Value and Usage of a Workaround Artifact: A Cognitive Work Analysis of “Brains” Use by Hospital Nurses

Abstract

We identify the value and usage of a cognitive artifact used by hospital nurses. By analyzing the value and usage of workaround artifacts, unmet needs using intended systems can be uncovered. A descriptive study employed direct observations of registered nurses at two hospitals using a paper workaround ("brains") and the Electronic Health Record. Field notes and photographs were taken; the format, size, layout, permanence, and content of the artifact were analyzed. Thirty-nine observations, spanning 156 hr, were conducted with 20 nurses across four clinical units. A total of 322 photographs of paper-based artifacts for 161 patients were collected. All participants used and updated "brains" during report, and throughout the shift, most were selfgenerated. These artifacts contained patient identifiers in a header with room number, last name, age, code status, and physician; clinical data were recorded in the body with historical chronic issues, detailed assessment information, and planned activities for the shift. Updates continuously made during the shift highlighted important information, updated values, and tracked the completion of activities. The primary functional uses of "brains" are to support nurses' needs for clinical immediacy through personally generated snapshot overviews for clinical summaries and updates to the status of planned activities.

Nursing Handover: A Content Analysis of Nurses’ Handwritten Notes

“…Although this study was conducted in 2014, the characteristics, content, and congruence of handwritten information shift-to-shift are relevant in the current health care environment. Similar characteristics and content of handover tools were found by Mount-Campbell et al (2019). Study findings and supportive literature suggest the importance of enabling personalization in the development of a standardized handover tool.…”

Technology barriers and strategies in coordinating care for chronically ill patients

“…J. Holden et al, 2013; Mount-Campbell et al, 2019; Novak, Holden, Anders, Hong, & Karsh, 2013; Tucker & Edmondson, 2003). These studies focus on healthcare workers in the hospitals, such as critical care nurses (Durso, Ferguson, et al, 2014; Durso, Kazi, & Ferguson, 2014).…”

“…Work-arounds have been found in the hospital environment where “informal temporary practices” are used to manage exceptions to normal workflow (Halbesleben, Savage, Wakefield, & Wakefield, 2010; Halbesleben et al, 2008). Work-arounds often occur when healthcare providers deal with problems created by technologies (Carayon et al, 2007; Ferneley & Sobreperez, 2006; Koppel et al, 2008; Mount-Campbell et al, 2019; Patterson, 2018). For example, nurses felt it was easier to document medication administration using bar code medication administration technology before the medication was given (Carayon et al, 2007).…”

“…Several studies have described strategies used by healthcare workers in dealing with technology problems or barriers (Durso, Ferguson, et al, 2014; R. J. Holden et al, 2013; Mount-Campbell et al, 2019; Novak, Holden, Anders, Hong, & Karsh, 2013; Tucker & Edmondson, 2003). These studies focus on healthcare workers in the hospitals, such as critical care nurses (Durso, Ferguson, et al, 2014; Durso, Kazi, & Ferguson, 2014).…”

Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System

“…In many settings, paper forms [e.g., patient admission forms in hospitals, (3)], paper handouts [e.g., financial advisors meeting with clients, (4)], printed documents [e.g., academic supervisors reviewing papers with their students, (5)], and handwritten notes on paper [e.g., taken by policemen, (6)] have persisted in the presence of digitization and technological innovation. In some cases, the use of paper persists despite explicit organizational incentives or sanctions intended to discourage use [e.g., paper charts used by physicians in outpatient care, (7); handwritten patient summaries used by nurses in hospitals, (8,9)].…”