We found that nurses experience significant challenges in navigating and integrating their information environment. Information gaps exist at all three levels of SA, in particular for frequent nursing tasks. Nurses' SA perception was challenged by the visibility of essential information, either because it was not easily accessible (eg, drug–drug compatibility, or drug–disease and drug–patient interactions) or because it was simply difficult to see at a distance as the nurse moved around the ICU. In addition, our observations showed that audible information was enveloped into background noise and so was not accurately perceived. Comprehension was also not well supported. To understand the correlation between the patients' status and current treatments, nurses needed to gather and integrate information from multiple devices such as the vital signs monitor, intravenous pumps, the ventilator, and electronic medical records simultaneously. Furthermore, equipment settings were often altered by others without notification, so nurses spent significant time double-checking settings, orders and clinical notes for congruency. Finally, SA projection was often difficult because information about the risk of adverse events or the likelihood of successful treatment required communication about care goals, expected results from treatments and the rate of change of key information. This kind of high-level information was not often available and took considerable effort to acquire.
Some of our task categories overlap with the categories as defined by other research: direct care, organization, medication management, and patient awareness.13
However, when compared with the work of Hendrich et al13
our work could show the relevance of information communication for nurses. We defined a communication category—with the focus on exchange of information and included documentation as we thought the main purpose of documentation was communicating information.
Our results are congruent with nursing theories that address nursing actions. The nursing intervention lexicon and taxonomy of Grobe et al26
identifies seven categories of nursing interventions based on a qualitative analysis of nursing statements. Their categories of ‘care need determination’ and ‘care vigilance’ are comparable to our category called ‘patient awareness’. Their category entitled ‘care environment management’is similar to our ‘organization’ category. In addition, informatics theories were not a part of the early work of Grobe et al26
but the early work of Graves and Corcoran27
and the model of human–computer interaction of Staggers and Parks,28
as well as later work by Staggers29
represent the device interaction components of ICU nurses' work. The informatics research organizing model of Effken,30
which takes into account nursing practice, cognitive decision-making, context and the patient's health in a broad sociotechnical perspective, is closest to this work. The current work expands the work cited above because it focuses on information gaps, determines critical information for integrated displays based upon frequent nursing tasks, and uses SA as a theoretical basis.
Concerning the information needs of nurses, our work expands current knowledge by listing detailed information deficits. Other research supports findings that nurses need to perform extensive information gathering,3
that their awareness of the patient and treatment is sometimes challenged,2
current devices do not support them adequately,3
and similarly demands for improved information access,3
and improved communication.25
However, expanding current knowledge, our research provides specific details about which information is missing during frequent task categories. We could identify specific information needs of nurses that are currently not sufficiently met and challenge the different levels of nurses' SA. This information advances current knowledge about current information deficits and can be used during the development and improvement of medical devices and information systems.
To prioritize task-specific support through new devices, our hourly frequencies of ICU nursing tasks add to the literature. Different to the percentages of nursing time spent for different tasks, as identified by Hendrich et al
these findings allow prioritizing new device development for tasks that are performed frequently by nurses.
When using the SA taxonomy to categorize information needs and to derive opportunities for the development of new integrated displays, devices better support the user's work. Situational awareness is the key to be able to act adequately and continuously assess the importance, urgency and details of tasks and combine them to a workflow. Nurses continuously need to react adequately on changes in the patients' status, to call a doctor in critical situations and to organize the less important tasks around urgent tasks. Therefore, our identification of requirements for integrated displays for nurses, based on the framework of SA, could lead to the development of better devices—devices that improve nurses' understanding, planning and execution of their daily work and lead to a higher awareness.
Integrated displays would better support nurses as they perform medication management tasks, provide more efficient information exchange between care providers, and enhance nurses' SA and context-sensitive decision-making.
Implications for error
We found that current devices at the ICU bedside do not adequately support nurses' activities. Such inadequate support might contribute to the high number of errors found by previous research, such as the high number of serious errors (61.4%) of Rothschild et al7
associated with medication management, and the 14.8% related to inadequate reporting or communication. Improving communication of clinical goals of care might significantly improve care, efficiency, and decrease errors. In one study, only 10% of ICU staff understood the goals of care on a daily basis; after implementation of a daily white board, 95% of the staff reported understanding the goals of care. One result was a significant decrease in the days of stay by 1.5 days.38
In another study, the quality of the nurse–physician communication was significantly related to medication errors overall.39
Finally, communication between physicians and nurses was involved in 43% of errors.23
The rate of errors peaked after shift changes and rounds,23
and nurses were found to forget what they were looking for while moving from one patient room to another.2
Implications for design
The results of this study support the need to incorporate critical information into bedside displays that go beyond the content of the monitor itself. Information should be organized around medication tasks, communication of critical information, and patient awareness to support efficient information exchange. Medication management tasks are performed frequently, and involve significantly more complex information needs than are met by current devices. Therefore, medication management information should be extremely accessible, including instant access to orders, notifications whenever orders have been changed, medication compatibility, medication-specific monitoring needs, and likely adverse side effects.
Synchronous communication between nurses and physicians increases shared knowledge and nurses' understanding of the patients' state.40
Particularly important is a shared display regarding the location of other clinicians, access information, and timing for assumed responsibilities.
Limitations/comment on methods
Our results are based on an adaptation of the participant observation method, questionnaires, and brainstorming to define design implications and recommendations based on theory. Other researchers have used cognitive work analysis41
or expert consultation to identify requirements for nurses' bedside displays.12
Cognitive work analysis might have resulted in more in-depth findings than our results but would have been more intrusive for nurses' workflow. An expert consultation method might have limited results to problems the users could recall without being in the context of work, a method that could have significant bias.21
Our methods have the advantage of integrating across three institutions with a variety of nurses and time slots. Similar to cognitive work analysis, we looked at the tasks nurses performed, the decisions they made, information searching behavior, and the overall context in which they performed their work. A limitation of the study is that the results were not validated by member checking. This study is also limited due to a restricted geographical area and a relatively few number of nurses, who were not selected randomly.
Future studies might include observations during the night shifts when accessibility of doctors and colleagues might be more limited, and different communication and decision support needs could prevail. Future work could additionally use our identification of tasks and information needs as a foundation to apply the fit between individuals, task, and technology framework or incorporate a model of work analysis45
or workload theory as the conceptual basis. Future research should focus on the detailed design of such integrated systems, to provide manufacturers with concrete design guidelines combining the ‘what’ with the ‘how’.