1. 1 Fixed and wireless nurse calls; - sources for awareness and interrupts Paper accepted at NoKoBit2010 Lill Kristiansen, telematikk, ntnu, lillk@item.ntnu.no lillk@item.ntnu.no (some animation on some slides, in particular on slide 5)

2. 2 2 Hva er Pasientsignal? (’Klokka’ ) English: nurse call (’The call bell’?) Pasientsignal (anrop/hasteanrop) utløses ved en pasientsammenheng for å tilkalle/alarmere helsepersonell Pasientsignalanlegget består av ulike trekkontakter, og trykknapper som anropspanel, rompanel, vaktromsapparat osv. Pasientsignalanlegget er tilkoplet ulike IKT-komponenter som Pasientsignalapplikasjon* på sengetuns-PC, Telefoni*, og Pasientterminal* [Dette] for å sikre en effektiv og presis tilkalling/alarmering av helsepersonell, som igjen kommer pasienten til gode *Se eget opplæringsmateriell for tilhørende IKT-komponent BEST.se Imatis.no

3. 3 3 Hva er sammenhengen? *Se eget opplæringsmateriell for Pasientsignalapplikasjon Tilkaller/alarmerer Utløser pasientsignal Pasient PC på sengetun På PC’en går et program 24-7 med tilgang til pasientsignalsoversikt, bemanningsplan, og pasientregistrering, kalt Pasientsignal- applikasjon* Sendes/vises Registrert i Bemannings- plan i Pasientsignal- applikasjon* Helsepersonell Telefon Vaktromsapparat Rompanel Tilhørende Pasientterminal Anropspanel Våtsone Pasientpanel BEST.se Imatis.no

4. 4 Picture from scenario/training I am presenting a CSCW-study, but here HCI seems to be a problem as well! In the real system things are different, remember the phone is inside the pocket! Tone Tonsrud Tilkalling rom 204 OKAvvis 14:45 12-05 SENG 102 14:40 Signalet må jeg nok avvise! Pasientsignal

5. 5 Pasient PC på sengetun Vaktromsapparat PC-client to set up the responsibilities per room (i hht bemaningsplan) Rompanel Pasientterminal Anropspanel Våtsone Pasientpanel Patient signal system: animation Ignore / timeout Reject Accept

6. 6 Methods Litterature studies from research field IS / CSCW / health informatics / pervasive-context 3 hours participation on telephony training for doctors (initial plan was training session for nurses) 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 Interviews with 2 head nurses (2 x 50 min. approx.)

7. 7 Former studies part 1 Coiera and Tombs, (1998): Propose wireless handheld devices due to the mobility of employees Study was sponsored by HP Scholl et al. (2007) (Tromsø) But wireless phone is more interruptive than fixed phone (Focus on the physicians, not nurses, no nurse calls) Bardram and Hansen (2004): Proposes AwarePhone (which requires location tracking) No nurse calls or phone calls from relatives Balka and Wagner (2006): Canadian wireless nurse call Issues of space, configurations and relations between users and ICT-staff in general terms

8. 8 Former studies part 2 McGillis Hall et al. (2010): Nurse calls may cause interrupts which again cause for medical errors "And there is no bread with the soup, and the patient is complaining that she has no bread, you know, and she [called] the nurse. The nurse is in the isolation room giving medications, and she thinks it is an emergency so she leaves the isolation room. [...].“ Did she not have any backup nurse(s)? Did she receive the call on her personal phone? Was patient unstable? Tjora (2004), Cabitza et al. (2005): Redundancy and (group) awareness may support coordination (save life)

9. 9 Former studies part 3 Ackerman (2000). There is a ”socio-technical gap”: The divide between what we know we must support socially and what we can support technically. ”When can [an ICT based] system successfully ignore the need for nuance and context? Brown and Randell (2004): The following is a false scenario! By building a context sensitive phone, when we enter a place where a ring tone would be inappropriate (such as a meeting, a cinema or a passionate embrace), our telephone automatically turns itself off, or becomes silent. This problem reduces to that of building an intelligent computer These former studies lead to the following questions:

10. 10 Our research questions: Which nuanced, contextual choices were previously (with the fixed nurse call system) carried out by the nurses in those cases when several patients needed help at the same time? Is the division of function between nuanced, contextual choices done by the nurses and choices done by the ICT system for nurse calls appropriate? Is the utilization and division of functionality between fixed devices (displays, panels and PCs) and wireless devices (phones) in the new system appropriate? Note: In particular we believe (following Ackerman and Brown and Randell) that some decisions shall be made by humans

11. 11 From UNN,Tromsø (Scholl et al.,2007) A study of doctors use of wireless phone long walking distances: a wireless phone is very convenient to place an outgoing call (or to reply to a page) But it is interruptive in many situations They find various workarounds such as: Not listing the wireless phone in the phone book  avoiding incoming calls Not carrying the wireless phone (leaving it in the office)  also to avoid incoming calls (avoids outgoing calls as well!) Forwarding calls to the pager  Unclear if this is ‘call forward unconditional’ (Umiddelbar omdirigering’) or call forward on no reply  the latter will probably cause some callers to hang up before the page is initiated, i.e. serve as an additional ‘filtering mechanism’ Their long term goal is expressed as fully automatic screening without human involvement

12. 12 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”

13. 13 Group Awareness in general 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]. Nursing: Not only employees, also the patient himself Group awareness may be totally ’virtual’ (ICT-mediated) As in distributed open source projects: emails, IM, forum,.. Often partly obtained via informal sources F2F (coffee break), oral comm. and visual line of sight … Formal sources in hospital may be: handover meeting (vaktskifte), EPR ICT sources in hospital may be: EPR, call plan/ nurse responsibility allocation, …

14. 14 St.Olav: Call plan / bemanningsplan Redundancy of function is directly related to the bemanningsplan in sengetunsklient (Imatis client/ 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 work allocation (and the building’s floor plan / line of sights matters as well)

15. 15 Awareness and redundancy Several sources are used together to obtain group awareness (partly redundant data, partly integrated, partly not) Cabitza et al: Redundancy is related to coordination since, for this replacement to be effective, appropriate information on the work context has to be collaboratively provided. I.e. group awareness is needed in the terms of Dourish and Belotti.

16. 16 Fixed and wireless together System view

17. 17 Stillevisning / silent mode Awareness via fixed displays In public places Duty room Work station area Inside a patient room Similar awareness via presence display inside medication room and meeting room Short audible sound Then only blinking display

18. 18 Interview guide (head nurses HN-x): Redundancy Assume that Pål in room 102 has called for help, and that nurse Anne is currently helping Pål. What will happen when Pelle is activating a nurse call? What do you believe that happen? What do you want to happen? Open questions like: Are nurses sometimes using ICT in a creative way?

19. 19 Findings The daily work Planned business: Meetings and breaks Unplanned business and the daily work Interrupts from nurse calls during phone conversations Personal wireless phones vs. redundancy and collective devices Redundancy of data between the fixed and wireless systems and reliability issues

20. 20 The daily work Planned vs. nonplanned: hard to draw a strict line for nurses. They are constantly multi-tasking Whiteboard use serve as a guideline The way the wireless nurse call system works with reject and ignore caters for busy hands and some other types of unplanned activities. Some interrupt issues

21. 21 Planned business / 2 h. meetings Meetings are scheduled on the whiteboard Phone calls (synchronous communication) will go via an administrative person. This person has a copy of the whiteboard available on paper. This person will then perform a manual screening of calls. A paper note may be the result of the phone call in such cases. “I was putting my phone on silent during a long meeting, but the phone was vibrating anyway on all incoming nurse calls”. (Nurse during observation) Nurse calls are almost synchronous (15 sec. timeout), but delivered technically as ‘text message’ No manual screening (responsibility allocation determines). No ‘opt-out’ / pause

22. 22 Lunch Word ‘lunch’ is non-existing in bid.spec., in training material ++ ”We have no fixed routines (...). We are not editing [the responsibilities] in Imatis (...). Some chooses to bring their phones to lunch (...). Others leave the phone in the work station area. Some nurses take out the battery ” (HN-2) Interrupt issue: ” I know that the nurse call will be forwarded quickly to the next person. But nurse calls during lunch may disturb many others during their lunches, which might be stressful” (HN-2)

23. 23 Lunch and long meetings: Proposal Introduce ’pause’ / status-function Manual setting (via phone/ Imatis sengetunsklient) For everyone to view. Should avoid ’illegal pauses’

24. 24 Unplanned business / Mobility “The best thing with the system is that I am available everywhere. “ Useful to receive phone calls when mobile May be an issue to receive (irrelevant) nurse calls in such situations Absence is not totally unplanned, oral agreements exists  Backup nurse knows that she needs to take these nurse calls The 15 sec. ringing is mentioned as interruptive by several nurses: When inside a patient room, when talking to a relative ++ Mobile device caters for mobility in positive ways, but may infringe on privacy and be interruptive

25. 25 Interrupts from nurse calls during phone conversations 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: 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 in silent mode for peripheral awareness

26. 26 Redundancy and reliability All nurses having experience with the IP-based wireless system will agree that they do not trust the wireless IP- based system as much as they trust the fixed system. Experience note from phase 1 highlight the need for the fixed system to work properly also during network outage, including working across sengetun during night Answer from management on the issue with nurse calls on the ear: “It is a requirement in the contract that signal/call/alarms [on the wireless device] shall have first priority” Disregarding the fact that fixed system may work as standalone system

27. 27 Proposal: Unplanned situations “When persons are away, there is always a reason, and that reason is that the person is occupied”. (HN-1, corridor ward) Ring only 2 ring (more like SMS delivery) Less interruptive Use the presence panel for peripheral awareness ”Vi tok klokka før også!”

28. 28 Users understanding the technology? It seems to be a problem that newly moved ward-1 does not know all configuration options The silent mode of the presence panels are not used; the fixed wall mounted displays are causing audible alarms from the whole ward (not only the bed court) during day time; The phone calls from relatives at WARD-1 is not organized the same way as in WARD-2. In total much more noisy in WARD-1 Lack of information on configuration options in the fixed system

29. 29 Technologists understanding the users? Training material does not seem to understand real use Invisible work  Caring for patients without answering a nurse call  The ‘task list’ (arbeidsliste) is not a list of complete tasks per nurse Invisible routines and invisible technology Nurses issuing nurse calls are hardly mentioned  Reg. out, and press new nurse call  A way to ask for assistance (non-urgent) The modern wireless part in focus, boring old fixed stuff becomes almost invisible Issues with terminology Anrop/signal/kollegavarsling/hasteanrop ‘klokka’ ‘stans-alarm’ are the word used orally

30. 30 On CSCW and IS research I lack technology descriptions and pictures in some IS/CSCW papers Balka and Wagner (2006) does not show the fixed buttons, impossible to judge level of awareness via fixed buttons and lamps from their description CSCW and design: The socio-technical gap  Not only ’how should it look’  What does it cost (e.g. to add location tracking with certain accuracy)? System architecture matters: The choice to have a loose integration (one-way arrow) from fixed to wireless system allow for reliability via redundancy

31. 31 Current research One student (Antoni) will prototype a simple version of the lunch pause function Further studies of understanding technology and use Issues of ’virtual ICT’ vs. ’real physical world’ Relation with ICT-dept, change requests etc. Fixed-Mobile Co-existence and context Subtle differences in ways users have configured BEST and Imatis (bed court borders may vary) Fixed devices: Offering context via its fixed location, alternative to centralized wireless location tracking(?) Building itself also offer ’affordances’ (Ero S.K.)  How does the ICT system support or destroy privacy borders and awareness / line of sight designed by the architect

32. 32 Questions?

33. 33 Details of the phone

34. 34 Fixed displays in old corridors Pictures from old St.Olav (from 2004 / 2009) In the ceiling Outside of the patient room a lamp may exist (not all places). Is this similar to the Canadian lamps?

35. 35 In duty room (circled) (in old corridors) Wall mounted display: Green/red similar to old displays in the ceiling Typically 3 displays in the ceiling all showing the same (the whole ward)

36. 36 Types of nurse calls in Norway Ordinary nurse calls (typically initiated by patients) Right part of display in ceiling + sound (opt. on lamp outside room) Heart arrests Right part of display in ceiling heavy blinking + heavy sound (opt. on lamp outside room) In addition ’presence in room’ is shown Left part of display in ceiling +(opt. on lamp outside room)

37. 37 Inside the patient rooms part 1 by the bed side Typically a string to be used by the patient May include a ’red signal’ for the nurse to issue a heart arrest (stans alarm) Which is an important message, ”and then we all run” as the nurses explains themselves. Typically the string is long and reachable for the patient and the ’red signal’ is located high up on the wall (unreachable for the patient). And convieniently close to the bed so nurse can stay with patient and call for help at the same time Pasient

38. 38 Inside the patient bed part 2, by the door frame Several types may exist: Old type with little support for awareness of rest of the ward, but audible sound for heart arrest (’stans alarm’) With display supporting awareness from rest of the ward via audible and visual signs

39. 39 In isolation rooms A special type used in (some) isolation rooms. The medium buttom is to call for assistance (not heart arrest, but help to lift patient etc.) Note: ’standing nurse+’ vs running nurse Where these exists the displays in the corridor show this as a special type as well (other blinking)

40. 40 Standing + vs. Running

41. 41 In new St.Olavs hospital The ward is more formally devided in 3 ’sengetun’ and each tun only show ’own’ nurse calls during daytime Awareness via line of sight (Zig-Zag) as explained by the architect Not:

42. 42 Some sengetun looks like a corridor: much more narrow, less windows etc.

43. 43 Awareness? Line of sight?

44. 44 AWAREphone (Bardram ++) ihospital.dk (prior to call) Ring Tekstbeskjed