Using Simulations to Integrate Technology into Health Care Aides' Workflow

Health care aides (HCAs) are critical to home care, providing a range of services to people with chronic conditions, aging or are unable to care for themselves independently. The current HCA supply will not keep up with this increasing demand without fundamental changes in their work environment. One possible solution to some of the workflow challenges and workplace stress of HCAs is hand-held tablet technology. In order to introduce the use of tablets with HCAs, simulations were developed. Once an HCA was comfortable with the tablet, a simulated client was introduced. The HCA interacted with the simulated client and used the tablet applications to assist with providing care. After the simulations, the HCAs participated in a focus group. HCAs completed a survey before and after the tablet training and simulation to determine their perception and acceptance of the tablet. Future deployment and implementation of technologies in home care should be further evaluated for outcomes.


INTRODUCTION
Health care aides (HCAs) are critical for the delivery of home care and provide a range of services to people with age-related chronic conditions, or individuals unable to care for themselves independently. About 1.2 million Canadians, 65 years and older, use home-care services annually [1]. In both the US and Canada, the demand for HCA services is increasing exponentially due to the aging population [2]. However, the current HCA supply will not keep pace with this increasing demand without fundamental changes in their work environment. One possible solution to alleviate some of the workflow challenges and workplace stress of HCAs is information communication technology (ICT), or more specifically, hand-held mobile devices.
In particular, the fundamental hypothesis underlying our work was that HCAs would be more effective in their tasks and more satisfied with their careers if they had ICT support for their care-delivery activities, including their daily schedule, their clients' care plans, relevant knowledge at the point of care, and the ability to communicate with each other and the home office whenever they deemed it useful.
II. OVERALL PROJECT PHASES The overall purpose of this project was to determine whether ICTs can address some of the workflow challenges HCAs face in Alberta, Canada. The study was conducted in three phases. Phase 1 involved an ethnographic study analyzing HCAs' workflows and team interactions. Based on the ethnographic study conducted in Phase 1, key workflow challenges were identified. Phase 2 involved consultations with service providers and expert groups to help identify potential uses of technology to resolve the issues identified in Phase 1. In addition, the design of an ICT suite occurred, that integrated already available and newly developed technologies to address the issues. Due to current health service policies, we could not measure the actual impact of these technologies in the actual practice, since the current scope of practice for HCAs prevents their deployment. Therefore, Phase 3 involved simulations to determine the HCAs' receptivity to using a tablet and to gather HCAs' and additional health team members' feedback on the utilization of tablets to aide with care provision. This paper reports on Phase 3 of the project, the pilot testing of the simulation protocol and technology simulations with health care aides in order to test the use of the technology to support workflow challenges.

A. The Information Communication Technology Solutions
Participant input from a key stakeholder symposium led to the choice of a tablet based on the Android platform to deploy ICTs to address the prioritized workflow issues.
A number of off-the-shelf applications were chosen to be deployed on the tablet for use by the HCAs. We used Skype to enable video-conferencing between the HCAs and their clients with the home-care office. We selected TiKL for the communications between the home-care team; TiKL is a 'push to talk' walkie-talkie application for chatting and voice communication. We chose Google maps as our geospatial information service to enable path finding to the clients' locations, which can be a challenge for HCAs visiting clients for the first time in sparely marked, rural areas. We also deployed a mobile client for a secure authoritative virtual learning community, established and maintained by home-care experts, the Continuing Care Desktop.
We also developed the HCAMobile App, to enable the HCAs to access their daily schedule, and to access and update the care plan for the clients they visit on a given day. This application ensures that HCAs have up-to-date information on their clients when they visit them and that the client's record is always up to date for the staff at the main office (as no transcription delays are introduced in the process).
Finally, we provided HCAs with a separate device, called SafeTracks, which is a GPS-enabled pendant that regularly reports the owner's location and uses the cellular phone service for to communicate this location to a service provider in case of an emergency.

B. Simulations with HCAs
As the proposed ICT solutions were not covered by provincial health services policies, we could not roll out ICT solutions across the province in current health care practice using real clients. Therefore, it was premature to collect data on ICT uptake by users, efficiency of the health care team and quality of care. Instead, we developed a simulation protocol using three client educators and two occupational therapy students. A client educator is a real client who volunteers (or is paid to) role-play in a scenario for educational or research purposes.
Simulations are often used in health professional education, both pre-licensure and post-graduate to enhance and develop competencies and clinical skills [3]. There is virtually no published literature on the use of simulation to train HCAs to integrate technology into their workflow to positively impact practice.

III. METHODS
The training and simulation protocol was pilot-tested with two health care aides from a local agency that was not a participant site in the project. We conducted interviews and focus groups to gather data on the perspectives of HCAs and managers on simulations using ICT solutions we introduced. These interviews and focus groups were audio-recorded and transcribed verbatim by a professional transcription service. Finally, we analyzed the transcribed data following a focused-ethnography analysis methodology, according to the same protocols used in Phase 1.

A. Training and simulations
In order to introduce the use of tablets with HCAs, simulations were developed. Initial training with the tablet involved basic operating instructions, and then advanced to more complex features, such as taking a picture, using Skype, searching for health-related information using the browser and using the HCA app, an application created by our project to support the efficient scheduling of HCA visits to clients and to provide HCAs with relevant, secure and timely client information at the point of care. Once an HCA was comfortable with the tablet, a simulated client was introduced. The HCA interacted with the simulated client and used the tablet applications to assist with providing care.
Training and simulation sessions took place in a laboratory space at the University of Alberta, while commuting to, and at a client educator's home. The sessions occurred over a period of 4 to 6 hours and covered the following topics: Informed consent, pretraining questionnaire (30 min), introduction to the tablet and applications and a short video (30 min), training (1 to 2 hours), simulation with a "tech buddy", commuting to and interacting with two client educators, interacting with a simulated remote case coordinator (1 hour), posttraining (or post-simulation) questionnaire and focus group (1 hour). In terms of applications, we introduced participants to apps that would be useful in their work, as described below.
The order of the training content facilitated the acceptance of ICT. Training was planned so as to first build on what HCAs might be familiar with, and then introduce applications in the order in which they might be used in their workflow: receiving a client file, navigating to a client's home, accessing a client's information and care plan, communicating with health care professionals and EMS, documenting and receiving/accessing just-intime information and support. During the simulations, HCAs and their tech buddies followed the cues of their client educators and the scenario. A tech buddy was a member of the research team who worked individually with the HCAs to guide their training. The tech buddies worked closely with the HCAs in a non-threatening manner to ensure an increasing comfort level with the HCA when using the tablet.
Over the course of each simulation, the following apps were used, some were developed by the research team, and some were "off-the-shelf": "Fruit Ninja" (to develop comfort with touching the screen and swiping), taking and emailing photos, writing emails, texting, voice dictating, accessing simulated client information and task lists through the HCAMobile application (developed by the research team), documenting task completion and follow up notes (typed and via voice dictation), speaking with one another over TiKL, initiate and receiving calls via Skype, using navigation application to find the way to a client's home, and to determine road and traffic conditions, make emergency calls on SafeTracks, and accessing information through a mobile simulation of the Continuing Care Desktop (an online database of practice guidelines and resources that align with provincial standards of care in continuing care).
After the simulations, the HCAs participated in a focus group. HCAs completed a survey before and after the tablet training and simulation to determine their perception and acceptance of the tablet. Since these technologies were designed to mitigate the challenges identified during Phase 1 of our project, a positive HCA attitude towards them would validate our hypothesis that the technologies could address the workflow challenges facing HCAs.

IV. RESULTS
Fifty-three participants completed the simulations, 32 of whom were HCAs. The individuals who participated in this third phase of the project were from rural/urban, community/facility, public/private locations. Table 1 summarizes the pre-training questionnaire results, which indicate that the HCAs' attitude after the simulations was strongly positive towards the technology; 68% wanted to learn more about the technology. Some participants who initially indicated that they strongly disagreed with the statement "I would use a tablet in my personal life," changed their minds after and stated that they would like to use one in their personal and work lives. These HCAs indicated that going back to the current paper-based system would be frustrating.

A. Focus group interviews
Six key themes were identified from the focus groups: 1) attitudes towards the tablets; 2) positive use of the technology; 3) negative use of the technology; 4) communication with the health team; 5) ICT impact on clients; 6) Recruitment, retention, recognition.

Attitudes towards the tablets
Generally, the HCAs and nurse managers who participated in the focus groups had positive attitudes towards the tablets and how they can benefit their lives on a professional and personal level. For many of the HCAs, their initial attitude was skeptical and almost negative towards the tablet. However, by the end of the training and simulations, the attitudes often changed to be more positive and receptive towards the tablet.