The vision for NurseMind emerged from what, with his software engineer (first career) eyes, Dan sees in the world of nursing. As a nursing student on clinical rotations, his instructor on occasion chided him for forgetting some task or detail. He asked his academic adviser (also a nurse) about this. She said, "You could carry a piece of paper in your pocket to remind you." Was that the best tool she could offer?
As it turns out, the answer is yes. Pretty much every nurse carries a wad of paper in her pocket. Each invents her own format. It serves three purposes:
- Keeping essential information literally at her fingertips.
- Reminding her of what is to be done for each patient.
- Collecting jottings, reminders for follow-up, notes for later entry into the patient charts or to discuss with colleagues, especially when giving report at shift change.
She even has a name for it: she calls it her "brain". No kidding. Sharon McLane, MS, MBA, RN-BC, and now PhD of the University of Texas at Houston documented this in her 2009 PhD dissertation, Understanding Nurse Created Cognitive Artifacts. "Cognitive artifacts" is a fancy term for that wad of paper.
In researching this gap in the profession's toolset, we have collected brains and keep them in a brain museum. We are planning a share-your-brain contest both as a continuation of this process and as a marketing channel. These brains -- and thousands like them -- reveal the mental burden of nursing work and the opportunity this represents.
NurseMind is a better solution. It is in many ways better than paper. It is an application program ("app") that runs on an Apple iPhone or iPod Touch that the nurse carries with her on the job. She gives it some basic information at the start of the shift to enable it to build the to-do list. As she works her shift, she checks things off with a tap of her finger. NurseMind reminds her when a time-sensitive task (e.g. giving a diabetic patient his insulin) is due, making sure nothing is forgotten. It also optimizes her workflow in small ways such as speeding the notation of vital signs (faster and more accurately than paper) and reminding of near-term tasks that require supplies to save trips to the stock room. It remembers details and frees her to concentrate on her patients.
For most nursing tasks, the problem is not that they are difficult (though several, such as starting an IV or inserting a catheter, demand a high level of skill) it's simply making sure they get done. For example, immobile patients must have their weight shifted in their beds every two hours to protect delicate skin from pressure ulcers (bed sores). This is one of many tasks that is not urgent (half an hour early or late makes no difference) but is nonetheless important. The nurse must make sure that it gets done.
It is surprising how little formal thought has been given to these essential mental nursing skills. In his years of nursing school, Dan saw not a single presentation -- not even a brief one! -- about time management nor about how to design and use brains. Students are lectured at great length about how to do the physical tasks of nursing but Dan recalls not a single professor speaking of the mental ones.
While the plural of anecdote is not data, it is pretty clear that little formal thought has been given to nursing time management. Dan's experience was at two well-regarded nursing schools (USF and SMU). None of the nursing textbooks offered any serious discussion of this topic, none of the faculty members Dan queried could suggest any method beyond the paper "brain", and most significantly, a literature survey (using the CINAHL and MedLine databases) yielded nothing more than a few fluffy trade rag articles about how to keep a to-do list.
In November of 2010, we made an informal survey of 10 working nurses in OR, L&D, Postpartum, Rehab, Medical-Surgical, and Outpatient Clinic at hospitals in the San Francisco Bay Area and Orlando, Florida and asked:
- What do you write down on your brain?
- What do you (or your students) forget to do during the shift?
- Do you have overtime routinely? Why?
- How do you manage your time to get breaks and lunch?
- Do you have any time management tools to share?
The survey results are here. Briefly summarized, they show that the problem is real, the memory burdens are substantial, and opportunities for error abound.
Dan has written about this in an essay entitled, Nurses Need Better Tools. Nursing is stressful work and errors can have dire consequences. Sources of this stress include the heavy cognitive load ("...how many discrete units of information can be retained in short term memory before information loss occurs"), multitasking, frequent interruptions, and the challenges of work that is increasingly complex in its content. Nurses must apply concepts from pathophysiology, psychology, medicine, pharmacology, etc., and must do so in the busy and elaborate environment of the modern hospital.