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Health Policy and Technology (2015) 4, 364377

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Juggling digitization and technostress:

The case of alert fatigues in the patient care
system implementation
Jiban Khuntiaa, Mohan Tannirub,n, Jack Weinerc

University of Colorado-Denver, United States
Oakland University, United States
St Joseph Mercy Oakland, United States

Available online 29 August 2015

Alarm fatigue; Policy mandates and business benets are propelling hospitals to implement several decision
IT implementation; support systems that can help nurses to aid in clinical care decisions. These systems can
Technostress; plausibly reduce errors and provide care by offering real-time alerts about possible adverse
Actor network; reactions. But nurses often suffer alert fatigue caused by excessive numbers of warnings
within the hospital while providing care. As a result, they may pay less attention to or even
ignore some vital alerts, thus limiting these systems' effectiveness. In this study, we explore
Organizational IT
policy how implementation of an intelligent care system in a hospital with the objective of
implementing several decision support systems inadvertently led to a set of alert fatigues.
Our analysis of fatigue related technostress suggests a change in management strategy that
involves synchronization of people, technology and policies, and is in support of patient care.
& 2015 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.

Introduction decision making when adhering to norms, dispensing differ-

ent alternatives, and choosing amongst different options;
Health care delivery within a hospital is highly person- health care will also be prone to similar errors [17,24].
centric. As much as individuals are prone to errors in These challenges are aggravated when it has a bearing on a
patient's life and death. For example, a nurse needs to
attend to the sores of a patient stranded in a hospital bed,
Corresponding author. School of Business Administration, Oak- or needs to administer medications on time.
land University, Rochester, Michigan, United States. It is often argued that information technology can help
E-mail addresses: (J. Khuntia), nurses and hospital staff to be alert and make decisions (M. Tanniru), based on alerts [8]. For example, a patient call system can (J. Weiner). alert a nurse to conduct a specic wash procedure.
2211-8837/& 2015 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
Juggling digitization and technostress 365

Extending the use of this to the clinical context, alerts can related stress across occupations has been studied, nursing
provide medication-specic information to control pain and is among nine other professions that have shown higher than
address adverse interactions due to improper food catering. average job related stress, attributed to high emotional
With the realization that decision systems can be helpful in content [9]. As technology use in health care has become
reducing the human cognitive load of remembering and more pervasive with the implementation of EMR systems and
administering appropriate and timely care, hospitals are alerts based on various patient conditions, this stress is only
implementing a number of decision-oriented care systems. going to become more severe.
These systems are intended to understand the patient work- Prior studies report that excessive alerts have been a
ows and introduce technologies with alerts to mobilize and major issue for medication adherence decisions [14]. Other
administer effective care on time [6,11]. Often these studies note that health care professionals (physicians,
systems use a repository of administrative and clinical doctors, nurses) often face alert fatigue and try to ignore
information as the knowledge base, in conjunction with a the repeated and perceived to be not-so-severe alerts
specic patient's condition, to trigger rule-based alerts. [23,27]. This raises a question about the effectiveness of
Other systems integrate a patient's medical record and these systems, as ignoring any type of alert, severe or
current patient condition (using various monitoring systems) otherwise, may lead to adverse consequences for patients.
to generate recommendations that are specic to an To overcome alert fatigue, prior studies suggest careful
individual patient's care regime. These systems can offer and thorough analysis of alert rules and mechanisms asso-
real-time alerts for drug administration, transfer to inten- ciated with each decision support system and the effective-
sive care units, and even code blue alerts. ness of rules that trigger their origination [12]. Some
Irrespective of the benets, care-focused decision sup- suggestions include reducing the number of alerts or making
port systems can cause stress on end users,-conceptualized them effective by reecting the nature of the patient
as technostress in existing information systems areas of condition they are supporting. Other studies suggest the
research [1,20]. A number of factors contribute to such consideration of the context of disease and care, age and
stress. Existing research mentions events, demands, stimuli, function of the end user (e.g., health care professionals) as
or conditions encountered by individuals in the work or well as other contextual parameters [25]. Indeed, a number
organizational environment as contributing factors [3]. of review articles in health care research note that although
In this study over a span of six months, we conducted a there have been enough studies on alarm fatigues, the
variation of an ethnographic study that uses a multi- relevant contextual and situational analysis of alarms is
dimensional approach to the analysis of an intelligent care lackingoften leaving the practitioners to ignore or manage
system, implemented at St. Joseph Mercy Oakland, a 443- the alert related issues internally (see [5,13,26]).
bed comprehensive community teaching hospital in the Contrary to the suggested solutions, most patient care
United States located in Pontiac, Michigan. SJMO is part of related decision support systems are designed for general
the Saint Joseph Mercy Health System, a member of Trinity use and are based on the existing knowledge base or
Health. Alerts designed to support several patient care evidence based rules and guidelines, and they do not reect
services in the hospital were analyzed for their relevance the context within which they are used in practice. In other
as well as the stress they caused on the health care staff. words, vendors of such systems do not allow customization
Feedback from multiple stakeholders, using various quali- of these systems to support patient or context related
tative methods and communication protocols, has led to a differentiation. While design exibility may be appropriate
review of organizational strategy used in implementing the for health care product offerings and their adoption into
system and the stress felt by the health care staff. Based on organizations, concerns associated with product malfunc-
our preliminary analysis, technology stress (referred to as tion or inappropriate use and the resulting legal action
technostress) can be addressed proactively if factors con- often prevent such exibility.
tributing to stress are discussed transparently and recom-
mendations are aligned to address the primary goal: patient
centered care.
Research context

The research context of this study is the analysis of an

Background intelligent care system implemented at St. Joseph Mercy
Oakland hospital (referred to as SJMO), located in southeast
Some of the job-related factors that are known to contribute Michigan in the United States. The study was conducted
to stress include: work relationships, your job, overload between May 2014 and December 2014. The leadership
control, job security, resources and communication, work team at SJMO has chosen to transform patient care services
life balance, pay and benets, commitment of the organiza- in the patient room (the unit of analysis in this case study)
tion to the employee, commitment of the employee to the and let this transformation lead to the alignment of health
organization, physical health, and psychological wellbeing. IT (digitization) efforts with improvement in patient care
Research categorizes these factors along two broad types: (1) services. The work discussed here started six years ago with
role-related stressors that include role ambiguity, role con- the development of a performance dashboard, which made
ict [10,22], and role overload [7]; (2) task-related stressors alignment of organizational outcomes with unit level ser-
[18] that include characteristics such as task difculty and vices and transparency in decision making a part of the
ambiguities in support of decision making. When work- organizational culture. The same organizational culture has
366 J. Khuntia et al.

encouraged innovations at unit level operations such as While not all technologies were fully in production mode
patient room services and aligned these transparently with for patient care support when the testing was done, the
core service delivery and performance measures. SJMO leadership decided to transition the entire hospital staff to
leadership's vision of creating a unique healing environment the new system in April 2014. Such a radical transformation
for patients, while at the same time leveraging the use of is bound to have a signicant impact on the health care staff
digitization in support of customized patient care, led to operations, some leading to natural stress. The methodol-
the design and development of an Intelligent Care System ogy used below has tried to separate the stress caused by
(ICS) in a new patient tower building over a two year time the rapid introduction of new technology with the stress
span (20122014). caused by alerts attributed to specic ICS technology
The ICS-led patient care transformation used a service- components, in order to develop mechanisms to reduce
centric approach that aligned each digitization effort (e.g. such alert-induced stress.
smart beds, RFID readers, hand-held devices, nursing station
consoles, etc.) with care delivery needs of patients, all
working together in an attractively architected physical
space (soothing art work, curved walls, self-contained care Methodology
delivery consoles and kiosks). In a highly connected world
today, the actor-network theory [15,19] argues for an The study uses a variant of the ethnography approach as its
effective blend of people and machines (actors) working core research method. Fundamental aspects of this
within a relationship network in support of service delivery, approach are prolonged exposure of a researcher to the
and this is one of the goals of SJMO leadership. The under- study environment, detailed collection of data through eld
lying theoretical perspective of this study focuses on the notes and interviews, and extensive review of data from
symbiotic triadic relationship between technology, actors and multiple perspectives [4,28]. The variation to this approach
relevant organizational policies to manage adverse conse- here relied on performing repeated cycles of the following
quences that stem out of IT implementation [29]. steps: (1) observation, interview and focused discussions,
St. Joseph Mercy Oakland leadership's vision for ICS (2) analysis and synthesis, (3) feedback for accuracy, and
within a holistic patient care environment in a new facility (4) quick recommendations for immediate action on some
was approved by their Board of Trustees in 2012. As is items while studying others for additional information. See
typical of many hospitals, the care services use a mix of Figure 1 for a description of this cycle. Such a cycle is
technology and health care artifacts and practices, and repeated, and both internal and some external stakeholder
sometimes these are adapted to meet diverse patient teams were involved in completing these cycles (see Table 1
needs. Some of these care services include patient comfort for the professionals interviewed for the study, along with
(e.g., family support), care quality improvement (e.g., their experiences). Given the radical implementation
timely pain management), and avoidable cost reduction approach used by the hospital leadership to transform the
(e.g., hospital acquired infections). However, ICS integrated patient care system, such a repeated cycle was considered
many of these care services in the new facility. Prior to the appropriate to catch critical issues quickly and give those
opening of the facility in April 2014, the leadership intro- involved in patient care some relief. The ultimate goal is to
duced the technology to select health care staff on one oor nd areas contributing to the technostress, so that recom-
in 2013. Both the feedback on ICS implementation and its mendations can be made to address these challenges.
impact on care delivery goals have shown promise with a Data gathering process and time spent: to collect data,
few concerns related to alert based stress. researchers used observation and individual interviews.

Figure 1 Research Methodology: a variant of ethnographic approach.

Juggling digitization and technostress 367

These methods were especially pertinent to this investiga- A sample documentation of three specic ows is shown
tion because they allowed researchers to conduct an in Figure A3.1A3.3. Three elements are common to the
intensive analysis of nurse and staff behaviors as they workows: rst, the patient's requirement or need that
performed care related services through close observations, must be attended to; second, a response plan that can help
subsequent discussions and interpretation of their state- to mitigate the concern quickly; and third, the action itself
ments. Data collection took place concurrently over an to address the concern. In between these work ow nodes,
eight month time period spanning between May and Decem- depending on the situation, there may be an escalation, or a
ber 2014. For more than 100 h, researchers observed decision to pass on the instruction to the designated
interactions relating to the systems, work-ows, and users. employee. The data collection happened during the work-
Findings of these observations consisted of descriptions of ow nodes and activities, mainly in the form of tangible
ows in patient rooms and on nursing oors, as well as response times, staff deployment patterns, action require-
information garnered while shadowing study participants ment and action taken, and other involved protocols.
(nurses and other health care staff). However, due to condentiality agreements, we cannot

Table 1 DSS alerts and technostress.

DSS Scenario Type of alerts Technostress: effects Solutions/Alternatives Outcome/Value


Nurse/ Patient Calls/phone rings to Constant interruption Different alarm tones Increase patient
staff interaction attend other cases between patient and or just a vibration interaction and
intelli- nurse depending on the type satisfaction.
gent of call (emergency,
phone pharmacy, doctor)
Patient Patient room alert The nurse has to go to Being able to turn off Increase patient
discharge ringing when patient is the patient room and the alarm from any safety and reduce
discharged from the physically turn off the other place, or staff/nurse stress.
reception or any other alarm. The patient dissociate patient room
part of the hospital might feel ignored/ discharge from other
frustrated discharge functions
Patient care Too many (3050) calls/ PCA stress and reduced Add call/message Increase PCA
assistant messages when PCA is productivity. Patient lters so that the PCA productivity and
(PCA) helping a patient feeling ignored or will not feel overloaded reduce fatigue,
overload frustrated with the calls increase patient
safety and
Bed Activation of Bed alarms sounding Ignoring frequent alarms Ergonomic design, Reduce alert
alerts/ alarm across the oor or to from same patient and/ sound to same side of fatigue, increase
alarms without any many oors when or interrupting duty. oor, and option of no- safety, and patient
reason patient simply getting up Nurses located at alarm if staff is present and staff
or out distant nurse stations in room satisfaction, reduce
are also alerted inefciencies in the
Deactivation The alarm is not Alarm issues to all oor The staff e-badge to be
of alarm deactivated even after a phones, and ceiling associated with bed
staff enters the patient warning beeps alert, which should
room throughout the oor deactivate the alarm
continuously with staff in room
Escalation of If patient request and Loud oor noise for all Management of the
alert wait time is more than patients. Some staff get alert logistics, and daily
10 minute, the alert is unknown alert requests, refreshment of
stepped up oor alarm it is not channeled to escalation rules based
and an automated dial the right staff on duty. on staff schedule and
call alert is placed over assignments.
phone to staff
368 J. Khuntia et al.

produce all the tangible data available, but only the ows and areas of noticeable stress associated with tech-
interpretation of the data in this study. nology. This feedback was presented to senior leadership to
During this process participants used open-ended ques- highlight some of the technical and operational challenges.
tions to develop insights about how events were experi- At the end of this cycle, the researchers provided two
enced and reported (see columns 13 of Table A3). The goal recommendations for actions: (1) some of the technical
is to understand the technology overview, patient support challenges included the use of VOALTE phones that link ICS
system goals, operational impact, etc. in support of the with nursing staff, and (2) some preliminary indication of
study. Extensive eld notes were collected, including draw- stress associated with alerts. Subsequent to the recommen-
ings, layouts, and workow patterns. We present a sample dations, the technology associated with VOALTE (new
of all the data collection details and instruments used in operating system) was addressed by September with new
Appendix A. Figures A1 and A2 show the schematic pre- phones.
sentation of the workows involved with the ICS system and Cycle 3 and 4: SeptemberOctober 2014 Internal leader-
components that are the focus of this study. Figure A3.1 ship and external research team (working independently):
A3.3 show the workow with three IT artifacts, e.g., the the research team was reassembled with an internal
nurse call system, the smart bed and the nurse phone researcher (a fellow from the Saint Joseph Mercy Health
systems. Table A1 provides the people interviewed along System ofce who is familiar with the health care domain,
with their proles, and Table A2 provides a sample note of but not with the ICS) and spent two months observing the
discussions and interviews from which the interpretation of operations on multiple nursing oors (sample work-ows are
results was done. shown in Figure A3.1 and A3.2) and talking to the health
care staff. Observations made through October are briey
summarized in the rst six rows of Table A3. Preliminary
feedback from the ICS was synthesized by the research team
Information collection and analysis cycles and presented to the care delivery staff for accuracy as well
as validation of some potential solutions to address the
The researchers, some with doctoral level training in challenges. Simultaneously, and independently, the nursing
qualitative methods, reviewed and analyzed all information leadership was holding meetings and collecting feedback
gathered. Although all the researchers had previous expo- from the nursing staff. The synthesis of the research team's
sure to the use of IT-based systems, they brought varying observations was presented to the internal nursing leader-
methodological and clinical perspectives to the data analy- ship group and the broader SJ leadership on Nov 14 to seek
sis. These diverse backgrounds allowed for discussion of consistency in the observations. As a result of Cycles 3 and
differing interpretations of what was observed. The 4, two recommendations for action were provided. First,
researchers used no predened theoretical perspective or several changes related to dropped calls and color-based
specic set of guidelines to direct their interpretations. alerts (that indicate a patient condition in a room) were
Data was collected until the researchers were condent implemented. Second, notication of certain type of alert
that the observed emerging patterns were valid or consis- (those that are considered not critical) was addressed.
tent when compared with observations made by other Cycle 5: OctoberDecember 2014 External research
observers as well as those directly interacting with the team: the research team continued the observation and
system (see Nov 14 meeting with senior management in analysis of the ows on other oors. Discussions were held
Table A3). The information collection and analysis involved with the nursing oor managers and other advocates.
four cycles. Each of the cycles described below provides the Several recommendations were suggested based on research
application of the spiral approach discussed in Figure 1. related to adoption/diffusion of the technology by indivi-
Cycle 1: Early analysis from the pilot prior to April 2014 duals (nursing staff) and multiple care providers (health
Internal to the hospital: in the rst cycle, the group care staff such as physical therapists, physicians, residents,
involved in the pilot implementation of the ICS, including etc.). Some of these changes call for policy changes along
nursing staff, chief medical informatics ofcer, CIO staff and with additional staff training and technology updates. See
others collected information and analyzed it for improve- Table 1 in the Results section below, which summarizes
ment. This cycle was internal to the hospital and tested the recommendations made to address technostress.
system in patient rooms on one nursing oor. As the results
showed promise for full scale ICS implementation, a con-
sensus was reached to involve external researchers to Results
gather and analyze more information on ICS impact on care
delivery staff. We identied six alert fatigues and technostress scenarios in
Cycle 2: second phase of the analysis May to June by an the hospital room context (see Table 1). Each scenario
external research team (faculty and graduate students of represents a specic work-ow or operation. The rst three
Oakland University): Subsequent to the rst internal cycle, alert scenarios are related to the nurse or staff intelligent
the external researchers were involved in analyzing the phone system: patient interaction, patient discharge, and
work-ow data and information (see Figures A1A3.3). The patient care assistant overload. The types of alerts in the
work-ow data used to design the ICS and feedback from three cases are related to either over burdening or unne-
the pilot tests were used as a starting point for additional cessary alerts.
analysis to assess the impact of ICS components on work- We suggest that for alert fatigue related to patient
Juggling digitization and technostress 369

Figure 2 Technology, people and policies.

eraction scenarios, a plausible solution or alternative is to research stream that as much as technology adoption and
use different alarm tones for different call types, or use adaptation research often calls for changing the nature of
vibration modes for calls which pose no serious threat or interaction among actors (people and technology) involved
urgency. Similar recommendations for patient discharge and in each service encounter [2], organizational policies can
patient care alert fatigue overload are noted in Table 1. inuence the way digitized service encounters can inuence
The second set of three alerts is associated with the smart IT implementation success [21]. These policies may impact
bed used by the patients: activation of alarm without reason, the way people involved in this service encounter (service
deactivation of the alarm (or continuous activation), and provider or service recipient) are incentivized to use or be
escalation. Again, these are reective of the way smart beds, supported by digitization, and can possibly inuence the
which are designed to address patient falls, can create alerts value realized in service delivery (See Figure 2) [16].
that may add signicant stress/distraction if these are not In terms of managerial implications, recognition of the role
tailored to a specic context. Based on the observations, of organizational polices/practices in the success of digitiza-
recommendations were made to contextualize these alerts to tion is even more critical when the core performance
care delivery, possibly change the technology itself (by reset- measures are inuenced signicantly by the success of the
ting to original level after a nurse attends to the patient), service encounter. In a patient-centered environment, digiti-
educating several health care staff members on the impor- zation has to lead to improved patient satisfaction, enhanced
tance of reinforcing the value of calling a staff member to the quality of care, and reduced costs. So, the stress created by
patient before they try to get off the bed, and lastly changing such digitization, if not addressed effectively, can inuence
the nurse scheduling to patients with high fall risk or select any or all three outcome measures. Stress on staff can reduce
room allocation to patients with high fall risk. While not all of care quality and lead to errors that can add more costs if
these changes may be feasible in the short run, it is important important signals are missed. Similarly, lack of timely response
to recognize that change management needs to consider the to patient requests, enhanced by digitization, can lead to
adaptation of any or all three elements during health care patient dissatisfaction if care delivery staff is distracted by the
transformation: people, technology and policies. same digitization. Therefore, how well an organization prior-
itizes requests, allocates the right resources to care delivery,
and leverages other resources (e.g., physical space) will
determine the degree of care delivery success. For example,
Discussion if smart beds and glycemic controls, etc. are going to require
greater integration of IT and nursing, then nurse scheduling
One area that has come under scrutiny in the implementa- and patient room allocation should be rethought, along with
tion of ICS are the policies related to care delivery when the the training of the entire care delivery team, to minimize
associated work-ows are digitized. Our key nding was disruptions to care.
that, while digitization is useful from an outcome perspec-
tive, one needs to recognize the complications, expected or
unintended, associated with such digitization on core care Conclusion
delivery and performance measures of the hospitals (cost,
quality, and patient satisfaction). Indeed, often the subse- In conclusion, we note that the triadic relationship of
quent adoption and use decision may be deterred or technology, people, and policies becomes even more
expedited based on some of the negative aspects rather critical as continuity of care postdischarge becomes an
than positive aspects, such as not using a stress-generating integral part of organizational core performance mea-
technology although it is very useful otherwise. sures. Already, with readmission costs and patient satis-
The contribution of our ndings relate to the information faction becoming key determinants of the hospital
systems research in a number of ways. We inform the revenue stream, how well a hospital extends the use of
370 J. Khuntia et al.

digitization to service encounters with patients post- Ethical approval

discharge may determine a hospital's competitive edge.
As wearable devices (such as vital sign monitoring Not required.
devices) and telehealth technologies start to support
remote communication between service providers and
patients, the effectiveness with which health care orga- Competing interests
nizations support post-discharge service encounters may
depend even more on the way organizational policies are None declared.
aligned with digitization efforts. These policies may have
to support cross-organizational collaboration, shared
incentive models, and inter-operable technologies. Author contribution

Jiban Khuntia: Study design, data dnalysis and writing.

Mohan Tanniru: Study design, data collection and writing.
Author statements Jack Weiner: Sponsorship of the study, review and writing.

Sources of funding
Appendix A. Data Collection Details and
The research was partially funded by a grant from St Joseph Instruments
Mercy IT Innovation Health Center (Grant no: 39309) to
Oakland University. See Figures A1A3 and Tables A1A3.

Figure A1 A schematic presentation of the process ow around the focal IT artifacts chosen for this study (and part of ICS at SJMO).
Juggling digitization and technostress 371

Figure A2 Flow chart of activities focusing on the nursing call system.

372 J. Khuntia et al.

Figure A3 (1) Nurse call workow. (2) Smart bed workows. (3) Nurse phone workows.

Table A1 People interviewed and their job proles and experiences.

Nurse manager Director of orthopedic and physical rehabilitation with over 10 years of experience.

Registered nurse 1 With more than 16 years of experience, worked in informatics for more than 8 years.
Nurse educator Works in disease management and education area, with more than 8 years of experience.
Registered nurse 2 Works in several units with more than 16 years' experience. Helped in several
Registered nurse 3 Fresh recruit, with around 1 year experience, but technology savvy.
New nurse 1 Fresh recruit, with less than a year's experience, but technology savvy.
Trinity fellow Recruit into informatics by Trinity Health System reviewing ICS
Logistics and operations manager More than 4 years hospital administrative experience.
Project manager, clinical With more than 8 years' experience at SJMO, and a few years prior experience to SJMO.
Chief information ofcer Over 10 years of experience with SJMO in IT Leadership roles
Juggling digitization and technostress 373

Table A2 Sample notes of discussions and interviews.

Date People Discussion notes and interpretation

Oct KAR, SAN and MEL (nurses BD assigned each of us a nurse to trail. KAR observed KLL on 7 South tower making the
15 and following issues:
iPhone disconnects while in nurse's pocket. Temporarily does not receive alerts until
nurse logs back on.
Bed Alarm on oor went off about every 30 s for a long period of time for one room.
Loud noise on phone and oor alarm sounded. Leads to alarm fatigue and nurses
ignoring the alarms.
Chair Alarm went off (similar to Bed Alarm) because rehab staff forgot to turn the
alarm off on bed and wall.
Assigning nurses to patient rooms in succession is very important to prevent
unattended rooms and alarms. KLL is assigned to rooms all over the oor instead of
One-handed hand washing while carrying a tray.
Call escalation when patient request had not been responded to within 5 min.
Beeping alert on oor and GS10 unit.
Oct KAR and SAN Observe KLL on 4 South a oor with the technology but different dynamics than
22 7South.
KLL's ve patient rooms were sequential. She was able to monitor all rooms from the
alcove while on her computer, assist patients when needed, as well as be accessible
when any doctor arrived.
Doctor/nurse availability and communication improves patient care. The whole oor
was much calmer, with green call lights on in more rooms for a longer duration than
on 7South.
The nurses were less stressed and able to spend more time on patient care. Patient
acuity is reduced with consistent room assignments.
The Nurse Manager was doing daily Rounds with nurses and called the next nurse. Her
phone logged off while in her pocket, so she was no't aware of the call. BD had to
physically go and nd the nurse. It is common for phones to log off in certain locations
on the oor (i.e. room 4915)
We observed escalation of an unanswered patient request. The alert went from PCA
to nurse to charge nurse. After 5 min, louder toned alarm on oor and sent to GS5.
The PCA was in the next room and was unable to respond to the patient.
Dec JEN (Nurse Educator) KAR We sat with Jennifer who logged in as a charge nurse on a Voalte phone so we could
1 and SAN (Nurses) observe alerts and escalations. There were about 10 fall alarms (to both oor and
phone) while we were with Jennifer. All were from rooms on the other side of the
oor, so she talked about why nurses do no't respond to repetitive alarms. We were
exposed to a small amount of alarm fatigue during this interview.
Jennifer uses the Accept and Call button to respond to patient requests, especially
if she was recently in their room. This Voalte button calls the room so nurse can check
on patient and deactivates the white light outside the room, but the nurse has to
physically go to the room to turn off alert. The request still goes through the
escalation rules until nurse gets back to the room. This helps patient satisfaction but
is not represented correctly in nurse response times.
Alarm fatigue was our biggest discussion topic. There are many alerts with different
tone indicators on both the Voalte phone and the oor alarms. All nurse input has
been directed toward dividing the oor into 3 areas and alerting nurses within a
reasonable range when alarms are triggered.

Note: Abbreviated notes are produced, with relevant points. The notes exclude a lot of details and other information. Names are not
real names.
374 J. Khuntia et al.

Table A3 Data collection instrument and interview sample notes.

Person Date Questions asked Goal Answers Identiers for

during an interview interpretation

IT dashboard 26-Sep-14 How the current Understand the Some of the data is Systems
coordinator dashboard operates dashboard that has not integrated into integration; data
and how is this been in place today to the iDashboard for evaluation
integrated to ICS? track organizational (current dashboard)
metrics and how the yet. The ICS data is
new ICS is connected sent to Cerner System
to it? (ERP of SJMO) and,
through a number of
automated and
manual transfers, is
uploaded to
iDeashboard (e.g. data
on patient falls,
hospital acquired
infections, etc.)
ICS nurse -tech lead 22-Sep-14 How does various Get an overview of See the Table 1in the Digitization of
components of the ICS the digitization of paper patient services
system support various work-ows
patient room work-
Nurse manager 29-Sep-14 How the system was is Understand See the Table 1 in the Technology
implemented? Are challenges in ICS paper adoption
there some oors got implementation, and
full technology in gain needed
operation, while permission for
others are getting on detailed analysis
Observations on the 1-Oct-14 How are nurses using Get focused See the Table 1 in the Impact on
nursing oor the system? How are information from paper operations
patient care assistants those using ICS in day -patient services
using the system? to day operations
15-Oct-14 What are the Understand the use of Technical: dropped Technology
differences in usage ICS and learn more phone calls or texts related
among different oors about challenges: while the phone is in challenges; stress
(7 East, 4 South, and operational or nurse's pocket related
7 South)? technical -inhibiting ability to challenges
address alerts; Some
dropped calls led to
escalation and time to
track the right nurse.
Stress related
Frequently bed alarms
went for a longer
time, contributing to
noise; chair alarm
went on as the staff
forgot to turn it off or
22-Oct-14 How is the oor with Comparison of When the patient Best case
the best operational rooms managed by a scenario or
implementation (or effectiveness nurse are next to each practice
fewest problems) other, access to rooms
using the system? was quick and nurse is
able to address
patient needs and
attend to physician
visits; The oor has
Juggling digitization and technostress 375

Table A3 (continued )

Person Date Questions asked Goal Answers Identiers for

during an interview interpretation

less noise and nurses

were able to spend
more time with
patients with less
Presentation of 10-Nov-14 How consistent are Review of Many observations on Reconciliation of
observations to the results with those observations with dropped calls, observational
management observed separately SJMO nursing frequent number of differences
by nurse management management alerts and associated
team? noise level, and nurse
fatigue all have shown
Nurse manager 1-Dec-14 How are alerts Assess potential There were 10 bed fall operational
responded to by impact of alerts on alarms from distant complexity;
nurses? nursing activity and rooms and nurses have additional
the impact of stress not responded to them activities; alert
on nursing operations as expected- possible confusion,
impact of stress; when scheduling
a phone alert shows a options
white light and alert
outside the room,
nurse has to enter the
patient room and has
to physically
deactivate it
Sometimes escalation
continues until nurse
answers the phone
adding more activities
that are not needed
deactivating the alarm
and answering the
phone are often
forgotten by the nurse
and contributes to
wrong data capture,
even if the patient is
serviced; Different
tone indicators on
different alerts both
on Voalte Phone and
oor causes too much
confusion; Dividing
the oor into three
areas and alerting
nurses within certain
range can improve
operational efciency
scheduling option
Which of these are Technology related Technology
related to technology? observationshelps related
efciency, quieter observations
oor with Voalte
376 J. Khuntia et al.

Table A3 (continued )

Person Date Questions asked Goal Answers Identiers for

during an interview interpretation

enforces good
practices such as
compliance on hand
washing, effective
communication with
other departments
Which are impacted Work ow related Work ow related
by work ow changes? observations-more observations
work today, but less
wasting of time;
improved doctor/
What are still issues Operational Operational
that need to be observationsreduce observations
addressed? alarm fatigue and
stress by better nurse
room assignments
(prioritized by:
continuity of care
based on acuity, and
sequential or
clustered room
assignments to reduce
delays in responding
to alerts)
Who else should be General General
involved in change recommendation: recommendations
management? Centrak badge should
be assigned to all
health care staff
including doctors and
rehabs, so they all
know what to do when
they hear alarms and
turn them off after
they attend to a
ICS nurse-tech lead 11-Dec-14 What are your nal Goal is to compile Metrics for follow-up Data capture on
thoughts on ICS nal ndings evaluation: Reviewed metrics
implementation? research ndings and
suggested some
specic metrics to
track to see how well
ICS is addressing some
key performance
indicators on the
Juggling digitization and technostress 377

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