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1.  A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life 
BMJ quality & safety  2011;20(1):15-24.
Backgrounds
Nursing workload is increasingly thought to contribute to both nurses’ quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualizing and measuring the effects of workload in health care. In contrast, we conceptualized a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes.
Methods
To test this model, we analyzed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care pediatric hospitals.
Results
Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading = .31) and burnout (path loading = .45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading = .25) and medication error likelihood (path loading = 1.04). Job-level workload was not uniquely and significantly associated with any outcomes.
Discussion
The human factors engineering model of nursing workload was supported by data from two pediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.
doi:10.1136/bmjqs.2008.028381
PMCID: PMC3058823  PMID: 21228071
workload; mental workload; patient safety; medication error; quality of working life
2.  Pharmacy workers’ perceptions and acceptance of bar coded medication technology in a pediatric hospital 
Background
The safety benefits of bar-coded medication dispensing and administration technology (BCMA) depend on its intended users favorably perceiving, accepting, and ultimately using the technology.
Objectives
(1) To describe pharmacy workers’ perceptions and acceptance of a recently implemented BCMA system and (2) to model the relationship between perceptions and acceptance of BCMA.
Methods
Pharmacists and pharmacy technicians at a Midwest US pediatric hospital were surveyed following the hospital’s implementation of a BCMA system. Twenty-nine pharmacists and ten technicians’ self-reported perceptions and acceptance of the BCMA system were analyzed, supplemented by qualitative observational and free-response survey data. Perception-acceptance associations were analyzed using structural models.
Results
The BCMA system’s perceived ease of use was rated low by pharmacists and moderate by pharmacy technicians. Both pharmacists and technicians perceived that the BCMA system was not useful for improving either personal job performance or patient care. Pharmacy workers perceived that individuals important to them encouraged BMCA use. Pharmacy workers generally intended to use BCMA but reported low satisfaction with the system. Perceptions explained 72% of the variance in intention to use BCMA and 79% of variance in satisfaction with BCMA.
Conclusions
To promote their acceptance and use, BCMA and other technologies must be better designed and integrated into the clinical work system. Key steps to achieving better design and integration include measuring clinicians’ acceptance and elucidating perceptions and other factors that shape acceptance.
doi:10.1016/j.sapharm.2012.01.004
PMCID: PMC3390462  PMID: 22417887
bar coded medication dispensing and administration systems; BCMA; technology acceptance; pediatric hospital
3.  Implementation of a Standardized Process for Ordering and Dispensing of High-Alert Emergency Medication Infusions 
OBJECTIVES
Pharmacies encounter challenges when ensuring safe, timely medication dispensing to patients in the pediatric intensive care unit, when high-alert medications are needed in emergent situations. Removal of these medications from nursing stock presented challenges to providing timely administration to critical patients. The project's purpose was to develop a new method for reducing dispensing time while improving patient safety in pediatric intensive care units.
METHODS
A committee of physicians, nurses, a clinical pharmacist, and pharmacy administration collaborated for process development. The process established a list of compounded, ready-to-use infusions stored in the pharmacy, immediately available for dispensing. The dispensing mechanism includes ordering and dispensing processes using an “Urgent Drip Request” form. Most frequently ordered infusions (dopamine, epinephrine, norepinephrine) were added to automated dispensing cabinets in critical care units in concentrations that could be safely infused centrally or peripherally.
RESULTS
During the initial 4 months, 71 “Urgent Drip Request” sheets were processed. Drug utilization evaluation demonstrated a dispensing time of less than 1 minute for drip medications leaving the pharmacy after the form was received. No sheets processed exceeded the institutional 30-minute turnaround time, nor were errors or delays documented. Limited turnaround time data existed preimplementation but was not robust enough for analysis. It was not ethically feasible to perform a head-to-head comparison with the previous method, as it might have resulted in delay of therapy and negative patient outcomes.
CONCLUSIONS
This program allows high-alert medication infusion availability in an expedited manner, removes potential for compounding errors at the bedside, and assures clean room preparation. This has improved pharmacy efficiency in provision of safe patient care to critically ill pediatric patients.
doi:10.5863/1551-6776-17.2.166
PMCID: PMC3470437  PMID: 23118669
emergency medications; high-alert medications; medication safety; patient safety; pediatric
4.  Before-and-After Study of Interruptions in a Pharmacy Department 
Background:
Few data exist on interruptions in the drug-use process in hospital pharmacies and their effects on patient care.
Objective:
The primary objective was to compare the hourly number of stimuli received and emitted (i.e., generated) by pharmacists and pharmacy technicians before and after implementation of measures intended to reduce interruptions. The secondary objective was to evaluate the impact of the corrective measures on 4 specific stimuli.
Methods:
This before-and-after cross-sectional observational study was conducted in the main dispensing area of the pharmacy department of a Canadian university hospital centre. Stimuli received and emitted by pharmacists and pharmacy technicians were counted before (2010) and after (2012) implementation of corrective measures designed to limit interruptions. The effect of corrective measures on targeted stimuli was measured with a t test.
Results:
Data were collected during a total of 93 randomly scheduled 30-min observation periods: 62 periods in 2010 (n = 2663 stimuli) and 31 periods in 2012 (n = 1217 stimuli). The average hourly stimulus rate (± standard deviation) was unchanged after implementation of corrective measures: 85.9 ± 22.2 in 2010 and 78.5 ± 20.1 in 2012 (p = 0.06). However, a significant decline was observed for many individual stimuli, including the number of face-to-face nonprofessional conversations among pharmacists (4.4 ± 4.2 in 2010 versus 1.2 ± 1.8 in 2012, p = 0.003).
Conclusion:
Despite the implementation of corrective measures, there was no statistically significant change in the hourly stimulus rates from 2010 to 2012. Other studies are needed to better characterize the nature and repercussions of stimuli, distractions, and interruptions.
PMCID: PMC3583790  PMID: 23467669
hospital pharmacy practice; drug-use process; interruptions; distractions; stimuli; pratique de la pharmacie hospitalière; processus de distribution des médicaments; interruptions; distractions; stimuli
5.  Job stress, fatigue, and job dissatisfaction in Dutch lorry drivers: towards an occupation specific model of job demands and control 
Objectives: Building on Karasek's model of job demands and control (JD-C model), this study examined the effects of job control, quantitative workload, and two occupation specific job demands (physical demands and supervisor demands) on fatigue and job dissatisfaction in Dutch lorry drivers.
Methods: From 1181 lorry drivers (adjusted response 63%) self reported information was gathered by questionnaire on the independent variables (job control, quantitative workload, physical demands, and supervisor demands) and the dependent variables (fatigue and job dissatisfaction). Stepwise multiple regression analyses were performed to examine the main effects of job demands and job control and the interaction effect between job control and job demands on fatigue and job dissatisfaction.
Results: The inclusion of physical and supervisor demands in the JD-C model explained a significant amount of variance in fatigue (3%) and job dissatisfaction (7%) over and above job control and quantitative workload. Moreover, in accordance with Karasek's interaction hypothesis, job control buffered the positive relation between quantitative workload and job dissatisfaction.
Conclusions: Despite methodological limitations, the results suggest that the inclusion of (occupation) specific job control and job demand measures is a fruitful elaboration of the JD-C model. The occupation specific JD-C model gives occupational stress researchers better insight into the relation between the psychosocial work environment and wellbeing. Moreover, the occupation specific JD-C model may give practitioners more concrete and useful information about risk factors in the psychosocial work environment. Therefore, this model may provide points of departure for effective stress reducing interventions at work.
doi:10.1136/oem.59.6.356
PMCID: PMC1740302  PMID: 12040108
6.  Organizational Traits, Care Processes, and Burnout Among Chronic Hemodialysis Nurses 
In light of evidence linking registered nurse (RN) staffing levels to patient outcomes in chronic hemodialysis facilities, U.S. government regulations have set minimum RN staffing requirements during dialysis. Consequently, facility administrators are focused on decreasing nurse attrition in this crucial practice setting. This study used a cross-sectional, correlational design to investigate the effects of workload, practice environment, and care processes on burnout among nurses in U.S. chronic hemodialysis centers and to determine the association between burnout and nurses’ intentions to leave their jobs. Findings indicate that predictors were associated with an increased likelihood of nurse burnout and that nurses experiencing burnout were more likely to be planning to leave their jobs. Findings have important implications for retention of nurses, enhancement of patient safety, and adherence to new federal staffing requirements in chronic hemodialysis units.
doi:10.1177/0193945909331430
PMCID: PMC2746111  PMID: 19270274
work environment; burnout; nurse–patient ratio; hemodialysis
7.  Cost-effectiveness of a vocational enablement protocol for employees with hearing impairment; design of a randomized controlled trial 
BMC Public Health  2012;12:151.
Background
Hearing impairment at the workplace, and the resulting psychosocial problems are a major health problem with substantial costs for employees, companies, and society. Therefore, it is important to develop interventions to support hearing impaired employees. The objective of this article is to describe the design of a randomized controlled trial evaluating the (cost-) effectiveness of a Vocational Enablement Protocol (VEP) compared with usual care.
Methods/Design
Participants will be selected with the 'Hearing and Distress Screener'. The study population will consist of 160 hearing impaired employees. The VEP intervention group will be compared with usual care. The VEP integrated care programme consists of a multidisciplinary assessment of auditory function, work demands, and personal characteristics. The goal of the intervention is to facilitate participation in work. The primary outcome measure of the study is 'need for recovery after work'. Secondary outcome measures are coping with hearing impairment, distress, self-efficacy, psychosocial workload, job control, general health status, sick leave, work productivity, and health care use. Outcome measures will be assessed by questionnaires at baseline, and 3, 6, 9, and 12 months after baseline. The economic evaluation will be performed from both a societal and a company perspective. A process evaluation will also be performed.
Discussion
Interventions addressing occupational difficulties of hearing impaired employees are rare but highly needed. If the VEP integrated care programme proves to be (cost-) effective, the intervention can have an impact on the well-being of hearing impaired employees, and thereby, on the costs for the company as well for the society.
Trial registration
Netherlands Trial Register (NTR): NTR2782
doi:10.1186/1471-2458-12-151
PMCID: PMC3306742  PMID: 22380920
Hearing loss; 'Need for recovery after work'; Economic evaluation; Psychosocial problems; Occupational physician; Integrated care; Intervention
8.  Assessment of informatization for the dispensing of medications at a university hospital 
Clinics  2010;65(4):417-424.
INTRODUCTION
Informatics and automation are important tools for the reduction of work, errors and costs in a hospital pharmacy.
OBJECTIVES
To describe the structuring and function of an informatized system for the dispensing of medications and to assess its effect on nursing and pharmacy services during the period from 1997 to 2003.
MATERIALS AND METHODS
In this descriptive and retrospective study, we performed an analysis of documents addressing the structuring and implementation of the informatized medication dispensing system. In addition, we analyzed the perceptions of nurses, pharmacists and pharmacy assistants who participated in the structuring phase of the system when interviewed about the effect of informatization on administrative aspects (e.g., requisition of medications, presentation of the dispensed medication and system operationalization).
RESULTS
The major advantages provided by the new system were 1) the elimination of manual transcripts for prescribed medications, 2) increased speed, 3) better identification of the doses prescribed by physicians, 4) medication labels containing all necessary identification and 5) practicality and safety of optical bar code-based verification of the requested and dispensed medications.
CONCLUSIONS
The great majority of the interviewees considered the informatized medication supply system to be of good quality. Analysis of the data provided information that could contribute to the expansion and refinement of the system, provide support for studies regarding the utilization of medications and offer new perspectives for work and productivity.
doi:10.1590/S1807-59322010000400011
PMCID: PMC2862670  PMID: 20454500
Dispensing of medications; Medication errors; Hospital pharmacy; Informatics; Electronic prescription
9.  Psychosocial Work Environment as a Risk Factor for Absence With a Psychiatric Diagnosis: An Instrumental-Variables Analysis 
American Journal of Epidemiology  2010;172(2):167-172.
Recent reviews show that self-reported psychosocial factors related to work, such as job demands and job control, are associated with employee mental health, but it is not known whether this association is attributable to reporting bias. The authors examined this question using objectively measured hospital ward overcrowding as an instrument. The extent of overcrowding provided a strong instrument for self-reported job demands but not for job control, and it was used to examine unbiased associations between self-reported job demands and sickness absence with a psychiatric diagnosis among 2,784 female nurses working in somatic illness wards in Finland. During the 12-month follow-up period (2004–2005), 102 nurses had an absence with a psychiatric diagnosis, 33 with a diagnosis of depressive disorder. Both greater extent of overcrowding and higher self-reported job demands were associated with increased risk of psychiatric absence. The latter association was stronger but less precisely estimated in an instrumental-variables analysis which took into account only the variation in self-reported job demands that was explained by overcrowding. Repeating these analyses with absence due to depressive disorders as the outcome led to similar results. Findings from this instrumental-variables analysis support the status of high self-reported job demands as a risk factor for absence with a psychiatric diagnosis.
doi:10.1093/aje/kwq094
PMCID: PMC2915486  PMID: 20534822
absenteeism; behavior; depression; employment; mental disorders; psychology; risk factors; sick leave
10.  An investigation into the effects of vacations on the health status in male white-collar workers 
There are many stress factors in occupational settings, and the lack of vacations could be one of factors in the context of work stress. The authors have been studying the relationship between workload and employee health. This time, an investigation into the effects of leisure vacations on worker health status using male white-collar employees aged 20–60 years engaged in a manufacturing company was conducted. The subjects were questioned on work stress factors including vacations and modifiers in their occupational settings, and on psychological and physiological stress reactions; that is, how often they were able to take leisure vacations every year, their average working hours a day and work stress factors from the Demand-Control-Support model. The questions also examined other factors concerning the employees such as type-A behavior and lifestyles as modifiers, diseases of the employees, physical complaints, feelings about sleep, perceived stress, job and life satisfaction, and stress reactions as measured by physiological examination. Correlation and logistic regression analysis were conducted with the 551 eligible subjects. The results were as follows: Leisure vacation was decreasingly related to some of psychological stress reactions after adjustment was made for working hours and for modifiers. Less vacation was increasingly related to the workers’ diseases especially among the employees aged 20–34, though the association was not statistically significant. Vacations did not show obvious association with physiological measures. These findings demonstrate the effectiveness and possibility of leisure vacation in controlling fatigue and maintaining the health of workers. Vacation should always be taken into consideration as a stress factor in a survey of the health problems of white-collar workers.
doi:10.1007/BF02931235
PMCID: PMC2723268  PMID: 21432504
Vacation; Leisure; Stress; Working hours; Lifestyle
11.  Pharmacy staff characteristics associated with support for pharmacy-based HIV-testing in pharmacies participating in the New York State Expanded Access Syringe Exchange Program 
Objective
To determine support of in-pharmacy HIV-testing among pharmacy staff and the individual-level characteristics associated with in-pharmacy HIV testing support.
Design
Descriptive, nonexperimental, cross-sectional study.
Setting
New York City (NYC) during January 2008 to March 2009.
Intervention
131 pharmacies registered in the Expanded Syringe Access Program (ESAP) completed a survey.
Participants
480 pharmacy staff, including pharmacists, owners/managers, and technicians/clerks.
Main outcome measures
Support of in-pharmacy HIV testing.
Results
Support of in-pharmacy HIV testing is high among pharmacy staff (79.4%). Pharmacy staff that supported in-pharmacy vaccinations were significantly more likely to support in-pharmacy HIV testing. Pharmacy staff that think that selling syringes to IDUs causes the community to be littered with dirty syringes were significantly less likely to support in-pharmacy HIV testing.
Conclusion
Support for in-pharmacy HIV testing is high among our sample of ESAP pharmacy staff actively involved in non-prescription syringe sales. These findings suggest that active ESAP pharmacy staff may be amenable to providing HIV counseling and testing to injection drug users and warrants further investigation.
doi:10.1331/JAPhA.2012.10194
PMCID: PMC3703741  PMID: 22825227
Injection drug users; HIV testing; pharmacy services; New York City
12.  Randomized Trial to Improve Prescribing Safety During Pregnancy 
Objective
This study sought to determine whether a computerized tool that alerted pharmacists when pregnant patients were prescribed U.S. Food and Drug Administration pregnancy risk category D or X medications was effective in decreasing dispensings of these medications.
Design
Randomized trial. Pharmacy, diagnostic, and laboratory data were linked to identify pregnant patients prescribed targeted medications. Women (n = 11,100) were randomized to intervention or usual care. Physicians and pharmacists collaborated on the intervention.
Measurements
The primary outcome was the proportion of pregnant women dispensed a category D or X medication. The secondary outcome was the total number of first dispensings of targeted medications.
Results
A total of 2.9% of intervention (n = 177) and 5.5% of usual care (n = 276) patients were dispensed targeted medications (p < 0.001): 1.8% of intervention (n = 108) and 3.9% of usual care (n = 198) patients were dispensed only category D medication(s); 0.9% of intervention (n = 54) and 1.2% of usual care (n = 58) patients were dispensed only category X medication(s); 0.2% of intervention (n = 15) and 0.4% of usual care (n = 20) patients were dispensed both category D and X medications (p = 0.05). This resulted in intervention patients receiving 238 dispensings of unique targeted medications and usual care patients receiving 361 dispensings of unique targeted medications (p = 0.03). The study was stopped primarily due to 2 false-positive alert types: Misidentification of medications as contraindicated in pregnancy by the pharmacy information system and misidentification of pregnancy related to delayed transfer of diagnosis information.
Conclusion
Coupling data from information systems with knowledge and skills of physicians and pharmacists resulted in improved prescribing safety. Systems limitations contributed to project discontinuation. Linking ambulatory clinical, laboratory, and pharmacy information to provide safety alerts is not sufficient to ensure project success and sustainability.
doi:10.1197/jamia.M2412
PMCID: PMC2244894  PMID: 17460126
13.  Do community pharmacists in Nepal have a role in adverse drug reaction reporting systems? 
The Australasian Medical Journal  2013;6(2):100-103.
Community pharmacies in Nepal serve both rural and urban populations and are an integral part of the Nepalese healthcare system. These community pharmacies are run by non-pharmacist professionals with orientation training on pharmacology and drug dispensing. Graduate pharmacists’ involvement in community pharmacy will help with patient counselling, dispensing of medication and promotion of safe and appropriate medicine use. Nepal has an organised pharmacovigilance system which incorporates adverse drug reaction (ADRs) from hospitals and tertiary care centres but not from the community. Involvement of pharmacists in community pharmacy will help in ADR reporting and, monitoring at community level and will help in promoting medication safety in the community. This article describes the community pharmacovigilance program in Nepal and the prospects for community pharmacists.
doi:10.4066/AMJ.2013.1544
PMCID: PMC3593519  PMID: 23483017
Community Pharmacy; Adverse Drug Reaction; Pharmacist; Nepal
14.  Job strain among blue-collar and white-collar employees as a determinant of total mortality: a 28-year population-based follow-up 
BMJ Open  2012;2(2):e000860.
Objectives
To investigate the effect of job demand, job control and job strain on total mortality among white-collar and blue-collar employees working in the public sector.
Design
28-year prospective population-based follow-up.
Setting
Several municipals in Finland.
Participants
5731 public sector employees from the Finnish Longitudinal Study on Municipal Employees Study aged 44–58 years at baseline.
Outcomes
Total mortality from 1981 to 2009 among individuals with complete data on job strain in midlife, categorised according to job demand and job control: high job strain (high job demands and low job control), active job (high job demand and high job control), passive job (low job demand and low job control) and low job strain (low job demand and high job control).
Results
1836 persons died during the follow-up. Low job control among men increased (age-adjusted HR 1.26, 95% CI 1.12 to 1.42) and high job demand among women decreased the risk for total mortality HR 0.82 (95% CI 0.71 to 0.95). Adjustment for occupational group, lifestyle and health factors attenuated the association for men. In the analyses stratified by occupational group, high job strain increased the risk of mortality among white-collar men (HR 1.52, 95% CI 1.09 to 2.13) and passive job among blue-collar men (HR 1.28, 95% CI 1.05 to 1.47) compared with men with low job strain. Adjustment for lifestyle and health factors attenuated the risks. Among white-collar women having an active job decreased the risk for mortality (HR 0.78, 95% CI 0.60 to 1.00).
Conclusion
The impact of job strain on mortality was different according to gender and occupational group among middle-aged public sector employees.
Article summary
Article focus
High job strain and its components, high job demand and low job control, predict cardiovascular and total mortality.
Although lower socioeconomic position is a risk factor for premature total mortality, few studies have explored the effect of job strain on mortality within socioeconomic groups and the ones that exist, report conflicting findings.
Key messages
In a population-based cohort of middle-aged public sector employees, low job control among men increased and high job demand among women decreased the risk of mortality during a 28-year follow-up.
High job strain increased the risk of mortality among white-collar men and passive job among blue-collar men compared with men with low job strain.
Active job among white-collar women decreased the risk for mortality compared with those with low job strain.
Strengths and limitations of this study
A major strength was the representative large sample of public sector employees working both in white-collar and blue-collar professions and the long follow-up time on mortality collected from the national mortality register.
A limitation is the self-reported job strain, however, high correlations between subjective and expert ratings on work conditions have been reported. The assessment of job strain was measured at a single time point in midlife which might imperfectly reflect long-term job strain, however, the municipal employees in our cohort had stable work histories indicating stability probably also for job strain during their earlier working life.
doi:10.1136/bmjopen-2012-000860
PMCID: PMC3307125  PMID: 22422919
15.  The Effect of Pharmacist Intervention on Herpes Zoster Vaccination in Community Pharmacies 
OBJECTIVE
To evaluate the effectiveness of community pharmacy-based interventions in increasing vaccination rates for the herpes zoster vaccine.
DESIGN
Prospective intervention study with a pre-post design.
SETTING
Three independent community pharmacies in Tennessee.
PATIENTS
Patients whose pharmacy profiles indicated they were eligible for the vaccine and patients presenting to receive the vaccine at study sites.
INTERVENTIONS
Interventions initiated by pharmacists to promote the herpes zoster vaccine included a press release published in local newspapers, a flyer accompanying each prescription dispensed at participating pharmacies, and a personalized letter mailed to patients whose pharmacy profiles indicated they were eligible for the vaccine.
MAIN OUTCOME MEASURES
Comparison of vaccination rates for the herpes zoster vaccine during the control period and intervention period and patients’ indication for their sources of education and influence in receiving the vaccine.
RESULTS
Vaccination rates increased from 0.37% (n=59/16121) during the control period to 1.20% (n=193/16062) during the intervention period (P<0.0001). Cochran-Armitage Trend analyses including the months before and after the interventions confirmed a significantly higher vaccination rate during the intervention month than other months analyzed. More patients indicated that they were educated about the herpes zoster vaccine by one of the pharmacist-driven interventions than by a physician, family/friend, or other source during the intervention period (P<0.0001 for all comparisons). Also, more patients were influenced to receive the vaccination as a result of one of the pharmacist-driven interventions rather than a physician (P=0.0260) or other source (P<0.0001). No difference in the effectiveness of patient influence was found when the pharmacy interventions were compared with family/friends (P=0.1025).
CONCLUSION
The three pharmacist-driven interventions were effective in increasing vaccination rates for the herpes zoster vaccine.
doi:10.1331/JAPhA.2013.12019
PMCID: PMC3648883  PMID: 23636155
Herpes zoster vaccine; interventional research; community pharmacy-based interventions; vaccination rate; pharmacist role
16.  Mental Workload during Brain-Computer Interface Training 
Ergonomics  2012;55(5):526-537.
It is not well understood how people perceive the difficulty of performing brain-computer interface (BCI) tasks, which specific aspects of mental workload contribute the most, and whether there is a difference in perceived workload between participants who are able-bodied and disabled. This study evaluated mental workload using the NASA Task Load Index (TLX), a multi-dimensional rating procedure with six subscales: Mental Demands, Physical Demands, Temporal Demands, Performance, Effort, and Frustration. Able-bodied and motor disabled participants completed the survey after performing EEG-based BCI Fitts’ law target acquisition and phrase spelling tasks. The NASA-TLX scores were similar for able-bodied and disabled participants. For example, overall workload scores (range 0 – 100) for 1D horizontal tasks were 48.5 (SD = 17.7) and 46.6 (SD 10.3), respectively. The TLX can be used to inform the design of BCIs that will have greater usability by evaluating subjective workload between BCI tasks, participant groups, and control modalities.
doi:10.1080/00140139.2012.662526
PMCID: PMC3344383  PMID: 22506483
BCI; Brain-computer interface; mental workload; NASA Task Load Index; NASA-TLX; Fitts’ law; EEG; electroencephalogram
17.  Medication use and rural seniors. Who really knows what they are taking? 
Canadian Family Physician  1997;43:893-898.
OBJECTIVE: To determine whether listings of current medications obtained from the office file of patients' attending physicians and the pharmacy record of patients' dispensing pharmacists corresponded to the actual use of medications in a group of non-institutionalized seniors residing in rural communities. DESIGN: In-home interviews followed by retrospective office chart and pharmacy database reviews. SETTING: Two rural communities in southern Alberta with populations of less than 7000 people. PARTICIPANTS: Twenty-five patients aged 75 years or older residing in the study communities, eight family physicians, and four dispensing pharmacies. MAIN OUTCOME MEASURES: Number of currently consumed prescription drugs, currently consumed over-the-counter (OTC) drugs, and stored or discontinued prescribed medications; knowledge of medications (prescribed, OTC, and stored) by family physicians and pharmacists; and number of prescribers or dispensing pharmacists. RESULTS: Patients took a mean of 56 prescribed medications, took a mean of 3.5 OTC medications, and had a mean of 2.0 stored or discontinued medications. Attending family physicians and primary dispensing pharmacists typically knew of only some of their patients' entire regimen of medications. CONCLUSIONS: Misinformation about medication consumption by seniors was common among health care providers. Undertaking routine medication reviews (with emphasis on OTC use), asking specific questions about actual consumption, encouraging use of one prescriber and one pharmacist, discouraging storage of discontinued medications and reducing use of medication samples should be of benefit.
PMCID: PMC2255534  PMID: 9154361
18.  Pharmacy-Based Medication Reconciliation Program Utilizing Pharmacists and Technicians: A Process Improvement Initiative 
Hospital Pharmacy  2013;48(2):112-119.
Background:
Pharmacists and pharmacy technicians have an opportunity to impact the quality of the medication histories and improve patient safety by ensuring accurate medication lists are obtained and complete reconciliation has occurred with the admission medication orders by owning the admission medication reconciliation process.
Objective:
To compare the quality of a pharmacy-based medication reconciliation program on admission utilizing pharmacists and technicians to the usual multidisciplinary process.
Methods:
This was a retrospective chart review process improvement study at a 186-bed tertiary care inpatient facility. Primary outcomes included both the accuracy of pre-admission medications listed and the reconciliation of those medications with admission inpatient orders. Technicians obtained patient medication histories. Pharmacists checked the technician-obtained medication histories and ensured reconciliation of those medications with admission orders.
Results:
Medication accuracy increased from 45.8% to 95% per patient (P < .001) and medication reconciliation increased from 44.2% to 92.8% (P < .001) and remained above benchmark.
Conclusion:
A pharmacy-based medication reconciliation program utilizing both pharmacists and technicians significantly increased the accuracy and reconciliation of medications on admission. These gains were maintained for the duration of the 6-month period studied and beyond per continued process improvement data collection.
doi:10.1310/hpj4802-112
PMCID: PMC3839485  PMID: 24421448
admission; medication reconciliation; process improvement
19.  Relationship between E-Prescriptions and Community Pharmacy Workflow 
Objectives
To understand how community pharmacists use electronic prescribing (e-prescribing) technology; and to describe the workflow challenges pharmacy personnel encounter as a result of using e-prescribing technology.
Design
Cross-sectional qualitative study.
Setting
Seven community pharmacies in Wisconsin from December 2010 to March 2011
Participants
16 pharmacists and 14 pharmacy technicians (in three chain and four independent pharmacies).
Interventions
Think-aloud protocol and pharmacy group interviews.
Main outcome measures
Pharmacy staff description of their use of e-prescribing technology and challenges encountered in their daily workflow related to this technology.
Results
Two contributing factors were perceived to influence e-prescribing workflow: issues stemming from prescribing or transmitting software, and issues from within the pharmacy. Pharmacies experienced both delays in receiving, and inaccurate e-prescriptions from physician offices. Receiving an overwhelming number of e-prescriptions with inaccurate or unclear information resulted in significant time delays for patients as pharmacists contacted physicians to clarify wrong information. In addition, pharmacy personnel reported that lack of formal training and the disconnect between the way pharmacists verify accuracy and conduct drug utilization review and the presentation of e-prescription information on the computer screen significantly influenced the speed of processing an e-prescription.
Conclusion
E-prescriptions processing can hinder pharmacy workflow. As the number of e-prescriptions transmitted to pharmacies increases due to legislative mandates; it is essential that the technology that supports e-prescriptions (both on the prescriber and pharmacy operating systems) be redesigned to facilitate pharmacy workflow processes and to prevent unintended consequences, such as increased medication errors, user frustration, and stress.
doi:10.1331/JAPhA.2012.12066
PMCID: PMC3623613  PMID: 23229979
E-prescribing; electronic prescribing; community pharmacy; workflow
20.  Issues Facing Pharmacy Leaders in 2013 
Hospital Pharmacy  2013;48(5):433-437.
The Director’s Forum provides directors of pharmacy practical ways to develop patient-centered pharmacy services. Pharmacy directors must understand the key issues facing their departments and incorporate strategies for these issues as part of their strategic planning process. Health care reform and the Affordable Care Act require that departments operate efficiently and closely monitor their drug expense. The American Society of Health-System Pharmacists’ Pharmacy Practice Model Initiative will serve as a valuable resource during 2013 to enhance the pharmacy practice model. By using their health care workforce, particularly pharmacy technicians, in an innovative way, pharmacy directors will allow the pharmacists to increase their clinical activity. By promoting the role of the hospital pharmacist to patients, directors will help to improve patients’ understanding of their medications and increase their satisfaction with their care. Finally by changing the activities of pharmacy students in practice models, the patient care role of the pharmacist can be expanded. Through a greater understanding of the issues facing them and their effect on the operations of the pharmacy, pharmacy directors will learn effective ways to develop patient-centered pharmacy services.
doi:10.1310/hpj4805-433
PMCID: PMC3839473  PMID: 24421500
21.  Personnel's Health Surveillance at Work: Effect of Age, Body Mass Index, and Shift Work on Mental Workload and Work Ability Index 
Introduction. Two great changes in developed countries are taking place: populations are ageing and becoming increasingly overweight. Combination of these factors with shift work is a risk factor for work ability and mental workload that are dynamic processes which change greatly throughout an individual's work life. The aim of this study was to investigate mental workload and work ability in textile workers and to identify factors which affect work ability and mental workload. Methods. This cross-sectional study was carried out among 194 male workers in textile industry. Employees based on their job group and work conditions have been divided into 6 categories. They completed work ability index and mental workload questionnaires during three work shifts. Body mass index (BMI) and demographic details were recorded. Results. All of the participants rated their work ability as moderate with high mental workload. The mean WAI and mental workload in age group were significant. The mean BMI was 25.5 kg/m2 (standard deviation 4.1) and the mean age was 40.22 years. There was a statistically significant correlation between work ability index and shift work. Conclusions. Unlike the previous study, a decrease point in WAI started in early age that may be due to life-style work and another psychological factor; on the other hand, NASA-TLX revealed high score in six subscales that can be another reason for low WAI.
doi:10.1155/2013/289498
PMCID: PMC3730146  PMID: 23956756
22.  Hospital pharmacists' participation in audit in the United Kingdom. 
Quality in Health Care  1993;2(4):228-231.
OBJECTIVE--To investigate systematically participation in audit of NHS hospital pharmacists in the United Kingdom. DESIGN--Questionnaire census survey. SETTING--All NHS hospital pharmacies in the UK providing clinical pharmacy services. SUBJECTS--462 hospital pharmacies. MAIN MEASURES--Extent and nature of participation in medical, clinical, and pharmacy audits according to hospital management and teaching status, educational level and specialisation of pharmacists, and perceived availability of resources. RESULTS--416 questionnaires were returned (response rate 90%). Pharmacists contributed to medical audit in 50% (204/410) of hospitals, pharmacy audit in 27% (108/404), and clinical audit in only 7% (29/404). Many pharmacies (59% (235/399)) were involved in one or more types of audit but few (4%, (15/399)) in all three. Participation increased in medical and pharmacy audits with trust status (medical audit: 57% (65/115) trust hospital v 47% (132/281) non-trust hospital; pharmacy audit: 34% (39/114) v 24% (65/276)) and teaching status (medical audit: 58% (60/104) teaching hospital v 47% (130/279) non-teaching hospital; pharmacy audit 30% (31/104) v 25% (68/273)) and similarly for highly qualified pharmacists (MPhil or PhD, MSc, diplomas) (medical audit: 54% (163/302) with these qualifications v 38% (39/103) without; pharmacy audit: 32% (95/298) v 13% (13/102)) and specialists pharmacists (medical audit: 61% (112/184) specialist v 41% (90/221) non-specialist; pharmacy audit: 37% (67/182) v 19% (41/218)). Pharmacies contributing to medical audit commonly provided financial information on drug use (86% 169/197). Pharmacy audits often concentrated on audit of clinical pharmacy services. CONCLUSION--Pharmacists are beginning to participate in the critical evaluation of health care, mainly in medical audit.
PMCID: PMC1055151  PMID: 10132456
23.  Development and Validation of a Surgical Workload Measure: The Surgery Task Load Index (SURG-TLX) 
World Journal of Surgery  2011;35(9):1961-1969.
Background
The purpose of the present study was to develop and validate a multidimensional, surgery-specific workload measure (the SURG-TLX), and to determine its utility in providing diagnostic information about the impact of various sources of stress on the perceived demands of trained surgical operators. As a wide range of stressors have been identified for surgeons in the operating room, the current approach of considering stress as a unidimensional construct may not only limit the degree to which underlying mechanisms may be understood but also the degree to which training interventions may be successfully matched to particular sources of stress.
Methods
The dimensions of the SURG-TLX were based on two current multidimensional workload measures and developed via focus group discussion. The six dimensions were defined as mental demands, physical demands, temporal demands, task complexity, situational stress, and distractions. Thirty novices were trained on the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task and then completed the task under various conditions designed to manipulate the degree and source of stress experienced: task novelty, physical fatigue, time pressure, evaluation apprehension, multitasking, and distraction.
Results
The results were supportive of the discriminant sensitivity of the SURG-TLX to different sources of stress. The sub-factors loaded on the relevant stressors as hypothesized, although the evaluation pressure manipulation was not strong enough to cause a significant rise in situational stress.
Conclusions
The present study provides support for the validity of the SURG-TLX instrument and also highlights the importance of considering how different stressors may load surgeons. Implications for categorizing the difficulty of certain procedures, the implementation of new technology in the operating room (man–machine interface issues), and the targeting of stress training strategies to the sources of demand are discussed. Modifications to the scale to enhance clinical utility are also suggested.
doi:10.1007/s00268-011-1141-4
PMCID: PMC3152702  PMID: 21597890
24.  The Moderating Role of Power Distance on the Relationship between Employee Participation and Outcome Variables  
Background: Many organisations have realised the importance of human resource for their competitive advantage. Empowering employees is therefore essential for organisational effectiveness. This study aimed to investigate the relationship between employee participation with outcome variables such as organisational commitment, job satisfaction, perception of justice in an organisation and readiness to accept job responsibilities. It further examined the impact of power distance on the relationship between participation and four outcome variables.
Methods: This was a cross sectional study with a descriptive research design conducted among employees and managers of hospitals affiliated with Tehran University of Medical Sciences, Tehran, Iran. A questionnaire as a main procedure to gather data was developed, distributed and collected. Descriptive statistics, Pearson correlation coefficient and moderated multiple regression were used to analyse the study data.
Results: Findings of the study showed that the level of power distance perceived by employees had a significant relationship with employee participation, organisational commitment, job satisfaction, perception of justice and readiness to accept job responsibilities. There was also a significant relationship between employee participation and four outcome variables. The moderated multiple regression results supported the hypothesis that power distance had a significant effect on the relationship between employee participation and four outcome variables.
Conclusion: Organisations in which employee empowerment is practiced through diverse means such as participating them in decision making related to their field of work, appear to have more committed and satisfied employees with positive perception toward justice in the organisational interactions and readiness to accept job responsibilities.
doi:10.15171/ijhpm.2013.12
PMCID: PMC3937939  PMID: 24596840
Job Satisfaction; Organisational Justice; Organisational Readiness; Organisational Commitment; Power Distance Culture
25.  Qualitative interviews of pharmacy interns: determining curricular preparedness for work life 
Pharmacy Practice  2012;10(1):52-56.
One of the key features affecting the transition from university to paid employment is the graduate’s perception of their capability to satisfactorily perform the work of a graduate. In some professions such as in nursing, the concept of "transition shock" is referred to. There is a need to understand how pharmacy students perceive the transition to their first job as intern pharmacists and identify potential curriculum gaps in their pharmacy studies. To date, little evidence around whether university programs are effective in equipping pharmacy graduates in transitioning to the world of work has been published.
Objective
To explore from the perspective of new pharmacy professionals, graduated from one Australian university areas that need to be addressed in pharmacy programs to prepare graduates for the transition to full-time work as interns in pharmacy.
Methods
Thematic analysis of interviews with interns.
Results
Subthemes were identified within the responses- relationships within the workplace and graduates needing to interest themselves in other people, adjusting to work hours and the differences between university assessments and performing in a workplace. Suggestions were made by graduates that the placement period within the pharmacy program be increased.
Conclusions
Pharmacy graduates appear prepared for the world of pharmacy work. The concept of "transition shock" or "transition stress" described for graduates of other health professions commencing work was not apparent.
PMCID: PMC3798162  PMID: 24155817
Clinical Competence; Education, Pharmacy; Internship, Nonmedical; Australia

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