FREE UNIVERSITY OF BOLZANO FACULTY OF COMPUTER SCIENCE

Thesis

Author: Christian Dallago

Thesis Supervisor: Pekka Abrahamsson Thesis Co-Supervisor: Daniel Graziotin

Submitted in partial fulfillment of the requirements for the degree of Bachelor in Computer Science and Engineering at the Free University of Bolzano/Bozen.

October, 2014

IMPROVING THE NURSING PROCESS THROUGH THE INTRODUCTION OF A WEB-BASED, MOBILE-ORIENTED INFORMATION SYSTEM. AN ACTION RESEARCH STUDY.

ACKNOWLEDGEMENTS

Thank you. To Daniel Graziotin, Pekka Abrahamsson, Riccardo Buttarelli, Marina Bonn and the nurses who I was pleased to work with for almost one year.

Thank you. To friends and family, too many to mention, that have stood by my side during my studies in Bolzano, Madrid and Charleston.

I dedicate this thesis to my mother, my brother and my sister,

as symbol of appreciation for the support, shelter and love you have given me in these years.

ABSTRACT The Nursing Process, which is a series of clinical judgement-based activities conducted by the nurses in order to ensure a correct patient care, relies heavily on data gathering and analysis. The data collection, storing and retrieval as part of the nursing practice are subject to continuous mutation and improvement initiatives by research activities. Nowadays, several challenges for improving the nursing process and the related documentation have arisen, because of the introduction of mobile devices. However, the majority of the proposals from the body of knowledge are on a theoretical level only. This thesis introduces a scientifically validated, Web and mobile-based information system for supporting and improving the nursing process. The work was conducted in the hospital of Bolzano/Bozen, Italy. We have set up an Action Research study to both understand and mutate the context to which this research is applied. This thesis reports the first action research cycle, conducted over a period of eleven months. The cycle consisted in two sessions of in-field observations and interview of the nurses, and a literature review that were employed for building a meaningful system. The system was implemented for revolving around the actions that are performed by the nurses every day, instead of digitalizing the already existing documents and forms. Thus, the system enhances the nursing documentation process but it does not interfere with the nurses’ habits and procedures. It uses mobile devices such as tablets and a touchscreen-enabled 55” television. We empirically validated the implemented prototype in the hospital setting through two exploratory controlled experiments. Overall, the results reveal an improvement brought in by our system in terms of performance and in terms of information quality.

RIASSUNTO Il processo infermieristico, che consiste in una serie di attività basate sul giudizio clinico svolto dagli infermieri per assicurare una corretta cura del paziente, si appoggia alla creazione e analisi di dati. La collezione, archiviazione e il recupero di dati concernenti la pratica infermieristica sono soggetti a continue mutazioni per scopi di miglioramento da parte di attività di ricerca. Oggigiorno, attraverso l’introduzione di dispositivi mobili, sorgono nuove sfide per migliorare la documentazione associata al processo infermieristico. La maggior parte delle proposte emerse dall’insieme di conoscenze sono basate solo sulla teoria. In questa tesi, dunque, introduciamo un sistema basato sul web, orientato all’utilizzo mobile e validato scientificamente per il supporto ed il miglioramento del processo infermieristico. Il lavoro è stato condotto presso l’ospedale di Bolzano/Bozen, Italia. Abbiamo istituito una Ricerca-Azione in modo da capire e contemporaneamente mutare il contesto in cui la ricerca è applicata. Questa tesi riporta il primo ciclo condotto in undici mesi di suddetta Ricerca-Azione. Il ciclo è consistito in due sessioni di osservazioni ed interviste sul campo, e un’analisi della letteratura che è stata utilizzata per creare un sistema significativo. Invece di digitalizzare l’attuale meccanismo di documentazione cartacea, il sistema è stato implementato per considerare le azioni che sono svolte dalle infermiere ogni giorno. Il sistema migliora dunque il processo infermieristico senza però stravolgere le abitudini e le procedure utilizzate dalle infermiere. Il sistema utilizza dispositivi mobili ed uno schermo tattile da 55 pollici. Abbiamo validato empiricamente attraverso due esperimenti esplorativi controllati il prototipo implementato nell’ambiente ospedaliero. Complessivamente gli infermieri riportano un miglioramento in termini di prestazioni e qualità delle informazioni attraverso l’utilizzo del prototipo.

KURZFASSUNG Um eine korrekte Pflege des Patienten zu gewähren, stützt sich die Pflegeplanung, wörtlich die klinische Beurteilung durch das Pflegepersonals, auf die Erstellung und Analyse von Daten. Das Sammeln, die Archivierung und die Abfrage der Daten des Pflegeprozesses unterliegen wiederholt Veränderungen durch Forschung, mit dem Anliegen die Dokumentation zu verbessern. Da heute immer öfter mobile Geräte eigesetzt werden, entstehen innerhalb dieses Dokumentationsprozesses neue Herausforderungen. Der größte Anteil der Vorschläge, die durch die gesammelten Erkenntnisse bereits vorgebracht wurden, stützt sich jedoch nur auf eine theoretische Basis. Diese Diplomarbeit stellt deshalb ein Web-System vor, das spezifisch auf mobilen Geräten zum Einsatz kommen soll, wissenschaftlich belegt ist, und durch welches der Pflegeprozess verbessert wird. Durchgeführt wurde diese Arbeit im Krankenhaus Bozen/Bolzano, Italien. Dabei haben wir die Form der Aktionsforschung gewählt, um den Kontext nicht nur zu verstehen, sondern ihn gleichzeitig auch durch unsere Beobachtungen zu verändern. Die Diplomarbeit stellt den ersten Zyklus dieser Aktionsforschung dar, dieser dauerte elf Monate. Der Zyklus unterteilt sich außerdem in zwei Phasen, der Beobachtung sowie Befragung vor Ort, und der anschließenden Analyse von bereits existierenden Arbeiten, mit dem Ziel ein bedeutendes System zu erstellen. Anstatt einfach die jetzige Papier-basierte Dokumentation zu digitalisieren, wurde das System so entwickelt, das es sich in die Tätigkeiten des Pflegepersonals einfügt. Das System verbessert demnach den Pflegeprozess, ohne jedoch die Gewohnheiten und Vorgehensweise der Pfleger zu verändern. Das System benützt mobile Geräte, sowie einen 55 Zoll Touchscreen. Wir haben den Prototyp durch zwei Forschungs- Experimente im Krankenhaus geprüft. Insgesamt berichtet das Pflegepersonal durch den Einsatz des Prototyps eine Verbesserung der Leistung und der Qualität der Informationen.

Table of Contents

1   INTRODUCTION ....................................................................................................... 1  

1.1   The nursing process ....................................................................................... 1  1.2   The documentation process in nursing practice ............................................ 2  1.3   Structure ......................................................................................................... 2  

2   RESEARCH METHOD ............................................................................................... 3  

2.1   Action Research ............................................................................................. 3  2.2   Data Collection and Analysis .......................................................................... 4  

3   ACTION RESEARCH CYCLE ..................................................................................... 6  

3.1   Diagnosis ........................................................................................................ 6  3.1.1   Field Observations ................................................................................... 6  3.1.2   Problem identification ............................................................................ 11  

3.2   Action Planning ............................................................................................ 11  3.2.1   Research Review ................................................................................... 12  3.2.2   Prototype Specifications by Research Review ...................................... 15  3.2.3   Field Observations ................................................................................. 15  3.2.4   Final Prototype Specifications and Plan ................................................ 17  

3.3   Action Taken ................................................................................................ 19  3.3.1   Implementation ...................................................................................... 20  

3.4   Evaluation ..................................................................................................... 25  3.4.1   Registration experiment ......................................................................... 26  3.4.2   Clinical handover experiment ................................................................ 28  3.4.3   Experiment Results ................................................................................ 29  

4   DISCUSSION ......................................................................................................... 31  

4.1   Implications .................................................................................................. 32  4.2   Limitations .................................................................................................... 32  

5   CONCLUSIONS ...................................................................................................... 33  

5.1   Future work .................................................................................................. 33  

REFERENCES ................................................................................................................. I  

APPENDICES ................................................................................................................. V  

Appendix A.   Registration activity flow charts ..................................................... V  Appendix B.   Prototype Mockups ....................................................................... XI  Appendix C.   Prototype ER diagram ................................................................. XIII  Appendix D.   Prototype filtering mechanism .................................................... XIV  Appendix E.   Registration experiment data analysis ....................................... XVII  

List of figures

Figure 1 - Action Research diagram ............................................................................ 3  Figure 2 - Floor plan of patients' rooms and central nurses’ office ............................. 5  Figure 3 – How the data is created when patient gets admitted to the hospital ......... 6  Figure 4 - How a nurse treats data about a patient during the shift ............................ 8  Figure 5 - Informal data gets destroyed when patient leaves ................................... 10  Figure 6 - Research card ........................................................................................... 16  Figure 7 - Ideal registration ........................................................................................ 17  Figure 8 - Mapping of the traditional documentation system to the devices ............ 18  Figure 9 - Sitemap relation between collections and content in pages .................... 20  Figure 10 - Reminders view ....................................................................................... 21  Figure 11 - Journal view with one open and one closed problem ............................. 22  Figure 12 - Measures view ......................................................................................... 23  Figure 13 - Hardware and running prototype in the hospital setting ......................... 24  Figure 14 - Floor plan with the prototype .................................................................. 25  Figure 15 - Controlled experiment design for registration diagram ........................... 26  Figure 16 - Average number of questions asked by the nurses using the traditional

system and the prototype ................................................................................... 27  Figure 17 - Scatterplot of the documentation time with the traditional system and the

prototype ............................................................................................................ 28  Figure 18 - Registration of 11.06.2014 ...................................................................... VI  Figure 19 - Registration 1 of 15.06.2014 ................................................................... VII  Figure 20 - Registration 2 of 15.06.2014 .................................................................. VIII  Figure 21 - Registration of 09.07.2014 ...................................................................... IX  Figure 22 - Registration of 10.07.2014 ....................................................................... X  Figure 23 - Single patient view .................................................................................. XI  Figure 24 - All reminders view ................................................................................... XII  Figure 25 - ER diagram for the prototype ................................................................. XIII  Figure 26 - Journal view without filtering for patient ............................................... XIV  Figure 27 - Journal view filtering for patient ............................................................. XV  Figure 28 - Measures filtered for patient and weight (displaying a graph) .............. XVI  

List of tables

Table 1 - Advantages and disadvantages of introducing a nursing support system – reproduced form [5] ............................................................................................ 13  

Table 2 - Drivers and inhibitors to adoption of wireless systems in hospitals as reported by [26] .................................................................................................. 14  

Table 3 - Quantitative data synthesis ........................................................................ 16  Table 4 - Registration experiment quantitative data .................................................. 27  Table 5 – Clinical handover experiment quantitative data ......................................... 29  

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1 Introduction

Nursing assistance is imperative to assure the well being of patients during and after their convalescence [1]. In order to improve the way the practice is executed, many approaches have been introduced [2]. What benefitted the nursing practice has been the conceptualization of nursing related activities as a process, as described by Orlando [2]. The process relies heavily on patient related data to ensure the correct patient care. For this reason, data collection, storing and retrieval as part of the nursing practice has gained much scientific interest [3]. One reason is that documentation related activities occupy up to 33% of the nurses’ working hours [4], [5]. Moreover, badly conducted documentation activities "[...] can lead to wrong treatment, delays in medical diagnosis, life threatening adverse events, patient complaints, increased health care expenditure, increased hospital length of stay and a range of other effects that impact on the health system [...]" [6, p. 1]. Since the introduction of digital devices such as Personal Computers (PCs) in hospitals, the way the patients’ data is handled has changed. The Nursing Informatics field [7] was born specifically for understanding and for reengineering it through information systems support. The early approaches to the digitalization of the nursing documentation were implemented on stationary PCs [8]. However, the nurses spend most of their time in mobility [9]. Thus, it has become necessary to implement new systems in a mobile-oriented way. These new mobile-oriented systems proved to introduce benefits for the nurses and for the nursing process [10]. However, it was also shown how dangerous badly implemented systems can be if put in a delicate environment such as the hospital setting [11], [12]. Much proposals have failed to deeply involve the nurses in the design of such systems [5]. Nurses are field experts and are able to “detect system deficiencies that are closely related to clinical impact […] issues that would be otherwise undetectable by system designers” ([5, p. 1]). In this thesis we will study how the nurses in the local hospital of Bolzano/Bozen, Italy, implement the nursing process, and how the documentation process is defined and acted. Given the lack of information system to support the documentation process, we performed an Action Research (AR) study, in order to innovate as well as research the nursing process in a real context. Thus we will answer to the question: Can the nursing process in the local hospital of Bolzano/Bozen benefit from the introduction of a mobile-oriented information system?

1.1 The nursing process

The American Nurses Association [13] defines the process in five steps, repeated in cyclic fashion:

1. Assessment: In this step a nurse collects physiological, psychological, sociocultural, spiritual, economic, and life-style related data of a patient, creating a record for the patient.

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2. Diagnosis: In this step the diagnosis reflects the nurse’s clinical judgment about the patient’s actual or potential health conditions.

3. Outcomes / Planning: Based on the patient’s record and diagnosis, the nurse should set some measurable and achievable short- and long-term goals for the patient, that shall be written in the patient’s care plan, so that other nurses and healthcare providers can have access to it.

4. Implementation: This step is implemented according to the previously outlined plan and the implementation is carried out throughout the hospitalization period and noted in the patient’s record.

5. Evaluation: This process has to be subject to continuous evaluation, as well as the patient’s conditions, that shall be re-evaluated and define new care plans as needed.

We can note that the basis of the process, as described above, relies heavily on two factors: one, the nurse’s judgment, that defines the process itself and the scope for the care of a patient; another more practical aspect instead is represented by the tools that the nurses use to collect and analyze data.

1.2 The documentation process in nursing practice

The production of nursing documentation has different purposes, from the exploitation of purely statistical data, to the support of the nursing process itself or the creation and retrieval of critical information in the occurrence of an emergency [14]. As emerged from nursing guidelines (e.g., [15]), the data collected in the process needs to be clear and consistent. This leads to a continuous stream of evolution improving the ways in which patient data are represented and collected, in order to reduce errors and maximize the effectiveness of patient care. In Italy, there are also regulations and laws that impose the creation of data for patients (for example, in pediatric nursing practice [16]).

1.3 Structure

In the following section, we will justify and describe our AR adoption towards the study, and we will present the results of its first cycle. The reader will notice the absence of a section devoted to describe the related work. Instead, the related work of this thesis will be described in the Action Research Cycle section, under the action planning section, because the literature review is preferably performed at that stage of AR. In the Action Research Cycle section, we will also report our observations and findings regarding the implementation of the nursing process in a ward of the hospital of Bolzano. Then, following the AR action taken step, we report the implementation of a prototype. In the evaluation step we will report the validation of the prototype through two experiments. Finally, we will discuss the outcomes of the cycle and elaborate on the two experiments, also by emphasizing the implications and limitations of this work.

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2 Research method

In this chapter we will present our approach towards the study. We will therefore discuss the Action Research (AR) methodology and present its structure.

2.1 Action Research

Action research as a term has been coined in 1946 by Lewin in his paper “Action Research and Minority Problems” [17]. Through Lewins’s work and the evolution of his idea, the structure of a new research methodology was created [18]. This type of research combines the theoretical research and the practical outcome of an action to solve a pre-defined issue [19]. There are several definitions and variants of action research (AR). However, the definitions agree on a basis, as represented in Figure 1. The basis of action research is represented by the combination of a set of steps that repeat as necessary in a cyclic fashion. These steps are diagnosis, action planning, taking action and evaluation, and they are described in the Action Research Cycle section. The steps are to be executed in a real-world environment, and each cycle should mutate the context in which AR is applied. This mutation should affect both the researchers and the subjects of the study, giving the research new horizons to operate. Following the general approach of AR as illustrated above, this research has been structured in one large cycle of 11 months with the four steps mentioned above. The results of this thesis provide a solution for the problem, and they lay down the foundations for future research.

Figure 1 - Action Research diagram

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2.2 Data Collection and Analysis

Crucial to the outcome and initiation of this research has been the participation of the nurses of a department of the local hospital of Bolzano. The nurses of the department –hence generically referred as to as “department” or “ward” because of agreements between the parties- proposed a collaboration between the Faculty of Computer Science of the Free University of Bolzano and the hospital. The project was initiated with two meetings between the research team, composed by the present writer and a colleague, the stakeholders, composed by the supervisors of this thesis, a nurse of the department and the Head of the nurses of the department. During the first meeting, the nurse working in the above-mentioned department informed us regarding the issue of the documentation of patients in the hospital. The documentation happens on paper only, which the nurse accuses of introducing inconsistencies, redundancy and time waste, as noted also by [4], [10], [20]. The nurse expressed interest in the implementation of a digital system to support the nursing process, especially the documentation process. In the following meeting the research team reported that the research on the topic was mostly outdated, infeasible or too detached from the real problem (i.e., based solely on literature without field observations). This issue was heightened by a lack of clarity in the requirements coming from the nurse. The customers wanted a problem to be solved, without being able to specify any detail regarding the solution. Because of these issues, the stakeholders and research team agreed that a field observation prior to conducting any extensive research on the nursing process and nursing documentation process was necessary to determine the scope of this research. The head of nurses (Head) for the department was informed. After the Head approval and the necessary privacy agreements, the research team spent two weeks observing the workflow in the ward. A total of 15 nurses were observed in their day-to-day activities, for a total of 25 hours. The observations have been performed in two time periods. In the first observation session, the research team observed all the 15 nurses for 10 days, at different times, with an average observation time quantifiable in one hour per day. During the second observations, the research team observed four of the nurses in five days, with an average observation time quantifiable in three hours per day. The implemented system, presented in the evaluation section, was empirically validated through two exploratory controlled experiments. After the observations, we made sense of the data collected. Langley’s visual mapping and narrative sense-making strategies [21] to theorize process data were needed. We (the present author and a colleague) have followed the nurses in their ward. The ward is represented in Figure 2, and it is composed by 11 two-bed rooms for patients, one office for all the nurses in the center of the ward and other offices for the administration, the doctors and the Head.

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Figure 2 - Floor plan of patients' rooms and central nurses’ office

As part of the agreement with the Head, the research team was not initially allowed inside patients’ rooms during nursing activities.

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3 Action Research Cycle

In this section we are going to present the outcome of the AR cycle completed in this research. We will identify the problems in the real-world environment we operate, define a plan to address the issues we identify, implement a solution and evaluate it.

3.1 Diagnosis

The first two weeks of observations served as starting point for the problem diagnosis. We have studied the situation in the ward, and we have generated three flow graphs. These graphs provide an overview of how information is retrieved and stored for a patient, starting from his/her request to be hospitalized to the departure after the therapy.

3.1.1 Field Observations

Figure 3 – How the data is created when patient gets admitted to the hospital

The sense-making process of the gathered information revealed that there are two kinds of data. We call formal the first kind of nurse-related data, which in Figure 3, 4 and 5 is represented on the right in blue and white. We call informal the data that in the figures appears on the left in orange and green. Definitions for both types of data follow. In Figure 3 we can see how the formal data is created for a patient at his/her arrival. This data consists in:

• A record (“Patient X”) inside a database that stores demographic data about patients of the hospital, and

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• A paper folder (“Patient X clinical folder”) that contains detailed information about (1) why the patient has been hospitalized, (2) other clinical data (such as allergies, diabetes, etc.), and (3) data needed for practical reasons (such as an emergency contact, if the patient carries goods, etc.).

A nurse registers the detailed data during the so-called “Anamnesi” phase. The “Anamnesi” happens when the patient is accommodated to his/her room. The “Anamnesi” itself is a paper-based questionnaire. This is filled out in the room with the patient while concurrently asking questions and completed immediately after visiting the patient in the nurses’ central office.

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Figure 4 - How a nurse treats data about a patient during the shift

The need for and distinction between formal and informal documentation becomes clear by following a complete shift of a nurse at the ward. Throughout the stay of the patient, the formal documentation is represented by the clinical folder of the patient (“Patient X’s clinical folder”), a collection of documents consisting of eleven or more A4 paper sheets that cover both clinical as well as practical aspects of the hospitalization and the patient.

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The clinical folder contains: 1. Measurements about the patient, such as maximum and minimum pressure,

weight, blood glucose level, etc. The measurements often have an associated timestamp; therefore, multiple measurements are often present.

2. Physiological, psychological and other clinical related information, such as if the patient is diabetic, if the patient is a postoperative, if the patient can not walk autonomously, if the patient is unresponsive, etc.

3. Practical data about the hospitalization and the patient, such as a reference phone number, the address of the patient, if the patient carries any valuable goods that need to be insured, the treatments and medications that have been given to the patient, etc. This data does not interfere with how the nurses have to deal with the patient.

The most relevant data for the nurses about the patients is represented by the first two sets of information, while the third kind of data is rarely needed during a patient’s hospitalization. Still, the practical data needs to exist for statistical and juridical reasons (for example, in pediatric nursing practice [16]). One of the key data that nurses need to manipulate easily is what has to be done for each patient – i.e.: a series of to-dos. This data is to be interpreted by the formal documentation, and thus the nurses have developed a strategy to extract it in forehand and keep it up to date also outside this set of documents (see below: “Whiteboard” and “Cavallerini”). The second important kind of data that has to be quickly available to the nurses are notes about needs to be kept in mind for each patient (see below: “Clinical Handover Document”). Also this data is usually an interpretation of the measures found in the formal documentation, for example a sudden weight loss implies attention in the diet of a patient. The conglomeration of this set of data composes what we call informal documentation, that is: a derivate and interpretation of the formal documentation and the passage of information between nurses during a shift change. In practice, the nurses use three ways to represent informal data:

• Clinical Handover Document: The word used in the ward is “Consegna”, which translated form the Italian means “delivery”. Its meaning in this context is that of clinical handover document as product of the clinical handover (as found in [22]). The information in this document is delivered from the nurses that are finishing their shift to the ones that are starting a new shift. Every nurse that is starting a shift writes her/his own clinical handover document (or “Consegna”), which generally is written in sections (each section representing a patient) on an A4 sheet of paper. The clinical handover document gets trashed when the nurse finishes his/her shift. The clinical handover document contains notes on the currently hospitalized patients (such as “Needs assistance to go to the bathroom” or “Has felt sick yesterday evening”) and it gets updated throughout the shift. The nurses add both reminders for the activities that they have performed on a patient (E.g.: “Helped to go to the bathroom”), as well as noticeable facts that the nurse

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might want to tell to the next one during the next clinical handover (E.g.: “Refuses to eat dinner”).

• Whiteboard: The nurses have a whiteboard in the central nurses’ office that is divided in different sections. Each section serves as a separate to-do list for some specific task (for example, one section contains a list of patients that need to be weighted and the date in which the measurement needs to be taken). Once a task has been fulfilled, it usually translates into a new measurement that will be written in the measurements part of the formal documentation.

• “Cavallerini”: Similarly to the whiteboard, the “Cavallerini” are a way to signal that some measurements for a patient have to be taken. The difference between this way of representing the information and the whiteboard is that the “Cavallerini” are specific for a patient and can be found on the side of the patient’s folder. Many nurses identify this system as superfluous seeing the existence of the whiteboard. The majority of the nurses don’t use it.

Added to these three written ways of representing information, there is a fourth one that is verbal and consist of the small updates that the nurses need to communicate amongst themselves during a shift. In fact, if a nurse performs a procedure on a patient writes it down on his/her “Consegna”, the other nurses working during the same shift can not be aware of this new information until the nurse that performed the procedure shares it with all the other nurses.

Figure 5 - Informal data gets destroyed when patient leaves

At the end of the shift, the nurses have to report their patient-related activities in a time management system. This is needed by the hospital management for estimating the assistance in hours that the nurses have given to each patient (for

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statistical reasons). In order to do so, the nurses retrieve information from both the formal and informal documentation sources, to see what they have done during the day. After they have completed this step, the nurses perform the passage of information to the nurses that start their shift and then trash their notes (i.e. their clinical handover document or “Consegna”). Informal documentation is destroyed when the patient leaves the hospital. That is, formal documentation is accompanied by distilled data coming from Informal documentation for correctly describing every procedure and aspect of the hospitalization. Formal documentation gets stored for at least ten years, as per Italian law on administrative documentation [23]. During the observations we were allowed to inspect both the formal and informal documents, as they were filled by the nurses. Additionally, we were provided blank formal documents and a set of three complete, anonymized patient clinical folders.

3.1.2 Problem identification

The first two weeks of observations provided us an idea of why the nurses would need a digital system to cope with the documentation process. As mentioned above, most of the information needed is a derivate of other (thus, introducing redundancy), it lacks in structure and, in general, there is an overflow of data. A digital system would need to restructure the documentation instead of faithfully reproducing it. We observed that the clinical handover document (“Consegna”) and the verbal passing of information during the shift are the central sources of patient data for the nurses. Literature highlights that clinical handover, if proved ineffective, "[...] can lead to wrong treatment, delays in medical diagnosis, life threatening adverse events, patient complaints, increased health care expenditure, increased hospital length of stay and a range of other effects that impact on the health system [...]" [6, p. 1]. We noticed that the verbal passing of information introduces several issues. These issues arise mainly because of the nature of the clinical handover document (that is, it is personal and therefore not updated in real-time with all the other nurses in the ward) and due to the Chinese-whispers phenomena [22], [24] in the verbal passing of information. Although the multiplicity of problems, for the first cycle of this research we decided to address the following aspects:

• Restructure the documentation • Create a prototype digital system using the new documentation mechanisms

Ultimately, the application should support the nursing process as used in the ward at the time, rather than shape it.

3.2 Action Planning

In order to understand how the information system prototype should be implemented, we conducted a research of the related work.

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We then formulated an implementation hypothesis. Prior to the actual action phase and the implementation of the prototype, we conducted five observation sessions that lasted approximately three hours each (see following section “Field Observations”). We then formulated a final implementation plan, which we actuated in the action part of this cycle.

3.2.1 Research Review

Alasalmi et al. study the core nursing process improvement Enabled by Wireless Services [10]. In their article, they compare the nursing documentation process, its phases and structure, to general business process structures. They explore the possibility to improve the process by utilizing the same technologies (mobile) that have proven to be successful in business process improvement. The authors discuss the results of introducing a mobile prototype based on Personal Device Assistants (PDA’s) to collect nursing documentation instead of paper-based documentation. Afterwards, the authors hypothesize further productivity related benefits of digitalizing hospitals such as automatic revelation of patient data through sensors, wireless tracking and touch by device paradigms. The research goal reported in the paper is to increase the productivity of nurses from a business perspective. The following discoveries of the study are of interest for the current research:

• The measures and the data about patients are written down on paper while visiting a patient and the process takes about one hour and a half for every visit. The data is later transcribed to Personal Computers (PC’s).

• Copying data and maintaining patient data up to date on the PC’s constitutes a waste of resources up to four hours per day.

• PC’s on carts and Laptops are expensive solutions to the digitalization process, thus PDA’s are a more feasible solution.

• NFC (Near Field Communication) is an interesting technology to store patient data so that the nurses can access it in place while visiting a patient.

Chen and Atwood exploit what nurses think in early mobile clinical system design stages [5]. The authors interviewed nurses in order to explore “the possibilities of evaluating a mobile clinical system prototype directly by nurses in the early system design stage” ([5, p. 1]). No implementation project of this research is mentioned. The paper reports the following results:

• A study published in 2008 [9] reports that it has been demonstrated that “approximately one third of their total working time on the move” ([5, p. 1]). This implies that mobile-based information systems are fundamental to accommodate the nurses’ needs, and that “traditional desktop applications are less likely to support the highly collaborative and mobilized nursing task” ([5, p. 1]), as also proved by other works [25].

• A badly implemented support system for nursing assistance can lead to grave consequences and endanger life of patients that depend on the

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system [11], [12]. This underlines the necessity to interact with the nurses since the early design stages, in order to deploy a system that can fit their needs.

• Nurses are field experts and are able to “detect system deficiencies that are closely related to clinical impact […] issues that would be otherwise undetectable by system designers” ([5, p. 1]).

• Computer- or laptop-based systems are bulky, thus are not valuable for hosting a nursing information systems [8]. On the other hand, PDA-based systems are not designed to support clinical work, due to hardware limitations of the PDAs,

• It is important to balance interactions between nurses and work interruptions. A system with easy communication and collaboration capabilities can lead to a high amount of interruptions.

• In the scenarios created to evaluate a nursing support system, the researchers explored the use of following technologies: tablet computers, digital white-boards, inter-department messaging systems, inter-department alarming systems, and context-aware systems.

• The result of the study on the opinions collected by the nurses in the evaluation of a nursing support system in the early stages of design is summarized in Table 1, which shows the advantages or disadvantages of introducing systems as the ones mentioned in the previous point.

Table 1 - Advantages and disadvantages of introducing a nursing support system – reproduced form [5]

Su and Gururajan study the Determinants for the use of wireless systems in traditional Chinese hospitals [26]. In their paper, the authors look for the factors that influence the use of wireless systems for healthcare in China. In particular there is interest in why these systems face a slow adoption, despite the at-the-time recent

Advantages Disadvantages Mixed Saving Time Interruptions Information Load Saving Resources Abuse Technology Ease of use Prevent Errors Technology Reliance Tracking charts and changes

Decreased Personal Interaction

Facilitating Distributive Work

Device issue

Bedside Care Technology Reliance Easy collaboration Medical Errors Access Information Not technology Savvy Easy Reading Misunderstanding Decision Making Technology failure Aware Information Missing Information Avoid multiple devices Emotional Mobile Privacy & Confidentiality

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investment from the Ministry of Health People’s Republic of China in new infrastructures. The authors report that previous research has shown that the inhibitors to the adoption of such systems are:

• Lack of user training • Lack of management support • Lack of supporting policies • Unsupportive of the complexity of the nursing process • High cost • Sensitivity of patient data • Limited empirical research available into the adoption of wireless systems in

healthcare The authors then identify a set of drivers and inhibitors to the adoption of wireless systems in hospitals, based on the previous points and the analysis of private interviews with 20 physicians that use such technologies in another country. These factors are represented in Table 2.

Table 2 - Drivers and inhibitors to adoption of wireless systems in hospitals as reported by [26]

Shiffman et al. report the factors that led to using pen-based tracking technologies over typing technologies, as well as the same approach based on Optical Character Recognition (OCR), and the obstacles to the use of computers in healthcare [27]. Also the paper proposes an implementation with a focus on recommendation, in order for the nurse (or visiting doctor) to generate a diagnosis starting from the symptoms described by the patient. The prominent aspects of this work are:

Drivers Inhibitors Attract more practitioners Legal barriers Reduce medical errors Complications in note taking due to

difficult read and write screens Reduce workload Administrative constrains Easy access to data Communication with colleagues Savings in time Communication with physicians Delivery of high quality information Problems in obtaining lab results Improved clinical flow Electronic medical records Better quality of service Electronic prescribing Saving effort Device usage barrier More contact time with patients Benefit evaluation barrier Improved public image Resource barrier Improved delivery of information Patient education Reduced overall cost Positive impact on patient safety Improved clinical performance Efficiency in communication

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• The implementation of an OCR system on PDAs to support the paper-based nursing documentation

• The recommender/intelligent system of the implementation.

3.2.2 Prototype Specifications by Research Review

The sense making of the previously reported literature review suggests us to build a system that adheres to the following concepts:

• Mobility • Easy typing • Message passing between users of the system (the nurses) • Focus on patient privacy • User acceptance starting from the early design stages • Limit input related error

Given the availability of modern, current technologies we hypothesized that the best implementation would rely on a mobile application that would interact with a central server. However, a more refined implementation hypothesis would be enabled through another set of field observations.

3.2.3 Field Observations

After the formulation of an implementation hypothesis, the research team conducted five in-field observations that lasted approximately three hours each. For this second series of observation there was a focus on the activity that takes place at the arrival of a patient at the ward, where a so-called “patient record” is created. We call this activity registration and it occurs at the “Anamnesi” phase (see above). This step of the documentation process is crucial as it is the first series of observations on the patient. The literature proved it to be the most fundamental and problematic to support correctly [28]–[30]. This is due to the fact that at this stage the highest amount of information regarding a patient is collected. The way this information gets collected needs to be structured and supported in the best possible way. Four different nurses were observed performing the registrations of five patients. During these observations, the team filled out a research card (reproduced in Figure 6) to track the sub-activities that compose the registration. For every of the sub-activities and for the macro-activity registration, the researchers measured quantitative and qualitative aspects.

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Sub-activity name: ____________________________________________ Frequency of sub-activity:

____________________________________________

Total time: ____________________________________________ Number of interruptions: ____________________________________________ Total time of interruptions:

____________________________________________

Time spent documenting:

____________________________________________

Main type of interruptions:

q Other Nurse q Other Patient q Technical aspects (malfunctioning measurement

devices) q Documentation related (retrieval, production of data) q Other ____________________________________

Frustrating aspects – weight:

• _________________________________ _________

• _________________________________ _________ • Questions asked – why: • _________________________________ _________

• _________________________________ _________ Figure 6 - Research card

In the AR cycle discussed in this thesis we are mostly interested in the quantitative data as we are trying to address quantitative issues (e.g.: diminish the time needed to create and retrieve patient information, as well as the way in which it is collected). We are thus not going to analyze the qualitative data here, as it is out of the scope of this cycle, and it will be the subject of another thesis. As for the quantitative data collected, we synthetized it in Table 3.

Patient Total time (min)

Time spent documenting (min)

# of interruptions

Interruptions time (min)

P1 26 18 8 3 P2 32 19 2 1 P3 36 25 4 2 P4 36 25 4 2 P5 90 48 0 44

Average 44 27 4.5 10.4

Maximum 90 48 8 44 Minimum 26 18 2 1

Table 3 - Quantitative data synthesis

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We also reconstructed the steps taken to perform each registration (See Appendix A) and later generated a flowchart that represents the ideal registration activity (Figure 7).

Figure 7 - Ideal registration

These more focused observations allowed us also to understand that, as the literature supports, the information about the patients is retrieved mostly while being in mobility (i.e.: while visiting a patient, as discussed in [9]). Thus, it is imperative for a nursing support system to guarantee the best user experience. Indeed, future studies will address this issue.

3.2.4 Final Prototype Specifications and Plan

Once we agreed that data saturation from the observations was reached, we (the present author and a colleague) finalized the system specifications and planned the implementation of the prototype. Following the Lean Startup approach of a Minimum Viable Product (MVP) [31], we decided to present a set of physical and logical aspects of the system that could help us achieve a measureable change in the nursing documentation process. The data gathered during the two Field Observations suggested that the nurses had the need to substitute their physical documentation artifacts with digital based artifacts. We proposed a mapping between the traditional documenting artifacts and those introduced by this research, as illustrated in Figure 8. Tablets emulate the function of the clinical handover document, a widescreen TV emulates the whiteboard, and a workstation allows a fast typing experience whenever this is needed.

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Figure 8 - Mapping of the traditional documentation system to the devices

The mapping was implemented with the following hardware purchase: • Fujitsu Server PRIMERGY TX140 S2 [32], with two 300GB Serial Attached

Small Computer Interface (SAS) drives in Redundant Array of Independent Disks (RAID) configuration of type 1 (i.e.: cloning the contents between the disks) and a NVIDIA GeForce GT 630 graphics card.

• Three Android-based Nexus 7 tablets [33] • A wireless router, based on the 802.11ac standard that offers Dual Band,

Gigabit connection capabilities, equipped with three external antennas [34] • A 55” touch capacitive widescreen TV [35] • A Windows PC to attach to the widescreen TV • A 15” screen to be used with the workstation • Necessary cables and accessories

From the point of view of the software, we convened that the prototype would consist solely in a Web-based application. While native mobile applications would address the issue of supporting mobility-based activities, web applications have the advantage to be hardware-independent. Given the heterogeneity of the required hardware (Android-based tablets, Windows based touchscreen TV and Linux-based workstation) a web-based application was preferable. We intended to develop the application using Meteor.js [36], a fast growing, reactive, open source framework for building JavaScript applications, based on Node.js [37]. Meteor.js gives the possibility to use the same language (JavaScript) to model both the server and client side of an application, aiming to simplicity. Meteor.js embraces the reactive programming paradigm [38]. Reactive programming divides the life of a system into instants, which are the moments where the system reacts. As opposed

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to sequential approaches, reactive programming divides the life of a system into instants, which are the moments where the system reacts. More specifically, Meteor.js allows developers to write code around data in an imperative style. Whenever the data changes, the whole code that employs that data is automatically re-called. Therefore, the results are automatically recalculated whenever data changes. Moreover, Meteor.js provides a controlled, distributed copy of the database among the clients connected to the application. Only the changes get pushed from and to the server. In practice, the server alerts all the clients of changes, pushing to them only the contents of the change, thus minimizing the amount of bandwidth needed and delegating to the clients the responsibility to represent the change. We also decided that a document-based database system could support our prototype better than a traditional relational database due to the nature itself of the data, which is mostly represented as objects with volatile and changing attributes. Therefore, we opted for MongoDB [39], that is also natively supported by Meteor.js. The team agreed that the software prototype would be developed and tested on the field.

3.3 Action Taken

The action part of this research consists in the implementation of the prototype, which was carried out in two months, with an initial week spent on design. During the design phase the research team developed some mockups. The mockups that would contain a mixture of all the elements that should appear in the prototype (see appendix C). The research team also drew an Entity-Relationship (ER) diagram (see appendix D). During the development the team has used a Kanban [40] board to enhance communication and have a graphical feedback of the progress so far.

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3.3.1 Implementation

As shown in Figure 9, the application was developed into five pages, with three main views that appear singularly and in combination in the different pages. The views, described in the following pages, are action based. They support the actions taken by the nurses over the day, instead of faithfully reproducing the formal documentation. Both the informal and formal documentation become part of one system, thus eliminating redundancy related problems. This structure of the system was enabled by a comparative analysis of the folders obtained during the observations.

Figure 9 - Sitemap relation between collections and content in pages

The three main views that generate content from homonymous collections are:

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1. Reminders: The reminders represent a set of activities that have to be

performed on the patients. They are organized in categories (such as “blood sample”, “glucose level”, “weight”, etc.). The general idea is that a nurse sets a reminder for a patient selecting the type of the reminder from the categories list and a due date that usually is within the subsequent three days. Additionally, a short text can accompany a reminder in order to define some particular aspect that transcends the category to which the reminder belongs. Once a reminder has been completed, it can be set to “done” or deleted. Additionally, a reminder can be postponed, so that if an activity is recurring, a nurse can postpone it instead of deleting and recreating it. Figure 10 is a screenshot of the Reminders view.

Figure 10 - Reminders view

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2. Journal: The journal is where nurses write what they have done for a patient, as well as peculiarities about the patient that need to be remembered throughout the hospitalization. In some cases these peculiarities define clinical problems (for example the infection of a wound). Nurses can flag entries as Problems, this giving them a different importance than normal Journal entries. The nurses can associate other entries of any kind (Measures, Reminders or other Journal entries) to a particular Problem. This way it is possible to track entries related to a problem and study what has been done to solve- or mediate to it and, for the reminders, what is needed in the future in order to address it. Figure 11 is a screenshot of the Journal view.

Figure 11 - Journal view with one open and one closed problem

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3. Measures: Measures are data items that reflect psychophysical conditions of the patient. The measurement types were elicited from the formal documentation. The measurement type can be picked from a list containing items such as weight, pressure, pain on a scale from zero to ten, etc. We also implemented a feature that shows a graph of the change for one particular measure of a patient, as we thought this could be helpful (see last figure in appendix D). Figure 12 is a screenshot of the Measures view.

Figure 12 - Measures view

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The other two pages are a combination of these three views in some useful ways. Namely, the “Problems” page offers a view of all the problems and the Measures, Reminders and Journal entries associated to each, while the “Home” page displays the information of a selected patient and static details about the hospitalization (such as if the patient is on a particular diet, is diabetic, etc.). While developing the prototype the research team decided upon some principles that would grant consistency throughout the use of the application. One of these principles was that every view should provide information about all currently hospitalized patients and there shall be a filtering mechanism, present in the whole application, which would allow the user to select a patient and to get in every page only the information related to that one patient. This concept was then extended, where applicable, to other elements in the views (for example a user can decide to filter all the weight measures for a specific patient. More about this can be found in Appendix D). Upon termination of the coding for the first version of the prototype, the research team translated the application in Italian in order to mediate to the impact of the new technology on the nurses.

Figure 13 - Hardware and running prototype in the hospital setting

After the implementation, the prototype and hardware were installed in a free, accessible room in the ward (See Figure 13 and Figure 14).

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Figure 14 - Floor plan with the prototype

3.4 Evaluation

The system was evaluated with two exploratory controlled experiments in natural settings. What this means is that the prototype did not substitute the existing system. This goes against one of the principles of AR that dictates that the outcome of the action of each cycle should introduce change in the context of operation and of the research itself. It is though clear that the changing nature of a prototype is undesirable in such an important context, where lives are at risk if the system ceases to operate. We therefore opted for a mixed approach that would give us enough material to start a new AR cycle, while not interfering with the long-term work of the nurses. Prior to evaluate the prototype trough two experiments, we trained four nurses involved in the evaluation. The workshops lasted approximately thirty minutes and the research team explained the major functionalities of the system. We then observed two aspects in which the system should introduce change in terms of

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time, quality and user satisfaction. These aspects were the registration phase and the clinical handover (“Consegna”).

3.4.1 Registration experiment

Figure 15 - Controlled experiment design for registration diagram

In this experiment we compared the performance of the new system against the old one, in terms of time, number of questions asked to the patients and quality of information perceived by the nurses. Figure 15 represents the following procedure:

• Nurse N1 performs the registration of Patient P1 using the Traditional system.

• Nurse N2 performs the registration of Patient P2 using the Traditional system in another room.

• The nurses exchange rooms (therefore patients) and system. • Nurse N1 performs the registration of Patient P2 using the Prototype. • Nurse N2 performs the registration of Patient P1 using the Prototype in

another room. • The experiment shall then be repeated with a new set of nurses (Nurse N3

and Nurse N4) and of patients (Patient P3 and Patient P4), inverting the use of the prototype and the traditional system (i.e.: At first both nurses will use the prototype and later both nurses will use the Traditional system).

We therefore obtained the quantitative data summarized in Table 4. The qualitative data was gathered through direct observation and interviewing of the participants.

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Given their unstructured and open-ended nature, they are not reported in this section. Instead, qualitative data complements the discussion around the quantitative date in the following section.

Table 4 - Registration experiment quantitative data

It can be seen from Table 4, that the number of questions asked to the patients are lower with the prototype, compared to the traditional system. Figure 16 demonstrates that the average number of questions asked to patients using the prototype is lower. Appendix E provides individual charts comparing the questions asked to each patient.

Figure 16 - Average number of questions asked by the nurses using the traditional system and

the prototype

28  

17  

0  

5  

10  

15  

20  

25  

30  

Traditional   Prototype  

Average  number  of  questions  

asked  

Patient

Nurse System

Time spent documenti

ng in minutes

Time interrupt

ed in minutes

test

Remaining time spent in

the room

with the patient

in minutes

Total time in minute

s spent in the

patient’s

room

Amount of interruptions while in patient’s

room

Number of

questions

asked to the

patient

Amount of times asked

for help w/

prototype

P1

N1 Traditional 19 1 16 36 1 33 N/A

N2 Prototype 18 1 4 23 1 15 3

P2 N1 Prototype 18 2 0 20 4 20 0

N2 Traditional 25 3 5 33 2 26 N/A

P3 N3 Prototype 21 2 10 33 5 23 4

N4 Traditional 15 0 2 17 0 23 N/A

P4 N3 Traditional 16 0 2 18 0 30 N/A

N4 Prototype 5 0 0 5 0 10 3

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The scatterplot in Figure 17 represents the time spent documenting with the traditional system and the prototype. It present two points for each patient, one for the time spent documenting with the traditional system and one for the time spent documenting with the prototype. The two lines depict the averages for the time spent documenting with the traditional system and the average time spent documenting with the prototype. The individual comparisons per case are provided in Appendix E.

Figure 17 - Scatterplot of the documentation time with the traditional system and the prototype

3.4.2 Clinical handover experiment

We decided not to perform our experiment on the real clinical handover, as in this first cycle our prototype would not substitute the existing system but only be used for evaluation. Therefore, since there are four nurses working during one shift, we could emulate the clinical handover (“Consegna”) phase, which usually happens in the early morning or at night. The experiment was carried out after the registration experiment explained above in the following way:

• Nurse N1 picks randomly either Patient P1 or Patient P2. • Nurse N1 proceeds to perform the clinical handover of the picked patient to

all nurses using the prototype. • Nurse N2 proceeds to perform the clinical handover of the other patient

(Patient P1 or Patient P2) to all nurses using the traditional system. • Nurse N3 picks randomly either Patient P3 or Patient P4. • Nurse N3 proceeds to perform the clinical handover of the picked patient to

all nurses using the traditional system. • Nurse N4 proceeds to perform the clinical handover of the remaining patient

(Patient P3 or Patient P4) to all nurses using the prototype.

19  

25  

16   15  18   18  

21  

5  

0  

5  

10  

15  

20  

25  

30  

1   2   3   4  

Time  spent  for  docum

entation  in  

minutes  

Patient  

Traditional   Average  Traditional  

Prototype   Average  prototype  

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We therefore obtained the quantitative data summarized in Table 5.

Nurse System Time Nurse N1 Traditional 2minutes 13seconds Nurse N2 Prototype 3minutes 20seconds Nurse N3 Traditional 45seconds Nurse N4 Prototype 2minutes 30seconds

Table 5 – Clinical handover experiment quantitative data

The data shows that the average time to perform the clinical handover with the Prototype is 2 minutes and 55 seconds, while the average time using the Traditional system is 1 minute and 29 seconds. Given the small sample obtained, inferential statistical methods are not appropriate. However, the following section will provide a sense making of qualitative and quantitative data.

3.4.3 Experiment Results

The results of the registration experiments have been studied. The analysis of the data highlights that the average time needed to collect and note the data of a patient with the prototype (15 minutes and 30 seconds) is slightly less (by 2 minutes and 45 seconds) than the time needed to register a patient with the traditional system. This improvement is relevant if the data created through the registration with the prototype is complete and meets with the quality expectations of the nurses. To be certain of this, the qualitative data and opinions collected through this experiment and the experiment on the clinical handover were used. Nurses reported no missing clinical data and noted no lack of quality in it. For example, Nurse N2 reported: “[using the traditional system] we often have to copy background data, such as patient name and birthdate to many different sheets. With the [prototype] system we cut this time out and just note what really counts at the moment […] the data I noted with the [prototype] system is as accurate as the data I write with the traditional system, but using the [prototype] system it is much easier and clearer to write this data down […]”. Additionally, we concluded that the average number of questions asked to patients regarding their hospitalization using the prototype (17 questions) is lower than the number of questions asked using the traditional system (28 questions). The quantitative data of the second experiment highlights an increment of average time to perform the clinical handover using the prototype. This goes against our expectations, as we hypothesized that the time needed to perform the handover with the prototype would be less, especially seeing that the listening nurses wouldn’t have to write down what was said during the procedure. The nurses report that “the [prototype] system gives you all the raw data of the patient, while we are used to operate on only notes that are an elaboration of what we observe during our

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shift and what has been told to us during previous clinical handovers” and see this as positive because “[using the old system] many times we miss information because our notes are incomplete or a product of too many elaborations”. Thus, we conclude that the increment of time in this experiment is due to a higher quality of information and information passing. In fact, on this regard, nurses report that with the new system they see all the information and feel compelled to talk about aspects that they would usually ignore, although they are relevant for patient care.

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4 Discussion

In this section, we discuss the outcomes of the cycle of AR described in this thesis. Through this thesis we studied the nursing process in one ward of the local hospital of Bolzano/Bozen. We studied the problems related to the nursing process, we implemented a prototype to support it and measured the changes that this system introduces. The nursing process relies on data. The way this data is to be collected, stored and organized is though not defined in the process. Throughout the first two steps of the AR cycle described in this work we have observed the nurses of a ward in the hospital of Bolzano in their environment and understood their approach towards data creation, storing and retrieval within the boundaries of the nursing process. Their documentation process and documentation techniques have been described. We then focused on developing an information system that would emulate their documentation techniques and support their documentation process, both to create a new technology that would support the general nursing process as well as to adapt the system to their specific needs. We made use of modern 7” Android-based tablets to support the nurses in mobility, rather than PDAs or laptop computers, as suggested by the research review. Additionally, we gave the nurses two stationary possibilities to interact with the system. One of these possibilities is represented by a workstation, while the second one is a 55” touchscreen TV that can interact with the system through an attached PC. We focused on creating a software prototype that would allow real-time collaboration between nurses through patient-data. We therefore created a web-based application that allows the nurses to access and store patient data from every room in the ward. To validate our prototype we conducted two experiments on aspects that we thought should highlight differences between the traditional documenting system and the new one. The quantitative and the qualitative data from our exploratory experiments confirm that our introduced action brings relevant improvements to the nursing process, already at the first cycle of AR. This findings support what had been discovered by previous work covered in the research review [5], [10]. We foresee that the system can reduce the average time needed to register a patient even more once the nurses are acquainted with the prototype (in fact, they were introduced to the system only right before the experiments and used it only for ten minutes before the registration experiment).

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4.1 Implications

The results of our experiments show that a mobile-based information system aimed for the support of the nursing process can provide the following benefits in the hospital setting:

• Quantitative benefits: o Improvement in time needed to register a patient o Reduction of questions asked to patient during registration

• Qualitative benefits: o Eliminate redundancy o Enhance sharing of information o Enhance collaboration o Enhance quality and completeness of data

The outcome of this research proves that there are great opportunities for improvement in the local hospital of Bolzano and, still, for this kind of work, with the current technologies, much can be done to facilitate the nursing process.

4.2 Limitations

The greatest limitation to this research is represented by the homogeneity of the sample on which the research was made. It was in fact limited to the nurses of one ward, as opposed to the whole hospital. Another limitation is the absence of other hospitals participating in the research. These limitations hinder the generalization of the results, also because no statistical inference could be performed. However, this work is a first exploration in order to solve a very complicated and complex problem. The initial results support the conduction of future cycles of AR and future work, because they indicate a potential benefit of the proposed solution.

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5 Conclusions

The Nursing Process relies heavily on data gathering and analysis, in order to ensure the correct patient care. For this reason, data collection, storing and retrieval as part of the nursing practice are subject to continuous mutation and improvement initiatives by research activities. Since the mass introduction of computer machines in hospitals, the way patients’ data is handled inside the hospital setting has changed dramatically. Many attempts to digitalize the documentation related to the nursing process have been made. Nowadays, more challenges for improving the nursing process and the related documentation have arisen, because of the introduction of mobile devices. However, the majority of the proposals from the body of knowledge are on a theoretical level only. There has been the need to introduce a scientifically validated system for supporting and improving the nursing process through mobile-oriented information systems. In this thesis we studied how the nurses of a ward of the local hospital of Bolzano/Bozen, Italy, approach the nursing process. After discovering the absence of information systems to support the creation and retrieval of patient related data, we have set up an Action Research study to both understand and mutate the context to which this research is applied. The thesis reports the first Action Research cycle as actuated in the hospital setting over a period of eleven months. The focus was to understand how the nursing process could benefit from the introduction of a web-based, mobile-oriented system. Therefore, we implemented such system, following the guidelines highlighted by the related work review and two in-field observation studies. The system revolves around the actions that are performed by the nurses every day, instead of digitalizing the already existing documents and forms. Thus, the system enhances the nursing documentation process but it does not devastate the nurses’ habits and procedures. We empirically validated the implemented prototype system in the hospital setting through two exploratory controlled experiments. The results reveal an improvement brought in by our system in terms of performance and in terms of information quality.

5.1 Future work

Our findings provide an initial support regarding a successful improvement program. However, they do also support the conduction of future cycles of action research. The next research steps should focus on User Experience improvements, as such improvements are hypothesized to bring the most desirable benefits in terms of performance and user satisfaction. Future studies should investigate an integration of our (or similar) systems with medical measuring devices. It is necessary to understand the limits of the employed data storing systems, in order to comply with national regulations regarding data retention.

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V

Appendices

Appendix A. Registration activity flow charts

In the following five customized flowcharts we will present the steps that compose the registration activity. Each flowchart represents the registration of a patient. Four different nurses performed the registrations. The structure is as follows:

• Boxes on the left denote steps that have been performed in presence of the patient.

• Boxes on the right denote steps that have been performed in absence of the patient (usually in the nursing office) while waiting for the patient to perform some task.

• Boxes in the middle (usually on the bottom) denote steps that have been performed after visiting the patient and returning to the nursing office to complete the registration activity.

The colour of the boxes indicate as follows: • Blue boxes represent steps that involve either retrieval or creation

of documentation. • Red boxes represent steps that have been done due to some error

during the activity.

VI

Figure 18 - Registration of 11.06.2014

VII

Figure 19 - Registration 1 of 15.06.2014

VIII

Figure 20 - Registration 2 of 15.06.2014

IX

Figure 21 - Registration of 09.07.2014

X

Figure 22 - Registration of 10.07.2014

XI

Appendix B. Prototype Mockups

In the following two figures we will show two mockups that we created during the design phase of the implementation. These two mockups where used as basis to generate all the views in the application.

Figure 23 - Single patient view

XII

Figure 24 - All reminders view

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Appendix C. Prototype ER diagram

In the following figure we show the Entity-Relationship (ER) diagram that we used to guide our development. As we used a non-relational database system, this diagram was of use especially to keep in mind what we were storing in the different collections of the database.

Figure 25 - ER diagram for the prototype

XIV

Appendix D. Prototype filtering mechanism

In the next three screenshots we are going to present the function of the Omni-present bar in the bottom of the page. The search area, as shown in the bottom of the figure below, serves as starting point to select a patient (either by name or by surname). Once the patient is selected, the bar will present the name of the patient and across all pages the content will be filtered for that patient. In the last figure we see how the filtering principle is extended to a view. Particularly, in this example we selected a patient and a measure in which we are interested. The items that will be displayed in that view will only regard that patient and that measure. In addition, we implemented the generation of graphs from the data of measures, in order to get a fast glimpse of the change of that data throughout the measurements.

Figure 26 - Journal view without filtering for patient

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Figure 27 - Journal view filtering for patient

XVI

Figure 28 - Measures filtered for patient and weight (displaying a graph)

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Appendix E. Registration experiment data analysis

In this section we will present a series of charts that we used to make sense of the data collected from the experiments described in this thesis. In the following group of charts we will show two bar graphs for each patient. The first bar represents the total time used by a nurse to register the patient using the traditional system. The second bar represents the total time used by a nurse to register the patient using the prototype. Each bar is divided in two:

• The lower part represents the time spent documenting (i.e.: writing on the paper or using the tablet).

• The upper part represents what we call overflow. This is time that the nurse spent in the room with the patient but not performing documentation-related activities. This time can be spent answering questions that the patient asked about the medical procedure, the room, or performing measures (for example taking the pressure), etc.

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To compare all four measures we will present them in a single chart:

19   18  

17  

2  

0  5  10  15  20  25  30  35  40  

Traditional   Prototype  

Time  in  minutes  

P1  

25  18  

8  

5  

0  5  10  15  20  25  30  35  

Traditional   Prototype  

Time  in  minutes  

P2  

16  21  

2  

12  

0  5  10  15  20  25  30  35  

Traditional   Prototype  

Time  in  minutes  

P3  

15  

5  

2  

0  

0  

5  

10  

15  

20  

Traditional   Prototype  

Time  in  minutes  

P4  

19   18  

17  

2  

25  18  

8  

5  

16  21  

2  

12  

15  5  

2  

0  0  5  10  15  20  25  30  35  40  

Time  in  minutes  

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Next we will represent the average (or mean) time of the two systems from the data of all patients.

18.75  15.5  

7.25  

4.75  

0  

5  

10  

15  

20  

25  

30  

Traditional   Prototype  

Time  in  minutes  

Mean  time  spent  interacting  with  patient  

Mean  time  spent  documenting  

XX

In the following charts we will study the number of questions asked to each patient using the traditional system and using the prototype:

To compare all four measures we will present them in a single chart:

33  

15  

0  5  10  15  20  25  30  35  

Traditional   Prototype  

Questions  asked  

P1  26  

20  

0  

5  

10  

15  

20  

25  

30  

Traditional   Prototype  Questions  asked  

P2  

23   23  

0  

5  

10  

15  

20  

25  

Traditional   Prototype  

Questions  asked  

P3  30  

10  

0  5  10  15  20  25  30  35  

Traditional   Prototype  

Questions  asked  

P4  

33  

15  

26  

20  23   23  

30  

10  

0  5  10  15  20  25  30  35  

Questions  asked