Case Study Research: An Example to Study the Tele

Case Study Research: An Example to Study the Tele-ICU Peter HOONAKKER1, Pascale CARAYON1,2, Adjhaporn KHUNLERTKIT1,2, Kerry MCGUIRE1,2 and Doug WIEGMANN2 1 2

Center for Quality and Productivity Improvement Department of Industrial and Systems Engineering University of Wisconsin-Madison Madison, WI, USA

Abstract In this paper, we describe advantages and disadvantages of a multiple case study research design to examine how tele-Intensive Care Unit (ICU) nurses sustain dynamic relationships with nurses in multiple ICUs. The analysis of one tele-ICU (individual case) allows us to examine communication styles used by the tele-ICU nurses and to link them to the particular characteristics and context of the tele-ICU. The analysis of several cases produces information about differences in communication by tele-ICU nurses. Key-words: Tele-ICU, multiple case study design, communication, nurses 1. Introduction For a long time, the case study –an in-depth investigation of a single event, individual, group, or organization- has had a negative reputation: case studies were considered as a weak social science method. Case studies were considered to be appropriate only to conduct the exploratory phase of a study, research methods such as surveys were better suited for the descriptive phase of a study and scientific experiments were the strongest method to establish causal relations (Platt, 1992; Yin, 1984). However, several famous case studies have shown that –when conducted properly- case studies can make a significant scientific contribution: Allison’s (1971) Essence of Decision: Explaining the Cuban Missile Crisis and Bernstein & Woodward’s (1974) All the Presidents Men. A major concern with case studies has been the lack of rigor and, consequently, poor validity and reliability. With regard to external validity, a major question is about the generalizability of results obtained from a single case. Recently, researchers have acknowledged that case study research can make significant scientific contributions and have proposed various guidelines for conducting case study research (Brown & Eisenhardt, 1997; Eisenhardt, 1989). Case studies typically combine several data collection methods such as archives, observations, interviews and questionnaires. This combination of different data collection methods can contribute to validity and reliability of the case study design.

1.1 The tele-Intensive Care Unit Supply of ICU providers is not increasing proportionally to demand (Angus, et al., 2000). The tele-ICU is, therefore, seen as a response to the shortage of critical care providers. Tele-ICUs can provide supplementary resources and help to the care provided by the ICU team at the bedside. Nearly 10% of all ICU patients are currently monitored by tele-ICUs. Intensivists and nurses in the tele-ICU support ICUs to provide 24/7 care, and can potentially improve the quality and safety of patient care (Breslow, et al., 2004; Rosenfeld, et al., 2000). One tele-ICU can for example monitor 16 ICUs in 12 different hospitals. A tele-ICU nurse can monitor about 50 Interactions with each ICU: ICU patients in several different ICUs - group cohesion - communication ICU #1 (see figure 1). This environment poses - dealing with conflict/disagreement - trust unique challenges. For instance, a - satisfaction with ICU tele-ICU nurse collaborates with many nurses and other healthcare Virtual ICU nurse ICU #2 providers working in various ICUs, in multiple hospitals, simultaneously. Despite the many reported successes of the tele-ICU organization, research ICU #3 Outcomes - virtual nurse: on tele-ICU is extremely limited; in - workload - performance particular nursing issues related to - job satisfaction tele-ICU have been overlooked - burnout (Cummings, Krsek, Vermoch, & Characteristics of each ICU: ICU #4 - size Matuszewski, 2007). Little is known - type (e.g., medical, cardiac, pediatric) - hospital about the work of nurses in the tele- organizational relation between ICU and virtual ICU ICU. Figure 1: Tele-ICU nurse 1.2 Communication in health care According to The Joint Commission (2007), two-thirds of the root causes of sentinel events (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient's illness) in the period 1995-2005 were communication-related. Several studies have shown that communication and coordination of providers within the ICU, as well as with other healthcare staff outside of the ICU, are strong contributors to patient and staff outcomes (Beuscart-Zephir, et al., 2005; Shortell, et al., 1994). However, we know relatively little about communication and what aspects of communication are important in relation to patient safety and quality of care. We know very little about communication between the tele-ICUs and the ICUs, but we assume that communication in the collaboration between the tele-ICUs and the ICUs they monitor is as important as communication within ICUs. In this paper, we describe how we use a multiple case study research design approach to examine how tele-ICU nurses deal with dynamic relationships when monitoring multiple ICUs and more specifically, how they communicate with ICU nurses.

2.

Methods

2.1 Design and Setting This study uses the multiple case study research design proposed by Eisenhardt and colleagues (Brown & Eisenhardt, 1997; Eisenhardt, 1989). Case study research helps researchers to understand a complex issue in its organizational context. Case study research emphasizes detailed contextual analysis of a limited number of events or conditions and their relationships. The case study research method is defined as: “an empirical inquiry that investigates a contemporary phenomenon within its real-life context; when the boundaries between phenomenon and context are not clearly evident; and in which multiple sources of evidence are used” (Yin, 1984 p. 23). We collected data at 4 tele-ICUs that varies in size and years of experience (see table 1). 2.2 Data collection and data collection instruments We used the following data collection methods: checklists, observations, semi-structured interviews, questionnaire surveys and field notes. All data collection instruments were tested in a pilot-study with a local tele-ICU. The checklist provided us with general information about the tele-ICU. Before the site visits, we sent the tele-ICU a form with questions about how long the tele-ICU had existed; the number of ICUs monitored; the number of tele-ICU intensivists and nurses employed; their shifts, etc… (see Table 1). We conducted 160 hours of observations in the four tele-ICUs: 40 hour per tele-ICU. We also conducted semi-structured interviews with 10 nurses in each tele-ICU for a total of 40 interviews. Interviews lasted on average 71 minutes (ranging from 46 to 139 minutes). We developed a questionnaire that was distributed to all nurses in the four tele-ICUs. The overall questionnaire response rate was 84%. 3.

Results

3.1 Checklists Table 1: Characteristics of participating tele-ICUs TICU #1 How long has the tele-ICU (TICU) existed? 4 years How many ICUs are connected to the TICU? 14 How many hospitals are connected to the TICU? 12 How many beds are monitored by the TICU? 153 How many nurses work in the TICU? 29 How many TICU nurses also work at the bedside 18 in the ICUs monitored by the TICU? (62%) How many beds does a TICU nurse monitor? 30 - 40 How many ICUs does a TICU nurse monitor? 2-6 How many physicians work in the TICU? 17

TICU #2 4 years 13 9 120 28 14 (64%) 30 Varies 23

TICU #3 10 years 7 5 103 14 5 (31%) ~ 50 3-4 15

TICU #4 6 years 15 8 260 42 ~7 (17%) 37 - 52 1-3 20

The 4 tele-ICUs differ on many characteristics. For example, tele-ICU #1 has existed for more than 10 years, while tele-ICUs #2 and #3 have only existed for 4 years. There are also differences in how many hospitals, ICUs and beds are connected to the tele-ICU and consequently, how many nurses and physicians are employed in the tele-ICU. For example, tele-ICU #3 (the smallest) is connected to 5 hospitals and 7 ICUs and monitors a maximum of 103 beds. Tele-ICU #4 (the largest) is connected to 8 hospitals and 15 ICUs and monitors 260 beds. Tele-ICU 3# employs 10 nurses (and 3 flex nurses), and tele-ICU #4 employs 43 nurses. 3.2 Observations Results in Table 2 show that tele-ICU nurses spend more than two-thirds of their time (around 70%) on information management (e-Care manager, EHR, monitoring and assessing the patient) and about one-quarter of their time on communication. Table 2 Percentage time spent on different activities, by tele-ICU (TICU) TICU 1 TICU 2 TICU 3 TICU 4 Category Information management 71.3% 69.2% 72.8% 86.8% Communication 26.1% 29.5% 25.3% 11.2% Other 2.6% 1.4% 1.9% 2.0% 100% 100% 100% 100% Total The different tele-ICUs spend about equal time on the different activities, with an exception for tele-ICU #4 where significantly less time is spent on communication and more time is spent on information management. Tele-ICU#4 has developed special software to facilitate communication in the tele-ICU. Results (see Figure 2) show that most of the communication occurs within the tele-ICU (78%) with other tele-ICU nurses (43%); other people in the tele-ICU (25%); and with tele-ICU physicians (10%). Only 10% of communication occurs with the ICUs: most of the time with ICU nurses (8%), others (non identified people in the ICU), patients and family (1%) and sporadically with ICU physicians (0.05%). In 9% of the observations it was impossible to identify who the nurse communicated with (Other) and in 2% of the time the nurse was listening to other conversations (2.3% non-participatory communication). Figure 2: Communication 3.3 Questionnaire survey Tele-ICU #2 scores highest on communication openness with ICU nurses and lowest on lack of communication accuracy (see Table 3). Tele-ICU #3 scores lowest on communication openness. Tele-ICU #1 has the most complaints about communication accuracy, but also scores highest on communication timeliness. Differences between the 4 tele-ICUs in lack of communication accuracy are significant (F=6.2, p