A Cognitive Task Analysis of the NICU uncovered examples of the following timing issues:

• Sequences, e.g. check baby’s airways, breathing then circulation (ABC);
• Delays, e.g., wait to check alarm is real before responding;
• Delayed Feedback, e.g., after changing the ventilator settings there is a 2-3 minute delay before change in blood gases become apparent
• Trends, e.g., improving state of blood gases should start to be visible 2-3 minutes after changes are made to ventilator settings;
• Temporal validity, e.g., manual blood gas data is only valid for 20-30 minutes;
• Deadlines, e.g., self-imposed deadlines for detecting improvement in baby’s condition;
• Pacing, e.g., taking observations on the hour boundary;
• Other, e.g., the inspiration and expiration time can be controlled for breaths delivered by the ventilator
The collaboration issues that were identified were:
• Organisational structure, e.g., the hierarchy inherent in communication and decision making
• Formal verbal communication, e.g., the daily ward round which implements the formal handover between the night shift and the day shift;
• Informal verbal communication, e.g., separate informal shift handovers for the nurses and the SHOs;
• Formal non-verbal communication, e.g., the extensive use of records in the NICU by all staff.

The implications of these findings can be summarised in two key aspects that should help to ensure that FLORENCE does not make the system of neonatal intensive care less dependable. The first lies in the education of the front line carers. During the SHOs induction training, the role and purpose of FLORENCE needs to be very clearly explained so that they know how FLORENCE integrates with the other aspects of their work. The second is the monitoring of the use of FLORENCE. As part of the checking of the progress of the SHOs, senior staff will need to monitor the usage of FLORENCE to make sure that front line carers do not become too trusting or over-reliant on FLORENCE. This will necessarily include checking how much SHOs are learning from communicating and collaborating with other staff. The process of monitoring the use of FLORENCE will therefore need to be an ongoing one.

Author: Gordon Baxter