Nursing Workflow Interrupted: The Shortcomings of Technology in Healthcare

Jonathan Dimas RN, BSN, CCRN 
PhD Student University of Utah College of Nursing 

The Good   

If you’ve ever listened to someone speak about emerging technology, at a symposium or in everyday conversation, there’s a pretty good chance you’ve heard about the countless benefits we now enjoy as a result of these technological advances.  “Look how fast…look how easy… look how much better… “, you get the idea.  Technology has already changed the world in so many ways it boggles the mind to consider what the future might bring.  The healthcare sector is no exception.  These advances are so numerous that to only list the most influential would take the length of an entire textbook, and still only scratch the surface. Healthcare breakthroughs such as the Human Genome Project, nanotechnology, and new insights into the human microbiome have brought about rapid changes, that are so profound we often don’t have the resources and infrastructure to manage the implications of new findings.  For the moment, however, let’s take a step back from the overwhelming and exciting technological leaps being made in pharmacogenomics, theranostics and tissue engineering. 

The Bad

If you’ve ever heard a nurse talking about charting in an electronic health record, or using a top of the line IV pump or using a barcode scanner when giving medications, there’s a pretty good chance you’ve heard about the countless headaches we now suffer as a result of these technological advances.  Unlike the incredible time and effort saving benefits that are usually seen with technological upgrades, the adoption of clinical technologies seems to move in the opposite direction.  A cursory search of PubMed, CINAHL and Google Scholar did not reveal any studies on the impact these technologies have on time, effort and workflow, but I’m confident that even a simple survey among nurses would reveal no small amount of unfavorable opinions. 

The (Ugly) Question

The question then becomes, why is it that with the phenomenal advances being made in healthcare science, the bedside is left to languish in subpar technologies?  Some of the self-explanatory concepts that helped form Vankatesh et al.’s Unified Theory of Acceptance and Use of Technology were: relative advantage, ease of use, job-fit, compatibility, and perceived usefulness (2003).  I’m not sure developers really had these in mind when creating the bedside technology we see in use today.  Nurses often bemoan the fact that they end up taking as much care of the computer as they do the patient.  It is one thing to complain, and another to come up with solutions… or at least to have a vision for the future. 

The Present

First, imagine a busy day as an ICU nurse.  You are caring for two, very sick patients that each require multiple dressing changes, near hourly medications (some IV drips, some liquid and some pills that need to be crushed and dissolved in solution), repositioning every 2 hours, oral care every 4 hours, bed baths, continual assessment and monitoring and, when necessary, communication with the interdisciplinary healthcare team.  Now imagine, as you go into the room to give your first medications, the patient’s barcode on their ID band has been inadvertently cut and is unusable.  You get a new one ordered, and when it finally arrives, another nurse has taken the scanner for use on another patient.  You get the scanner back, and you realize you accidentally threw away the packaging to the pills you had to crush, and you have to go back to the medication dispenser to get a new package that you have to scan and then return to the dispenser.  Your first round of medications is complete!  Now onto charting the assessment and interventions that you performed while you’re in the room.  You log on to the computer at the nurse’s station and receive an unexpected downtime warning.  Seems like a good opportunity to go get your second patient squared away, before returning to chart both patients’ assessments and interventions… but first to track down that barcode scanner again.  You finally sit down to chart, and you have to page through 6 different tabs and several different pages just to get a basic assessment complete.  I could go on, but I hope the frustration is evident. 

It may seem like an implausible story, intentionally filled with mishaps, but I assure you this is par for the course in many institutions.  And where in that scenario, did the nurse connect with the patient?  When did the family get spoken to and consoled?  These frustrations with technology aren’t just impediments to nurse workflow.  They take away from our ability to connect with our patients and their families.

The Future?

My hope for the future is that new technologies will be designed to make our jobs easier, and allow us to get back to the bedside where we belong.  I readily acknowledge the benefits of electronic healthcare records, for the management, access and storage of data.  Interface and usability need to become a priority to developers in the future.  Why haven’t Apple or Microsoft, companies known for their excellence in user interface and operability, dipped their toes in the electronic healthcare record market? (*Hint, hint*)

My vision of a perfect technological interface would look something like this.  I come to work and receive report on my patients.  I put on my work glasses, which contain an unobtrusive display screen, object recognition capability, location tracking and audio/video recording installed.  I walk into my patient’s room with the medications and supplies I will need.  The patient’s chart is automatically opened as I enter, since the device “knows” whose room I’m in.  I introduce myself and talk with patient about our plan for the day, and when I’m ready, I give the verbal prompt “assessment,” and begin verbalizing my findings into the recorder.  I’m now ready to give medications, and give the appropriate prompt.  The glasses recognize that I’m in the correct room and visually recognize the packaging and barcodes of each medication I’m giving to the patient and charts them as I go; I only give half a vial for one medication and let the recorder know.  I’m ready for the dressing change and again I give a prompt, and verbalize my assessment.  The wound is looking much better and I give a command to snap a photo for the physician, so the wound does not have to be undressed an hour later when they come for rounds.  I check the patient’s blood glucose and recognize the need to adjust the insulin drip.  My display screen shows me the blood glucose trend and any other labs I request, and lets me know the new rate to set the insulin pump.  I tell the IV pump the new rate, and it makes the changes after confirming the new settings are correct.  I perform the other routine tasks, verbalizing my actions as I go.  As I walk out of the room, my display screen reminds me to reposition the patient since it’s been 2 hours, and I neglected to tell the recorder I had done so.  I complete the task and walk out of the room without having to sit down and chart a thing.  The family approaches as I exit and I walk back into the room with them and sit down to answer their questions and soothe their distress. 

As far-fetched as it may sounds, the technological capabilities already exist (e.g. Google Glass, Bluetooth headsets, Dragon dictation, Natural Language Processing).  Now we need enterprising scientists and clinical practitioners to collaborate and make this fictional account into a reality.  The promise of technology can then, move nurses out of their computer chairs and bring them back to the bedside.

Reference

Vankatesh, V., Morris, M., Davis, G., & Davis, F., (2003) User acceptance of information technology: Toward a unified view. MIS Quarterly 27(3), 425–478.

This work is by Jonathan Dimas licensed under a Creative Commons Attribution 4.0 International License