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The neonatal intensive care unit (NICU) is both a high-technology and high-touch environment where technology and human caring are delivered in sync. As we ring in the New Year with a fresh resolve to transform practice and improve neonatal outcomes, this first issue of 2023 highlights many nurse-designed and -innovated improvements. Articles in this issue spread the gamut from targeting safe sleep, pain control with sucrose, ultrasound-guided line placement, inadvertent delivery changes of lipid infusions, standardized surgical wound assessment, and more concept-based foci on equity, care coordination, and more. Across these articles, the purpose of Advances in Neonatal Care (ANC) is clear:
ANC provide content that supports a foundation and direction for neonatal nurses in Increased Awareness, Education/Professional Development, Setting the Standard of Care, and Leadership, as well as the basis for an interface to the greater Community that supports neonatal intensive care.1(p189)
Each author in this issue of ANC started with a problem and innovated a solution. The purpose of this editorial is to inspire you to share your own nurse-led improvements to provide a perspective on nursing's unique clinical expertise in designing technology or system changes.
Nursing, as a profession, provides a unique perspective to design teams developing technologies in healthcare. However, nurses are not always included in the design process, or their input is undervalued. We are not “just nurses” but rather highly educated, experienced professional leaders who have expert knowledge about our respective workflows and environments. Nurses are natural innovators. If a work process doesn't work for us, we will find a way to make it work—which some may call “disruption.” The solution is to have nurses “at the table” to assist with designing technologies if not there will be others making the decisions for us. Nurse-informed technologies will lead to better products and more importantly optimal outcomes for our tiny patients.
Solutions to problems often present through introduction of a new technology. Technology is broadly defined as an informational exchange using an electronic environment to solve a problem and thus expanding our human capacity.2 The emergence of technologies, though advantageous, finds nurses in a dilemma between learning a new technology and incorporating it into an already busy workflow. Nursing workflows consist of collecting and analyzing data and then making decisions based on the obtained information. Technological tools are commonly implemented before they are ready for the specialized environment of the NICU. Meaning it is often left to the user to figure out the bugs to either fix the technology or avoid it altogether, creating mistrust. The implementation of the electronic health record is an example of a technology that was launched before it was ready to be used efficiently in the NICU. We all can relate to needed neonatal-specific customizations to documentation that simply were not done (eg, time of last bath, incubator servo mode/set temperature). Nurses had the choice to either document information elsewhere or not at all. The electronic health record was designed more for auditing care than delivering care. Consequently, there were problems with retrieving information that presented risks to patient safety. In contrast, there are also times when users are so dependent on a technology that inconsistent information is not realized. Remember, technology is a tool and not a substitute for your critical thinking skills and clinical expertise.
Unfortunately, the technology that was intended to make our workflows more efficient can end up disrupting or increasing work.3 Inherently, all technology initially increases workflow. However, workflow disruption is mitigated by incorporating users (eg, neonatal nurses) at the design phase of the technology.4 If nurses find value to a technology, it is adopted quickly. However, when technology disrupts their workflow, adoption may be slow or even result in work-arounds.5 Work-arounds are when the technology is used in a matter that it was never intended and can threaten patient safety, although one study showed that when NICU nurses used work-arounds, they were often to benefit the patients.3
When designing for improvement, workflow impacts must be considered, and designs should fully leverage the clinical wisdom of nurses and other clinicians who are directly affected by the change. Hoover6 recommends design thinking be paired with a human-centered design process, which aims to be useful to the users (see Figure 1 for design process). Steps in the design thinking process then starts with empathizing with a group of people and the problem that they are trying to solve, in this case—the healthcare team, the nurse, the parents, and perhaps other organizational or sociopolitical stakeholders. Next, the problem is framed through defining it. In human-centered design at this stage, stakeholders are engaged to coalesce the group around a clear, shared problem. Next, the group moves to step 3, which is to “ideate” where they brainstorm creatively different solutions (defined as a service, process, or product that may or may not be technology-based) to solve the problem. The fourth step is to prototype the solution. Eventually, it would proceed to a “build” stage where the new process or product is developed enough to be tested with a group. This doesn't mean it has to be completely perfect, because at the fifth step—testing—the solution will be evaluated. When problems are noted, they can be fixed before the final product is refined and implemented. From a human-centered design perspective, testing also enables the team to show that the solution helps to meet a goal of the users, is useful, and doesn't induce harmful unintended consequences.
FIGURE 1: Design thinking situated within Human-centered Design.
Design can start as simply as with storyboarding, marking out what the change is, who it involves, and what impacts it will have and forecasting potential positive and negative outcomes. Next steps involve creating case scenarios where the identified change is implemented and asking direct care clinicians to give feedback on how they think they would implement or use what is being suggested. Then, a pilot can be conducted where the new process or technology is tried out for a specific period of time. Feedback should be elicited and analyzed and then incorporated into a next-stage pilot. Finally, after at least 2 trial cycles, the change can be incorporated at the unit level. The key is to enable feedback to inform future improvements in the process or technology. When deciding about purchasing a new technology for a unit, these steps can be walked through during trial phases before the decision to purchase is made. In large systems, where procurement is handled separately from the direct clinical team, extra efforts will need to be made to illicit different perspectives about the usefulness and impact of the technology within these specialized environments.
In summary, we applaud the authors in this issue who courageously innovated change. We hope that their experiences inspire others to move to action and to solve other NICU problems. Start with an optimistic belief that change is possible, engage your team with empathy to define the problem you will solve, and do the next good thing to move to action and improve neonatal intensive care. This attitude could also assist nurses who are finding problems with technologies or other “solutions” that have been adopted in their NICU and help them to define the challenge, engage stakeholders, and move to ideating options to improve their experience with the “solution.” That may mean modifying it, retesting it, or perhaps abandoning it. Expecting developers to engage our input to ideate, prototype, and test is not too much to ask when we all have the same goal—better care and best possible outcomes for our most fragile customers.
—Katherine M. Dudding, PhD, RN, RNC-NIC, CNE
Assistant Professor
The University of Alabama Birmingham
[email protected]
—Sheila M. Gephart, PhD, RN, FAAN
Professor Interim Chair Biobehavioral Health Sciences
Division, University of Arizona College of Nursing
[email protected]
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