Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: A prospective randomized controlled study☆
Highlights
► Integrated information display for ICU nursing tasks across medication management, patient awareness and team communication was shown to increase nurses’ situation awareness. ► Integrated information for a broad range of tasks decreased task completion time. ► Integrated information was most beneficial for nurses’ perception and comprehension tasks.
Introduction
The high-risk environment of the intensive care unit (ICU) exposes patients to frequent preventable medical errors and high associated costs, potential end-organ damage and even death [1]. Among contributing factors are complex drug regimens, opportunities for error induced by the complexity of the ICU environment, numerous high-risk medications, and calculation and administration errors for intravenous (IV) drugs [1].
The potential of medical errors increases if nurses have low situation awareness of their patient's health status and treatment plan [2]. Situation awareness describes the operators’ awareness, understanding, and anticipation of the future development across three levels: perception, comprehension and projection [3], [4]. Perception means that the user is aware of the state of the system (e.g., a nurse can see the displayed blood pressure or can visually assess respiratory distress). Comprehension describes the user's understanding of the meaning of the perceived variables of a system (e.g., a nurse understands that the blood pressure is lower than it should be considering the patient's condition or that the respiratory distress is new or particularly severe). Projection refers to the user's expectation of consequences for the system and its future developments (e.g., a nurse anticipates that the patient could go into shock due to the falling blood pressure or that the respiratory distress might be due to an allergic reaction that must be treated immediately). For nurses, having a low situation awareness could mean that they are, for example, not aware of important treatment-relevant information, they do not understand the implications of information they see, or their anticipation of the patient's treatment course is wrong, leading to inadequate actions.
Currently, nurses have difficulty maintaining adequate situation awareness of the patient and treatment [5]. Nurses need to cope with an abundance of information [5] obtained through medication databases, electronic medical records, ventilators, patient calls and conversations with patients, colleagues, and other clinicians, all at different locations. Medical devices contribute to nurses’ reduced situation awareness because these devices do not effectively support their perceptual, cognitive, and physical capabilities [6]. Current devices are not intuitive [6], [7], are not designed to support nurses work or thought processes [8], and do not provide the information at the place and time needed [9]. For example, some patient monitor designs inadequately code the priority or type of alarm, causing failures in their detection and perception, or overload the user's auditory and/or visual perception with too many signals leading to errors of omission (missed alarms) [6]. Furthermore, nurses sometimes struggle to remember all the necessary information for treating patients [10].
Information integrated in one display or metaphor could improve nurses’ situation awareness. Information integration can be broken into two levels: variable level and system level integration. For variable level integration, multiple data points are combined into a single pattern or metaphor which changes its appearance depending on the values of the individual variables. For system level integration, information is consolidated and aggregated from multiple sources in one location, for example, taking ventilator, vital signs and infusion pump information and showing it on one display screen. Both types of integration could be expected to enhance situation awareness. For example, operators’ situation awareness increased when using integrated information in Anesthesiology [11], during air traffic control tasks [12], and might increase shared understanding among care providers [13]. A study by Zhang et al. [11] found increased situation awareness comprehension in anesthesiology but did not find a difference for situation awareness perception; projection tasks were not measured. Effken et al. [14] found an ecological display did not improve nurses’ recognition speed but improved treatment efficiency when 12 variables were present together. Doig et al. [15] found that nurses accuracy of blood gas incident identification increased significantly when using a visualization tool that consolidated multiple variables, significantly reducing response times. Miller et al. [16] found improved detection of patient changes when nurses used a display that grouped information around physiological functions. However, these displays only supported a limited range of tasks such as patient monitoring. ICU nurses still have to refer to additional devices to get the “big picture” of the patient and perceive, understand, and predict the patient and treatment process. They need to simultaneously obtain information from multiple screens or applications—a situation which likely leads to a high perceptual workload and low SA.
When nurses need to understand the implications of information they see or anticipate the patient's treatment course, a holistic picture of the patient and treatment is essential. Without this holistic picture, medications, for example, cannot be administered with sufficient patient safety. A “one-stop-shop” display could increase nurses’ situation awareness and potentially increase their time efficiency. Although previous research indicates a need for consolidated information sources [7], [9], [17] to support nurses in a broad range of tasks (a “one-stop-shop” for information), formal evaluations of nurses’ situation awareness and task completion time when using broad purpose displays are not yet available.
The motivation for this study is to address the open research questions about how nurses’ situation awareness can be increased and how nurses’ work environments can be improved. Thus, the current study on integrated information displays is one aspect of helping increase situation awareness for ICU nurses at the bedside. This study is part of a larger project [18], [19]. In the first phase of the project, we observed nurses in ICUs at three tertiary care hospitals and identified information gaps during nurses’ medication management, patient awareness, and team communication at all three situation awareness levels. We identified ideas to address these gaps [18], [20], [21]. Then, we developed and iteratively refined an integrated information display prototype based on feedback from nurses working in four ICUs—Medical, Surgical, Burn-Trauma, and Neurological Critical Care [22].
The study measured the effects of an information display integrating data in one location compared to traditional displays. We tested the following specific hypotheses: (A) Nurses have higher situation awareness on all three levels when using an integrated information display compared to using traditional displays. (B) Nurses have a shorter task completion time when performing tasks of all three situation awareness levels when using an integrated information display compared to using traditional displays.
This study was approved by the local ethics committee (the Institutional Review Board of the University of Utah) and all subjects gave informed consent to participate in the experiment.
Section snippets
Organizational setting
The study was performed at the University Hospital, University of Utah Health Science Center, Salt Lake City, Utah, US, a 425-bed tertiary care medical hospital and regional referral center. The setting was a Burn Trauma ICU, approved as a burn center by the American College of Surgeons and a Level I Trauma Center. Here pediatric and adult patients who are thermally, chemically, or electrically injured are treated as well as patients from the Medical ICU (as overflow). The unit has 60 nurses,
Study design
The counter-balanced (display order), repeated-measures design compared a traditional display with an integrated display on the dependent variables of situation awareness (accuracy of the participants’ answers), and task completion time (response time from seeing the question to submitting the answer). Since performance is known to vary widely across individuals, a repeated measures design was selected to control for individual differences, participants received both study conditions in random
Demographic and other study coverage data
The participating 12 burn trauma ICU nurses (8 females) had a median age of 31.5 years (range 23–57). Their self-rated median nursing expertise was 7 (1 = novice, 9 = expert), and their ICU experience was a median of 3 years (range 1–24). Participants used computers on average 5 hours per day. The median study duration was 23 min (range 15–47 min) for each of the two display settings.
Unexpected events during the study
Two participants had to repeat the training and competency test before entering the study, but none were excluded.
Discussion
Our study showed that an integrated information display supporting a broad range of tasks, increased nurses’ situation awareness and decreased task completion time compared to traditional displays. For both displays, projection tasks took longer to complete than perception or comprehension tasks.
Potential explanations for the nurses’ significantly lower situation awareness with the traditional display might be the deliberately complex tasks they had to perform in our evaluation study, which,
Conclusion
An integrated ICU information display increased ICU nurses’ situation awareness and decreased task completion time for medication management, assessments of the patient's state and team communication. Integrated displays have the potential to decrease errors, increase nurses’ productivity and could enable nurses to react faster to a patient's clinical needs. Although integrated information displays have great potential promise, current technological factors such as bidirectional device
Conflict of interest statement
The study was partially funded by a grant from Drägerwerk AG, Lübeck, Germany, a manufacturer of medical devices. Authors SK, NS, M. Görges, MH, JA, and DW received parts of their salary through the grant whilethe study was conducted. Authors CW, DL, and M. Gondan have no conflict of interest to report. The study sponsor had no involvement in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript
Contributions
Conception and design were done by S. Koch, C. Weir, M. Haar, N. Staggers, J. Agutter, D. Liu, M. Görges, D. Westenskow. Data collection was done by S. Koch and M. Görges. Analysis of the data was done by M. Gondan. Interpretation of the data was done by S. Koch, N. Staggers, and C. Weir. Drafting was done by S. Koch, N. Staggers, and M. Gondan. Critical revision for important intellectual content was done by S. Koch, C. Weir, N. Staggers, M. Haar, and J. Agutter. All authors approved the final
Acknowledgements
We acknowledge the contributions, advice, and support of John Hurdle, Tamara Laukert, Eric Boam, Amanda Sheeren, Laureen Whitaker, (University of Utah), Kai Kück (Drägerwerk AG), and the ICU nurses who participated.
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ClinicalTrials.gov Identifier: NCT00714012.