The Hidden Lives of Nurses’ Cognitive ArtifactsFunding 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.
13 January 2016
accepted: 30 July 2016
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.
- 1 Hardey M, Payne S, Coleman P. ‘Scraps’: hidden nursing information and its influence on the delivery of care. J Adv Nurs 2000; 32 (01) 208-214.
- 2 Klee K, Latta L, Davis-Kirsch S, Pecchia M. Using continuous process improvement methodology to standardize nursing handoff communication. J Pediatr Nurs 2012; 27 (02) 168-173.
- 3 Randell R, Wilson S, Woodward P, Galliers J. The ConStratO model of handover: a tool to support technology design and evaluation. Behav Inf Technol 2011; 30 (04) 489-498.
- 4 Randell R, Woodward P, Wilson S, Galliers J. Public yet private: The status, durability and visibility of handover sheets. Proceedings of the 21st IEEE international symposium on computer-based medical systems (CBMS), IEEE 2008; 500-502.
- 5 Staggers N, Clark L, Blaz JW, Kapsandoy S. Nurses’ information management and use of electronic tools during acute care handoffs. West J Nurs Res 2012; 34 (02) 153-173.
- 6 Staggers N, Clark L, Blaz JW, Kapsandoy S. Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses’ handoffs on medical and surgical units: Insights from interviews and observations. Health Informatics J 2011; 17 (03) 209-223.
- 7 McLane S, Turley J, Esquivel A, Engebretson J, Smith K, Wood G, Zhang J. Concept analysis of cognitive artifacts. ANS Adv Nurs Sci 2010; 33 (04) 352-362.
- 8 McLane S, Esquivel A, Turley J. Developing a taxonomy and an ontology of nurses’ patient clinical summaries. Stud Health Technol Inform 2009; 146: 352-357.
- 9 Norman DA. Cognitive artifacts. In: Carroll J. editor. Designing interaction: psychology at the humancomputer interface. New York: Cambridge University Press; 1991: 17-38 (Cambridge series on humancomputer interaction 4)
- 10 Hutchins E. Cognition in the wild. Cambridge (MA): The MIT Press; 1995
- 11 Hazlehurst B, Gorman P, McMullen C. Distributed cognition: an alternative model of cognition for medical informatics. Int J Med Inform 2008; 77 (04) 226-234.
- 12 Alvarado K, Lee R, Christoffersen E, Fram N, Boblin S, Poole N, Lucas J, Forsyth S. Transfer of accountability: transforming shift handover to enhance patient safety. Healthc Q 2006; 09: 75-79.
- 13 Athwal P, Fields W, Wagnell E. Standardization of Change-of-Shift Report. J Nurs Care Qual 2009; 24 (02) 143-7.
- 14 Baldwin L, McGinnis C. A computer-generated shift report. Nurs Manage 1994; 25 (09) 61-64.
- 15 Caruso E. The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. MEDSURG Nurs 2007; 16 (01) 17-22.
- 16 Davies S, Priestly M. A reflective evaluation of patient handover practices. Nurs Stand 2006; 20 (21) 49-52.
- 17 Mosher C, Bontomasi R. How to improve your shift report. Am J Nurs 1996; 96 (08) 32-34.
- 18 Welsh C, Flanagan M, Ebright P. Barriers and facilitators to nursing handoffs: recommendations for redesign. Nurs Outlook 2010; 58 (03) 148-154.
- 19 Collins SA, Stein DM, Vawdrey DK, Stetson PD, Bakken S. Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review. J Biomed Inform 2011; 44 (04) 704-712.
- 20 Wilson S, Galliers J, Fone J. Cognitive artifacts in support of medical shift handover: an in use, in situ evaluation. Int J Hum Comput Interact 2007; 22 (1–2): 59-80.
- 21 Abraham J, Kannampallil T, Patel VL. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. J Am Med Inform Assoc 2014; 21 (01) 154-162.
- 22 . Joint Commission announces 2006 national patient safety goals for ambulatory care and office-based surgery organizations. 2005
- 23 . JCAHO to look closely at patient handoffs: communication lapses will be key focus. (Joint Commission on Accreditation of Health Care Organizations). HealthCare Benchmarks and Quality Improvement 2005; 12: 143-144.
- 24 Randell R, Wilson S, Woodward P, Galliers J. Beyond handover: supporting awareness for continuous coverage. Cogn Technol Work 2010; 12 (04) 271-283.
- 25 Nielsen J. Usability engineering. Boston: AP Professional; 1993
- 26 Shneiderman B, Plaisant C. Designing the user interface. 5th. Upper Saddle River (NJ): Addison-Wesley; 2010
- 27 Thorne S. Interpretive Description. Walnut Creek (CA): Left Coast Press, Inc; 2008
- 28 Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995; 18 (02) 179-183.
- 29 Muhr T. Atlas/Ti for Windows Version 6.1 1997.
- 30 Saldaña J. The coding manual for qualitative researchers. Los Angeles: Sage Publications Ltd; 2009
- 31 Beck CT. Qualitative Research: the evaluation of its credibility, fittingness, and auditability. West J Nurs Res 1993; 15 (02) 263-266.
- 32 Chiovitti RF, Piran N. Rigour and grounded theory research. J Adv Nurs 2003; 44 (04) 427-435.
- 33 Wilson M. A template for safe and concise handovers. MEDSURG Nurs 2007; 16 (03) 201-206.
- 34 Jones P, Nemeth C. Cognitive artifacts in complex work. Lectures Notes in Artificial Intelligence 2005; 3345 LNAI: 152-183.
- 35 Kelley T, Docherty S, Brandon D. Information needed to support knowing the patient. ANS Adv Nurs Sci 2013; 36 (04) 351-363.
- 36 Leight SB. Starry night: using story to inform aesthetic knowing in women’s health nursing. J Adv Nurs 2002; 37 (01) 108-114.
- 37 Radwin LE. Knowing the patient: a process model for individualized interventions. Nurs Res 1995; 44 (06) 364-370.
- 38 Bonis SA. Knowing in nursing: a concept analysis. J Adv Nurs 2009; 65 (06) 1328-1341.
- 39 Bruni A, Gherardi S, Parolin L. Knowing in a system of fragmented knowledge. Mind Cult Activ 2007; 14 (01) 83-102.
- 40 Paton B. Knowing within: practice wisdom of clinical nurse educators. J Nurs Educ 2007; 46 (11) 488-495.
- 41 Forbes A, Surdeanu M, Jansen P, Carrington J. Transmitting narrative: an interactive shift-summarization tool for improving nurse communication. In: IEEE Workshop on Interactive Visual Text Analytics; Atlanta, Georgia: 2013
- 42 Senathirajah Y, Bakken S. Architectural and usability considerations in the development of a Web 2.0-based EHR. Stud Health Technol Inform 2009; 143: 315-321.
- 43 McLane S, Turley JP. One Size Does Not Fit All: EHR Clinical Summary Design Requirements for Nurses. NI 2012: Proceedings of the 11th International Congress on Nursing Informatics 2012; 2012: 283.
- 44 Smoker TJ, Murphy CE, Rockwell AK. Comparing memory for handwriting versus typing. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2009; 53: 1744-1747.
- 45 Mangen A, Anda LG, Oxborough GH, Brønnick K. Handwriting versus keyboard writing: effect on word recall. J Writ Res 2015; 07 (02) 227-247.