tasks that simulated flight operations such as changing the radio frequency based on air traffic control messages, balancing the fuel levels in simulated fuel tanks, and aiming a reticle in a designated moving target using the cyclic control. Cognitive load was defined by the frequency of events. Micromovements were defined by changes in the center of pressure (COP) of the seat pan and COP standard deviation. It was found that the high cognitive workloads had the highest NASA-TLX scores including mental demands, temporal demands, and effort. The neck area had the highest overall levels of discomfort followed by upper back. The highest standard deviation for COP shift and number of micromovements occurred for medium cognitive workloads. While there were some interesting trends, few trends reached a statistical significance due to high variability among subjects for the outcome variables.     

Cognitive workload analysis in rail signalling environments

When working in safety critical environments, such as railway signalling, technologies are often used to assist the operator in order to make safe decisions as well as to increase efficiency. Keeping mental workload at manageable levels is one of the most critical factors to ensure that tasks can be completed in a safe and effective manner. Numerous methods have been used to measure mental workload, but none of these have managed to show the use of distinct resource pools. This paper therefore measures the levels of usage of different cognitive processes when typical tasks are carried out in two railway signalling environments. To that end, the Multiple Resource Questionnaire is used. The aims of this paper are twofold: First, it establishes the value of the Multiple Resource Questionnaire as a technique in human factors. Second, it investigates and compares the cognitive resources required to carry out the railway signalling task in two different signalling environments.     

Modeling and predicting mental workload in en route air traffic control: critical review and broader implications

OBJECTIVE: We perform a critical review of research on mental workload in en route air traffic control (ATC). We present a model of operator strategic behavior and workload management through which workload can be predicted within ATC and other complex work systems. BACKGROUND: Air traffic volume is increasing worldwide. If air traffic management organizations are to meet future demand safely, better models of controller workload are needed. METHOD: We present the theoretical model and then review investigations of how effectively traffic factors, airspace factors, and operational constraints predict controller workload. RESULTS: Although task demand has a strong relationship with workload, evidence suggests that the relationship depends on the capacity of the controllers to select priorities, manage their cognitive resources, and regulate their own performance. We review research on strategies employed by controllers to minimize the control activity and information-processing requirements of control tasks. CONCLUSION: Controller workload will not be effectively modeled until controllers' strategies for regulating the cognitive impact of task demand have been modeled. APPLICATION: Actual and potential applications of our conclusions include a reorientation of workload modeling in complex work systems to capture the dynamic and adaptive nature of the operator's work. Models based around workload regulation may be more useful in helping management organizations adapt to future control regimens in complex work systems.     

Challenges of IT implementation for supporting collaboration in distributed organizations

The study focuses on the implementation of information technology (IT) for supporting collaboration in distributed organizations, i.e. organizations consisting of two or more semi-autonomous units in different geographical locations. Six case studies of IT implementation projects have been conducted, focusing on the challenges in the implementation process as seen from the perspective of the implementation team. Being of an exploratory nature, the study has identified a large number of issues that have influenced the different stages in the implementation process. The implementation context studied is found to imply several additional challenges for the implementation team, compared to ‘traditional’ intra-organizational IT implementation. This is a result of greater autonomy among the participating units, heterogeneous technological platforms and logistical barriers in the implementation activities. Resistance from the organizational units, technological incompatibility and lack of incentives for adopting new work practices, are identified as major barriers in the implementation. In general, the implementation is found to require a process of maturation, where implementers and adopters gradually develop an understanding of how the technology can support the organizational needs.     

Vigilance requires hard mental work and is stressful

OBJECTIVE: We describe major discoveries and developments in vigilance research. BACKGROUND: Vigilance tasks have typically been viewed as undemanding assignments requiring little mental effort. The vigilance decrement function has also been considered to result from a decline in arousal brought about by understimulation. METHODS: Recent research in vigilance is reviewed in four areas: studies of task type, perceived mental workload during vigilance, neural measures of resource demand in vigilance, and studies of task-induced stress. RESULTS: Experiments comparing successive and simultaneous vigilance tasks support an attentional resource theory of vigilance. Subjective reports also show that the workload of vigilance is high and sensitive to factors that increase processing demands. Neuroimaging studies using transcranial Doppler sonography provide strong, independent evidence for resource changes linked to performance decrement in vigilance tasks. Finally, physiological and subjective reports confirm that vigilance tasks reduce task engagement and increase distress and that these changes rise with increased task difficulty. CONCLUSIONS: Converging evidence using behavioral, neural, and subjective measures shows that vigilance requires hard mental work and is stressful. APPLICATION: This research applies to most human-machine systems that require human monitoring, particularly those involving automated subsystems.     

Experience of Stress,Musculoskeletal Discomfort,and Eyestrain in Computer-Based Office Work: A Study in Municipal Workplaces

A questionnaire on the use of information technology and stress at work was administered in 3 organizational units of a large municipality in 1996. Three hundred seventy-nine employees from several professional groups (e.g., architects, engineers, lawyers, clerical workers, draftspersons, etc.) answered the questionnaire. The age of the respondents ranged from 21 to 62 years (M = 45.2, SD = 8.7). Sixty-one percent of the respondents were women, and 39% were men. Psychosocial and organizational factors were related to the experiences of psychological stress as well as to musculoskeletal disorders and problems with vision. Women reported stress and all symptoms more often than men. The occupational groups differed according to the main sources of stress. Age associated with the concern about changes in tasks and responsibilities, lack of competence, and difficulties in using computers. In regression analyses, workload and haste, management and work atmosphere, work demands, defects of the workplace, and gender explained 42% of the experience of mental stress and anxiety. Twenty-five percent of the complaints of discomfort of the upper limbs were explained by workload and haste, management and atmosphere, defects of the workplace, hours of daily computer use, and gender. Nineteen percent of the problems with vision were explained by age, workload and haste, defects of the workplace, hours of daily computer use, skills in computer use, and stress related to computer use.     

Stress reactions to computer‐interactive tasks as a function of task structure and individual differences

The resurgence of interest in occupational stress has resulted in an emphasis on identifying work conditions that are potentially causal in generating stress reactions and psychological disorders among workers. Although a considerable knowledge base related to this topic has evolved, relatively little is known regarding the impact of computer technology on incidence of job stress. This issue is especially important for older workers, given the increased use of computers in most occupations, the aging of the workforce, and the changes in cognitive and physiological capacities that occur with increased age. The study reported in this article was concerned with developing a methodology to evaluate stress for computer‐interactive tasks as a function of the mental workload of the task and the age of the individual. Sixty‐five women ranging in age from 25 to 70 years performed three computer‐interactive tasks that varied as a function of information processing complexity and pacing requirements. The methodology encompassed physiological, subjective, and performance measures. Results indicated differences in sensitivity among the measures as a function of task and age. The data also indicated age differences in stress reactions and performance. The findings are discussed in terms of the suitability of computer tasks for older people.     

Mental workload and cognitive task automaticity: an evaluation of subjective and time estimation metrics

Abstract

The evaluation of mental workload is becoming increasingly important in system design and analysis. The present study examined the structure and assessment of mental workload in performing decision and monitoring tasks by focusing on two mental workload measurements: subjective assessment and time estimation. The task required the assignment of a series of incoming customers to the shortest of three parallel service lines displayed on a computer monitor. The subject was either in charge of the customer assignment (manual mode) or was monitoring an automated system performing the same task (automatic mode). In both cases, the subjects were required to detect the non-optimal assignments that they or the computer had made. Time pressure was manipulated by the experimenter to create fast and slow conditions. The results revealed a multi-dimensional structure of mental workload and a multi-step process of subjective workload assessment. The results also indicated that subjective workload was more influenced by the subject's participatory mode than by the factor of task speed. The time estimation intervals produced while performing the decision and monitoring tasks had significantly greater length and larger variability than those produced while either performing no other tasks or performing a well practised customer assignment task. This result seemed to indicate that time estimation was sensitive to the presence of perceptual/cognitive demands, but not to response related activities to which behavioural automaticity has developed.     

Strategic context and patterns of IT infrastructure capability

The importance of a firm's information technology (IT) infrastructure capability is increasingly recognised as critical to firm competitiveness. Infrastructure is particularly important for firms in industries going through dynamic change, for firms reengineering their business processes and for those with multiple business units or extensive international or geographically dispersed operations. However, the notion of IT infrastructure is still evolving and there has been little empirically based research on the patterns of IT infrastructure capability across firms.We develop the concept of IT infrastructure capability through identification of IT infrastructure services and measurement of reach and range in large, multi-business unit firms. Using empirical case research, we examine the patterns of IT infrastructure capability in 26 firms with diverse strategic contexts, including different industry bases, level of marketplace volatility, extent of business unit synergies and the nature of firm strategy formation processes. Data collection was based on a combination of quantitative and qualitative methods with multiple participants.More extensive IT infrastructure capability is defined as a combination of more IT infrastructure services and more reach and range. More extensive IT infrastructure capability was found in firms where: (i) products changed quickly; (ii) attempts were made to identify and capture synergies across business units; (iii) there was greater integration of information and IT needs as part of planning processes; and (iv) there was greater emphasis on tracking the implementation of long term strategy. These findings have implications for both business and technology managers particularly in regard to how firms link strategy and IT infrastructure formation processes.     

Studying the impact of interoperable electronic health records on workflow in ambulatory care

Many of the proposed benefits of health information systems, particularly those regarding efficiency, are assumed to be caused by changes in clinical provider and staff workflow. Assessing the extent to which electronic health records (EHRs) are having the expected effects and identifying barriers to anticipated improvements requires a detailed understanding of how such systems affect day-to-day work activities. This study utilized interviews and observations to develop prototypical workflow models of day-to-day activities in ambulatory practices, allowing activity changes due to the implementation of EHRs with varying levels of interoperability to be identified. Primary and specialty care practices from a multi-county region were sampled. Results showed that EHRs did not consistently improve efficiency, but variously reduced, added, or simply changed work tasks. The impact depended on the work process, level of interoperability, and type of provider involved, as well as aspects of the user interface design. Additionally, implementing EHR systems did not eliminate the use of paper from work processes. Implications for successful implementation and design of EHR systems are provided.Relevance to industryEffectively designing and implementing health IT systems in clinical settings requires an understanding of how the IT system will impact, and be integrated with, existing work activities, and how these impacts may depend on the level of interoperability achieved by the IT system.     

The relationship between safety climate and recent accidents: behavioral learning and cognitive attributions

OBJECTIVE: The association between accidents and subsequent work unit safety perceptions was assessed to address cognitive and behavioral changes following accidents. BACKGROUND: Many studies attempt to predict accident rates using measures of work unit safety, but effects vary considerably. Conversely, this study examined whether recent accidents may be positively associated with work unit safety perceptions, as suggested by behavioral learning mechanisms (increases in safety investments following accidents) or cognitive mechanisms (defensive attributions regarding accident causality). METHOD: Lagged squadron-level accident experience was correlated with work unit safety perceptions obtained through a 61-question safety climate survey administered to 6,361 individuals in U.S. Navy flight squadrons. RESULTS: Positive associations between minor or intermediately severe accidents and future safety climate scores were found, although no effect was found for major accidents. CONCLUSION: We suggest that accident history should be considered when examining work unit safety perceptions because recent accidents may be associated with higher safety climate scores. We did not find that this varies systematically with accident severity, and longitudinal research on additional samples is needed to further test this possibility. APPLICATION: This research may be used to refine measurement of work unit safety and to examine impacts of accidents or safety violations on workers' cognitive processes and group behavioral changes.