Fragmentation in Care and the Potential for Human Error

Andrew Shepherd and Olga Kostopoulou, Cognitive Ergonomics Research Group, Loughborough University, UK

Keywords: neonatal intensive care, information exchange, teamwork, task analysis


In neonatal intensive care medical and nursing staff must coordinate care and treatment to facilitate a baby’s recovery and development. Staff must monitor the baby’s health and treatment in order promptly to detect deviation from a satisfactory state and identify when treatments are not working as planned. Detected problems require a swift response — to predict the consequences of the deviation, to diagnose a problem, or to revise the current care and treatment plan. Such decision-making requires knowledge of principles of care and treatment, the operation of equipment, the significance of biological indicators, rules of discretion, as well as knowing something of the baby’s history.

While the care and treatment of babies must be continuous over days or weeks, members of staff change. All staff are subject to shift-changes. Nurses and doctors also have different sorts of expertise and responsibility and are, therefore, engaged with the baby in different ways at different times. Collaborating effectively entails communication — through records, formal handovers, and informal verbal exchanges.

This paper considers issues of task fragmentation and problems associated with communication systems designed to minimise its effect. It describes strategies for understanding neonatal intensive care tasks aimed at identifying sources of latent human error and overcoming the potential problems of fragmenting care.


The beginning of independent life is a dangerous time for a baby. A complication during labour or an illness can have serious or even life-threatening consequences. Moreover, to survive, babies born prematurely must be given special support and care, above and beyond what parents alone can offer. Such care is provided in Neonatal Intensive Care Units (NICUs). The majority of patients in NICUs are premature babies and it is in this group that 60% of all neonatal deaths occur (Merenstein & Gardner, 1993) . NICU care and treatment entails keeping those babies alive and well, so that their organ systems mature with time and the babies can function autonomously.

Neonatal Intensive Care is carried out by highly qualified medical and nursing staff. Despite their commitment, their working arrangements embody features that can give rise to human error. Some latent errors arise from the nature of individual tasks. Several tasks are intrinsically difficult due to their high information content, the probabilistic nature of some information, the uncertainty of outcome, the criticality of error, and the stressful context in which work is done. However skilled individual members of staff may be, their effectiveness will be blunted if the information upon which they base their judgements is inadequate. Problems arise in this respect because of the inherent difficulties of the need to collaborate and communicate effectively within a team. We argue that difficulties that arise as a consequence of inadequate information exchange between team members can only be dealt with by exploring team functions and more effectively understanding the respective duties of colleagues.

Research Strategy

Methods for investigating real behaviour in real contexts are not clear-cut. Clearly, behaviour is influenced by the information available to personnel and the resources that can be used to make changes. It is also affected by the expertise of staff, their attitudes and perspectives, their individual and collective experience and the factors which affect and have affected the circumstances that emerge to be dealt with, including the costs and consequences of actions.

Cognitive psychology has a role to play in understanding how human beings use information to carry out decision making tasks, but its methods tend to preclude a proper understanding of the range of factors that affect performance in real contexts. Cognitive psychologists tend to focus on testing hypotheses about the structures and processes of cognition and are usually motivated to devise tasks that suit their interests, rather than explore real tasks. Ethnographers take a different perspective, observing behaviour in a real context, whether or not this behaviour is directed towards the goals of the system of which they are a part. This approach may fail to take account of infrequent events if these do not occur during periods of observation (Room, 1984). This would be a critical omission since infrequent events often yield serious outcomes and have not been anticipated. Therefore, contingency plans may not have been devised or appropriate responses practiced by staff.

Where a researcher’s motivation is directed towards establishing hypotheses for improving aspects of a system, the system’s goals must be understood. However, so too must those activities that do not appear directly related to meeting systems goals. Understanding some personal goals can point to strategies that staff adopt for coping with the main goals, or with the tedium or other stresses of the work context. These may be vital for a workplace to be effective. Thus, two consultants from different units engaged in diagnosing the problems of a seriously ill baby were seen to talk, from time to time, about common acquaintances and organisational aspects of their respective hospitals. This was done in a light-hearted manner. When one of these consultants was questioned afterwards he admitted that he was deliberately trying to inject some normality into proceedings. In some cases, people may do things that are counter-productive and these too need to be understood in terms of the purpose that these activities serve.

Neonatal intensive care exists for a purpose and staff are employed to prosecute that purpose. However, as with all work contexts there are many things going on besides the pursuit of the stated goals of the group. These can include social tensions and rivalries. Interactions between staff can be influenced by a desire to promote relationships as well as the need to communicate information pertinent to care and treatment. In the case of neonatal intensive care, the goals of staff can change from that of promoting life to that of managing a dignified death. Staff are cognisant about the well being of families as well as the babies and adapt their behaviours to balance these objectives in an appropriate manner. Issues such as these must be picked up by any researcher as a prime focus for research or as part of the context that needs to be understood in order to investigate cognition in an appropriate manner.

In resolving the interactions between contextual factors and cognitive factors we question the validity of any simple approach. We have sought an understanding of what staff are employed to do. We have identified the tasks that staff must carry out to achieve these goals and the contextual factors that affect performance. We have identified the factors that could be redesigned or modified to improve performance. We have then examined these constituent tasks to establish how information is used. We are currently investigating design hypotheses concerned with helping staff communicate more effectively.

Fieldwork in NICUs:

We have undertaken fieldwork at 4 different NICUs. The aim of these visits was to observe the complex NICU environment, to provide a general perspective on how tasks are carried out, and to identify when, why and from what sources, information is obtained. These observations showed how units were organised and drew attention to the fact that units are all different. Discussion with staff also placed in perspective the purpose of neonatal intensive care, which was crucial to a proper understanding of how units function.

Initially, our intentions were to record observations faithfully. With greater familiarity with units, we became more reticent about this. We were reticent about filming and recording in front of families. Families observed at the point of greatest crisis were distraught and vulnerable. We were equally concerned about risking the trust of staff in recording utterances that they might subsequently feel compromised their positions. Part of this problem rested with the nature of shiftwork. We made substantial effort to explain the purpose of our work to staff, yet continually encountered staff who had not been at our briefings or who had not read the documentation we had left for other staff. Moreover, work pressures in units were so heavy it was difficult to arrange satisfactory briefings. Any researcher entering this field must confront these questions of ethics and trust. A researcher would need to feel confident that the benefits of such recording justified these intrusions.

We attempted a number of formal approaches to recording data. We attempted a form of activity classification both at shift handover and during the shifts. Activity charts were used to establish the extent to which a nurse's attention switched between patients and between the various care activities. We also attempted to obtain estimates of the nurse’s perception of risks to the baby as a shift progressed. However, all of these efforts proved to be of little benefit during our initial investigations and little insight about tasks was gained. Part of the problem was due to the nature of the different cases. Common events, such as nursing routines that occurred every hour, were easy to document and did not need any formal observational methods to identify what was happening. Non-routine events, however, were difficult to observe because we did not fully understand terminology and motivation. In an attempt to understand what was going on, we asked questions to staff while they were working. We took care to do this only when staff had time to answer and avoided interrupting during obvious critical activities. Most of our questions concerned the purpose of a current activity, how tasks fitted together and the information links between them. Questioning was also directed towards documentation issues. To understand the documentation better, we looked at records and talked to staff. We looked at how records were structured, when they were filled in and how they aided care decisions.

As we became more familiar with these units, we became more focused and sought answers to specific questions, concerning the information recorded on the nursing and medical notes, how nursing and medical notes differ, how doctors communicate treatment plans to nurses and protocols for shift handover. We explored these issues by studying situations of interest and questioning the persons involved. We employed retrospective analysis in cases where we observed something interesting and asked the person what went on. We confronted nursing staff with notes to enable them to talk us through what happened and why certain decisions were taken. Input from doctors was also sought to complement these observations.

The outcome of these interventions was a clearer understanding of the purpose of neonatal intensive care, how staff worked with one another and how staff carried out their duties. From this we were ably to obtain greater insight into organisation of units, team activity, the potential risks to care and the manner in which tasks are carried out and information is used.

The Organisation of NICUs

Location: NICUs are situated in large tertiary care centres near the maternity ward. They are divided in three areas: maximal intensive care, high-dependency intensive care and special care. Babies are allocated to each area according to the severity and instability of their condition. Most babies requiring maximal intensive care are ventilated and their vital signs are continuously monitored. Our research focuses mainly on maximal and high-dependency intensive care because these areas involve higher information load due to greater number of interventions, monitoring a greater number of parameters, and dealing with more unstable patients requiring more frequent assessments, changes in treatment and documentation.

Staff and their Duties: The staff of units serve both the care and treatment of babies and the organisation of the unit itself. Thus staff are concerned with working within a budget and meeting a range of organisational targets.

Medical staff in NICUs include Consultants, Registrars and Senior House Officers (SHOs). Consultants and Registrars are involved more in treatment planning than in direct provision of care, while SHOs carry out invasive procedures, prescribe drugs and fluids and make a limited number of treatment decisions. Consultants and Registrars are specialists in neonatal intensive care. SHOs are not specialist but are on the unit to undertake a medical placement that might last only 6 months before moving to another placement in a different area of medicine. Thus, there is no reason to assume that SHOs have any specific career aspirations in neonatal intensive care. Senior Consultants have a managerial role too. This includes ensuring the unit is adequately resourced and interacting with the wider managerial structures of the hospital.

Most of the nurses in NICUs are qualified in neonatal intensive care. Nurses are allocated 1 to 3 babies during each shift and are constantly with them. They monitor them, keep them comfortable, feed them according to the care plan, administer medication and record their observations routinely and also when changes occur. They bring such changes to the attention of doctors who decide on treatment modifications. Some of the more senior nursing staff have managerial roles. Nurse Managers have an important role in staff deployment and maintaining standards. Ward sisters provide a supervisory role in which they ensure that day to day performance of staff is satisfactory.

While it is useful to separate managerial and organisational aspects of care from the direct care and treatment of babies, these aspects often interact. For example, decisions concerned with admitting babies or allowing them to go home affect both the best interests of the baby and their families and organisational factors such as the availability of cots and the use of other resources. Equally, if an SHO were undertaking a routine test on all babies in the unit a ward sister may choose to limit access in order to minimise disturbances to the babies. This may be inconvenient to the SHO carrying out the tests but judged to be in the best interests of the babies.

The general patterns of duties described above applied in all units, but it was clear that there were several variations regarding how these activities were carried out. The manner of communication and collaboration between staff varied for a variety of reasons. Some staff were new to this form of nursing. Some staff were experienced at this form of nursing yet had little experience of working in their current unit. Other staff had considerable experience of colleagues and of the unit. They understood the strengths and weaknesses of colleagues and reflected this is the way in which they were able to share descriptions of babies and conditions. It meant that they could communicate with one another in more coded and more efficient ways than colleagues without such familiarity. For example, staff could refer back to cases where they had a common experience.

Formal differences between staffing on units also existed with regard to the employment of specialist categories of staff. For example, Nurse Tutors were experienced nurses who also had unique unit wide experience and responsibility. Their seniority enabled them to obtain a broad perspective that was beneficial to the unit in ways other than simply providing educational support. Nurse Practitioners were particularly interesting. These were usually senior nurses who had been trained to undertake responsibility for some of the more invasive treatments as well as taking responsibility for care. Thus, they were able to provide a more seamless support for the baby, without the need to communicate between professions. They were specialists and were able to build up substantial experience. They were, therefore, able to compensate for the comparative lack of experience of SHOs. Moreover, Nurse Practitioners provide excellent insight into the benefits of integrating care and treatment.

The Working Goals of NICU Staff

Critical to our understanding of NICUs was properly understanding the goals of staff. Our perception of their tasks shifted from initially assuming a model of ‘diagnose and treatment’ to recognising that, in general, the role of staff in NICUs was to sustain life systems until the baby was able to mature and become self-sufficient. Premature, and some full-term babies who experience problems prior to birth and during labour, need special support after they are born. The aim of staff in NICUs is to sustain life of such babies by appropriately augmenting immature organ systems and treating disturbances, for example, in supplementing oxygen and controlling the thermal environment. When the baby's condition is stabilised, staff aim gradually to reduce and eventually remove this augmentation in order to promote self-sufficiency. Then the baby is safe to go home.


Formal documentation is essential within NICUs as a means of communicating information and as a means of recording what action was taken. Such records of activity can serve in cases where a review of treatment is necessary and in cases of litigation.

Two of the most important forms of documentation are the Treatment Plan and the Care Plan. The Treatment Plan is created by the doctor in charge of a case. It will specify treatments to be given and conditions to be maintained. This provides guidance for later medical staff who might be concerned with modifying treatments in the light of new circumstances, it can provide targets and it provides guidance for nursing staff concerning parameters for monitoring. The Care Plan is the province of the nursing staff. It will set out the pattern of care activities to be followed and will record systematically the baby’s response to care and treatment.

Treatment and Care Plans look forward. Staff are also required to maintain records, specifying the nature of each intervention, current status of key health parameters and any observations made concerning the nature of treatment. Thus, exceptional circumstances would be recorded here, including the kinds of things that ought to be conveyed to colleagues.

Litigation is the reason that nurses are required to record practically everything, irrespective of whether its importance. This is not only time consuming but also results in large amounts of information making it difficult to for staff integrate it and to single out the most important events. Moreover, there is extensive duplication of information both between and within medical and nursing records which is prone to transcription errors. Gopher et al. (1989) found that 28% of the overall activities in a respiratory ICU were recorded in both medical and nursing notes, while 18% were not recorded at all, suggesting incomplete documentation. Indeed, staff were aware of these problems and the possibility of combining records in a more rational way was raised on a number of occasions.

Neonatal Intensive Care as a Team Activity

Neonatal intensive care is a complicated activity that requires several interdependent individuals collaborating for a common goal, performing different tasks and contributing their individual expertise. Nurses need to be constantly with the care babies to monitor their vital signs, respond to changes and provide routine care. Doctors assess babies, decide on their treatment and sometimes determine the conditions for care and monitoring. The contribution of other experts, such as physiotherapists, lab workers and social workers, may also be required. At the level of action, however, neonatal intensive care is essentially an individual activity, as a single nurse looks after one or more babies during a shift; it is less the case that several people co-operate to carry out a single task. Gopher et al. (1989) estimated that 84% of the activities carried out in a respiratory ICU were performed by a single nurse. The doctor is called upon when the nurse cannot or is not allowed to deal with a non-routine situation. This constitutes a difference with other supervisory tasks, such as process control, where operators work. In power generation or transport control, for example, each operator may be engaged in controlling different parts of the same system and, therefore, should be able to form a representation of what each other is doing in order not to interfere with what their colleagues are trying to do. This contrasts with NICU nurses who may not need to know what goes on with the rest of the babies in the unit (although they often have some general idea which helps them to cover for their colleagues for short breaks). They do need to know what went on before they took over caring for a particular baby, and they need to know the goals of the current treatment plan.

Concurrent Activity: When doctors are involved with the baby, the onus remains on nurses to maintain their basic nursing duties. This was brought into focus during one incident observed. The seriousness of the baby’s condition engaged the attention of 3 Consultants. Normal routines were severely interrupted and the baby’s nurse seemed to focus her attention towards supporting the doctors. After observing this incident for about 2 hours, the nurse seemed then to start working independently of the doctors to carry out normal recording and make more typical nursing interventions. When questioned afterwards, she admitted that the incident had prompted them to suspend their normal activities and then she realised that the basic nursing functions were being neglected.

Information Collaboration: Since carers (nurses and doctors) work independently, they gain different information on the basis of their involvement in a baby's care. The amount and content of information gained will be a function of the events to which the carer has been exposed and the tasks carried out. As a result of continuous contact with the babies, a nurse is likely to know a great deal more about a particular baby than doctors or other practitioners who have only short and intermittent contact. Information gained at any one stage of care can influence execution of care tasks at another stage. Since different carers carry out different tasks, they need to have all the appropriate information available. This has implications for complete documentation and efficient communication.

Doctors rely on information provided by nurses to make treatment decisions. This information is usually documented but most of the time, according to our observations, it is provided verbally by the nurse either voluntarily or upon the doctor's request. At the same time, doctors may possess some types of information that need to be shared with the nurse. This includes, diagnostic or prognostic information and information about treatment goals and reasons underlying treatments, which could help the nurse to deliver care more efficiently and be more alert to changes in the baby's condition. Cases were reported where Doctors had stipulated care and treatment actions without notifying nurses of their motivations. For example, to enable the baby to develop self-sufficiency, it is sometimes necessary to withdraw some aspects of treatment to prompt the baby to cope. However, this will subject the baby to temporary discomfort. Where the nurse is unaware of the Doctors motivation in this respect, he/she may act in a way to alleviate discomfort, by adjusting sedation, for example. In this way, the Doctor’s strategy for treatment is compromised.

Information communication is therefore a very important aspect of neonatal intensive care and a determinant of its quality. Gopher et al. (1989) found that the dominant cause of errors in a respiratory ICU were problems related to complete and clear documentation and transfer of information between staff members. Staff in the NICUs that we visited characterised communication problems as one of the most common problems in the everyday operation of the units.

The Traditional Roles of Doctors and Nurses

Relationships between staff appear to owe more to the traditional roles of doctors and nurses than to any rational assessment of how such relationships and lines of communication should best be organised and supported in neonatal intensive care. Thus, certain demarcations in responsibility are assumed, with nurses ‘nursing and caring’, and doctors ‘diagnosing and planning treatment’. In some cases, the distinction is explicitly stated, with the implication that nurses have little discretion.

In reality, these distinctions are blurred, with both types of staff engaging in both types of activity. For example, nurses may facilitate diagnosis and treatment planning by anticipating and collecting relevant information in order to inform doctors. In one incident reported to us, an experienced nurse was prompted to question the validity of a ‘normal’ blood oxygen reading. Taken at face value, the baby’s health was entirely satisfactory. However, this nurse had taken note of prior treatment interventions and had noted that four hours earlier, on the previous shift, the baby had been given an increase in oxygen and no change to this had been made since then. The Nurse extrapolated from the current condition to the next occasion for routine monitoring and was concerned that the baby would be at risk from excess oxygen. She had no discretion to act directly, but was at liberty to call the Consultant who then made the appropriate adjustment.

Equally, doctors must appreciate the importance of 'minimal handling' and ensure that treatment interventions do not compromise recovery. Minimal handling is a care principle of utmost importance for nurses because it is this that allows the baby to rest — this is one of the most effective means by which a baby can recover. Specialist Consultants and Registrars appreciate this, but the less experienced SHOs may not. It is clear that there can be conflict between the inexperienced SHO and the experienced Nurse. Effective senior nurses are strong characters indeed!

If this anticipation and co-operation did not occur, then it would be difficult for NICU teams to work so effectively. Therefore, examination of the organisation of NICU teams and the information infrastructure that supports them is important in resolving performance problems.


Cooperation depends upon communication. There are a number opportunities or channels for communication.

Shift handover: Shift handovers occur between nurses going off shift handing over responsibilities to other nurses and doctors going off shift handing over responsibilities to other doctors. The role of shift handover is to facilitate a smooth transition from one shift to the next without interruption in care. It is intended to help oncoming staff quickly to update their knowledge of the babies and to identify changes that occurred since they were last on shift. It can helps them to put the babies in order of severity and to prioritise attention. It can provide information on things to look out for, on unusual and important events that occurred during the previous shift, events that may have been recorded but may be missed amidst the detail of other recorded information. It can provide a summary of what needs to be done and of any changes in the care plan that were decided during the previous shift.

However, there are risks inherent in handover. For example, some important information may be omitted, there may be ambiguity in the verbal communication leading to misperceptions, erroneous inferences and suppositions. Biases may be introduced in the information search of the oncoming shift (Grusenmeyer, 1991). The outgoing shift may fail to direct the oncoming shift's attention to important events and aspects of care. The oncoming shift may fail to memorise or take into account some transmitted information or may fail to check the validity and completeness of the transmitted information before starting care activities and continue with a wrong practice ‘inherited’ from the previous shift (Grusenmeyer, 1995).

In some of the NICUs that we observed, handover was done from memory and neither the outgoing nor the incoming shift kept notes. Moreover, oncoming nurses often started their care activities without consulting the records. Shift change is indeed a critical phase of work in terms of safety; a higher number of accidents have been found during shift changeover in other contexts than during the shift or at the end of the shift (Godimus et al., 1977, cited in Grusenmeyer, 1991). Gopher et al. (1989) found peaks of errors immediately following each shift change of nurses in a respiratory intensive care unit. According to Grusenmeyer (1991), there is a period when the oncoming operator is trying to gain information and is not "fully operational" for his tasks which increases the likelihood of incidents.

Our observations of handovers revealed a vast range of personal styles that were difficult to assess from the viewpoint of their adequacy. A major problem that arose was that staff were conscious of being watched and tended to be more comprehensive that they might otherwise have been — this was as much to help inform us than simply that they were on their best behaviour. We witnessed a wide range of styles. In some cases, a nurse would systematically work through a standard template of observations, while in other cases the nurse would be briefer. Sometimes the on-coming nurse would ask questions. Sometimes the nurse coming on shift was already familiar with the baby and little had changed. As babies become more stable and staff are more confidant of their prognosis, the handover communication centred more around the families and their increasing involvement in treatment. Sometimes, very little information would be conveyed and the on-coming nurse would move into a nursing routine that revealed nothing of the previous exchange. This suggested, that in many cases, the handover served little purpose in terms of obtaining information. Indeed handover could serve simply as a ritual to enable people to engage and disengage with the task or with coming to work. As a means of providing information, it could exist to confirm that all is as would be expected for a baby of these characteristics. It could provide specific information about crises or any observations concerning the baby’s health or response to specific treatments.

Ward rounds: Ward rounds are a different context for information exchange in which all staff concerned with a baby are present. They occur daily and involve doctors going to each cot, reviewing and discussing the case, examining the baby and deciding on whether revisions to the treatment plan are warranted. The nurse in charge of the baby is usually present to provide information and to comment on the baby's progress. The doctors write the new treatment plan in the medical notes and the nurse updates the care plan in the light of the doctors' latest instructions.

Substantial verbal exchange of information takes place during ward rounds but only part of it is recorded. Doctors rarely record the reasons behind their decisions, although they may communicate them verbally to the nurse in charge of the baby or other doctors present. The nurse may not record the doctor's reasons in the nursing notes (it is not a type of information that she is required to record) and may not inform her shift successor about them (because she forgot or did not consider it important). Verbal information can easily get lost and staff often commented on this. Of course, people cannot record everything and read everything. It would be too time consuming and inefficient. Therefore, judging which information is important and would be useful to the next person coming on shift seems to be an essential skill in intensive care.

Fragmentation of Care and Treatment

NICU babies require continuous monitoring, as they can quickly become very unstable and their appearance may not sufficiently indicate an impeding deterioration. Moreover, only a limited number of invasive tests can be made on neonates, which makes continuous, non-invasive monitoring even more important (Cunningham et al., 1992). The interdependency of staff in the delivery of care suggests that if the forms of communication exchange were in some way deficient, then care could suffer. In the description of NICUs given above it is clear that care is fragmented as staff change shift and as they engage at different stages of the baby’s treatment and care.

Fragmentation of care between doctors and nurses can also reflect their respective traditions and philosophies. For example, some doctors are not concerned with how the baby is establishing feeds; this is considered one of the nurses' main activity. Nurses are interested in maintaining the baby's comfort, whilst doctors are more interested in delivering treatment. Delivering treatment often compromises the baby's comfort, providing a constant source of tension between doctors and nurses. This gap between doctors and nurses is reflected in separate handovers and separate records which result in overlapping information but also in valuable information not getting across, simply because staff think that colleagues are not interested. Some members of both the nursing and medical staff have pointed out that it is necessary to have joint doctor-nurse treatment decisions. This suggests that they acknowledge the fragmentation in care and its potential consequences.

Functional Analysis of NICU teams and the tasks of team members

In cases where demarcation within teams has evolved through local practices, it is difficult to predict where performance failures due to inadequate staff interactions may arise. What constitutes an individual task is unclear, as is the relationship between individual tasks. This is made more complicated due to local variations in team organisation and relationships. To take account of these variations, we have adopted the strategy of first examining the general function of delivering neonatal intensive care and then seeing how this may be resolved into different tasks. This has been done using Hierarchical Task Analysis (Annett et al. 1971; Shepherd 1995, 1997). Hierarchical Task Analysis is a method of describing tasks in terms of the operations that aim to meet functional goals and plans which describe the conditions under which goals must be met to satisfy the conditions of their superordinate goal.

Figure 1: Main Tasks in NIC

Figure 1 shows the top level of this analysis illustrating how staff must take information from the previous shift (1) to inform their principle activities of maintaining equipment (2) and maintaining care and treatment (3). At an appropriate stage of the day, the wardround is conducted to review each babies development and to enable information exchange to take place between different members of the team. Finally, responsibility must be handed over to the next shift (5).

The importance of this part of the analysis is to set the context in which care and treatment are delivered. Indeed, the elements of handover (1 & 5) cannot be understood without reference to what goes on within care and treatment (3). The general nature of the model at this level reflects how different members of staff may be engaged. Thus all NICU staff are concerned with handover, care and treatment and being engaged in ward rounds. We have included the operation concerned with maintaining equipment and supplies. If this is not done to a satisfactory standard, then the standards of treatment and care are at risk. We observed a critical event where a piece of equipment was called for during an emergency. First the technician bringing it went to the maternity ward instead of the NICU, thereby causing delay. Then, when the equipment arrived it was found to be unservicable and an alternative strategy for dealing with the problem had to be pursued. The potential consequences of this sort of event do not need to be spelled out. Clearly all staff must issue unambiguous instructions to each other and certain staff must be given responsibility to make routine investigations to guarantee the availability of such crucial equipment. This applies whether or not these staff are members of the NICU or other staff within the hospital.

The central activities that we wish to address are described in Figure 2. This shows how the tasks involved in ‘Care for and treat babies in NICUs’ (3) are set out. These functions are reasonably standard and would apply to most NICUs irrespective of their specific organisation.

Figure 2: Principle Tasks Identified in Delivering Care and Treatment. Each of these is further developed in the Full Task Analysis

The Principal Goals of Managing Care and Traetment: We have focused on the aspects of treatment and care provided in NICUs. This is seen as the external control of immature organ systems to facilitate development to a state where the baby may be safely discharged, transferred to another unit or be terminally cared for. For example, the babies may not be able to sustain their cardiorespiratory function and regulate their temperature and fluid homeostasis and, therefore, require assistance. Such control should be administered in a way that does not damage the baby's organ systems (e.g., lung or eye damage due to excessive mechanical ventilation is a common side effect of NICU treatment). External control should be gradually reduced and eventually removed, so that the baby can regulate its own bodily functions. Both provision of and weaning from support require careful assessment, continuous monitoring and adjustment. Moreover, they require dealing with routine deviations as well as tackling unexpected problems.

Figure 2 shows how care and treatment depends upon a cycle of activities including monitoring key indicators of the baby's condition and monitoring the adequacy of current care and treatment plans; delivering routine care and treatment; treatment planning; and communication. Some task elements, such as the monitoring tasks must be conducted throughout. Others are done in response to certain events, for example, the baby entering the ward or various unacceptable conditions arising.

For the purpose of discussion, we have categorised the types of tasks identified by the task analysis as procedural tasks, monitoring tasks, care and treatment planning tasks, care management support and communication tasks.

Procedural : These tasks are ‘settle the baby and make initial measurements’ (1) and ‘carry out treatment/care and specified monitoring activities according to current schedule’ (7). Care and treatment planning tasks are proceduralised to a large extent, due to the difficulty of diagnosing and treating highly unstable, highly interacting organ systems. Most of the time, treatment consists of selecting an established method and appropriately adapting it to accommodate individual differences and ongoing responses (Shalin & Bertram, 1996).

The word ‘procedural’ denotes tasks that are generally executed in a fixed way and are often straightforward, requiring little discretion. Procedural tasks in the context of neonatal intensive care include obtaining routine measurements such as temperatures, obtaining blood samples, administering drugs, delivering oxygen, giving fluids, inserting a catheter, intubating/extubating, suctioning etc. These are the ‘normal’ routines of nursing and treatment delivery. On further analysis it becomes clear that each of these is subject to variation, some of which requires judgements to be made by the nurse or SHO carrying out the task and some of which require information to be supplied by the doctor responsible for the treatment plan. Invasive treatments or the administration of drugs to alleviate pain, for example, will yield different responses from different babies. If a nurse recognises that one method of treatment is unsuitable for a particular baby, then an alternative method for achieving the same nursing goal must be found. The nurse will then know what to do on the next occasion and should inform colleagues to ensure that the baby is not discomforted unnecessarily. Thus the team can learn about the characteristics of individual babies. It soon becomes obvious that these ‘procedural’ tasks all rely on information being provided by colleagues to ensure they are dealt with most effectively. It is also clear that each task provides opportunities for staff to learn new things about caring for and treating the baby to communicate to other members of the team.

It must also be acknowledged, though, that some treatments are intended to be followed irrespective of some temporary discomfort to the baby. In these cases, the routes to follow must be made explicit to staff and reasons given. This must be done in a way in which instructions and motivations can be conveyed beyond the members of staff who were present when the original decision was taken. If this is not done, then nursing staff may promote comfort at the expense of the treatmentplan.

Monitoring: Three types of monitoring are identified. First, ‘maintain baby’s comfort’ (8), is concerned with nursing decisions. Nurses will ensure that babies are not too cold or have been discomforted by an item of equipment slipping out of position, for example.

Second, nurses are engaged in reviewing and evaluating whether the baby is progressing satisfactorily in accordance with the current treatment plan’ (9). Here, their job is to make general observations of the baby and to take various measurements from which judgements are made about the baby’s progress. They will record the information or draw problems to the attention of a doctor. At one level this task appears straightforward. The nurse needs to know the target parameter, the target value and the tolerances to be accepted. It can be assumed that there is little judgement and expertise involved, a view held by some doctors. In practice, monitoring can be a complex task. Where a nurse is heavily loaded, he or she must prioritise and, therefore, needs to understand factors associated with criticality and recoverability in order to direct attention in an optimal way. Where a parameter is seen to go outside acceptable tolerance, the nurse must investigate the problem. Is a poor pulse signal the result of the pulse sensor being dislodged by the baby moving or is there general concern? Is the current acceptable reading of oxygen in the blood the sign of a healthy baby or is it a transitory state following an earlier intervention? If the nurse failed to anticipate these problems or failed to account of the factors that would direct an effective schedule of monitoring behaviour, then the nurse would be less effective, despite what doctors might say about the level of discretion a nurse has.

The third type of monitoring is ‘monitor adequacy of current treatment plan’ (3). If the baby’s response to treatment is unsatisfactory, then the doctor might decide to be more cautious and revise the treatment plan. Alternatively, the baby might be progressing well and the doctor decides that treatment must move forward. For example, the nurse might notice that the baby is making spontaneous attempts to breathe and so the doctor might decide the baby should be weaned off the ventilator. Where such action is taken, the treatment plan is revised. The nurse needs to know this so that greater attention can be given to the baby during this critical phase of change and because other vital signs will be disturbed caused by anxiety brought on by the change.

Care and treatment planning: These tasks include ‘specify treatment/care plan’ (2) and ‘revise treatment/care plan’ (4). The importance of the process of prescribing a treatment plan has been made clear. This is the responsibility of doctors. Their task is to make medical judgements, either to identify a problem or to prescribe what to do next. Much neonatal care treatment planning is done in conditions of uncertainty. Because of the fragility of the organism and the idiosyncratic nature of some problems, doctors are often uncertain. Their task is not necessarily one of diagnosing, then confidently prescribing. They are often making their best judgement about what treatment will help stabilise the baby and allow it to settle before progressing the treatment. As a consequence, they must rely upon the effectiveness of the nursing staff in obtaining information and of nursing staff and SHOs in delivering care and treatment. Paramount, of course is the effective monitoring in between to ensure that treatment is progressing well. This means that unless nurses and SHO fully understand the motivations of doctors in prescribing a course of treatment and unless they understand the parameters to which they must now attend, the effectiveness of treatment might be compromised. The interelationship between task elements and, hence, staff, is again emphasised.

Treatment planning directs the strategy for care and treatment. It may involve diagnosis or simply prescription of an established programme of treatment on the basis of assessment of the baby's condition. Sometimes treatments are prescribed with little confidence, but something has to be done. Treatment planning is invariably followed by treatment actions, and then careful monitoring and assessment to determine treatment effectiveness. Thus, a treatment plan should inform monitoring and testing activities in terms of parameters to be monitored and diagnostic tests, routine or non-routine, to be carried out.

Care management support: This is seen as the management of the care and treatment interventions. It was emphasised to us that one of the prime treatments that babies can be given was to allow them to rest. Unnecessary disturbances will arrest progress. Exercising some degree of forward planning by care staff will ensure that everything that needs to be done will be done, but that it is coordinated to minimise upset. Thus, preparing and revising the schedule of treatment/care activity for the baby (5 & 6), needs to be taken seriously and respected as a task. We have seen strong-willed senior nurses drive this process very effectively, because they know that unless they do so, other staff may cause interruptions to care which could have been avoided.

Communication: Communications are vital. Both ‘record/relate significant observations, events and inferences’ (10) and ‘provide information to next shift’ (11) depend upon staff understanding what is of significance to promote treatment and care, above and beyond the information that will be routinely monitored. The information judged to be significant must be formally recorded or committed to memory. Where information is obtained during a complex procedure or decision making task, then the carer may simply forget to make a record of it.

Errors and Error Handling

Our observations and task analysis have revealed a number of opportunities for error inherent in the NICU system. Errors are frequent and often relate to unavailability of information. Fortunately, the system can often prevent such errors from developing into incidents. Defence mechanisms include duplication, staff memory and shiftwork. Thus, information that has been omitted from one record may exist in a different record. Information that has not been recorded may be remembered because it was verbally expressed at some point. Information that may be missed by one shift may be picked up by the next shift. However, it is evident that such defences are informal and sometimes may not work or may work to the detriment of the system. For example, duplication in records is time consuming and may lead to transcription errors resulting in inconsistencies. Memory of verbal exchanges is notoriously unreliable. NICU staff repeatedly comment on how often information gets lost or altered through verbal communication. The involvement of various members of staff in the care of an individual baby increases the likelihood of information being picked up but at the same time increases the likelihood of information getting lost. There is a big difference between a member of staff obtaining a piece of information and using it to perform a task and a member of staff obtaining a piece of information and communicating to a colleague who will then use it to perform that task.

The Experimental Programme

The potential sources of error revealed by our fieldwork are plausible yet remain hypothetical. The logic of the care task, observations made of events and incidents and comments made by various NICU staff give credence to these suggestions, but they do not consitute categorical evidence.

Our current phase of research is to investigate these potential weaknesses further and to investigate ways in which problems might be overcome. Thus, we have developed baby simulations whose health can be monitored, where problems to be introduced in their development and treatments can be administered. Our current simulation has been programmed on Stella™, a modelling package available to run on desktop computers. Individual babies are represented by running the baby simulation on different iMac™ computers. Different ‘babies’ are given different initial states, different recovery characteristics and different problems to contend with. We are using the simulations to invistigate how engagement with different tasks influences the manner in which people handle information and how they communicate with colleagues. Thus, we are investigating, for example, the benefits of different ways of training people to think about their task, different forms of representing records and different protocols for briefing colleagues. We also plan to investigate the development of teams over time, observing how their skills and relationships develop and how, as a consequence, they learn to share information.

We hope to establish how various elements, including computer displays, recording formats, training and protocols for verbal communication, can be designed to improve the handling of information in contexts such as these. The outcome of such work can never be in the form of a categorical finding that we can be confident of applying to real situations and we are fully aware of the constraints of this approach.. However, through such methods we would seek support for more viable design hypotheses than can be obtained through observational studies alone.

Observations and Conclusions

Our studies of neonatal intensive care have revealed a complex working environment in which different people with different expertise and responsibilities and working across different shifts, must collaborate in order to maintain the care and treatment of babies at extreme risk. Through observations and task analysis, we have identified a wide range of variations of practice, even though the basic processes of care are common between units.

A particular observation has been the complex interdependency between different sorts of care task, especially from the perspective of sharing information. The need for staff to collaborate is paramount. Yet there are clear indications that this collaboration can be compromised by problems of communication brought about by the fragmentation of tasks across staff.

Several aspects of the NICU context lend themselves to redesign, including the format of records, the effectiveness of training and protocols for shift handovers. Making recommendations in this respect depends upon further research into the design of information artifacts. This is one reason why simulation studies are recommended to supplement observational studies, even though the simulation of these tasks severely compromises the realities of the real NICU context.

One area that has been noted, which cannot be studied in a task simulation, concerns the traditions of the medical and nursing professions. The staffing of NICUs owes much to the traditional relationships that have emerged between doctors and nurses. Yet, if NICU staffing were to be specified from the perspective of good team and job design, the recommended allocation of responsibilities would probably look very different. There is scope for more clearly identifying how nurses undertaking monitoring and care tasks can more effectively anticipate the requirements of medical staff undertaking treatment planning. And there is scope for prescribing better ways for medical staff to convey their plans to the staff who will be responsible for carrying them through.


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We would like to acknowledge all of the staff of Neonatal Intensive Care Units who have given us their time and demonstrated their expertise.


Dr Andrew Shepherd, Cognitive Ergonomics Research Group, Department of Human Sciences, Loughborough University, Loughborough Leics, LE11 3TU, UK. Telephone: +44 (0)1509 223028.
Fax: +44 (0)1509 223940. Email:

Dr Shepherd is an applied psychologists with particular interests in task analysis, training, interface design, team .

Dr Olga Kostopoulou, Cognitive Ergonomics Research Group, (see above).
Telephone: +44 (0)1509 263171 ext. 4271.
Fax: +44 (0)1509 223940. Email:

Dr Kosopoulou is an applied psychologists with particular interests in diagnosis and faultfinding with a particular interest in medical settings.