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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
Providing healthcare professionals with cognitive aids, whether a simple checklist or an information system, improves patient care and reduces information-processing constraints for caregivers. However, to achieve these objectives, these aids must be adaptable and ergonomic.
Cognitive Aids to Support Healthcare Professionals offers an unprecedented presentation of the different forms of cognitive aids, as well as an analysis of these aids as gateways for channelling resources to support mental activity and a general framework to simply model cognitive aids as Turing machines.
Throughout this book, healthcare professionals, executives, hospital managers, healthcare engineers, ergonomists and trainers will find ergonomic advice on the choice or design of cognitive aids, and also, more generally, on the roles that cognitive aids play in activities.
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Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Foreword
Acknowledgments
Introduction
PART 1: Cognitive Aid as a Gateway
Introduction to Part 1
1 Defining a Cognitive Aid
1.1. Cognitive aid as a support device for mental activity
1.2. Cognitive aid defined as an instrument
1.3. Gateway function
2 Cognitive Aid: A Gateway Between the Individual and their Environment
2.1. The cognitive system: knowledge in the head and in the environment
2.2. Cognitive aid as a psychological instrument
2.3. Conclusion
3 Routing Analytical Thinking to Support Intuition
3.1. Intuitive thinking: vulnerable thinking
3.2. The power of analytical thinking
3.3. Formal logic to elucidate reasoning
3.4. Conclusion
4 Routing Intuitive Thinking to Support Analysis
4.1. The vulnerability of analytical thinking
4.2. The power of intuitive thinking
4.3. Slowness and risks in accessing intuitive resources unaided
4.4. Access to intuition thanks to cognitive aids
4.5. Conclusion
5 Routing Prescribed Tasks to Support the Actual Activity
5.1. Guidelines from domain experts
5.2. Instructions from hospital managers
5.3. Care: a system with tight coupling
5.4. Conclusion
PART 2: Cognitive Aid as a Turing Machine
Introduction to Part 2
6 Analyzing the Work Domain to Design a Tape
6.1. An ecological interface for supervising an emergency service department
6.2. The techniques of work domain analysis
6.3. Conclusion
7 Task Analysis for Designing a Network of States
7.1. Task analysis techniques
7.2. Designing a fast and frugal tree
7.3. Designing a communication protocol
7.4. Designing the operation procedure for using a cognitive aid
7.5. Conclusion
Conclusion
References
Index
Other titles from iSTE in Health Engineering and Society
End User License Agreement
List of Tables
Chapter 1
Table 1.1. Study by Dryver et al. (2021): median percentage of interventions p...
Chapter 2
Table 2.1. Criteria for evaluating the qualities of a cognitive aid in terms o...
Chapter 3
Table 3.1. Observed rhythms during simulated resuscitation, with or without sp...
Table 3.2. Examples of questions to stimulate critical thinking among nursing ...
Chapter 5
Table 5.1. Essential components for refining guidelines, according to the Guid...
Introduction to Part 2
Table I2.1. Gateways and design choices for rather exhaustive or selective inf...
Chapter 6
Table 6.1. Abstraction hierarchy describing the diagnosis of abdominal pain. T...
Table 6.2. Comparative illustration of three documentary supports based on pre...
Chapter 7
Table 7.1. List of communication recommendations during patient management in ...
Table 7.2. Summary of elements for designing a cognitive aid based on the Turi...
Conclusion
Table C.1. Steps for designing a checklist (from Hales et al. (2008))
List of Illustrations
Chapter 1
Figure 1.1. Simplified double-scale decision model (adapted from Rasmussen (19...
Figure 1.2. Surgical Safety Checklist proposed by the World Health Organizatio...
Figure 1.3. Cognitive aid in the pocket of a medical resident in an emergency ...
Figure 1.4. Cognitive aid in the pocket of a senior physician in an emergency ...
Chapter 2
Figure 2.1. Cognitive aid as a bidirectional gateway between the individual an...
Figure 2.2. Cognitive aids: subset of psychological instruments and instrument...
Figure 2.3. The vortex analogy to describe the progression in the oxygenation ...
Figure 2.4. Screenshot of the “DansMaBlouse” application. Reproduced with perm...
Chapter 3
Figure 3.1. Resources of analytical thinking (system 2) are brought to intuiti...
Figure 3.2. Graphical representation of the risk of death following surgery
Figure 3.3. MOHer-Lyer’s perceptual illusion
Figure 3.4. Transition from intuitive to analytical perception with the assist...
Figure 3.5. Cognitive gateways facilitating access to analytical thinking from...
Chapter 4
Figure 4.1. Intuitive resources (system 1) that are brought to analytical thin...
Figure 4.2. Klein’s recognition-primed decision model applied to nurses decisi...
Figure 4.3. Cognitive gateways facilitating intuitive thinking from a Hst of i...
Figure 4.4. Facilitating affordances for identifying laryngoscopes (direct per...
Figure 4.5. Simulated intubation on a mannequin during parabolic flight (micro...
Chapter 5
Figure 5.1. Prescribers (hospital executives, domain experts) can transmit tas...
Figure 5.2. Guidelines integrated into dedicated cognitive aids for various st...
Figure 5.3. Use of a large touchscreen displaying instructions during a traini...
Figure 5.4. A direct coupling between the expected tasks (directives, protocol...
Figure 5.5. Operation of a loosely coupled system equipped with shock absorber...
Figure 5.6. Example of a “1st contact” sheet used during the activity (Morinea...
Figure 5.7. The buffer functions of the “1st contact” sheet between patient re...
Introduction to Part 2
Figure I2.1. A Turing machine, which simpHstically delineates the process of r...
Figure I2.2. Example of instructions for a Turing machine that writes symbol S...
Chapter 6
Figure 6.1. The tape of a Turing machine
Figure 6.2. An old “scroll-out” checklist with two joysticks, aboard US milita...
Figure 6.3. Representation of an abstraction hierarchy (rows) and an aggregati...
Figure 6.4. Network of relationships within the abstraction hierarchy for “abd...
Figure 6.5. Turing machine modeling of the search for clues to conduct an ABCD...
Figure 6.6. Table for depositing “patient” files at the emergency reception, b...
Figure 6.7. Table for depositing “patient” files at the emergency reception, a...
Figure 6.8. Turing machine modeling file processing with a file queue, before ...
Figure 6.9. Turing machine modeling the processing of files with two file queu...
Figure 6.10. Main elements that should compose a cognitive aid according to th...
Chapter 7
Figure 7.1. The state transition network of a Turing machine agent
Figure 7.2. An example of interpretable cognitive aid as a state network of a ...
Figure 7.3. The HTA method for modeling task achievement in goals, sub-goals a...
Figure 7.4. Matrix for pairwise comparison of variables in refugee care. “A > ...
Figure 7.5. Fast and frugal tree for the psychological care ofrefugees by the ...
Figure 7.6. The short communication Ioop ensuring the reliability of an oral m...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
Foreword
Acknowledgments
Introduction
Begin Reading
Conclusion
References
Index
Other titles from iSTE in Health Engineering and Society
WILEY END USER LICENSE AGREEMENT
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Health and Patients Set
coordinated byBruno Salgues
Volume 5
Cognitive Aids to Support Health Professionals
Thierry Morineau
Foreword by Dr. Morgan Jaffrelot
First published 2024 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms and licenses issued by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at the undermentioned address:
ISTE Ltd27-37 St George’s RoadLondon SW19 4EUUK
www.iste.co.uk
John Wiley & Sons, Inc.111 River StreetHoboken, NJ 07030USA
www.wiley.com
© ISTE Ltd 2024The rights of Thierry Morineau to be identified as the author of this work have been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.
Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s), contributor(s) or editor(s) and do not necessarily reflect the views of ISTE Group.
Library of Congress Control Number: 2024937865
British Library Cataloguing-in-Publication DataA CIP record for this book is available from the British LibraryISBN 978-1-78630-954-9
Foreword
We might have assumed that beyond the surgical checklist, the notion of cognitive assistance would lead us far from our caregiving concerns. However, Thierry Morineau, a (deeply) engaged professor of ergonomics, both in the academic curriculum of health science students and in the daily routines of healthcare providers, elucidates in this volume the significance of cognitive aids within the healthcare domain. This book will provide insights for healthcare professionals in their daily practice. Furthermore, it will enlighten managers, be they administrative or caregiving. Ultimately, it is poised to assist health science educators in raising awareness among healthcare providers about the intricate interplay between individuals and their surroundings throughout both initial training and ongoing education programs. Through the diverse perspectives offered in this book, and depending on their stance towards care contexts, readers can discover “psychological instruments” (to take one of the concepts presented) to contemplate the multifaceted aspects of cognitive aids.
Healthcare professional
The healthcare provider will be capable of assessing both the vulnerability and the resilience of their reasoning in a given situation. Implicit within the text, we comprehend the fragility of an individual’s reasoning at times and the imperative to assist them in maintaining accurate perception of the situation and in decision-making. Presently, there is scant emphasis in healthcare provider curricula on explaining cognitive vulnerability. Implicitly, the culture of “zero tolerance” for errors still prevails. Teaching clinical reasoning, including its vulnerabilities and biases, is now an essential requirement (Pelaccia 2016a; Audétat et al. 2017).
Confronted with this acknowledged vulnerability, the concept of “cognitive aid” must carve out a role within the action process. Analogous to a pilot facing a critical situation, such as an engine fire, who necessarily engages in automatic actions followed by written checks before relying on a to-do list, healthcare providers should be able to reference a notebook in critical scenarios without being suspected of incompetence. Regrettably, ingrained habits prove challenging to alter, and the management of risk and error in the healthcare domain is still nascent. Encouragingly, this cultural shift can occur organically within teams, on the ground, fostering awareness of underlying issues, devising novel workflows and integrating cognitive aids into their practice. Consequently, the team can serve as a cognitive aid unto itself for healthcare providers (Kahneman et al. 2021).
Manager
In hospital management, a critical misunderstanding revolves around the role ascribed to service protocols and procedural documents. Their functions, as well as those of data collection sheets, often harbor ambiguity and consequently are poorly grasped by healthcare providers. Regrettably, these documents are frequently viewed solely through the lens of activity tracking, overlooking their potential to assist professionals in avoiding errors during cognitive overload. “Protocols remain tucked away in binders while monitoring sheets serve merely to trace healthcare providers”. Such critical disparities between what is prescribed and what is actually implemented may stem from protocols that are challenging to understand and ill-suited to the real-life contexts of healthcare providers’ work. Therefore, there is a need to design user-friendly documents that actively support action. To achieve this goal, Thierry Morineau proposes a co-design approach involving future users, aiming to initiate a gradual process of appropriation.
Teacher
Contemporary trends in pedagogy underscore the significance of developing contextualized teaching methodologies to facilitate the transfer of learning (Vanpee et al. 2009). In this regard, teacher training cannot overlook an understanding of ergonomics. It involves drawing insights from this discipline to analyze and characterize professional scenarios based on work analysis methods. Prioritizing the identification of key contextual elements within which actions are performed will enable the prioritization of those elements that need to be taught (didactic translation). This, in turn, requires implementing a pedagogical transposition to organize teaching, learning and assessment activities effectively (Parent and Jouquan 2013).
The cognitive analysis of work, as presented in the book through the TMTA (Turing Machine Task Analysis) method, enables the identification of key information involved in triggering knowledge schemas or heuristics.
This approach is particularly relevant for educators engaged in health simulation development, providing valuable insights for enhancing scenario design. Indeed, the analysis of activity (whether prior to or provoked during debriefing) allows us to transcend the apparent realism and similarity of a simulated (reconstructed) situation, aiding in a deeper understanding of its authenticity from the learners’ perspective. Understanding the challenges involved in solving a healthcare problem may lead to identifying vulnerabilities that could be mitigated through cognitive assistance. Considering the role of external cognition in reasoning does not mean losing sight of internal cognition; rather, it involves integrating it into the broader cognitive system that emerges from the interaction between individuals and their environment. This facilitates the development of a dynamic appropriation of procedural, conditional and declarative knowledge.
Cognitive aid as a Turing machine
However, how can we conceptualize a cognitive aid that provides the necessary and sufficient information to progress through a protocol and meet the support needs of users in context? By depicting a cognitive aid like a Turing machine, the second part of the book offers concrete proposals by characterizing:
a working document like a Turing machine tape that is read by an agent to find information supporting their activity;
a network of mental states to navigate through to ensure adherence to a protocol or work procedure.
Cognitive aids range from very simple to highly sophisticated information systems. The Turing machine model serves to unify all of these systems, enabling them to be understood as genuine cognitive aids in a given situation.
Keywords…
Another point of entry into the book could be through keywords.Indeed, aside from certain professions (such as occupationaltherapists, psychomotor therapists, physiotherapists) whereergonomics (especially physical) is taught, ergonomics (especially cognitive) remains a discipline that is rarely emphasized in health science studies. Yet, today, concepts and issues such as human factors, contextualized teaching and learning, mental load, the need for cognitive gateways,the relevance of cognitive aids, the degree of coupling between the healthcare provider and the situation, modes of analytical and intuitive thinking, work analysis, gaps between prescribed tasks and real activity, the awareness of internal cognition, as well as cognition inscribed within the working environment, are integral components of a health professional’s daily environment.
This book as a gateway
So, how to use this book. For some, it serves as an introduction to ergonomics, while for others, it functions as a compendium of experiments and studies aimed at illustrating methods for designing, testing and using cognitive aids.
As an educator, I can only express gratitude to Thierry Morineau for his significant contribution to the healthcare provider community. Through his exploration, he forges a link between ergonomics and healthcare. Consequently, this book prompts numerous questions that emerge upon reading: How can students be trained in the use of cognitive aids? What role should these aids play in health sciences curricula? Answers to these questions unfold through the pages of this indispensable resource, serving as both a cornerstone in the field and a catalyst for creativity.
Morgan JAFFRELOT
Emergency Physician
Associate Professor in the Department of Anesthesiology and Intensive Care
Université Laval, Quebec
Teaching Assistant in the Master 2 Program in Health Sciences Pedagogy
CFRPS, University of Strasbourg
Acknowledgments
This book could not have come to fruition without the wealth of exchanges and collaborations from which I have so fully benefited with healthcare providers, health educators, healthcare executives and managers, particularly within the Ponchaillou University Hospital in Rennes, the B3S Simulation Center at the Centre Hospitalier de Bretagne Sud in Lorient, the Centre Hospitalier Bretagne Atlantique, the Saint-Avé Public Mental Health Institution, the Morbihan Medical-Psychological Emergency Unit, the Normandy Medical-Psychological Emergency Unit, the Morbihan Emergency Care Teaching Center and also within the Vannes Institute for the Training of Health Professionals, where I was graciously accommodated for two years within its team.
This book was also able to draw on the trust of partners such as the National Research Agency, the National Network of Maisons des Sciences de l’Homme, the Maison des Sciences de l’Homme of Brittany, the Brittany region, the Biotech Santé Bretagne, the company Excense, the National Center for Space Studies (CNES), AirZeroG and, of course, the Bretagne Sud University and the team at the LP3C (Psychology Laboratory: Cognition, Behaviour and Communication).
Finally, my gratitude extends to Morgan Jaffrelot, who graciouslyshared his insightful perspective on healthcare professionals andprovided valuable guidance towards certain lines of reflectionthat proved to be fruitful during the writing of this book. For this English edition, it was a genuine pleasure to benefit from the expertise and positive demeanor of Ms. Nivetha Velupur, the translator.
Introduction
“Working is a favor when it helps us think about what we are doing.”
Mossi Proverb, West African People
Patient safety is closely linked to the quality of the working conditions of healthcare professionals. A challenging environment for healthcare professionals is a source of errors, as it induces discomfort, stress and fatigue. Workplace hardship is defined in the French Labor Code as encompassing three factors:
physical constraints: handling loads, awkward postures, vibrations, etc.;
a harsh physical environment: toxic chemical agents, noise, ambient temperature, etc.;
the pace of work: night work in successive and alternating shifts, repetitive work, etc.
The working conditions of many healthcare professionals often “tick” these three boxes, making this sector particularly demanding. To improve these working conditions, physical ergonomics1 (analyzing gestures and postures, environmental factors such as acoustics, lighting, temperature, etc.) provides concepts, methods and recommendations that can lead to design or redesign proposals for a given workstation. Using physical ergonomics means both providing solutions to healthcare professionals and reducing the likelihood of adverse events affecting the health of caregivers and patients.
However, discomfort, stress and fatigue - the primary stressors generated by unsuitable working conditions – may also be linked to another aspect of the job. This other aspect pertains to the informational environment in which healthcare professionals are immersed. Information from patients, colleagues or an increasing number of information systems, coupled with a substantial amount of knowledge required to comprehend each care situation, often leads to an excessively high mental workload. The influx of information from transmitters and receivers (patients, colleagues, alarms, phone calls, etc.) interrupts tasks or time-sharing, disrupting trains of thought. This over-solicitation of mental activity poses risks of forgetfulness or confusion, potentially resulting in errors. Here, cognitive ergonomics, a branch of ergonomics, can offer concepts, methods and ultimately solutions to facilitate information management, reduce psychological discomfort, mental fatigue, stress and error frequency. Moreover, it has been established that musculoskeletal disorders can be caused not only by improper gestures, postures and work rhythms but also by cognitive and/or psychological overexertion (ANACT 2008; Zelano 2014). In other words, the issue of physical strain intersects with that of mental strain.
Concretely, one way to impmve the informational workingenvironment is to make cognitive aids available to caregivers.Cognitive aids are intended to relieve the mental workload2, reduce the risks associated with task interruptions or multitasking contexts, and ensure care reliability with regard to good practices. Also, if a cognitive aid is not yet available “off the shelf’，it is possible to design one from scratch. Health professionals and managers of medical facilities obviously did not wait for ergonomists to design their cognitive aids. However, it is necessary to emphasize that the implementation of a cognitive aid is not an insignificant intervention. It is a journey fraught with pitfalls that, in some cases, can lead to devices that, despite the laudable intentions of their designers, do not achieve their objectives or even constitute an additional constraint leading to explicit or implicit rejection by users. To achieve an effective means of improving the cognitive conditions of work, a cognitive aid must undergo in-depth reflection regarding its purposes and the consequences on the work situation. The pitfalls that cognitive aid designers face are potentially multifold. They can arise from doubts or even negative prejudices within teams regarding the impact of such a device on their working conditions. Paradoxically, designers may also struggle with their own biases regarding the ease of developing an aid and the assurance of achieving a positive impact on working conditions.
We will have the opportunity to elaborate on the barriers that have been observed in the field during the integration of a new cognitive aid. However, we can already mention the bureaucratic aspect of a cognitive aid embedding itself in the format of a new form in daily activities. On a workstation already burdened with multiple constraints, adding what would be an additional constraint is inherently very risky, and in this regard, we can fully understand the apprehensions of future users regarding a new work document, whether it is in paper or digital format.
Other blocking points can arise from the unwise enthusiasm that designers invest in their cognitive aid projects. Many cognitive aids used in the field of health or in other domains, where safety and complexity issues to be managed are equally crucial, are manifested through a simple sheet of paper on which instructions are to be followed or information is to be verified. Taking the example of the checklist, which represents the “primary” cognitive aid in the workplace, it essentially involves ticking a series of checkboxes on a piece of paper. For a cognitive aid designer, this implies that merely writing on a sheet placed on the edge of a table, based on their personal representation of work, is sufficient to create a cognitive aid.
Another false hope, more sophisticated in nature, involves the mere transfer, without adaptation, of cognitive aids used in other domains, such as aeronautics, directly to the realm of healthcare, with the expectation of yielding effective devices. While, as we will explore, endeavors in risk management and cognitive aid design originating from aeronautics have indeed facilitated, and continue to facilitate, substantial advancements in the healthcare sector, these endeavors do not provide comprehensive solutions. Healthcare professionals undeniably encounter specific work constraints distinct from those of airplane pilots. Therefore, it is imperative to acknowledge and address these constraints accordingly.
Confronted with these potential pitfalls, intentionally exaggerated here to underscore them, as well as numerous other pitfalls worthy of recognition, the reader must be cautioned that cognitive ergonomics3 does not offer ready-made solutions for designing cognitive aids. In this book, we will explore ergonomic recommendations, albeit primarily limited to providing general advice on information presentation within a working document. The contributions of ergonomics are primarily elsewhere.
Conceptually, cognitive ergonomics, rooted in cognitive psychology, demonstrates how cognitive aids naturally integrate into human information processing strategies on a daily basis, functioning as psychological instruments.
Through its theoretical assumptions, cognitive ergonomics posits that a workstation or service fundamentally constitutes a system with a certain dynamic equilibrium point. Consequently, the introduction of a new cognitive aid involves a transient imbalance, ultimately leading to the establishment of a new equilibrium point that may not necessarily be more satisfactory than the previous one.
Finally, a crucial contribution of cognitive ergonomics lies in the methodological realm. While general recommendations often have limited applicability, analysis of the work practices of prospective users of cognitive aids is an essential method to ensure that the device meets the needs of the field and does not become an additional constraint imposed upon the work system.
The aim of this book is to illustrate the various contributions of cognitive ergonomics for both designers and users of cognitive aids. The initial phase of this inquiry centers on the fundamental objectives of cognitive aids (Part 1). From this foundation, the specific functions of individual cognitive aids are delineated (Chapter 1). It becomes apparent that cognitive aids serve as conduits between an individual’s internal cognition and the external cognition embedded within the environment (Chapter 2). While knowledge often resides initially within the minds of healthcare providers, the implementation of cognitive aids facilitates the transfer of this knowledge to the external environment, thus engendering distributed cognition. Moreover, the introduction of cognitive aids frequently involves a shift in information processing strategies among users, transitioning from intuition-based reasoning to the analytical thinking facilitated by cognitive aids (Chapter 3). Nonetheless, it is also demonstrated that a move towards increased intuition, facilitated by certain aids, can be both feasible and beneficial (Chapter 4). Furthermore, cognitive aids serve as frameworks for providing directives and work procedures, thereby integrating into communication methods for instructing personnel navigating the complexities of real-world constraints (Chapter 5).
Lastly, the reader will discover methodological elements fordesigning a cognitive aid as a comprehensive information system, capable of providing fundamentally relevant information (Part 2).This objective will involve modeling cognitiveaids as Turing machines. Consequently, a cognitive aid can beconceptualized as both a strip of tape used by an agent to store information (Chapter 6) and/or as a network of mental states of the agent using this tape (Chapter 7). Each perspective will bring forth its array of methods and techniques for work analysis, reasonably enabling us to aspire to devices that genuinely enhance the working conditions of healthcare professionals and, consequently, the modalities of patient care.
Notes
1
Ergonomics (or
human factors)
is defined as “the scientific discipline that seeks to understand the fundamental interactions between humans and the other components of a system, and the profession that applies theoretical principles, data, and methods to optimize the well-being of individuals and the overall performance of systems” (IEA n.d.).
2
Workload encompasses both physical and mental (or cognitive) loads. It refers to the resources mobilized to meet the demands imposed by the execution of a task (Leplat
1977
).
3
Cognition can be defined as the collection of information processing operations conducted by a living organism or an artificial agent, including perception, reasoning, memorization, planning, etc. Cognition is distinguished from affective and conative processes (will and motivation).
PART 1Cognitive Aid as a Gateway
Introduction to Part 1
Health cognitive aids represent one of the significant outcomes of the development of risk management policies in healthcare facilities. It is noteworthy that risk management policies offer an original perspective on adverse events that may arise within a healthcare service, a viewpoint that is not to be taken for granted. No longer is it solely about interpreting the sudden deterioration of a patient’s condition as merely reflecting the natural progression of their illness, the limitations of medical intervention in restoring health or attributing it to errors made by individual caregivers due to their lack of expertise. Instead, risk management encourages viewing adverse events as indicators, among other factors, of the vulnerability inherent in the overall work system in which these events occur. This approach involves adopting a systemic outlook on healthcare delivery and necessitates sufficient detachment from the emotions evoked by a patient’s death, as well as from the conventional inclination to assign blame according to principles of individual legal responsibility.
Opting for a systemic interpretation of an adverse event involves understanding this event as a consequence of the context in which patient care was administered. This context, which forms the daily working conditions for medical and paramedical caregivers, comprises multiple components, complicating the analysis. Moreover, within the system, information circulates between individuals, within the same individual throughout tasks, and during interactions with materials and diverse physical environments. Consequently, the operational dynamics of a healthcare delivery system result from numerous interactions among these components, generating information that requires processing.
When considering this systemic perspective, coupled with the notion that the fundamental benchmark for assessing the effective functioning of a system is the individuals comprising it, we arrive at an approach referred to as the “human factors” approach. Once this viewpoint is embraced, attention can be directed towards the challenge of designing a cognitive aid within the work system. The design objective will be to ensure the long-term reliability of certain information flows, extending beyond specific events. This may involve tasks such as verifying the operational status of medical equipment, facilitating access to care protocols or enhancing communication quality within a team. Designing a device with consideration for how operators process information within a work system constitutes cognitive engineering.
Throughout the first part of the book, we will delve into a pivotal aspect of the design process: the question of what purpose a cognitive aid serves, its objective. For instance, a cognitive aid may aim to store information in hardware memory, deemed more resilient than healthcare providers’ short-term memory, especially under time constraints. However, a potential pitfall arises when viewing cognitive aids solely as compensatory tools for caregivers lacking in information processing skills or rationality. Through this lens, cognitive aids risk being perceived merely as vehicles for delivering more information, fostering logical reasoning and promoting standardization in judgments and decisions. There is even the danger of them being seen as replacements for caregivers, assuming some of their responsibilities. Caregivers, susceptible to cognitive biases, may overly rely on vague intuitions, hunches or ingrained habits, deviating dangerously from protocols and directives issued by the hierarchy through official documents.
By regarding cognitive aids as mere instruments among others, distinguished by their ability to serve as gateways that facilitate the transfer of cognitive resources from various internal or external sources to the individual within the work system, constructive advancements can be made in proposing cognitive aids that are tailored to work contexts. Positioned as an instrument, cognitive aids act as intermediaries between caregivers and their working environment. In this initial section of the book, the examination of various definitions of cognitive aids within the framework of risk management, along with a thorough exploration of the gateway concept, will enable us to explain the fundamental purposes of cognitive aids.
1Defining a Cognitive Aid
In defining cognitive aids, we will begin with the notion that they are devices designed to bolster mental activity in order to prevent failure. This definition is rooted in the historical adoption of the concept of cognitive aids within the hospital domain. Subsequently, we will explore a definition that regards cognitive aids as instruments among others, subject to ergonomic criteria. The integration of these two definitions will culminate in the proposal of a novel third definition, conceiving cognitive aids as pathways for cognition.
1.1. Cognitive aid as a support device for mental activity
Defining a cognitive aid as a support device for mental activities offers a clear advantage: it is a definition that is both simple and intuitive, being the first to come to mind. A cognitive aid serves to facilitate, ensure reliability and enhance the security of task execution by addressing perception, reasoning, memory, decision-making and action planning. Cognitive aids can support one or more stages of information processing to prevent omissions and failures.
To examine the integration of a work aid within mental activity more precisely, cognition can be conceptualized as a chain of information processing with its stages. The double-scale decision model proposed by Rasmussen (1986) illustrates such a processing chain (Figure 1.1).
This processing chain consists of several major phases, comprising mental states and mental operations:
phase 1 : perception of the situation for identification of the state of the world (activation of the perceptual system, observation of the detected data, identification);
phase 2: development of a mental model for decision-making, task definition (interpretation of this state of the world and evaluation of alternatives for decision-making);
phase 3 : decision and execution of a task (definition of a task, formulation of the task in terms of procedure, execution of actions);
in addition to these three phases, it is possible to include cross-sectional short- term or long-term memorization operations.
Figure 1.1.Simplified double-scale decision model (adapted from Rasmussen (1986)) with the types of cognitive aids supporting the stages of information processing
The processing phases are interconnected in the logic of the “perception-action’’ cycle, meaning that the execution of actions by an individual (phase 3) alters the state of the world and thus their perception of the situation, leading to the analysis of new information (phase 1). Based on each of these information processing phases, three types of cognitive aids can be distinguished. These aids contribute to achieving the outcome expected from each phase of information processing.
Identification aids:
these are the devices that facilitate the identification of the state of the situation and the assessment of its components. The
checklist
is a typical example.
Decision aids:
by proposing alternatives or linking the state of the world with decisions to be made, these aids provide support in defining tasks to be carried out. Examples include a chart showing the evolution of sizes and weights in children or, in a more sophisticated manner, software using artificial intelligence.
Action aids:
a list of actions to be carried out
(to-do list),
a working procedure describing the steps to be followed during the execution of a task guides the execution of actions.
Memory aids:
recording information on a paper or digital document brings with it a function of storing information that reduces memorization efforts. A simple sheet of paper listing a set of
items
is a cognitive aid of this type, as well as a computer database.
The implementation of a checklist, a decision aid, a procedural document guiding the action or a memory aid has concrete consequences on the work situation, on the individual in activity (referred to as an “operator” in ergonomics). Implicitly, the presence of a cognitive aid implies a relationship with, on the one hand, an aid designer (manager, expert, ergonomist) who has deemed that assistance was necessary, defined its content, form and conditions of use and, on the other hand, an operator (doctor, nurse, aircraft pilot, etc.) who is the recipient and must apply it. This relationship is not neutral as it rests on a “helper/recipient” dynamic that places the operator-user in an asymmetrical position where part of the knowledge related to their work, part of their expertise, now depends on cognitive assistance tasked with replacing certain mental operations previously handled solely by the operator. The introduction of a checklist modifies the step of identifying the state of the world by imposing a specific order of environmental exploration and a set of objects to be identified exhaustively. A decision aid bypasses a series of arguments and calculations by directly presenting an interpretation of the situation. A to-do list provides the sequence of actions to follow, allowing for quick reference when taking action. Lastly, a memory aid avoids immediate memorization, thus enabling immediate forgetting. Therefore, to some extent, though following a similar logic of skills delegation, the introduction of a cognitive aid raises the same issue as job automation: a device takes the place of the human operator in certain information processing tasks.
In the realm of healthcare, the establishment of a “helper/assisted” relationship through the introduction of cognitive aid between a prescriber (the aid’s designer, the manager, the expert) and an operator (the caregiver) may be perceived as atypical. Indeed, the social stereotype associated with caregivers is that of the “helpef’. Assisting caregivers is not an intuitive scheme. Moreover, the medical community also perpetuates the stereotype of the “knowledgeable individual”. Nevertheless, through cognitive assistance, the aim is to provide them with support. This support seeks to offset a portion of their intellectual activity, which is inherently counterintuitive. Testimonials from caregivers indicate that these social representations of the caregiver and the knowledgeable individual exist both within the general populace and among healthcare professionals, for better – the anticipation of well-deserved social recognition – and for worse – the feeling of needing to embody a superhero, dedicating oneself entirely to the profession without the need for support.
These stereotypes undoubtedly account, at least partially, for the fact that it was not until the late 1990s that the concept of medical error gained recognition within institutions, becoming an operationalized concept in hospitals in a rational, almost “detached’’ manner, one might say. Initiating this genuine revolution in a field in which error and the notion of error-preventing aid were taboo, the hospital sector followed the trajectory set by pioneering studies in the field of aeronautics.
1.1.1. The birth of cognitive aids: from aeronautics to the hospital sector
On October 30, 1935, at 9:30 a.m., on the Wright Field takeoff runway in Ohio, a prototype military aircraft crashed while taking off with five crew members on board. Despite the pilot’s high level of expertise - he was a test pilot - during takeoff he forgot to disengage the control that blocked the control surfaces of the aircraft, an essential component for steering the flight path. This control was one of the innovations introduced in the cockpit of the prototype aircraft 299, which would later become the B-17 Flying Fortress. Previously, the control surfaces were manually locked and unlocked on the fuselage by ground crews before takeoff.
One of the primary lessons drawn from this accident was the realization that complete reliance on the ability of pilots, even expert ones, to memorize all the intricacies of new aircraft models was not feasible. As cockpits grew in complexity, it became necessary to provide pilots with checklists enabling them to verify a set of variables before executing any critical phase of the flight (Boyne 2013). Consequently, the checklist emerged as a cognitive aid and swiftly became an indispensable component of flight procedures in military aviation (Chaparro et al. 2019).
The issue of pilots’ ability to cope with increasing technological complexity gradually permeated the field of civil aviation. Indeed, the 1970s and 1980s witnessed the emergence of airliner models in which programmable logic controllers (PLCs) played an ever greater role, introducing new commands and control indicators to be assimilated by the crew. Consequently, the use of cognitive aids in cockpits naturally became imperative. During this period, civil aviation reports of flight incidents and accidents revealed that adverse events in cockpits most often pertained not to flying skills per se, but rather to peripheral skills that do not apply to the core activities for which pilots are trained. These skills, termed non-technical skills, involve operators’ ability to effectively manage the resources at their disposal to address degraded situations, a concept initially referred to as cockpit resource management and later as crew resource management (CRM). Effective resource management encompasses various skills beyond basic piloting, including communication within the crew, task organization (task management), optimal team synergy (leadership and followership), appropriate decision-making based on accurate situational awareness (Endsley 1995), stress management in degraded contexts, among others. The importance of CRM in crash prevention was a key conclusion of a NASA/Industry workshop in 1979 (Lauber 1979). To optimize the assimilation of CRM best practices, the civil aviation industry will need to train pilots on flight simulators and provide them with cognitive aids.
About two decades later, the healthcare sector embraced the issue of human error and the measures to address it. A groundbreaking study on medical errors conducted across a broad spectrum of American hospitals played a pivotal role in raising this awareness. This study, documented in a 1999 report by the Institute of Medicine (IoM) (Kohn et al. 1999), became a cornerstone in the field. Its title, “To err is human”, subtly reflects the stereotype of the “knowledgeable individual” being infallible, prevalent in the healthcare domain. Within this report, the authors estimated that at least 44,000 – possibly up to 98,000 – individuals died annually in the United States due to preventable medical errors. In France, since the release of the IoM report, the Ministry of Health has conducted three studies on adverse events associated with healthcare facilities (known as ENEIS): in 2004, 2009 and 2019. The latest study, ENEIS 3 (Michel et al. 2022), conducted in 2019, involved a one-week follow-up on adverse events in a sample of hospitals. This investigation revealed 123 serious adverse events (SAEs) among 4,825 patients, averaging 4.4 SAEs per 1,000 days of hospitalization, with 34% of these events deemed preventable. Comparing these figures to those from the 2009 study, the authors observed a significant decrease in preventable SAEs and their severity. However, this positive trend was not statistically significant for surgeries conducted in non-university hospital centers, critical care and implantable medical devices. The authors hypothesized that various risk management plans and programs, including the implementation of the surgical checklist introduced in France in 2010, contributed to these advancements.
A medical error, as defined in the IoM report, refers to a failure to execute an action according to the intended plan or the implementation of an inappropriate action to achieve a goal. The medical errors documented in the report encompass all facets of medical practice (Leape et al. 1993):
the diagnostic process: diagnostic errors or delayed diagnoses, inadequate or omitted clinical examinations and failures in interpreting examination results;
treatment: surgical, procedural or examination errors, as well as mistakes in administering medications, dosage errors, treatment delays and inappropriate care;
preventative measures: failures in administering prophylactic treatments or monitoring treatment effects;
Notes
1
See:
https://max.medae.co/
.
2
A task is defined as “a specified goal under predetermined conditions” (Leplat and Hoc
1983
). This goal can be assigned by a supervisor or initiated by the individual themselves. The conditions encompass various aspects including physical, organizational, social and functional factors.
