State of Science in Alarm System Safety: Implications for Researchers, Vendors, and Clinical Leaders.

Alarm fatigue is a complex phenomenon that needs to be assessed within the context of the clinical setting. Considering that complexity, the available information on how to address alarm fatigue and improve alarm system safety is relatively scarce. This article summarizes the state of science in alarm system safety based on the eight dimensions of a sociotechnical model for studying health information technology in complex adaptive healthcare systems. The summary and recommendations were guided by available systematic reviews on the topic, interventional studies published between January 2019 and February 2022, and recommendations and evidence-based practice interventions published by professional organizations. The current article suggests implications to help researchers respond to the gap in science related to alarm safety, help vendors design safe monitoring systems, and help clinical leaders apply evidence-based strategies to improve alarm safety in their settings. Physiologic monitors in intensive care units-the devices most commonly used in complex care environments and associated with the highest number of alarms and deaths-are the focus of the current work.

Employing a user-centered cognitive walkthrough to evaluate a mHealth diabetes self-management application: A case study and beginning method validation.

INTRODUCTION: Self-management of chronic diseases using mobile health (mHealth) systems and applications is becoming common. Current evaluation methods such as formal usability testing can be very costly and time-consuming; others may be more efficient but lack a user focus. We propose an enhanced cognitive walkthrough (CW) method, the user-centered CW (UC-CW), to address identified deficiencies in the original technique and perform a beginning validation with think aloud protocol (TA) to assess its effectiveness, efficiency and user acceptance in a case study with diabetes patient users on a mHealth self-management application. MATERIALS AND METHODS: A total of 12 diabetes patients at University of Utah Health, USA, were divided into UC-CW and think aloud (TA) groups. The UC-CW method included: making the user the main evaluator for detecting usability problems, having a dual domain facilitator, and using three other improved processes: validated task development, higher level tasks and a streamlined evaluation process. Users interacted with the same mHealth application for both methods. Post-evaluation assessments included the NASA RTLX instrument and a set of brief interview questions. RESULTS: Participants had similar demographic characteristics. A total of 26 usability problems were identified with the UC-CW and 20 with TA. Both methods produced similar ratings: severity across all views (UC-CW = 2.7 and TA = 2.6), numbers of problems in the same views (Main View [UC-CW = 11, TA = 10], Carbohydrate Entry View [UC-CW = 4, TA = 3] and List View [UC-CW = 3, TA = 3]) with similar heuristic violations (Match Between the System and Real World [UC-CW = 19, TA = 16], Consistency and Standards [UC-CW = 17, TA = 15], and Recognition Rather than Recall [UC-CW = 13, TA = 10]). Both methods converged on eight usability problems, but the UC-CW group detected five critical issues while the TA group identified two. The UC-CW group identified needed personalized features for patients' disease needs not identified with TA. UC-CW was more efficient on average time per identified usability problem and on the total evaluation process with patients. NASA RTLX scores indicated that participants experienced the UC-CW half as cognitively demanding. Common themes from interviews indicated the UC-CW as enjoyable and easy to perform while TA was considered somewhat awkward and more cognitively challenging. CONCLUSIONS: UC-CW was effective for finding severe, recurring usability problems and it highlighted the need for personalized user features. The method was also efficient and had high user acceptance. These results indicate UC-CW's utility and user acceptance in evaluating a mHealth self-management application. It provides an additional usability evaluation technique for researchers.

The Imperative of Solving Nurses' Usability Problems With Health Information Technology.

BACKGROUND: Health information technology (IT) usability issues are a key concern for nurse executives and nurses. OBJECTIVES: The aims of this study are to understand usability pain points faced by nurses regarding the use of health IT, identify their impact and importance, discuss responsibilities, and develop possible solutions to improve the health IT-user experience for nurses. METHODS: Twenty-seven experts were interviewed including nursing leaders, informaticists, executives, engineers, researchers, and human factors experts across acute care, long-term care, and vendor settings. Semistructured questions guided the interviews, and content analysis was used to identify themes. RESULTS: Four themes emerged: 1) user experience pain points, 2) importance of the issues, 3) the responsibility gap, and 4) acting on usability issues. CONCLUSION: Nurses continue to endure significant health IT-usability issues that negatively impact patients, nurses, and healthcare organizations. Solutions include enhancing the voice of nursing at the national and local levels, creating a digital strategy for nursing, providing incentives to improve usability in health IT, and accelerating the understanding of nurses' work intended to inform and translate nurses' work into health IT design.

"I want to know everything": a qualitative study of perspectives from patients with chronic diseases on sharing health information during hospitalization.

BACKGROUND: Patient-centered care promotes the inclusion of the most prominent and important member of the health care team, the patient, as an active participant in information exchange and decision making. Patient self-management of a chronic disease requires the patient to bridge the gap between multiple care settings and providers. Hospitalizations often disrupt established self-management routines. Access to medical information during hospitalization reflects patients' rights to partner in their own care and has the potential to improve self-management as well as promote informed decision making during and after hospitalization. The objectives of this study were to elicit the perspectives of patients with chronic disease about desired medical information content and access during hospitalization. METHODS: This exploratory study incorporated a qualitative approach. The online survey included the research team created open and limited response survey, demographic and hospital characteristic questions, and the Patient Activation Measurement instrument (PAM®). Convenience and social media snowball sampling were used to recruit participants through patient support groups, email invitations, listservs, and blogs. The research team employed descriptive statistics and qualitative content analysis techniques. RESULTS: The study sample (n = 34) ranged in age from 20 to 76 (µ = 48; SD = 16.87), Caucasian (91%, n = 31), female (88%, n = 30) and very highly educated (64%, n = 22 were college graduates). The PAM® survey revealed a highly activated sample. Qualitative analysis of the open-ended question responses resulted in six themes: Caring for myself; I want to know everything; Include me during handoff and rounds; What I expect; You're not listening; and Tracking my health information. CONCLUSIONS: This study revealed that hospitalized patients want to be included in provider discussions, such as nursing bedside handoff and medical rounds. Only a few participants had smooth transitions from hospital to home. Participants expressed frustration with failures in communication among their providers during and after hospitalization and provider behaviors that interfered with patient provider communication processes. Patients also identified interest in maintaining their own health histories and information but most had to "cobble together" a myriad of methods to keep track of their evolving condition during hospitalization.

Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings.

BACKGROUND: In early 2016 the Partnership for Health IT Patient Safety released safe practice recommendations for the use of copy-paste for electronic health record (EHR) documentation. These recommendations do not directly address nurses' use of copy-forward to document patient assessments in flow sheet software in hospital settings. Similar to clinicians' use of copy-paste and copy-forward with progress notes, concerns exist about patient safety issues from the use of potential inaccurate or outdated information to achieve increased efficiency of documentation. METHODS: A multiple-methods approach-which included a literature review, litigation search, stakeholder analysis, and consensus opinion from experts from multiple disciplines-was employed. RESULTS: Four recommendations correspond closely with copy-paste guidance for EHR documentation from the Partnership: (1) Provide a mechanism to make copied-forward content easily identifiable, (2) Ensure that the provenance of copied-forward content is readily available, (3) Ensure adequate staff training and education regarding the appropriate and safe use of copy-forward in flow sheet software, if available, and (4) Ensure that copy-forward practices are regularly monitored, measured, and assessed. A fifth additional recommendation is made to improve the efficiency of data entry mechanisms, which may reduce patient safety risk. Emerging promising areas for innovation are to optimize interface usability and flow sheet content, use templates, use digital photographs, and eliminate work-flow steps with better methods for authentication and data entry. CONCLUSIONS: A thoughtful and measured approach to safe use of copy-forward in flow sheets by nurses in hospital settings is expected to result in improvements in efficiency of documentation, work flow, and accuracy of information.

Patients' Perceptions and Experiences of a mHealth Diabetes Self-management System.

Chronic diseases, including diabetes, constitute a substantial disease burden around the world. Mobile self-management systems now play a significant and increasingly important role in patients' disease management. Yet, patients' perceptions of these systems after longer-term use are largely unexplored. A random sample of 10 diabetes patients was assessed immediately after they exited a larger, 6-month randomized controlled trial on the use of a mHealth system called Care4Life. This descriptive, exploratory study assessed patients' perceptions and experiences of mHealth using a questionnaire and semistructured interview whose development was guided by the Technology Acceptance Model. Results indicated that patients saw clear benefits in using the technology and had favorable behavioral disease outcomes after using Care4Life. Suggestions for improving the system were highly individual despite the apparent homogeneity of the patient group. The study begins to fill the gap about the longer-term use of mHealth systems in chronic disease management and reflects the significance of individual needs for mHealth systems.

An evaluation of patients' experienced usability of a diabetes mHealth system using a multi-method approach.

OBJECTIVE: mHealth systems are becoming more common to aid patients in their diabetes self-management, but recent studies indicate a need for thorough evaluation of patients' experienced usability. Current evaluations lack a multi-method design for data collection and structured methods for data analyses. The purpose of this study was to provide a feasibility test of a multi-method approach for both data collection and data analyses for patients' experienced usability of a mHealth system for diabetes type 2 self-management. MATERIALS AND METHODS: A random sample of 10 users was selected from a larger clinical trial. Data collection methods included user testing with eight representative tasks and Think Aloud protocol, a semi-structured interview and a questionnaire on patients' experiences using the system. The Framework Analysis (FA) method and Usability Problem Taxonomy (UPT) were used to structure, code and analyze the results. A usability severity rating was assigned after classification. RESULTS: The combined methods resulted in a total of 117 problems condensed into 19 usability issues with an average severity rating of 2.47 or serious. The usability test detected 50% of the initial usability problems, followed by the post-interview at 29%. The usability test found 18 of 19 consolidated usability problems while the questionnaire uncovered one unique issue. Patients experienced most usability problems (8) in the Glucose Readings View when performing complex tasks such as adding, deleting, and exporting glucose measurements. The severity ratings were the highest for the Glucose Diary View, Glucose Readings View, and Blood Pressure View with an average severity rating of 3 (serious). Most of the issues were classified under the artifact component of the UPT and primary categories of Visualness (7) and Manipulation (6). In the UPT task component, most issues were in the primary category Task-mapping (12). CONCLUSIONS: Multiple data collection methods yielded a more comprehensive set of usability issues. Usability testing uncovered the largest volume of usability issues, followed by interviewing and then the questionnaire. The interview did not surface any unique consolidated usability issues while the questionnaire surfaced one. The FA and UPT were valuable in structuring and classifying problems. The resulting descriptions serve as a communication tool in problem solving and programming. We recommend the usage of multiple methods in data collection and employing the FA and UPT in data analyses for future usability testing.

A Modified User-Oriented Heuristic Evaluation of a Mobile Health System for Diabetes Self-management Support.

Mobile health platforms offer significant opportunities for improving diabetic self-care, but only if adequate usability exists. Expert evaluations such as heuristic evaluation can provide distinct usability information about systems. The purpose of this study was to complete a usability evaluation of a mobile health system for diabetes patients using a modified heuristic evaluation technique of (1) dual-domain experts (healthcare professionals, usability experts), (2) validated scenarios and user tasks related to patients' self-care, and (3) in-depth severity factor ratings. Experts identified 129 usability problems with 274 heuristic violations for the system. The categories Consistency and Standards dominated at 24.1% (n = 66), followed by Match Between System and Real World at 22.3% (n = 61). Average severity ratings across system views were 2.8 (of 4), with 9.3% (n = 12) rated as catastrophic and 53.5% (n = 69) as major. The large volume of violations with severe ratings indicated clear priorities for redesign. The modified heuristic approach allowed evaluators to identify unique and important issues, including ones related to self-management and patient safety. This article provides a template for one type of expert evaluation adding to the informaticists' toolbox when needing to conduct a fast, resource-efficient and user-oriented heuristic evaluation.

A qualitative evaluation of the crucial attributes of contextual information necessary in EHR design to support patient-centered medical home care.

BACKGROUND: Effective implementation of a Primary Care Medical Home model of care (PCMH) requires integration of patients' contextual information (physical, mental, social and financial status) into an easily retrievable information source for the healthcare team and clinical decision-making. This project explored clinicians' perceptions about important attributes of contextual information for clinical decision-making, how contextual information is expressed in CPRS clinical documentation as well as how clinicians in a highly computerized environment manage information flow related to these areas. METHODS: A qualitative design using Cognitive Task Analyses and a modified Critical Incident Technique were used. The study was conducted in a large VA with a fully implemented EHR located in the western United States. Seventeen providers working in a PCMH model of care in Primary Care, Home Based Care and Geriatrics reported on a recent difficult transition requiring contextual information for decision-making. The transcribed interviews were qualitatively analyzed for thematic development related to contextual information using an iterative process and multiple reviewers with ATLAS@ti software. RESULTS: Six overarching themes emerged as attributes of contextual information: Informativeness, goal language, temporality, source attribution, retrieval effort, and information quality. CONCLUSIONS: These results indicate that specific attributes are needed to in order for contextual information to fully support clinical decision-making in a Medical Home care delivery environment. Improved EHR designs are needed for ease of contextual information access, displaying linkages across time and settings, and explicit linkages to both clinician and patient goals. Implications relevant to providers' information needs, team functioning and EHR design are discussed.

Toward an Understanding of Wisdom in Nursing

As nurses, we seek to better understand how to gain nursing 'wisdom' and apply this wisdom in our daily practice. Yet the concept and experience of 'wisdom in nursing practice' has not been well defined. This article addresses wisdom-in-action for nursing practice. We briefly describe nursing theory, review the wisdom literature as presented in various disciplines, and identify characteristics of wisdom by analyzing four models of wisdom from other disciplines. We also present the ten antecedents of wisdom and the ten characteristics of wisdom identified in our analysis of the wisdom literature, discuss and summarize these antecedents, and conclude that understanding these ten antecedents and the ten characteristics of wisdom-in-action can both help nurses demonstrate wisdom as they provide nursing care and teach new nurses the process of becoming wise in nursing practice.

Quality of reporting randomized controlled trials in cancer nursing research.

BACKGROUND: Results of randomized controlled trials (RCTs) provide high-level evidence for evidence-based practice (EBP). The quality of RCTs has a substantial influence on providing reliable knowledge for EBP. Little is known about the quality of RCT reporting in cancer nursing. OBJECTIVE: The aim of this study was to assess the quality of reporting in published cancer nursing RCTs from 1984 to 2010. METHODS: A total of 227 RCTs in cancer nursing published in English-language journals and indexed in PubMed or Cumulative Index to Nursing and Allied Health Literature were reviewed using the Jadad scale, key methodologic index (KMI), and the Consolidated Standards of Reporting Trials (CONSORT) checklist to assess the quality of reporting methodological aspects of research and the overall quality of reporting RCTs. RESULTS: Adherence to reporting metrics was relatively low, based on the Jadad score (M = 1.94 out of 5, SD = 1.01), KMI scores (M = 0.84 out of 3, SD = .87), and adherence to CONSORT checklist items (M =16.92 out of 37, SD = 4.03). Only 11 of 37 items in the CONSORT checklist were reported in 80% or more of the studies reviewed. The quality of reporting showed some improvement over time. DISCUSSION: Adherence to reporting metrics for cancer nursing RCTs was suboptimal, and further efforts are needed to improve both methodology reporting and overall reporting. Journals are encouraged to adopt the CONSORT checklist to influence the quality of RCT reports.

Measuring nursing informatics competencies of practicing nurses in Korea: Nursing Informatics Competencies Questionnaire.

Informatics competencies are a necessity for contemporary nurses. However, few researchers have investigated informatics competencies for practicing nurses. A full set of Informatics competencies, an instrument to measure these competencies, and potential influencing factors have yet to be identified for practicing nurses. The Nursing Informatics Competencies Questionnaire was designed, tested for psychometrics, and used to measure beginning and experienced levels of practice. A pilot study using 54 nurses ensured item comprehension and clarity. Internal consistency and face and content validity were established. A cross-sectional survey was then conducted on 230 nurses in Seoul, Korea, to determine construct validity, describe a complete set of informatics competencies, and explore possible influencing factors on existing informatics competencies. Principal components analysis, descriptive statistics, and multiple regression were used for data analysis. Principal components analysis gives support for the Nursing Informatics Competencies Questionnaire construct validity. Survey results indicate that involvement in a managerial position and self-directed informatics-related education may be more influential for improving informatics competencies, whereas general clinical experience and workplace settings are not. This study provides a foundation for understanding how informatics competencies might be integrated throughout nurses' work lives and how to develop appropriate strategies to support nurses in their informatics practice in clinical settings.

Using a content analysis to identify study eligibility criteria concepts in cancer nursing research.

The aims of this study were to (1) identify and categorize study eligibility criteria concepts used in cancer nursing randomized controlled trials and (2) determine the extent to which a previously identified set of study eligibility criteria, based primarily on medical randomized controlled trials, were represented in cancer nursing randomized controlled trials. A total of 145 articles of cancer nursing randomized controlled trials indexed in PubMed or Cumulative Index to Nursing and Allied Health Literature and published in English from 1986 to 2010 were screened, and 114 were eligible. Directed content analysis was conducted until data saturation was achieved. Forty-three concepts categorized into eight domains were extracted from 49 articles published in 27 different journals. Most of the concepts identified were related to health status, treatment, and demographics domains. Although many concepts matched to the previously identified study eligibility concepts based on medical research, new concepts may need to be added to fully represent cancer nursing research. This study provides a solid foundation for future study of mapping the concepts to existing standardized terminologies to identify which systems can be adopted. Nursing researchers can use these eligibility criteria concepts as a guideline in structuring the eligibility criteria for their studies.

Research on nursing handoffs for medical and surgical settings: an integrative review.

AIMS: To synthesize outcomes from research on handoffs to guide future computerization of the process on medical and surgical units. BACKGROUND: Handoffs can create important information gaps, omissions and errors in patient care. Authors call for the computerization of handoffs; however, a synthesis of the literature is not yet available that might guide computerization. DATA SOURCES: PubMed, CINAHL, Cochrane, PsycINFO, Scopus and a handoff database from Cohen and Hilligoss. DESIGN: Integrative literature review. REVIEW METHODS: This integrative review included studies from 1980-March 2011 in peer-reviewed journals. Exclusions were studies outside medical and surgical units, handoff education and nurses' perceptions. RESULTS: The search strategy yielded a total of 247 references; 81 were retrieved, read and rated for relevance and research quality. A set of 30 articles met relevance criteria. CONCLUSION: Studies about handoff functions and rituals are saturated topics. Verbal handoffs serve important functions beyond information transfer and should be retained. Greater consideration is needed on analysing handoffs from a patient-centred perspective. Handoff methods should be highly tailored to nurses and their contextual needs. The current preference for bedside handoffs is not supported by available evidence. The specific handoff structure for all units may be less important than having a structure for contextually based handoffs. Research on pertinent information content for contextually based handoffs is an urgent need. Without it, handoff computerization is not likely to be successful. Researchers need to use more sophisticated experimental research designs, control for individual and unit differences and improve sampling frames.

Efficacy of a computerized simulation in promoting walking in individuals with diabetes.

BACKGROUND: Regular walking is a recommended but underused self-management strategy for individuals with type 2 diabetes mellitus (T2DM). OBJECTIVE: To test the impact of a simulation-based intervention on the beliefs, intentions, knowledge, and walking behavior of individuals with T2DM. We compared two versions of a brief narrated simulation. The experimental manipulation included two components: the presentation of the expected effect of walking on the glucose curve; and the completion of an action plan for walking over the next week. Primary hypotheses were (1) intervention participants' walking (minutes/week) would increase more than control participants' walking, and (2) change in outcome expectancies (beliefs) would be a function of the discrepancy between prior beliefs and those presented in the simulation. Secondary hypotheses were that, overall, behavioral intentions to walk in the coming week and diabetes-related knowledge would increase in both groups. METHODS: Individuals were randomly assigned to condition. Preintervention measures included self-reported physical activity (International Physical Activity Questionnaire [IPAQ] 7-day), theory of planned behavior-related beliefs, and knowledge (Diabetes Knowledge Test). During the narrated simulation we measured individuals' outcome expectancies regarding the effect of exercise on glucose with a novel drawing task. Postsimulation measures included theory of planned behavior beliefs, knowledge, and qualitative impressions of the narrated simulation. The IPAQ 7-day was readministered by phone 1 week later. We used a linear model that accounted for baseline walking to test the main hypothesis regarding walking. Discrepancy scores were calculated between the presented outcome and individuals' prior expectations (measured by the drawing task). A linear model with an interaction between intervention status and the discrepancy score was used to test the hypothesis regarding change in outcome expectancy. Pre-post changes in intention and knowledge were tested using paired t tests. RESULTS: Of 65 participants, 33 were in the intervention group and 32 in the control group. We excluded 2 participants from analysis due to being extreme outliers in baseline walking. After adjustment for baseline difference in age and intentions between groups, intervention participants increased walking by 61.0 minutes/week (SE 30.5, t(58 = 1.9, )P = .05) more than controls. The proposed interaction between the presented outcome and the individual's prior beliefs was supported: after adjustment for baseline differences in age and intentions between groups, the coefficient for the interaction was -.25, (SE 0.07, t(57 = -3.2, )P < .01). On average participants in both groups improved significantly from baseline in intentions (mean difference 0.66, t(62 = 4.5, )P < .001) and knowledge (mean difference 0.38, t(62 = 2.4, )P = .02). CONCLUSIONS: This study suggests that a brief, Internet-ready, simulation-based intervention can improve knowledge, beliefs, intentions, and short-term behavior in individuals with T2DM.

Exploration of the e-patient phenomenon in nursing informatics.

The availability of health information on the Internet has equalized opportunities for knowledge between patients and their health care providers, creating a new phenomenon called the e-patient. E-patients use technology to actively participate in their health care and assume higher levels of responsibility for their own health and wellness. This phenomenon has implications for nursing informatics research related to e-patients and potential collaboration with practitioners in developing a collective wisdom. Nursing informatics can use the data, information, knowledge, and wisdom (DIKW) framework to understand how e-patients and clinicians may achieve this collective wisdom. Nurse informaticists can use constructivism and Gadamerian hermeneutics to bridge each stage of this framework to illustrate the fundamentals of patient and clinician interactions and commonality of language to achieve a collective wisdom. Examining the e-patient phenomenon will help nurse informaticists evaluate, design, develop, and determine the effectiveness of information systems used by e-patients. The Internet can facilitate a partnership between the patient and clinician and cultivate a collective wisdom, enhanced by collaboration between nurse informatics and e-patients.

ICU nurses' evaluations of integrated information displays on user satisfaction and perceived mental workload.

Consolidated information from multiple sources (patient monitors, electronic medical records, infusion pumps, ventilators, medication references) may improve nurses' work and patient safety. Objective. Two hypotheses were tested, that integrated information displays (a) improve nurses' satisfaction and (b) lower perceived mental workload. Methods. In a counter-balanced, repeated measures design (integrated vs. traditional display) 12 ICU nurses performed realistic tasks using both display types. Results. Nurses' user interaction satisfaction was higher with the integrated display and it received more positive comments. Nurses' mean perceived mental workload scores were also lower, having significant differences in effort and frustration dimensions. A lower mental workload may reduce errors and improve treatment times. Integrated information displays have great promise, but technological factors such as bidirectional device communication must be addressed if these displays are to achieve their potential for improving patient safety.

Improving the Safety, Effectiveness, and Efficiency of Clinical Alarm Systems: Simulation-Based Usability Testing of Physiologic Monitors.

BACKGROUND: Clinical alarm system safety is a national patient safety goal in the United States. Physiologic monitors are associated with the highest number of device alarms and alarm-related deaths. However, research involving nurses' use of physiologic monitors is rare. Hence, the identification of critical usability issues for monitors, especially those related to patient safety, is a nursing imperative. OBJECTIVE: This study examined nurses' usability of physiologic monitors in intensive care units with respect to the effectiveness and efficiency of monitor use. METHODS: In total, 30 nurses from 4 adult intensive care units completed 40 tasks in a simulation environment. The tasks were common monitoring tasks that were crucial for appropriate monitoring and safe alarm management across four categories of competencies: admitting, transferring, and discharging patients using the monitors (7 tasks); managing measurements and monitor settings (23 tasks); performing electrocardiogram (ECG) analysis (7 tasks); and troubleshooting alarm conditions (3 tasks). The nurse-monitor interaction was video-recorded. The principal investigator and two expert intensive care units nurse educators identified, classified, and validated task success (effectiveness) and the time of task completion (efficiency). RESULTS: Among the 40 tasks, only 2 (5%) were successfully completed by all the nurses. At least 1-27 (3%-90%) nurses abandoned or did not correctly perform 38 tasks. The task with the shortest completion time was "take monitor out of standby" (mean 0:02, SD 0:01 min:s), whereas the task "record a 25 mm/s ECG strip of any of the ECG leads" had the longest completion time (mean 1:14, SD 0:32 min:s). The total time to complete 37 navigation-related tasks ranged from a minimum of 3 min 57 s to a maximum of 32 min 42 s. Regression analysis showed that it took 6 s per click or step to successfully complete a task. To understand the nurses' thought processes during monitor navigation, the authors analyzed the paths of the 2 tasks with the lowest successful completion rates, where only 13% (4/30) of the nurses correctly completed these 2 tasks. Although 30% (9/30) of the nurses accessed the correct screen first for task 1 and task 2, they could not find their way easily from there to successfully complete the 2 tasks. CONCLUSIONS: Usability testing of physiologic monitors revealed major ineffectiveness and inefficiencies in the current nurse-monitor interactions. The results indicate the potential for safety and productivity issues in completing routine tasks. Training on monitor use should include critical monitoring functions that are necessary for safe, effective, efficient, and appropriate monitoring to include knowledge of the shortest navigation path. It is imperative that vendors' future monitor designs mimic clinicians' thought processes for successful, safe, and efficient monitor navigation.

Nurses' responses to differing amounts and information content in a diagnostic computer-based decision support application.

Nurses often need to make quick decisions with incomplete diagnostic information while they are under time pressure. The use of a data-driven, computerized decision support approach in daily work activities has great potential to facilitate precise and context-sensitive use of the information implicit in nursing diagnoses. This study explored optimal information amounts and levels of information content for designing and implementing a diagnostic nursing decision support system. Specifically, the use of probability data for likely nursing problems and the preferred number of displayed nursing problems were presented to expert and novice nurses. The study used a counterbalanced, repeated-measures, and factorial design. The authors developed two scenarios: (1) a pneumonia patient with diabetes mellitus complications and (2) a patient with controlled diabetes who also had a bone fracture. A previously developed prototype for a diagnostic nursing decision support system was used to display the information. Eighteen novice and expert nurses from two hospitals in Korea participated. Results for the differing levels of content did not differ significantly with level of expertise, but the preferred amount of information was significant for the two groups of nurses. The differing information needs of novices and experts should be considered when designing future computer-based decision support.

A usability assessment of AHLTA in ambulatory clinics at a military medical center.

The investigators conducted a formal usability evaluation of the military's electronic health record known as Armed Forces Health Longitudinal Technology Application (AHLTA). Seventeen providers from different specialties in the ambulatory setting were interviewed and observed at a military medical center. Data were analyzed by human factors experts. Observations and interviews yielded four major usability findings: (1) limited AHLTA use during the actual encounter, (2) difficulties in obtaining situational awareness of the patient, (3) work-arounds with nonintegrated systems, and (4) frustrations in the use of the structured documentation. This assessment is congruent with usability concerns voiced in other military health system (MHS) and nonmilitary clinical systems. Improving the usability of future MHS clinical systems could lead to improved clinical decision making, patient safety, and increased information accuracy.