Test a model of family physician job satisfaction and commitment.
Data Sources/Study Setting
Data were collected from 1,482 family physicians in a Midwest state during 2000–2001. The sampling frame came from the membership listing of the state's family physician association, and the analyzed dataset included family physicians employed by large multispecialty group practices.
Study Design and Data Collection
A cross-sectional survey was used to collect data about physician working conditions, job satisfaction, commitment, and demographic variables.
The response rate was 47 percent. Different variables predicted the different measures of satisfaction and commitment. Satisfaction with one's health care organization (HCO) was most strongly predicted by the degree to which physicians perceived that management valued and recognized them and by the extent to which physicians perceived the organization's goals to be compatible with their own. Satisfaction with one's workgroup was most strongly predicted by the social relationship with members of the workgroup; satisfaction with one's practice was most strongly predicted by relationships with patients. Commitment to one's workgroup was predicted by relationships with one's workgroup. Commitment to one's HCO was predicted by relationships with management of the HCO.
Social relationships are stronger predictors of employed family physician satisfaction and commitment than staff support, job control, income, or time pressure.
Job satisfaction; commitment; working conditions; family physicians
Healthcare settings can be hectic, demanding, time-constrained environments. Within these environments, health care professionals (HCP) are expected to perform tasks that often require their undivided attention. However, HCPs are frequently interrupted, which can distract their attention and add to the complexity of their work. That said, not all interruptions are bad; many interruptions are essential to the patient care process and provide HCPs with necessary information. This paper systematically reviews the peer-reviewed literature on interruptions in healthcare settings to determine the state of the science and to identify gaps. It then provides a complex sociotechnical systems approach to understanding interruptions in healthcare.
Interruption; Distraction; Healthcare; Human Factors; Systems Engineering
A systematic literature review was performed to identify variables promoting consumer health information technology (CHIT) acceptance among patients. The electronic bibliographic databases Web of Science, Business Source Elite, CINAHL, Communication and Mass Media Complete, MEDLINE, PsycArticles, and PsycInfo were searched. A cited reference search of articles meeting the inclusion criteria was also conducted to reduce misses. Fifty-two articles met the selection criteria. Among them, 94 different variables were tested for associations with acceptance. Most of those tested (71%) were patient factors, including sociodemographic characteristics, health- and treatment-related variables, and prior experience or exposure to computer/health technology. Only ten variables were related to human-technology interaction; 16 were organizational factors; and one was related to the environment. In total, 62 (66%) were found to predict acceptance in at least one study. Existing literature focused largely on patient-related factors. No studies examined the impact of social and task factors on acceptance, and few tested the effects of organizational or environmental factors on acceptance. Future research guided by technology acceptance theories should fill those gaps to improve our understanding of patient CHIT acceptance, which in turn could lead to better CHIT design and implementation.
The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.
macroergonomics; work system; sociotechnical system; organizational context; SEIPS model; healthcare quality; patient safety; patient-centered care; care coordination; job stress; workload; interruptions; system design; mixed methods research
The use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices.
To study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices.
We conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9–14 days over a 4–8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach.
All practice members and selected patients in seven community-based primary care practices in the Northeastern US.
The impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care.
The complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.
electronic health records; primary care; work burden; qualitative research
To identify predictors of nurses' acceptance of bar coded medication administration (BCMA).
Cross-sectional survey of registered nurses (N=83) at an academic pediatric hospital that recently implemented BCMA.
Surveys assessed seven BCMA-related perceptions: ease of use; usefulness for the job; social influence from non-specific others to use BCMA; training; technical support; usefulness for patient care; and social influence from patients/families. An all possible subset regression procedure with five goodness-of-fit indicators was used to identify which set of perceptions best predicted BCMA acceptance (intention to use, satisfaction).
Nurses reported a moderate perceived ease of use and low perceived usefulness of BCMA. Nurses perceived moderate-or-higher social influence to use BCMA and had moderately positive perceptions of BCMA-related training and technical support. Behavioral intention to use BCMA was high, but satisfaction was low. Behavioral intention to use was best predicted by perceived ease of use, perceived social influence from non-specific others, and perceived usefulness for patient care (56% of variance explained). Satisfaction was best predicted by perceived ease of use, perceived usefulness for patient care, and perceived social influence from patients/families (76% of variance explained).
Variation in and low scores on ease of use and usefulness are concerning, especially as these variables often correlate with acceptance, as found in this study. Predicting acceptance benefited from using a broad set of perceptions and adapting variables to the healthcare context.
Success with BCMA and other technologies can benefit from assessing end-user acceptance and elucidating the factors promoting acceptance and use.
Bar coded medication administration systems; BCMA; technology acceptance; TAM; implementation science; pediatric hospital; human factors
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.
(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.
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.
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.
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.
bar coded medication dispensing and administration systems; BCMA; technology acceptance; pediatric hospital
Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit.
A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings.
The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student.
The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.
Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses’ perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses’ perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.
health information technology; bar coded medication administration; process change; patient safety; human factors engineering
The purpose of this paper is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.
We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.
Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, its consequences, discuss possible solutions and suggest a research agenda which may lead to methods to reduce the problem.
Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.
Primary Health Care; Information Management/Informatics; Complexity Science; Medical Errors; Practice Management
With the advent of personal health records and other patient-focused health technologies, there is a growing need to better understand factors that contribute to acceptance and use of such innovations. In this study, we employed the Unified Theory of Acceptance and Use of Technology as the basis for determining what predicts patients' acceptance (measured by behavioral intention) and perceived effective use of a web-based, interactive self-management innovation among home care patients.
Cross-sectional secondary analysis of data from a randomized field study evaluating a technology-assisted home care nursing practice with adults with chronic cardiac disease.
Measurement and analysis
A questionnaire was designed based on validated measurement scales from prior research and was completed by 101 participants for measuring the acceptance constructs as part of the parent study protocol. Latent variable modeling with item parceling guided assessment of patients' acceptance.
Perceived usefulness accounted for 53.9% of the variability in behavioral intention, the measure of acceptance. Together, perceived usefulness, health care knowledge, and behavioral intention accounted for 68.5% of the variance in perceived effective use. Perceived ease of use and subjective norm indirectly influenced behavioral intention, through perceived usefulness. Perceived ease of use and subjective norm explained 48% of the total variance in perceived usefulness.
The study demonstrates that perceived usefulness, perceived ease of use, subjective norm, and healthcare knowledge together predict most of the variance in patients' acceptance and self-reported use of the web-based self-management technology.
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.
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.
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.
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.
workload; mental workload; patient safety; medication error; quality of working life
Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes such as job satisfaction.
This study sought to measure the effect of workload on safety and employee outcomes in two pediatric hospitals and to do so using a novel approach to pharmacy workload measurement.
Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, rushing) and internal (concentration, effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression.
Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, rushing) negatively impacted medication safety and employee well being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout, and even had a positive effect on job satisfaction.
Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.
Workload; mental demands; medication error; safety; employee well being; human factors
Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.
Vulnerabilities in the medication management process can lead to serious patient harm. In intensive care units (ICUs), nurses represent the last line of defense against medication errors. Proactive risk assessment (PRA) offers methods for determining how processes can break down and how people involved in such processes can contribute to or recover from a breakdown. Such methods can also be used to identify ICU nurses’ contribution to the quality and safety of medication management.
A PRA method was conducted in a cardiovascular ICU to identify and evaluate failure modes in the nursing medication management process. The contributing factors to the failure modes and the recovery processes used by nurses were also characterized.
A total of 54 failure modes were identified across the seven steps of the medication management process. For the 4 most critical failure modes, nurses listed 21 contributing factors and 21 recovery processes. Ways were identified to redesign the medication management process, one of which consists of dealing with work system factors that contribute to the most critical failure modes.
From a data-analysis viewpoint, the PRA method permits one to address a variety of objectives. Different scoring methods can be used to focus on either frequency or criticality of failure modes; one may also focus on a specific step of the process under study. Developing efforts towards eliminating or mitigating contributing factors would help reduce the criticality of the failure modes in terms of their likelihood and impact on patients and/or nurses. Developing systems to support the recovery processes used by nurses may be another approach to process redesign.
Increasing interest in end users’ reactions to health information technology (IT) has elevated the importance of theories that predict and explain health IT acceptance and use. This paper reviews the application of one such theory, the Technology Acceptance Model (TAM), to health care. We reviewed 16 data sets analyzed in over 20 studies of clinicians using health IT for patient care. Studies differed greatly in samples and settings, health ITs studied, research models, relationships tested, and construct operationalization. Certain TAM relationships were consistently found to be significant, whereas others were inconsistent. Several key relationships were infrequently assessed. Findings show that TAM predicts a substantial portion of the use or acceptance of health IT, but that the theory may benefit from several additions and modifications. Aside from improved study quality, standardization, and theoretically motivated additions to the model, an important future direction for TAM is to adapt the model specifically to the health care context, using beliefs elicitation methods.
Technology use; behavior; health information technology; technology acceptance model
We conducted an intervention to increase adoption of three dairy farming practices shown to reduce certain traumatic and musculoskeletal injury hazards.
The intervention disseminated information to 4,300 Wisconsin dairy farm managers about three safer, more profitable production practices (barn lights, bag silos, and calf feed mixing sites) using information channels upon which these managers were known to rely. We evaluated rolling, independent, community-based samples at baseline and after each of two intervention years. We also evaluated a single sample after the intervention's second year from 1,200 Maryland dairy farm managers who were exposed only to the intervention's nationally distributed print publications, as a “partially exposed” comparison group.
In before/after comparisons, Wisconsin managers reported getting more information from print media, public events, and resource people for barn lights and bag silos. Also, Wisconsin managers, in comparison with Maryland managers after the intervention's second year, reported getting more barn lights and bag silo information from public events and resource people, but not from print media. Analyses that adjusted for farm manager, farm operation, and herd variables associated the intervention with increased Wisconsin manager adoption of all three practices after the second intervention year: barn lights (odds ratio [OR] = 2.268, 95% confidence interval [CI] 1.476, 3.485), bag silos (OR=3.561, 95% CI 2.684, 4.728), and calf feeding sites (OR=2.433, 95% CI 1.059, 5.591). There were also increases in awareness of barn lights and calf feeding sites.
Disseminating information to managers through well-known information channels was associated with increased reports of information gathering, adoption, and awareness of safer, profit-enhancing work practices in a high-hazard industry.
Sicker patients with greater care needs are being discharged to their homes to assume responsibility for their own care with fewer nurses available to aid them. This situation brings with it a host of human factors and ergonomic (HFE) concerns, both for the home care nurse and the home dwelling patient, that can affect quality of care and patient safety. Many of these concerns are related to the critical home care tasks of information access, communication, and patient self-monitoring and self-management. Currently, a variety of health information technologies (HITs) are being promoted as possible solutions to those problems, but those same technologies bring with them a new set of HFE concerns. This paper reviews the HFE considerations for information access, communication, and patients self-monitoring and self-management, discusses how HIT can potentially mitigate current problems, and explains how the design and implementation of HIT itself requires careful HFE attention.
Health Information Technology; Home Care; Human Factors; Work System
The authors develop a typology of clinicians' workarounds when using barcoded medication administration (BCMA) systems. Authors then identify the causes and possible consequences of each workaround. The BCMAs usually consist of handheld devices for scanning machine-readable barcodes on patients and medications. They also interface with electronic medication administration records. Ideally, BCMAs help confirm the five “rights” of medication administration: right patient, drug, dose, route, and time. While BCMAs are reported to reduce medication administration errors—the least likely medication error to be intercepted— these claims have not been clearly demonstrated. The authors studied BCMA use at five hospitals by: (1) observing and shadowing nurses using BCMAs at two hospitals, (2) interviewing staff and hospital leaders at five hospitals, (3) participating in BCMA staff meetings, (4) participating in one hospital's failure-mode-and-effects analyses, (5) analyzing BCMA override log data. The authors identified 15 types of workarounds, including, for example, affixing patient identification barcodes to computer carts, scanners, doorjambs, or nurses' belt rings; carrying several patients' prescanned medications on carts. The authors identified 31 types of causes of workarounds, such as unreadable medication barcodes (crinkled, smudged, torn, missing, covered by another label); malfunctioning scanners; unreadable or missing patient identification wristbands (chewed, soaked, missing); nonbarcoded medications; failing batteries; uncertain wireless connectivity; emergencies. The authors found nurses overrode BCMA alerts for 4.2% of patients charted and for 10.3% of medications charted. Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations. Shortcomings in BCMAs' design, implementation, and workflow integration encourage workarounds. Integrating BCMAs within real-world clinical workflows requires attention to in situ use to ensure safety features' correct use.
To monitor the experience of participants in a field evaluation of a home care Web support service we developed a survey to measure patient technology acceptance. Predictors of the acceptance model were selected from the technology acceptance literature. Cognitive interviewing was used to improve the validity of the survey items. We also describe the methods used to develop the survey.
This paper describes the process we used to design the HeartCare website
to support Technology Enhanced Practice (TEP) for home care nurses engaged
in providing care for patients with Congestive Heart Failure (CHF). Composed
of communication, information, and self-monitoring functions, the
HeartCare website is aimed at supporting best practice nursing
care for these patients. Its unique focus is professional practice, thus
the scope of this project is greater and more abstract than those
focusing on a task or set of activities. A modified macroergonomic analysis, design
work system analysis, and focus groups utilizing participatory
design methodology were undertaken to characterize the nursing
practice model. Design of the HeartCare website required synthesizing
the extant practice model and the agency’s evidence-based heart
failure protocols, identifying aspects of practice that could be enhanced
by supporting technology, and delineation of functional requirements
of the Enhanced HeartCare technology. Validation and refinement
of the website and planning for user training activities will be accomplished
through a two-stage usability testing strategy.
Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement.
The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.
The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value.
The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.
Human factors; Patient safety; Information technology; Human error; Quality improvement