Phase 2:

Contextual Inquiry & Analysis

Roles & Contributions

Concept Statement

REVISED System Concept Statement

The Nurse Tracking Wall (NTW) is an interactive, ambient dashboard and companion haptic pager system designed to mitigate chronic "alarm fatigue" and streamline the overall coordination at hospital nursing stations. The system translates complex vitals into prioritized, "at-a-glance" visual cues using room-based blocks that employ color-coded urgency (ex: increasing redness for higher risk) and specific icons (ex: a lung for respiratory distress) to provide immediate diagnostic context. Unlike pre-existing traditional monitors, the NTW allows nurses to interact directly with the wall or their pagers to expand patient details, view recent trends, and acknowledge or silence alarms by having it connect and sync with their own pager/communication device. Beyond simple vitals, the NTW integrates vital workflow tasks, including automated charting notifications via bell icons to ensure compliance, a searchable supply room locator to reduce logistical frustration, and a dedicated "Pathos" section for patient-family dynamics to humanize care. By substituting low-risk alerts with silent haptic pulses that only escalate to auditory signals if unacknowledged, the NTW empowers nursing staff to prioritize patient care through non-intrusive, data-driven visualization and logistical support.

Rationale for Changes

This revision addresses the feedback which regarded the lack of implementation details and also included the variety of supported tasks we recognized from our interviews:

Implementation Specifics: The statement now explicitly defines interaction methods where nurses "click or tap" blocks on the wall or pager to expand data in order to get a holsitic view on contributing signals to patient charts. It also elaborates on the specific actions like marking a status as "normal" or "to monitor more closely".
Expanded Task Scope: To move beyond just a "pager extension," or a dashboard which some hospitals already have, the scope now incorporates specific requirements from your table, such as charting reminders (AAB2.7) and logistical supply room management (CA5.8) - Please see requirements table below.
Prioritization & Customization: It addresses the "alarm fatigue" feedback by detailing a nurse confidence value flagging system and customizable alert sounds, ensuring not every notification is treated as a crisis and each situation is handled with the appropriate care.
Human-Centered Design: By including the "Pathos" requirement (BC6.4) which we found during the WAAD analysis, the system now supports the nursing student's desire to build a deeper connection with patients through shared personal and family notes.

Revised Technical Summary

Our system reduces alarm fatigue by turning most “beeps” into a shared, easy-to-scan view of unit risk using three connected parts: a Status Wall at the nurses’ station (one tile per room), a nurse pager/mobile app for personal alerts and quick actions, and a central hospital-network server that ties everything together. The server pulls in real-time bedside monitor/device data (HR, BP, SpO₂, RR, ventilator values, plus technical signals like, poor probe contact or disconnect) and hospital record/assignment context (patient → room mapping, ordered target ranges, and flags like expected abnormal/baselines when available) through whatever integration interfaces the hospital supports (device feeds and/or APIs). It standardizes units and timestamps, checks data quality to separate real deterioration from sensor noise, and computes a single per-room “risk state” with urgency (normal → watch → needs attention → urgent), likely category (respiratory/hemodynamic/neuro/technical), and confidence; if patient↔room mapping is missing or stale, the room is marked unknown/stale rather than guessed.

The Status Wall does not connect directly to monitors - it receives real-time room-state updates pushed from the server and displays the latest state per room. The pager/app subscribes to the same updates but filters them to a nurse’s assigned rooms, and it’s two-way: nurses can acknowledge, mark expected/watch, or request escalation, which updates the server and immediately updates the wall and other clients so the whole team stays aligned. Most alerts are visual on the wall and visual/haptic on the pager/app, while audible alarms are reserved for must-not-miss events (e.g., sustained severe hypoxia/hypotension, lethal arrhythmias, ventilator disconnection) or urgent states that persist, worsen, or go unacknowledged, with those escalation rules enforced centrally to keep wall and pager consistent.

Client Contact

During the most recent client contact, we talked about how this new research allowed the project to move beyond a technical pitch to a more problem-backed solution that addresses actual pain points identified during contextual inquiry. While the client expressed enthusiasm for the inclusion of "pathos" and logistical tools, they emphasized that the next phase should really focus on ensuring the hands-on interaction remains efficient and that interaction does not become a burden during high-stress shifts. This phase has been a big change from the initial concept, as we look to integrate these new findings into the system concept. The client noted that this shift toward a centralized hub for coordination is a promising direction, though they are interested to see exactly how these interactions are implemented as the project moves into the technical design and prototyping stages.

Contextual Inquiry

The Process:

Motivations

We are primarily focused on understanding how health professionals provide care to patients in a hospital setting. This ranges from the simplicity of giving medication to the complexity of communicating with multiple departments to fill orders for your particular patient. Understanding that there is a lot that goes on in patient care, we wanted to learn more about what that actually means for different nurses in the field. Through these interviews, we hope to gain a full picture of what care looks like and the tasks, activities, and perspectives on that care.

Client Meetup/Discussion

While prepping for the interviews, we discussed with one of our clients Jackson about the high-level duties and workflows that a nurse has on a day to day basis. This information gave us a little more familiarity with the profession and not only allowed us to ask more meaningful and specific questions but also understand answers that may use nursing-specific language. It helped us perform more efficient and information-dense interviews. One task was figuring out the different user classes and how different roles are differentiated in duties. Jackson helped clear any confusion with these roles.

Since much of what a nurse works with in regards to patient-care requires HIPAA compliance, work artifacts are more difficult to gather from interviewees themselves. As such, in the interviews, we often asked for the specific name of systems, practices, etcetera and would after find the system online in a form that is HIPAA compliant. Then, we would contact our client Jackson to confirm the image we found matches the description of what the user describes (ex: Pyxis machine).

Throughout the drafting of the hierarchy table in this section, Jackson was contacted to validate the accuracy of the role descriptions, and their subsequent interactions with each other.

User Interviews

In our first group meeting, we decided that we were going to try and contact as many people of differing work roles, so we could gather a broad range of experiences. Using LinkedIn, faculty directories, and personal contacts, we reached out to over 40 different individuals and they broke down into the following categories: medical students, doctors, nursing students, nursing instructors, practicing nurses, and nurse scientists. For extra information, this is a link to the spreadsheet we used to keep track of who we contacted, who we set up interviews with, and any other supplemental information.

Of those we contacted, we were able to contact and complete 7 successful interviews. Many individuals did not respond (especially the doctors), some stopped communicating in the middle of correspondence, and others were only available after the scheduled deadline. Of those we interviewed: 4 are current nursing students, 1 is a pediatrics ICU nurse, 1 is a clinical instructor for pediatrics at UVA, and 1 Doctor from VCU. All of our interviewees fit the work role of a nurse, but fulfill different types of user classes: nursing student, PICU nurse, nursing instructor. Note that both of our clients, Rafiq and Jackson, were also used as interviewees.

Through these interviews, we hoped to gain insight into (1) the daily care that a nurse provides and how they personally provide it, (2) aspects of the job they struggle with, and (3) what they really enjoy or would like more of.

These interviews were conducted in two ways. The first was having two interviewers, one who would take notes and the other who would ask questions; this allowed the one asking questions to be fully engaged in the conversation and keep it as natural and fluid as possible without having to worry about capturing data. Similarly, some interviews were done individually and recorded using either Zoom's built-in record feature or the IPhone's voice memo feature. These recordings were then transcribed and analyzed. The latter option allowed for more autonomy in the interview and made it much easier to gather the accuracy of what the user said word for word when analyzing the recording.

Work Practice, Work Roles, User Classes in the Work Domain:

Above is a hierarchical diagram of the nursing care domain. From top to bottom the levels are, respectively, work domain, work role, and user class. The boxes filled with green are roles that the team were able to interview directly. The boxes filled with blue are work roles or user classes that we did not get to interview directly, but were mentioned many times by the individuals interviewed. They are included to show their relevancy to nursing care and the possibility of their activities being impacted by our envisioned system. The blue work roles could also be synonymous with intermediary roles because of how they help the nursing role complete their tasks.

These six work roles were chosen for their relevance and connection to nursing care. Below is a short description of their responsibilities in the domain and why we chose to include them:

Nurse: the central player, they are responsible for the majority of care to the patient's mental and physical well-being. They are the advocate for and the eyes on their patients.
Doctors: Doctors are responsible for putting in orders and requesting certain care for the nurses. They are often hands-off and focus on pathological issues. Doctor's will typically only see the patient twice a day, morning rounds and evening rounds, which means they are primarily a role that provides instruction for what care should be given, rather than performing such care. Additionally, education, skills, and background look much different than other roles.
Occupational Therapist and Physical Therapist: These are considered special team roles. They assist some patients to help with a specific caring need like learning how to use the phone again or walking. They are not vital to all nursing care but very vital to a niche of the patient population. They require different training and licensure than other roles .
Providers: Providers are individuals who are the mediators between nurses and doctors. They can fulfill many of the same functions as doctors, like prescribing medication, but they have a lot more direct and frequent contact with patients and the nursing staff as a whole. They are often the first in line when a nurse needs more advanced advice than regular nursing needs.
Pharmacist: Pharmacists are responsible for dispensing and verifying medication before it reaches the patient. They are critical for providing safe cafe by checking dosage, potentially harmful interactions, and order accuracy. They rarely interact with patients themselves, but are frequently in contact with nurses for questions and concerns. Like other roles, their training and licensure is much different and has little direct patient care aspects.

Going deeper into the nurse work role, here is a description of the individual user classes and the reasoning for including them:

Nursing Student: Nursing students are learners in the clinical setting who are performing almost all duties a registered nurse (RN) can do under supervision of a clinical instructor. They perform much of the same duties as RNs; however, only having one patient in the day versus the typical four. Interviewing nursing students can be beneficial because since they are learning, they are very cognizant of their actions. Lastly, since the team is made up of students, it's much easier to have individuals of closer personal connection agree to interviews.
Nursing Instructor: Nursing instructors are experienced nurses that have shifted from direct patient care to teaching and supervising nursing students. They're top priority is making sure that their students are giving high-quality care and following all safety procedures. This means that instructors likely have the more up to date information on what is expected of nurses in the hospital, making them a perfect asset for gathering information about procedures and standards.
Floor Nurse: Floor Nurses are RNs who provide direct day-to-day patient care in hospitals. They are responsible for the majority of the care for a patient and represent the most common and central nursing user class in the work domain. Their primary role is to care for patients. This makes them an easy choice to include them in this hierarchy.
Charge Nurse: Charge nurses are experienced floor nurses that take on a supervisory role for their shift. They could also be considered a head nurse. They are in charge of assigning staff jobs and handling any floor issues. This shift in practice that is more managerial is why this was included in the hierarchy. They are an important bridge between nurses and doctors or providers, which means they have a unique experience for nursing care coordination.
Nurse Practitioner: NPs are specific type of nurse that is more advanced and requires more licensure. They have the authority to diagnose, prescribe, and write orders, and function very similar to a provider. However, since their unique nature in being an extension of a nursing education, and the majority of NPs having registered nurse experience, and all having nursing student experience, it was a fitting addition to the nurse work role.
Licensed Nursing Assistant: LNAs have very similar roles as a nurse but in a lower capacity. They often have teh same privileges as a nursing student but not in an education setting. They often support nurses in basic care and often need RN supervision. There non-education basis is why they are under the nurse work role.

Initial Interview Questions:

Since all of our interviewees were of the nursing work role, we ended up using the questions below for all interviews. However, it should be noted that many of the interviews were fluid and natural. Some group members would use opening and closing questions only and interview primarily using follow up questions, only using the written questions to bring the conversation back to life or back on topic.

Client Questions:

What are some things all nurses have to do throughout their day?
What do you think nurses would find the most frustrating in their day-to-day?
Who are nurses mainly communicating to?
What technologies are most used in the hospital?
What are the most common tasks for nurses?
Why do you think most people go int nursing

User Questions:

Opening/Context Setting

Can you walk me through what a typical shift looks like for you from start to finish?
What unit or specialty do you work in, and how long have you been in this role?

Core Activities & Workflow

What are the main tasks you're responsible for during your shift?
How do you prioritize when multiple things need your attention at once?
Can you describe how you coordinate with doctors, other nurses, and support staff throughout the day?
What information do you need to access most frequently, and where do you get it?

Tools & Technology

What systems, tools, or technologies do you use regularly in your work?
Which of these work well for you, and which create friction or slow you down?
How much of your time would you estimate is spent on documentation versus direct patient care?

Challenges & Pain Points

What are the most frustrating or challenging aspects of your daily work?
Can you give me a specific example of a recent situation that was particularly difficult or time-consuming?
What tasks feel like they take longer than they should?
If you could change one thing about how you work or the tools you use, what would it be?

Closing

Is there anything important about your work that we haven't covered?
What do you wish for people designing healthcare systems or tools to better understand nursing work?

Collecting raw context task data:

We collected most of our data through both research and interviews. When analyzing interviews, researching softwares and technologies was an important step to better understanding nurses' work practices.

One barrier we faced was HIPAA compliance. Most of the technology used involves confidential patient information. As such, we were not be able to observe nurses writing up notes, charting patient details, etc. Using the notes from the interviews, we could, however, look up the software mentioned and gather publicly available information. Especially for EPIC software, there are very litle public screenshots of specific pages and our clients are unable to show their EPIC programs due to their own responsibility as healthcare providers to abide by HIPPA.

Additionally, we used our client Jackson to walk through screenshots of EPIC to clarify what interviewees were mentioning in their interview answers, what certain icons mean, and when they would be used.

For other devices like the Telesitter and Vocera, the company's website provided ample information about the features and usage of the product.

Work Artifacts:

The devices immedietly below all do a similar thing for hospital staff: save time. With the amount of work one nurse has to get through in a day, it shows the fast-paced, compact schedule they deal with in their job. The portability of these machines, being on wheels or simply compact, emphasizes the constant movement hospital staff have for various duties.

The Telesitter

Night shift nurses will set these up in multiple rooms, so one person can watch multiple patients at once. This helps increase patient safety by always having eyes on the patients who are higher risk. This allows more time for nurses to be focused on patient care in other areas. These are often used on night shift. The Telesitter does have speakers if the remote nurse needs to talk to the patient and can allow remote nurse to alert bedside nurse in case of an emergency. This object shows that hospitals and healthcare are trying to find ways to have on individual do the job of many at once. This consolidation of tasks to one person shows the industries value of efficiency in work distribution. But it also shows that they may be stretching staff thin due to the often hospital staff shortages. It is important to take into cnosideration

Vocera

a hands-free assistant that many nurses use to call coworkers about HIPAA information, schedule timers, etc. Most modern device used right now by individuals. Not required by floors, preference by nurses. This allows for easier and faster communication between staff. Can be used to quickly get help in case of an emergency. This artifact shows an increased need to multitask among nurses. Having hands-free device explain that many of a nurses tasks requires both hands. They really are doing a lot of "hands-on" work.

Zebra phone

Technology that Nakayla Figgins, one of our interviewees, uses on her ICU floor. She mentions that it is hard to type on, very bulky, and an older model due to a restrictive budget. This creates a secure line to call coworkers about HIPAA related information. Her unit uses this daily to get in contact with each other, providers, doctors, pharmacists, etc. Similar to the Vocera, since nurses are always moving from room to room, grabbing supplies, they need a system that is portable and compact for their duties.

Dinamap

This vital signs machine allows nurses to take multiple vitals at the same time. The name stands for Device for Indirect Non-invasive Automatic Mean Arterial Pressure. Having it on a cart allows it to easily be moved around the room and to different patients. The machine can measure blood pressure, oxygen saturation, heart rate, and temperature at the same time. This significantly increases efficiency and the automation after application allows nurses to assess things like physical appearance and pain. It also allows for accuracy and consistency across results. This artifact does a good job showing the movement of a nurse. They are not sitting all day, they are moving things Dinamap around constantly to different room, which is why they need things to be on wheels in order to be portable. The fact that the machine does so much at once exhibits the need and attempt to reclaim time from the nurses.

Pyxis Machine

The machine below is held on all patient floors of the hospital. It is used to track, hold, and supply medications to patients. There are three main components (annotated in the image) which can only be accessed by signing in with valid credentials using the monitor in the top left. This is a secure way to acquire medications fast and effectively.

Nurses will have med-passes (giving medication to patients) as little as every 3 hours to as long as every day. During every med-pass, nurses are required to go to this machine to gather the correct medication. This system really underscores the need and requirement for repetitition in a day's work. Nurses are constantly coming to this machine for medications, so it has to have everything they may need right there. Since these are on virtually every floor of the hospital shows some of the overlap nurses have across specialties. The modular aspect, however, shows that nursing specialties are also not exactly the same, they need tools that can adapt to their specific needs because every unit varies in protocols, tools, etcetera. The wheels again show the portability need for nurses.

EPIC software (charting system):

Features:

The Brain: An hour by hour schedule for the day that shows all of the medications, labs, and other important time-sensitive tasks
- There are no screenshots of this page available online, only snippets through social media posts like the following to the right
- below is an annotated screenshot of what some of the icons mean
  - These are the main tasks that a nurse sees in "The Brain"
    - Flowsheet tasks: assessments done by the nurse and be filled out in the flowsheet page (see next)
    - Labs due
    - Medication due
  - The tasks should be complete between the hours that the icon is listed

Flowsheets (on the right): This page in EPIC helps nurses track and record different measurable factors of patient health and status over time. This can range from urine output to respiratory rate. This is a running log of the patient's condition
- A floor nurse or nursing student may fill out a flow sheet every four hours.
- A charge nurse may only use it to review the progress of a patient
They fill out data in a tabular format and includes data points like vital signs, intake and output, pain assessments, skin assessments, and many others.

List of other work actiivites:

How orders come through
How exacly the supply rooms are used
How pyxis machine is used exactly
What the bedside call buttons are for different codes
Logging into nursing station how does that work

This is the main technological system that nurses use on a daily basis to track everything that they are doing in regards to patient care. It is also used as a means of communication between nurses and doctors, it has reccomends schedules for different tasks like med-passes or labs due, and has a place to write in notes about the patient.

This charting system is just as much as it is for the patient as it is for the nurse. When charting, you are not only puting into paper the status of the patient and their care, but also creating a systematic paper trail of your actions in case of lawsuit. A common phrase among nurses is "if you didn't chart it, you didn't do it." This is an extremely important software that keeps track of medical records, patient history, and more.

Epic and charting in general is extremely important to showing nurses work practice because a lot of their time in the hospital is spent charting on softwares like Epic. Charting helps nurses, doctors, and any other healthcare providers develop, analyze, and ammend a patient's care plan, a pillar of what healthcare is for. Day to day, nurses have very busy schedules, juggling multiple patients at once, and need a system to track tasks and message coworkers. It allows nurses to unburdern themselves from the mental overload of having to remember when meds are due, who to contact in case of emergency, so they can really focus on caring for their patient. Charting is very important for the sake of the nurses job. It is a digital footprint of all of the things they have done in the day in regards to the patient; it holds their work practices. They track when they turn a patient, when they give patients food, when they give patients a bath, when they help patients out of bed, when patients go to the bathroom.

Below are some work artifacts from our progress in interviewing relevant people for our project. We created a spreadsheet with possible interviewees to keep up with who we could or have contacted. We also kept an updated folder with detailed information about what we gathered from each interview.
NOTE: We really tried to get in person observation/shadowing visits (given the unique nature of our users) and emailed/contacted over 50 indivudlas across various care units. However we did not receive enough responses back for this to happen within the alloted time frame.

Scripts:

Script 1 - Caroline Kenny

Q. What type of work do you do?

A. Right now, I'm a nurse practitioner student and a clinical instructor for the undergrad nursing students at UVA. I teach them on their pediatric rotation in the inpatient pediatrics unit at the hospital, where we go in for a 12-hour shift once a week. And then in my other job, I am a nurse working in the pediatric outpatient clinics through UVA.

Q. Could you walk us through a routine patient check or how one might go?

A. Since we have specialty clinics, it depends on which specialty the patient is coming from. In general, the patient will come and check in at the front desk and the front desk will mark them on the electronic health record as ready for the visit. A nurse will review their (the patient's) chart to look at any orders that the providers have placed, check out their history and if see if they need any blood work. Then, they (the nurse) will go to collect the patient from the waiting room and confirm their name and date of birth before bringing them back to their visit room. Here, we (nurses) will grab height, weight, vital signs and confirm any allergies they may have. We also go through the home medications that they're taking; we check the medication, the dosing, and how many times a day. After this, depending on the specialty, we run different tests; if you're in the diabetes clinic, we'll do a blood test, if in cardiology, we'll do an EKG of their heart rhythm, and then other clinics run other appropriate tests. When we're done with this, we let the other members of the care team know that the patient is ready.

Q. Can you tell us more about the EHR that you've interacted with?

A. There's an inpatient Epic and then there's an ambulatory. Ambulatory is just another word for outpatient setting, which is when patients are not admitted to the hospital. So when I'm in the hospital, I'm using the inpatient Epic and when I'm at work, I'm using the outpatient Epic. All the nurses and providers can see all the patients. The nurses have a specific program that runs that allows them to do everything they need to do and the provider has a specific program that runs that allows them to do everything that they need to do.

Q. Could you elaborate on what you mean by provider?

A. A provider is a higher level clinician who can diagnose and prescribe medication. They can take care of patients with chronic illness, prescribe their medications, and figure out their treatment plan. This is usually a doctor, a physician's assistant, or a nurse practitioner.

Q. Are the ambulatory EPIC system and the inpatient EPIC systems connected?

A. They are connected. Information that you're looking at in the ambulatory setting will also contain all their information from an inpatient stay that they had and vice versa. So, they are the same system, it's almost just like a different view.

Q. What are some of the common gripes or problems that you might have with the current communication workflow in terms of how you're alerted about something or just in general?

A. For the current workflow, you can right click on a patient's name and then you select to change their status. So the people at the front desk will change the patient's status to ready to be seen by the nurse. Then the nurse will change the status to "I'm seeing the patient" and then when they're done, they'll change it to "ready for the next person". I think this sort of system works pretty well — unless you (the nurse, doctor, etc.) forget to change the status.

Q. Does the system alert you in any way?

A. No, it doesn't ping or anything. So, you just have to keep refreshing the page to stay informed. This was something that I thought of today, if I wasn't paying attention or if I screwed up or the computer went to sleep, that would be bad. But no, there's no alert information embedded other than seeing the message on the screen of the patient's status.

Q. Does the workflow differ between units or clinics?

A. Yes. In the ICU, there is a lot more communication. Most of the communication is over chat message. In my experience in a different state, it was embedded in Epic; at UVA, it's through a different system, but it's still just messages. I would say that's almost the main form of communication. If there's an emergency, there's an alert system and a pager system where everyone who needs to know about the emergency will be pinged on their pager.

Q. Is this messaging tool an app on your phone or a separate device?

A. In my experience, Epic has a messaging system embedded in it, which is super easy to work with. You just click on the patient's chart and then click 'message' and choose who you want to message and it would send a message with that patient's information. We could definitely be doing that in the outpatient setting right now but at UVA, they use a pager system. Also, Vocera is another form of communication in the hospital (inpatient). It's like a little microphone that we can put on our badge. The nurses, doctors, physicians, assistants, and everyone else wears it. This is the best way to reach people. Instead of calling them on the phone, you press the button on the vocera and say "Call Alice" and then it will send a ping to their Vocera and they'll answer. It also includes the pager system so when there's an emergency, you'll get a Vocera alert The Vocera is also on your computer, which is where you can text messages. I haven't used it as much but it's super helpful, it's like a hands-free phone.

Q. Could you walk me through what a typical shift at a more macro level looks like for you? Rather than patient by patient?

A. It's an eight to five shift, with a 30 minute lunch break at the middle of the day. For the outpatient center, we have usually four to five nurses in each clinic. We have anywhere from 30 to 50 patients to see a day. As the patients are ready, the nurses will take them one by one and get everything that they need to done. We don't really have a system for distributing patients, it's sort of whoever is available when the next patient is ready.

Q. Aside from Vocera and Epic, what other systems, tools, or technologies might you use throughout your day?

A. For an inpatient job, we use both CERNER and EPIC are the main technologies, and the most important. We also have a patient status board, which is a big screen on the unit, that will show us how well each patient is doing on the entire pediatric floor; this must have been a quality improvement project at some point. It's a map of the hospital floor and there's a dot in every patient's room. If the dot is red, it means the patient might be having an emergency, they're not stable and this patient needs attention. If it's orange, they might be decompensating and we need to help. If it's yellow, they're not as stable as they were and we're a bit concerned. If it's green, then we're fine. So, this is a big piece of technology that is utilized in the hospital just for awareness. We also have a lab transport system; you can get any lab samples, put it into a plastic tube, and place it into a space in the wall, where it gets sucked up and shot down somewhere else. You type in a code to send it off and can send the lab samples to almost anywhere in the hospital. Vitals machines are important, those are in every patient's room. There's a continuous telemetry monitor, like a continuous heart monitor, for patients that have cardiac concerns so you can always see their heart rate and rhythm. That information will be in their bedroom and also at the nurse's station

Q. Are there any system or technologies in place right now that you feel slow you down or create any friction?

A. The messaging system, especially if someone doesn't read your message or if they're not answering, which is typical, but people aren't really calling on the phone very often. Also, if an order isn't signed by a provider, then a nurse can't sign it or move forward with the order. So if the doctor doesn't see that an order is placed, the nurse can't do anything.

Q. As a nurse, how much would you say is spent on documentation and administrative tasks versus direct patient care?

A. Documentation generally just takes a long time. It's just a slow process, clicking through everything and following all the regulations of what nurses have to document with every shift. Generally, you have to click and type and click and type. For example, you have to measure exactly what the output that you've done is is and put it into Epic. There's not much information that is pulled automatically. On the provider side and on the nursing side, we have to type out notes and make sure all the information is correct, so charting takes up a lot of time in general. To better answer your question, it depends on the role. n my job right now, it's mostly patient care, there's not a lot of documentation. But when you have a high acuity patient, you're documenting almost as much as you're spending with the patient.

Q. There are some tools, like AI, that are said to be able to take better notes. Are you using any of these tools?

A. I have not seen many providers use it in the clinic setting or on rounds. I don't know if it's necessarily approved. I think it's pretty highly regulated depending on where you are. Thinking just in terms of nursing documentation, you have to document a full assessment like head to toe and every body system. So, an AI tool where you could go to the patient room and just speak out what you're seeing and have that be automated and pulled into the chart would be convenient. Then, you can go in and edit it if there's any issues. I'm sure there's privacy concerns with that, but if the patient consents to it, then that would just be much more efficient in terms of documenting at the same time that you're doing the assessment. I could see it being beneficial, 100%, but I don't think it has made its way into inpatient setting at UVA yet.

Q. Would you personally be interested in having like an AI companion or anything to help ease that workload of manually having to document?

A. Yeah, I think it'd be super interesting. Though I think with HIPAA, like patient security and privacy, there is a big concern with that. As for the documentation burden, things just get missed a lot and there's human error that ends up interfering with patient care and plans of care just because it's forgotten or it's typed wrong or something like that. And obviously that can also happen with AI, but to have that type of technology to assist with in the moment documentation would be pretty cool.

Q. Is there anything important about your work that we haven't covered or something that you wish people designing healthcare systems or tools could do to better understand nursing work?

A. Yeah, I think even if the Vocera could capture a nurse doing a full head-to-toe assessment, like speaking what they're seeing in their assessment and that goes into the chart would be helpful. Nurses are keeping so many things in their brain at once until they get the chance to sit down and document. There's just more room for AI to help make what the nurses are doing more efficient because they're moving around and taking care of five different patients at once. That's what's kind of happening with like AI provider notes; NPs and MDs are able to have all their documentation done in the moment when they're interviewing that patient.

Q. Is the Vocera similar to a walkie talkie? How is your experience with it?

A. Yeah, that's a good comparison. I think it's probably using the hospital Wi-Fi system, because you can be anywhere; you don't have to be within Bluetooth range or anything. Somehow it has everyone in the hospital's name and contact information embedded in its hardware. You can speak like with a walkie talkie over the phone, whereas with a pager, you're receiving a small message. I think with the pager system, people will receive on their pager, but not everyone has a pager, so you can page to someone's email.

Q. Do you feel like the pager system that's in place right now is good or convenient?

A. It seems a little bit antiquated to me. At my old hospital, in New York, we only used the pager for emergencies. That was like a separate kind of like emergency alert system. All the nurses and other level providers all had phones with Epic on it and so you would get messages on the phone; you could obviously also call on the phone. Typing a pager message for someone to receive over email seems a bit strange to me, it seems like a little bit old-fashioned. But I don't totally know the advantages and disadvantages of the paper system as it is.

Script 2 - Shashank Nadampalli

Q. To start off, could you walk me through the very beginning of your shift and how you interact with the hospital’s systems?

A. The process starts with signing in using my badge and punching the time card. Immediately after that, we have a group meeting during the shift change. This involves the incoming shift and the charge nurse from the previous shift to get up to speed. Once the meeting wraps up, we are assigned to specific pods. That’s when I sign into the computer to actually see the tasks waiting for me.

Q. Once you’re signed into your pod, how do you identify and document the specific clinical tasks you need to prioritize?

A. The system shows us everything that needs to be done, like performing IVs, cleaning patient charts, and other clinical duties. When we complete something, like an IV, we record all the details in the system, such as the specific type of IV and exactly where it was placed on the patient.

Q. When you are away from the terminal performing these tasks, how does the system reflect progress?

A. Most of the task completion is handled directly on the computer. If I’m stuck in a room or particularly busy, sometimes someone else might punch it into the system for me to keep the record updated.

Q. I noticed you’re wearing a headset. How has the transition to that device changed the way you communicate compared to the old phone or pager system?

A. We’ve moved away from phones to these headsets, which is a big shift. However, there are definitely friction points. There’s also a human element where people just don’t respond when they hear their name called over the set, which can be frustrating.

Q. Beyond the individual headsets, how do you use technology?

A. We still have physical whiteboards in every room that list the patient’s name, age, and gender. We are transitioning to using TV screens for patient information and brief notes about their condition. We usually put the chief complaint on those screens.

Q. How are tasks distributed among the team?

A. It’s not really a top-down assignment where a person tells you exactly what to do. It’s more so the responsibility of the nurse assigned to that patient. The tasks appear in the computer system and if you’re in the area and see a task available, you’re expected to jump in and complete it.

Q. In terms of physical access, do you ever find yourself waiting for a terminal or computer?

A. We usually have at least six computers per pod, and sometimes up to ten laptops available for staff use. It’s shared between the doctors, nurses, and other staff, so we usually have enough stations to get our charting done.

Q. We’ve seen a lot of discussion around AI-assisted charting. Are you seeing doctors or other providers using integrated transcription tools yet?

A. I’m not entirely sure which specific tools they are using, but I do know that there are AI or transcription features integrated directly within the Epic system that they utilize occasionally.

Script 3 - Kate Motherway

Q: Why did you get into nursing?

A: I feel such a calling towards it, and this is genuinely what I was made to do. I just love it. The patient-centered care and the patient interactions are just fantastic. I love that I get to be on my feet all day. Every single day I wake up for clinicals really annoyed because I'm waking up at 5 AM, but then I get there and suddenly everything is fine. I end up having a great day and I wouldn't want to be anywhere else. It's pretty much just been awesome.

Q: Have you had past clinicals?

A: I had one day that was half NICU, half labor and delivery, and one day that was half labor and delivery, half postpartum. Those experiences were not as good as the experience I've had now, just because the vibe of the nurses on each floor can change a lot. On the neuro floor, all of the nurses are so open and welcoming. They're so excited to have extra hands, which you would think would be the norm because nursing is known to be a short-staffed job. But on labor and delivery and postpartum specifically, I just remember feeling so unwanted. They did not care about us being there, they didn't really let us do anything, and they would just sit in a circle and yap while we stood there. Those were literally only two days though. We've had a lot of sim lab days. I did one shadow day sophomore year on the cardiac floor and that was boring, but that was also because it was just a shadow so I didn't have any skills yet. The vibe of each floor can differ a lot just by the type of nurses that the specialty attracts.

Q: What do you like most about the neuro post-op stuff?

A: I feel like I've really gotten to know my patients. There have been a couple of days where I come back on a Thursday and the patient I had on Tuesday is still there, and I go check up on them and we totally bond. That helps me provide better care because you know the patient and they're comfortable with you. There are also just a ton of older patients because everyone gets a stroke when they're old, and I love my older patients so much. They're actually so fun. The other day, a lady said she was going to put me in her will. I was like, okay, she has dementia, that's not going to happen, but still. I took a gerontology class last semester and we learned about how in non-modern societies, back in the day, everyone had big families and they all lived in the same house their whole lives. Once people grew old, you would have someone to take care of you because things really do diminish as you age. But now people have a couple of kids, the kids move away and have their own busy lives because modern society requires us to be constantly on the go, and these older people just really get neglected. One of my patients fell and wasn't found for five days in her home, and she fell on a heater, so her pressure injuries were just insane. The sweetest little old lady. Things like that are heartbreaking. As a student, I only have one patient at a time instead of four like a normal nurse, so I can really spend my time with these people, get to know them, and give them the humanity they deserve. That's something I prefer over postpartum, where the mom just wants to be spending time with her new baby, which makes total sense. That's been my experience on neuro so far. I don't know if it's a specialty I'll go into, but for learning it's been a fantastic environment.

Q: When you're doing the one-on-one with just one patient, are you fully independent?

A: It depends. For med passes we need our clinical instructor there. But for any basic LNA skills, we can pretty much do it independently. A lot of the time I'll grab another nursing student and we'll do things together just because everyone likes to stay busy and nobody wants to be sitting around. I generally follow my nurse's care plan for the patient, but I can perform that care plan on my own.

Q: Do you ever deviate from the care plan, or do you stick to it pretty closely?

A: It's not like a strict care plan. It's just things like turn them every two hours, get vital signs every four hours. If I have nothing to do, I'll literally just walk around the unit and pop into my nurses' patients' rooms and ask if they need anything. Because I have more free time, I'm able to provide better one-on-one care, and that's something I'm trying to take advantage of as a student before I become an actual RN.

Q: Is there a specialty you're leaning more towards?

A: I've realized I really like cardiac, just from learning about it. But I've always felt a calling towards oncology. I really like forming connections with my patients and I like long-term care because you get to build those relationships. I'm actually applying to a program that UVM is offering for the first time where, instead of just being placed on a floor for med-surg clinical next semester, you're paired with an oncology nurse and follow their schedule on the oncology floor. I'm really excited to try that out. I've also taken a real interest in hospice and palliative care, because I've realized I really enjoy providing comfort measures and that's kind of what palliative care does. As for hospice, I think we as a Western society avoid the topic of death in a very destructive way, because it is inevitable for literally every person on earth. The more we confront and accept it, the better death we can have, because our bodies know how to die. We just resist it so much. No one should die in a hospital with ten tubes in them. People have better deaths when they're in their homes, surrounded by people they love, comfortably, even if it means they have two fewer months of living. I really prioritize quality of life over quantity. So those are my top three choices right now, but we'll see. The versatility in nursing is awesome. I even work in a pediatrician's office right now and that type of nursing is very different from what I'm doing in clinicals.

Q: How is it different?

A: I'm just a medical assistant there, so it's more like patients come in, you run labs, you see them for an hour. You do get to see patients multiple times, but it's just your average pediatrician visit. They're generally healthy and not completely reliant on you. I do firmly believe in the importance of preventative care and first-line measures, so I think it's really important work. It's just a little more boring because there's less hands-on stuff for me to do.

Q: Do they have a system for lining up preventative care when patients are being discharged?

A: They try to. It really depends on the barriers the patient has. Insurance is always a big problem. On our neuro floor, most patients go to rehab after a stroke because they have one-sided weakness and need to build that back up, so there's not as much discharge follow-up since they're going to another medical facility. But if a patient were being fully discharged home, you would educate on things like low-sodium diets and how to prevent clots from forming again. Diet, exercise, and preventative measures for modifiable risk factors are really important discharge education topics.

Q: What is your experience discharging patients?

A: Honestly, I haven't had a ton of experience with discharging patients. I've only had one discharge and it was to our stroke rehab facility. That only took a while because the transport bus took a while to arrive. So I don't feel like I can speak to that very much yet.

Q: What would you say is your main task during the day in clinical?

A: Mostly comfort care. It is a lot of basic hygiene, a lot of running and getting things for patients. Our main daily tasks are a head-to-toe assessment in the morning, vital signs, and increasingly med passes. A big one is getting patients up and out of bed since a lot of them aren't allowed out of bed alone, so I'm helping move them to their chair or to the bathroom or to a commode, or walking with them around the unit. Just basic activities of daily living that they can't fully perform on their own while in the hospital.

Q: Are they requesting things through a system, or are you just kind of around all day?

A: You're mostly just around. They have a call bell, and if they need something they'll press it. Then it's either you or the LNA who responds. LNAs are fantastic people and help with everything. I'm honestly doing more of an LNA job right now than a full-time nurse job, but I am also following my nurse around. She's more involved in the plan of care, medications, and communicating with doctors. I haven't messaged a doctor at all. The nurses talk to doctors a lot, get updates on how care is looking, things like that. But right now my job is mostly the hands-on, bedside stuff.

Q: Do you talk to doctors at all?

A: I haven't really. The nurses handle most of that communication, whenever they need a certain medication or have a question about a patient's care.

Q: How are your supply rooms?

A: Pretty good. They're a bit of a Where's Waldo situation sometimes, but once you learn where things are it gets easier. They're labeled, and the nurses are so helpful that if I can't find something I can just ask and they'll point me right to it since they've worked there for years and know it like the back of their hand. They're generally well-stocked. There have only been one or two times where a patient asked for something we didn't have.

Q: Have you found anything more challenging than you expected, or something frustrating throughout the day?

A: Today we were dealing with a rectal tube situation with a lot of bleeding and a lot of smell, and I'm also on day three of my period, so I got very nauseous. That was the first time I really tried to power through something and couldn't. I had to step out of the room or I was going to become another patient. Beyond that, I had a patient who was our age, a young person who had been in a really bad car accident and sustained a traumatic brain injury. That was just emotionally taxing. Their entire life changed in a matter of minutes, and they were processing that on top of the fact that their friend in the car had also died. I've talked to nurses and others about how empathy is so important as a nurse, but it's also so easy to lose, because it's really hard to be empathetic without bringing those cases home with you. That's honestly been my biggest struggle: maintaining the awareness that this is a full person with a past and a future and not just a patient in a case study, while also protecting my own mental health. If you take on every single patient's emotional weight, you're going to burn out very quickly. Finding that balance is going to be my biggest learning curve.

Q: Did they do any training for that?

A: Kind of. One project we have during clinical is that every week someone presents a self-care method they use and the whole group does it together. Today one of my friends said her self-care was cooking and she made guacamole for everyone. Mine was yoga, so I had everyone practice breathing techniques. Someone else was journaling, so we all wrote for ten minutes. I've really appreciated that aspect. I think it's also something that just comes with communication and time. I was talking with my clinical instructor about it today and she agreed that it's one of those things that just takes time.

Q: Do you know if they have any formal resources for that?

A: They do. Especially for codes or when a patient dies, they do debriefs. I haven't participated in a whole floor debrief because we haven't had any patients pass or code on our floor yet, knock on wood. But I've heard they can be ineffective sometimes, especially when it's very common. We had a sim lab last week where we ran code blues, and my professor who works on the cardiac floor said theirs are honestly pretty ineffective at this point because they have to do them so often. I think it depends a lot on the floor and the vibe of the staff. My clinical group is fantastic though, and I feel like we've debriefed really well.

Q: How long is your debrief? Do you do it right after clinical?

A: We have clinical from 7 to 2 and then we debrief for an hour, 2 to 3, and sometimes we go over because we just can't stop talking. Jackson is usually dead by that point and just wants to go to sleep. He's doing back-to-back clinicals, Thursday and Friday, and Thursday is eight hours and Friday is twelve hours. My clinical group gets along so well and I'm so grateful for it.

Q: What is your main network of communication when you're in the hospital?

A: I mostly communicate with my fellow nursing students, my nurse, and my clinical instructor. The nurses communicate more with the doctors, and then there's the rapid response team that covers the whole hospital. I'm on a bit of a lower level right now, so my communication circle is smaller.

Q: How big is your clinical group?

A: Seven people. I think eight is the max.

Q: Do you do any charting right now? What program do you use and what's your experience with it?

A: We use Epic. Everyone says it's super annoying and it is, but you kind of just get used to it. We chart everything, and especially because we're only assigned one patient at a time, they're very big on charting as much as you can because you have the time. It is a bit of busy work, but I've never really had a problem with it. A lot of the time there are pre-made answer options that make it go quickly.

Q: Why do you think people find it so annoying?

A: To be fair, I only have one patient I'm charting on right now. If I had four, I think I would be really annoyed. It also just takes so much time away from patient care. We were actually talking about that in our clinical debrief today. My clinical instructor was saying that yes, charting is very important and you need to do it because you might get sued at some point, but do not let it take away from your patient care. There are so many little things in nursing that take maybe ten to twenty minutes and are so important for the patient: a bed bath, getting them new sheets, combing their hair, getting them the food they actually like, talking with them. Little things that don't take up much time but are so meaningful. The thing is, then you have to chart on them after, so it takes double the time, and when you multiply that across four patients it's a lot. I can totally see how it takes away from actual care.

Q: How long would it take to chart something like a bath?

A: Charting a bath is not long, maybe not even five minutes. But it's one of those things that just adds up on your to-do list after a while. I do think they're important though, because I shower every day, so why shouldn't my patient get to?

Q: Roughly how many times do you think you chart in a day?

A: I have a decent amount of downtime most days where I'll just open the chart and add things, because you can never really overchart. The head-to-toe assessment takes the longest, maybe around ten minutes. Then there's the note at the end of the day, another ten minutes or so, and then charting vitals throughout the day. I'd say a total of thirty to forty-five minutes of actual charting, but that's just for one patient and I might be overestimating.

Q: Is there anything I haven't touched on that you think is super important to know about nursing?

A: I think the most important thing is something I get asked about a lot, which is why nursing and not medicine. People don't realize how different those positions are. Nurses are really at the center of patient care. They are the communication link between all of the providers, the pharmacy, the techs, and the LNAs, and they are face to face with the patient every single day. That's what's so important to acknowledge about nursing: how patient-centered it is, not just pathology-centered. There are also a lot of things within certain hospitals and the way they're run that can take away from that care or make it draining and lead to burnout, things like charting or other systemic issues. I obviously don't have a ton to complain about since I'm not a full nurse yet, but I do acknowledge that the way some hospitals operate can make it really difficult for nurses to actually do their job. Overall though, nursing is so patient-care-centered, and that's what I love about it.

Extra (Long) Script: Nakayla Figgins Transcript

Deniz Barmas - Raw notes from interview

making usre patients feel okay

comfort rounds

making sure people feel okay

passing meds

isolated meds

physical examination

changing
signs and symptoms

checking vitals

blood pressure

patient understanding

making sure they’re well

pediatrcs:

chronic

- advocate for them

- quality of life

- focus on illness rather than quality of life

hard to gauge clinical:

discharged fairly quickly

favorite: see so much

patient variability
never know who walks in the door
community of staff members
double check what you are doing

least favorite:

management of things
- failure to communicate changes between nurses
- not clear expectations on training
  - depending on where you’re going
- well-prepared to work on a unit
current system
- orientation/residency program
- work under a nurse to acclimate to setting
- gradually you ween you to independence

EPIC:

easy to use
- really labeled
- search through the things
difficult ot view previous results
- history
- at same things
- in terms of layout
- patient notes
  - in and out of hospital → better way to organize
  - filter by visit

outpatient experience:

complaining about wait time
yelling at them for during eye exam
miscommunication
- bad at having translators
- vast majority are spanish speakers
  - relying on family members
  - made it difficult for parents
    - frustration with inclusivity
well checks for kids

computer:

charting
take vitals
log in grab medication
- trouble
  - medication won’t come up
  - thinks there is a medication still on the unit
    - empty container
      - contact pharmacy to fill
        fill med supply room
        patient specific thing
        labeled with room number of A/B
        always double check with chart
        no name for privacy name

Supply Room:

a bunch of stuff thrown into the same place
things overflowing
no one restocking
- never seen anyone restocking
- call in to request restock
always difficult to try and find something
over-time get discombobulated
organization system
- things running out and no one say anything
- call and request
rural/underfunded:
- things being out of stock
  - PPE equipment

supply room: no badges
- specific/limited what’s in the room
supply room: badges
- kids can’t get in
standardized recommendation?

medication supply room: always badge
- sometimes in locked medication room
- sometimes just behind nurses station
  - higher risk population?

Communication:

depends on hospital
no response
hierarchy structure gets in the way
direct communication between individuals
EPIC used as means of communication
doctors and nurses: care plans
something going on with patient:
- call with provider
  - clear communication
charge nurse: direct communication
not listened to by physicians
- rude
- power dynamics can be difficult
nurse management
- hearing back from people

take longer than they should:

discharging patients
- waiting for paperwork
  - provider puts in order
  - nurse goes through print off hospital educational pamphlet with condition and medication
    - walk through with everything with patient
      - records are sent to new care facility
  - care manager and social workers help with that
  - help with picking up medication
- no time restraint on when they can leave
- doctors will do rounds in mornings
- getting order put in takes a while
  - main thing that causes to take a bit longer
- several hours
- getting them out the doors

bedside nursing:

standards for it overwhelmed
- working for 4-5 patients at a time
- each on 15 different medications
- balancing family
don’t have protected breaks
no safeguards to protect their wellness
- incredibly difficult to unionize at virginia
  - can’t have working environment
- advocating for it, developing contract, negotiations are very hard for new grad nurses
  - always be on night shift
    - carcinogen
- complaints → go to nurse manager and charge nurse
  - effectiveness not so sure
  - systemic based issue, not much they can do
- most have mental health resources
- mentally and emotionally draining
- dependent on facility
federally nurses don’t have protected lunch break
not taking good care of nurses
ratios are not safe or sustainable

Contextual Analysis

Raw context

pediatrcs:

chronic
advocate for them
quality of life
focus on illness rather than quality of life

like to see:

patient variability
never know who walks in the door
community of staff members
someone double checks what you are doing

management of things
- failure to communicate changes between nurses
- not clear expectations on training
  - depending on where you’re going
- well-prepared to work on a unit

current workflow uses manual status updates
- staff right-click patient names to change status (ready for nurse, being seen, ready for provider)

pressure to not interrupt the doctors because they are doctors

chaotic to know when teams are coming in and fit in nursing care between them

night shift complaints:
- 7pm-7am disrupts circadian rhythm severely
- hard to maintain social connections

A LOT of disdain shown towards supply rooms:

each supply room has a code you have to type and some have different codes on the same floor/unit
- have to memorize or ask if forgotten
very non-common sense organization
- diapers in one room, wipes in another
- all but one item in an IV kit in one room and the last one in another room
  - does not make sense
sometimes need to go to two or three different supply rooms on the unit to get what you need
no way to search what is in what

Work Activity Note

NS5.1 : Nursing Student wants to focus on giving patients a better quality of life

NS5.4 : Nursing student likes to see diverse patient list & never knowing who will walk in the door.

NS5.5 : Nursing student really likes the community of staff members

NS5.7 : Nursing student thinks there is poor management at times

NS5.8 : Nursing student finds that there are failures to communicate changes between nurses

NS5.9 : Nursing stduent thinks there isn't clear expectations on what you get out of training

N3.5: NP has to manually click for update changes

NS4.10: Nursing student notes pressures from nurse-doctor dynamics

NS4.9: Nursing student mentions that nursing care is often delayed by unexpected issues

N2.1 Nurse feels night shift disrupts sleep + circadian rhythm severely

N2.3 : Nurse's social life disrupted due to night shift hours

N2.6: Hospital supply room is very disorganized

N2.7: Hospital supply room has no searchable system - must memorize or constantly ask for stuff

The WAAD

Milestones:

Monday February 16: Start writing out Work Activity Notes - Continued into Tuesday, February 17.

Wednesday February 18: Finish Work Activity Notes and create Work Activity Diagram

Working:

Final WAAD:

Explanation:

The building of the WAAD took two sessions. In the first session, we split up the interviews among group members and all wrote work activity notes for all seven interviewees. For session two, we formed the work activity affinity diagram. We started by laying out all of the sticky notes face up on the table and took turns reading Post-Its. When one was read aloud, we discuss connections, possible reoccurring themes, and what lessons we can take away from the notes. Pretty early on, there were some larger themes popping out to us like communication, Epic software, and patient-care; categories that remained until the very end.

One large take away found towards the end was the importance or the recurring theme of connection and empathy amongst nurses themselves, co-workers, patients, or patient families. We decided to put all of these different subcategories under the larger category "Pathos" because we thought that nurses really cared for their emotions and the emotions of others and building up healthy connections around them. Many interviewees expressed a preference for longer term care and the importance of empathy. Because so many notes touched on empathy and emotion independent of connection, we thought "Pathos" was a more fitting name than "connection".

Another large category uncovered during the WAAD was the importance of communication. As discussed earlier, charting and documentation is a large part of nurses' work practice and is done for communication reasons, either for your future self, coworkers, or the patient themself. Additionally, many nurses brought up other forms of communication, either face-to-face or technologically through devices like Vocera or pagers or hospital-provided telephones. It is extremely important for information in the hospital to be efficient and accurate; with so many different individuals playing a hand in a singular patient's care, there are a lot of places where information can get lost, not received, or simply forgotten.

Rationale for Groupings:

At the highest level, the system is called "Hospital Setting" due to the fact that the group is focusing on in-patient-care, which is done in a hospital.

Below this are four categories:

Communication: high-level category explained above. The subcategories include:
1. General Communication: This category is organized in terms of "General", "Pros", and "Cons", since there was both a lot of negative feedback on the current communication system that is not done with charting and some that simply laid out what the current practice is with little to no emotional tone.
2. Charting/Documentation: We quickly decided this was an important category due to the sheer number of notes related to the topic.
  1. Epic More than half of the charting/documentation notes relate to and mention Epic in some form.
    1. PROS/CONS/GENERAL: Since Epic has so many notes under it, having it split into these three subcategories helps better understand why individuals are mentioning it.
Pathos: high-level category explained above. The subcategories include:
1. Healthcare provider wellbeing: Many individuals mentioned the negative health effects that nursing can have and since we are trying to increase the quality of the workplace, that includes their health.
2. Hospital role dynamics: Since there is so much information exchange by word of mouth, there are lot of workplace dynamics between nurses, charge nurses, and doctors and there are many pain points within these connections that could be addressed.
3. Patient-Nurse connection: Nurses especially stressed the importance of connecting with the patient, but also not having the time to connect. The gap between the current a desired patient-nurse connection seemed very large by interviewees.
4. Empathy: Many interviewees find empathy one of the most important traits to have while working, but it can also strain their mental health if not balanced correctly. Trying to take care of the nurses health should be noted and taken into consideration.
Concerns: There were many concerns in different parts of the hospital and believe these should be combined into one larger category that encapsulates all of the concerns on the hospital floor that do not fit into the other categories listed due to the fact that there might be overlap or reoccurring themes across concern categories like organization, time management, etc. The subcategories include:
1. Supply Room Concerns: For many of the nurses interviewed, they expressed varying distaste for this room. Since there was never any positive attributes mentioned, we thought it appropriate to group these notes together due to the emotion shown towards it.
2. Management Concerns: management expressed to cause a lot of issues, but not as pressing as others.
3. Patient Care Concerns: The safety and happiness of the patient can sometimes be curbed by paperwork, short staffing, etc. Since we are trying to increase the quality of patient care nurses can give healthily and effectively, this is a very important concern.
4. General Concerns
5. Legal Liability Concerns: multiple nurses quoted "if you didn't chart it, you didn't do it" in terms of legal situations, so we thought it important due to the frequency the issue came up.
Workflow:
1. Preferences: Taking into account nurses personal preferences is important to understanding the diversity and overlap between varying individuals of different backgrounds.
2. Procedure: These gave a direct look at the specific work practice in the hospital. This was split up into "Cons" and "General"; the fact that there were no positives with the procedures highlighted the need for the group.

Specifics of Final WAAD:

It takes a minute to load, but all post-it notes should be clear enough to read. If it, please use this link.

Work Roles:

Nurse: These are the primary actors in providing care. Regardless of Nursing level, this role interacts the most with the patients. They are the main source of emotional care to patients
Doctor: These play a key role in advising and directing Nurse roles on care instructions; they are vital to giving personalized physiological care plans to nurses for patients

Machine Roles:

Epic: The biggest software used to track, plan, and communicate care between providers. Can create custom plans based on medication and now implements AI to help nurses chart.
Pagers: Helps healthcare workers communicate with each other about patient status, changes in plans, etc. Communication is cental to the functioning of the hospital
Vitals Machine: This is key to giving nurses and doctors a readable and understandable metric of different components like heart rate, oxygen saturation, blood pressure, etc. Sends real time updates, alerts based on the demographics of the patient, and can automatically record data.

Flow Model:

Requirements

We analyzed our final WAAD and translated any relevant work activity notes into design requirements. We paid special attention to the concerns our interviewees laid out during our talk with them. We identified those work activity notes from recognizing language that pertains to personal experience, such as "X feels Y during Z" or "X thinks this about Y." These pain points experienced during their work hours are linked to problems that our project could potentially solve. We also paid attention to specific preferences about work procedure. For example, if a nurse preferred to use one technology over the other, we would examine why those preferences exist. We'd then use what we found to serve as potential extra features for our project. Per the instructions, we used a tabular format to organize our design interaction requirements. We based the 'WAAD ID' on the labeled WAAD hierarchy, as specified on the instructions to maintain a consistent connection between it and our table. We also included prioritization levels, which further helped set the foundation for our envisioned work practice.

Link to the requirements table in case there is any trouble accessing the table below.

Modeling

Flow Model - Existing Work Practice:

Depicting our existing work practice as a flow model was useful because it made clear the activities and procedures that occur in an ICU unit. Building the model forced us to map the full chain of events that occur as a nurse attends to a patient: bedside monitors/ventilators/pumps generate an audible alarm and an alarm message, which may also route to a central monitoring station and sometimes to a pager/phone alert. From there, the primary nurse decides what to do next - assessing and intervening at the bedside, documenting in the EHR, and escalating to other roles (MD/APP for critical events and respiratory therapy for ventilator/respiratory issues). Showing those handoffs alongside documentation helped clarify how clinical work is split across people and systems.

What we learned most from creating the model is where the pain points of the current practice occurs. The model highlights that many bedside alarms are high-volume and not actionable, which contributes to alarm fatigue and increases the risk that important alarms are missed or delayed. It also shows how false alarms or poor signal quality can waste time and attention, because the nurse still has to investigate before knowing whether anything is truly wrong. Finally, mapping the communication paths (pager/phone alerts, calls/texts, and verbal coordination) revealed a common coordination problem: ownership can become unclear, leading to duplicated responses or gaps where everyone assumes someone else is handling it. Overall, the model helped us move from a vague sense of problems that occur within an ICU unit to a clear understanding of where information is lost, when decisions are made, and which interactions create extra work or risk in the current workflow.

Flow Model - Envisioned Work Practice:

Depicting the Envisioned Work Practice as a flow model helped in this case to show how the NTW works as a centralized coordination hub that integrates people, systems, and information flows across the hospital floor. In this model, providers enter orders in EPIC, which automatically populate task lists and patient status blocks on the NTW, reducing manual updates and missed charting. Pharmacists check medications and refill Pyxis, with medication availability syncing to the NTW so nurses can view real-time status and receive reminders for med-pass. Patient vitals and call-button alerts feed directly into the NTW, where notifications are graphically displayed and prioritized; if unacknowledged, they roll to the change nurse and can trigger silence haptic pager notifications to reduce alarm fatigue. Nurses use the NTW to monitor patient status, locate supplies through live inventory data, and coordinate responses without relying on fragmented tools like pagers and verbal handoffs.

Through this mapping of the structured flows the model illustrates how the centralization of alerts, documentation prompts, and resource visibility reduces cognitive load, clarifies task ownership, and enhance communication across roles while maintaining integration with existing systems rather than replacing them.

Social Model

We decided to use the social model as the third model and it was developed to capture the psychological aspects of the hospital ward in order to move beyond just roles to visualize the internal and external pressures that share how care is delivered across the entire hospital. It worked really well since Pathos is literally one of our WAAD subcategories. In this model, the Nursing Staff and Clinical Staff are situated as core human nodes, whose work is constantly influenced by other entities like EHRs (Epic), the Hospital Supply Room, and a high-stress Ambiance.

The model uses "thought bubbles" to represent the firsthand concerns of the nurses and specifically the fear of liability regarding charting and the emotional conflict of balancing empathy with alarm fatigue and developing a patient nurse connection. Influences are mapped using directed arcs, such as the "Mandatory Documentation" pressure from policy domains and the "Advocacy" influence nurses share on patients.

Unlike a Flow Model, the Social Model allows us to visualize the "always-on" nature of the role and the overload that affects all types of healthcare providers, which is the core problem our system aims to solve. The Social Model is the only textbook model that explicitly captures these emotional facets of work practice. And by validating barriers, it allowed us to map the "Interpersonal Dynamics" breakdown using lighting bolts between nurses and doctors.

Phase02a Checkpoint

Pandas - Phase02a Checkpoint

Document Link: https://docs.google.com/document/d/1Y9W3LJcpGKb45rnLhkOAjSvB0oHz6w36WHDu5J-eCps/edit?usp=sharing

Your initial discussion with Rafiq Zaib, or any impediments in getting in touch with them:

Reached out to our client Rafiq Zaib, an active medical resident, to gain insight into communication workflow in a clinical environment. There were no major impediments in getting in touch with clients.

Discussion Notes:

As of right now the best method is using the patients chart to directly communicate between nurses and other providers. It keeps everyone on the same page and the patient chart is easily accessible.

Other hospitals use pagers that can either be a number they have to call or room they have to meet in or the pager might be a phone type these are less advantageous bc you don’t have access to patient info immediately the first couple sentences are usually confirming who the patient is and what room number they have (and they sometimes get those wrong/mixed up)

Secondly the phone pagers lose service constantly unless you’re in an area that has service like hallway or room you’ll be fine but in staircases or elevators they often get the call cut and disrupts workflow. Recently what’s become big is patients accessing their charts virtually and talking to drs directly. Nurses are also supposed to reach out to our patients and tell them what their results are on this online thing whenever we get the results back.

Discussion with Jackson Suess (Client #2) - Explicitly state the work activities, the work practice, and the work domain (or questions you have about them):

Work domain: Hospital Environment

Work activities (specific steps that are taken to perform and complete the work practices):

Knocking on door before entering
Asking for patient’s name and date of birth every time you enter the room
Hand sanitizing each time you enter the room
Charting unusual notes

Work practice (general steps that work roles take):

Taking vitals
Bathing
Medications
IV
Dressing wounds
Limited emotional support

The identified work roles and user classes for your users-interviewees (who will you interview and why?)

Work roles:

Nurses:
- Nurses are the primary caretakers of patients and need to be constantly aware of a patient’s stability
Doctors
- Doctors respond to patients on a higher level and manage nurses and patients

User classes:

Nurses
- PICU Nurse
  - Experienced in what ICU care looks like for children
- Cardio ICU Nurse
  - Shows how the ICU runs when patients are heart-critical
- Nursing Student
  - Experienced in general nursing practices for beginner nurses
- Nurse Scientist
  - Knowledgeable about what nursing practices are proven and what data to track
- Clinical Instructor of Nursing/Other Nursing Instructors
  - Knowledgeable about how ICU skills are taught and where beginners make mistakes

Doctors
- General Doctors

The number of interviews you took and any planned interviews remaining; the distribution of interviewees by work role/user class.

So far only one initial interview was held with one client. Future interviews are planned to be held with a variety of clients with different work roles in order to get a fleshed out understanding into the communication workflow for all roles. We are currently reaching out to UVA nurses, doctors, researchers, etc. to try and observe in the field.

We are attempting to get access to the nursing simulation room to have hands on access and more time to get a full idea of the space nurses are in the most.

Contacts Status: https://docs.google.com/spreadsheets/d/1_1bFLI3cSPLrp_vAC9LxMiZdmKeNh36EHNx3g4hb4mU/edit?usp=sharing

General Interview Questions

What type of work do you do?
Walk me through how a routine patient check is?
What are common gripes you have with the current communication workflow?

Opening/Context Setting

Can you walk me through what a typical shift looks like for you from start to finish?
What unit or specialty do you work in, and how long have you been in this role?

Core Activities & Workflow

What are the main tasks you're responsible for during your shift?
How do you prioritize when multiple things need your attention at once?
Can you describe how you coordinate with doctors, other nurses, and support staff throughout the day?
What information do you need to access most frequently, and where do you get it?

Tools & Technology

What systems, tools, or technologies do you use regularly in your work?
Which of these work well for you, and which create friction or slow you down?
How much of your time would you estimate is spent on documentation versus direct patient care?

Challenges & Pain Points

What are the most frustrating or challenging aspects of your daily work?
Can you give me a specific example of a recent situation that was particularly difficult or time-consuming?
What tasks feel like they take longer than they should?
If you could change one thing about how you work or the tools you use, what would it be?

Closing

Is there anything important about your work that we haven't covered?
What do you wish people designing healthcare systems or tools to better understand nursing work?

Page updated

Google Sites

Report abuse