Appl Clin Inform 2016; 07(03): 832-849
DOI: 10.4338/ACI-2016-01-RA-0007
Research Article
Schattauer GmbH

The Hidden Lives of Nurses’ Cognitive Artifacts

Jacquelyn W. Blaz
1  School of Nursing, University of Wisconsin-Madison
Alexa K. Doig
2  College of Nursing, University of Utah
Kristin G. Cloyes
2  College of Nursing, University of Utah
Nancy Staggers
2  College of Nursing, University of Utah
› Author Affiliations
Funding This project was supported by grant number R36HS022183 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
Further Information

Publication History

received: 13 January 2016

accepted: 30 July 2016

Publication Date:
19 December 2017 (online)



Standardizing nursing handoffs at shift change is recommended to improve communication, with electronic tools as the primary approach. However, nurses continue to rely on personally created paper-based cognitive artifacts - their “paper brains” - to support handoffs, indicating a deficiency in available electronic versions.


The purpose of this qualitative study was to develop a deep understanding of nurses’ paper-based cognitive artifacts in the context of a cancer specialty hospital.


After completing 73 hours of hospital unit field observations, 13 medical oncology nurses were purposively sampled, shadowed for a single shift and interviewed using a semi-structured technique. An interpretive descriptive study design guided analysis of the data corpus of field notes, transcribed interviews, images of nurses’ paper-based cognitive artifacts, and analytic memos.


Findings suggest nurses’ paper brains are personal, dynamic, living objects that undergo a life cycle during each shift and evolve over the course of a nurse’s career. The life cycle has four phases: Creation, Application, Reproduction, and Destruction. Evolution in a nurse’s individually styled, paper brain is triggered by a change in the nurse’s environment that reshapes cognitive needs. If a paper brain no longer provides cognitive support in the new environment, it is modified into (adapted) or abandoned (made extinct) for a different format that will provide the necessary support.


The “hidden lives” - the life cycle and evolution - of paper brains have implications for the design of successful electronic tools to support nursing practice, including handoff. Nurses’ paper brains provide cognitive support beyond the context of handoff. Information retrieval during handoff is undoubtedly an important function of nurses’ paper brains, but tools designed to standardize handoff communication without accounting for cognitive needs during all phases of the paper brain life cycle or the ability to evolve with changes to those cognitive needs will be underutilized.

Citation: Blaz JW, Doig AK, Cloyes KG, Staggers N. The hidden lives of nurses’ cognitive artifacts.