USER-CENTERED MOCK-UP DESIGN EVALUATION OF THE BEDSIDE IN THE INTENSIVE CARE UNIT AT A CANADIAN TERTIARY CARE HOSPITAL

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1 USER-CENTERED MOCK-UP DESIGN EVALUATION OF THE BEDSIDE IN THE INTENSE CARE UNIT AT A CANADIAN TERTIARY CARE HOSPITAL MUGHAL WAQAR A. Employee Health Services, Simon Fraser Health Region, 260 Sherbrooke Street, New Westminster, British Columbia, Canada, V3L 3M2, waqar_mughal@sfhr.hnet.bc.ca Graduate Studies, School of Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada NARIYA MIZUKA, ABDULLA ZAHEER, PURVES-SMITH JOE Undergraduate Studies, School of Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada Abstract The purpose of this study was to evaluate potential modifications to the Intensive Care Unit (ICU) bedside at a tertiary care hospital in Canada. Modifications were made to the desk/chair system, the monitor/module locations, and the bedside layout addressing the intravenous pumps located at the head of the bed in order to reduce the risk of musculoskeletal injury to the nursing staff. Statistical analysis of the user surveys indicates improvements in the design of different aspects for the two mock-up bedsides. The study identified instances where favourable modifications made to one aspect of the bedside also created difficulties in another aspect. This study has also demonstrated that some simple and low cost solutions may provide positive results in injury prevention in an ICU, and that it is important to evaluate any changes to the nursing work environment on-site (on-unit) whenever possible. Keywords: Ergonomics, musculoskeletal injury prevention, intensive care nursing ÉVALUATION CENTRÉE SUR L UTILISATEUR DE MOBILIER DE CHEVET DANS UNE UNITÉ DE SOINS INTENSIFS D UN CENTRE HOSPITALIER SPÉCIALISÉ CANADIEN Résumé Le but de cette étude était d évaluer ce qui pouvait être modifié au chevet du patient de l Unité des soins intensifs (USI) dans un hôpital de soins tertiaires au Canada. Des modifications ont été apportées au système bureau/chaise, à la position du moniteur et au schéma des pompes situées à la tête de lit pour réduire les risques de blessure musculo-squelettique du personnel infirmiers. L analyse des données sur les usagers indique des améliorations au design de certains aspects des deux modèles de chevets de lits. L étude identifie des cas où des modifications apportées à un aspect du chevet comportent des inconvénients pour d autres facteurs. L étude a aussi démontré que des modifications simples et peu dispendieuses peuvent réduire les blessures dans les unités de soins intensifs, et que c est important d évaluer tout changement possible à apporter aux lieux de travail en soins infirmiers. Mots clés : Ergonomique, prévention des blessures musculo-squelettiques, unité des soins intensifs. 162

2 INTRODUCTION The heavy workload of medical personnel has been attributed to more training, increasingly complicated instruments, more documentation, and higher patient turnover due to shorter lengths of treatment in the intensive care unit (ICU). These factors together have lead to the increase in physical and psychological demands placed on the nurses(1). Work-related musculoskeletal disorders may be caused by an acute overload beyond the tolerance limits of the tissues or by an accumulation of submaximal loads and mediated through the related physiological responses(2). An on-site study was designed to evaluate the subjective ratings of perceived risk of musculoskeletal injury in the context of specific tasks at the ICU bedside. This paper reports the findings of the study and discusses the implications for attempting to modify the work environment in a critical care setting. METHODS Subjects All subjects were female in the user group (one respondent did not indicate gender), and all were Registered Nurses. The subjects had an average height of 5.3 feet (range= , SD=0.22 feet, n=22). Ten of the nurses were between the ages of 30 and 39, ten were between 0 and 9, and one was in the age group (n=21). The group had an average of 11.0 years experience working in intensive care nursing (range= , SD=7.51, n=22). Thirteen of twenty respondents reported wearing corrective lenses. The nurses in the study group were divided into two height groups in order to evaluate the effect of stature on the user's perception of risk of musculoskeletal injury at the bedside. The nurses were split at the 50th percentile, with 11 subjects falling in the range of feet and 11 subjects in the range of feet. System Description The intravenous () pumps mechanically regulate the administration of intravenous fluids into the patient. They have a membrane-button panel with a backlit display, allowing the nurse to observe and modify the settings on the pump. The Monitors are mounted to the wall at the head of the bed, off to one side (see Figure 1). They display the vital signs (i.e., electrocardiograph, heart rate, blood pressure, SPO 2 ) from the patient and require constant observation. The information comes to the Monitor from the Modules, a CPU with connection ports for up to 8 leads. Surface leads are attached to the patient with a connection module at the other end, which inserts into the Modules CPU. Throughout this paper, the term Modules refers to the actual CPU unit. Description of Modifications An ergonomic assessment completed by the evaluators identified the critical tasks that were to be the focus of modifications to the bedside. A user-centred design process used to develop the changes to the unit. During informal brainstorming sessions with the ICU nurses, possible modifications were evaluated on paper and a group of changes were selected for implementation and evaluation. Three components of the bedside were identified for modification: the location of the pumps, the height of the Monitor, and the height of the Modules. The modifications were made to two bedsides: Trial Bedside 1 and Trial Bedside 2. Table 1 lists the modifications in detail, comparing the Normal Bedside (control) to the changes made at Trial Bedside 1 and 163

3 Trial Bedside 2. Figure 1 shows the corresponding plan view of the layouts of each of the bedsides. Table 1. Comparison of different aspects of each bedside evaluated. Normal Bedside Trial Bedside 1 Trial Bedside 2 On straight shelf On angled shelf , on flat shelf On pole , on slant shelf Normal Bedside plan view Trial Bedside 1 plan view Trial Bedside 2 plan view Figure 1. Plan views of the three bedsides. The nurses are required to transfer the pumps from the equipment storage shelf at the bedside to the bed in preparation for transporting the patient out of the ICU to another area of the hospital (i.e., CT Scan). The pump shelf in Trial Bedside 1 was designed to reduce the amount of reaching required to access and lift the pumps when the nurses are preparing the patient for transfer out of the ICU. The use of poles at Trial Bedside 2 was meant to eliminate the need to transfer the pumps altogether. We expected that Trial Bedside 2 would receive the most favourable scores by the nurses. The Monitors were lowered at each of the trial bedsides to reduce the amount of shoulder flexion and neck extension experienced when a nurse uses the buttons on the monitor or simply looks at the Monitor. The Modules were lowered to reduce shoulder flexion experienced while inserting and removing the different Modules. The slant shelf was used to direct the front of the Modules up toward the user (Trial Bedside 2), as opposed to being positioned horizontally at waist height (Trial Bedside 1). Experimental Design The study was a repeated-measures design with the same six questions asked at each of the three bedsides (Question factor). The normal bedside served as a control against the two modified bedsides (Bedside factor). The participating nurses were divided into two heights groups based on the reported heights of the nursing staff (Groups factor). Data Collection A user survey was designed to capture the subjective response of staff to the different aspects of each modified bedside. The survey collected user profile data and had three sets of six questions that were asked at the Normal Bedside, Trial Bedside 1 and Trial Bedside 2. The purpose of the six questions was to capture the nurses perceptions of different human factors issues associated with using specific pieces of equipment at the bedside: the awkwardness of using the equipment, the physical effort required to move the equipment, or 16

4 the difficulty in using the equipment in their respective locations. Visual Analog Scales were used to score the subject s response to each question where a lower score reflected a lower perceived risk of musculoskeletal injury. The user trials occurred over the course of four days. Nursing staff members were approached individually to ask if they would like to participate in the study. Consent forms were signed prior to a nurse s participation. At each bedside, the nurse was required to perform the tasks of preparing for transport and changing bags and lines and then record their response in the corresponding section in the survey. If they were unable to perform these tasks physically (due to high traffic at the bedside, or in respect of patient needs) they were asked to go through the motions as if they were going to be performing these tasks. Completed surveys were either handed to evaluators or placed in an envelope at the nursing station in the ICU. Statistical Analysis Descriptive statistics were used to identify the group frequencies, percentiles, mean scores, standard deviations and range. Analyses of Variance (ANOVAs) were used to determine significant effects of the modifications at each of the bedsides. Pre-planned Helmert contrasts were used to determine where differences occurred among the different factors. Alpha was set a priori at α=.05. RESULTS Out of the 33 surveys distributed, 22 were returned for a 66% response rate. The ANOVA results for the pump questions in the survey revealed a significant main effect for Bedsides (p<.001), and a preplanned contrast revealed that, when averaged over all three questions relating to the pumps, Trial Bedside 2 received the most favourable score (x=22.198, SD=5.02) when compared to Trial Bedside 1 (x=.993, SD=.399) and the control bedside (x=71.810, SD=2.383). There was no significant difference between the responses by the Taller and Shorter nurses (p=.0). The ANOVA results for the Monitor survey questions data revealed a main effect for Bedsides (p<.001). Preplanned contrasts showed that, when averaged over both survey questions, the mean score for the control bedside (x=3.280, SD=.279) was significantly different from the mean score for Trial Bedside 1 (x=16.77, SD=3.297, p<.001) and Trial Bedside 2 (x=13.263, SD=3.231, p<.001), but the mean scores for the trial bedsides were not significantly different from each other (p=.19). Another result showed a significant interaction effect for Groups x Question (p=.009). This was largely due to the responses to the interaction question by the Taller nurses (x=1.768, SD=.605) and the Shorter nurses (x=29.850, SD=.830). There was also a significant interaction effect for Groups x Bedside x Question (p=.05). There was no significant difference between the responses by the Taller and Shorter nurses (p=.333). The ANOVA results for the Modules survey questions data found a main effect for Bedsides (p<.001). Preplanned contrasts showed that, when averaged over all bedsides, the mean score for the control bedside (x=37.59, SD=3.889) was significantly different from the mean score for Trial Bedside 1 (x=16.20, SD=.826, p=.001) and Trial Bedside 2 (x=15.85, SD=3.102, p<.001), but the mean scores for the trial bedsides were not significantly different from each other (p=.85). There was no significant difference between the responses by the Taller and Shorter nurses (p=.381). 165

5 DISCUSSION The ANOVA results for the pump survey questions indicated that the arrangement for Trial Bedside 2 had the least amount of perceived risk of musculoskeletal injury as defined by our survey questions. Specifically, the staff found the pump transfer task to be easier at Trial Bedside 2 than either of the other two bedsides. This finding supported our hypothesis regarding the modifications made to the trial bedsides. However, comments from the survey indicated that the design of Trial Bedside 2 had some limitations beyond the pump transfer task, namely the space available in the elevator used to transport the patients from ICU to the other areas of the hospital. The current method of affixing the pumps to bed poles does not take any extra space in the elevator, whereas the use of poles would reduce the amount of space. This may make it difficult to fit all four staff members that accompany the patient into the elevator. The ANOVA results for the Monitor data indicate that we are on the "right track" since the mean scores for both Monitor modifications at the trial bedsides were significantly better than the control bedside. The data also indicated that the Taller nurses found it easier to read the monitor than the Shorter nurses. However, the difference between the two groups was not consistent across all bedsides, as indicated by the significant interaction effect for Groups x Bedside x Question. This tells us that nurses of different statures perceive risks differently at the bedside, depending on the physical arrangement. As an example, the use of poles eliminates the need for the physical lifting of the pumps in preparation for transporting the patient out of the ICU. However, the ability to view the monitor may be negatively impacted since the poles place the bags close to monitor height at the side of the bed, potentially blocking the view of the monitor. The ANOVA results for the Module survey question indicated that lowering the Modules is an improvement over its current location, although it remains unclear which shelf arrangement, flat or slant, is the better of the two alternative designs. CONCLUSION To reduce risk of musculoskeletal injury to nursing staff, modification to the work environment must be considered. The results of this on-unit mock-up evaluation have shown that some simple modifications can reduce the relative perception of risks of musculoskeletal injury in the critical care nursing environment. However, the modification of the bedside in an ICU is not a straightforward task. A modification may make an improvement in one area but create problems in another. It is best to perform the evaluation in the actual work environment with simple low-fidelity mock-up designs. The on-unit evaluation approach used in this study allowed the subject-matter experts to provide feedback prior to the expenditure of resources to make substantial changes to the work environment. This study highlights the need for healthcare ergonomics to look at the entire system when performing any assessment, since there are many users and many systems working together in a healthcare environment. Any changes must be considered in the context of the purpose of the overall system of healthcare, which is to care for the patient. REFERENCES (1) Friesdorf, W., Schwilk, B., Hahnel, J., Fett, P. and Weideck, H. 1990, Ergonomics Applied to an Intensive Care Workplace, Intensive Care World, 7(), (2) Jensen, C., Laursen, B. and Sjogaard, G. 1995, Shoulder and Neck, Biomechanics in Ergonomics, Ch. 11,

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