There is more to monitoring a nuclear power plant than meets the eye

High visual salience of alert signals can lead to a counterintuitive increase of reaction times

It is often assumed that rendering an alert signal more salient yields faster responses to this alert. Yet, there might be a trade-off between attracting attention and distracting from task execution. Here we tested this in four behavioral experiments with eye-tracking using an abstract alert-signal paradigm. Participants performed a visual discrimination task (primary task) while occasional alert signals occurred in the visual periphery accompanied by a congruently lateralized tone. Participants had to respond to the alert before proceeding with the primary task. When visual salience (contrast) or auditory salience (tone intensity) of the alert were increased, participants directed their gaze to the alert more quickly. This confirms that more salient alerts attract attention more efficiently. Increasing auditory salience yielded quicker responses for the alert and primary tasks, apparently confirming faster responses altogether. However, increasing visual salience did not yield similar benefits: instead, it increased the time between fixating the alert and responding, as high-salience alerts interfered with alert-task execution. Such task interference by high-salience alert-signals counteracts their more efficient attentional guidance. The design of alert signals must be adapted to a "sweet spot" that optimizes this stimulus-dependent trade-off between maximally rapid attentional orienting and minimal task interference.

Toward Joint Activity Design: Augmenting User-Centered Design with Heuristics for Supporting Joint Activity

From their common roots in Human Factors Engineering, Human-Centered Design and Cognitive Systems Engineering have drifted into distinct fields over the past three decades, each developing beneficial heuristics, design patterns, and evaluation methods for designing for individuals and teams, respectively. GeoHAI, a clinical decision support application for preventing hospital-acquired infection, has yielded positive results in early usability testing and is expected to test positively in supporting joint activity, which will be measured through the novel implementation of Joint Activity Monitoring . The design and implementation of this application provide a demonstration of the possibilities and necessities to unify the work of Human-Centered Design and Cognitive Systems Engineering when designing technologies that are usable and useful to individuals engaged in joint activity with machine counterparts and other people. We are calling this unified process Joint Activity Design, which supports designing for machines to be good team players.

The Validity of the SEEV Model as a Process Measure of Situation Awareness: The Example of a Simulated Endotracheal Intubation

OBJECTIVE

In the context of anesthesiology, we investigated whether the salience effort expectancy value (SEEV) model fit is associated with situation awareness and perception scores.

BACKGROUND

The distribution of visual attention is important for situation awareness-that is, understanding what is going on-in safety-critical domains. Although the SEEV model has been suggested as a process situation awareness measure, the validity of the model as a predictor of situation awareness has not been tested.

METHOD

In a medical simulation, 31 senior and 30 junior anesthesiologists wore a mobile eye tracker and induced general anesthesia into a simulated patient. When inserting a breathing tube into the mannequin's trachea (endotracheal intubation), the scenario included several clinically relevant events for situation awareness and general events in the environment. Both were assessed using direct awareness measures.

RESULTS

The overall SEEV model fit was good with no difference between junior and senior anesthesiologists. Overall, the situation awareness scores were low. As expected, the SEEV model fits showed significant positive correlations with situation awareness level 1 scores.

CONCLUSION

The SEEV model seems to be suitable as a process situation awareness measure to predict and investigate the perception of changes in the environment (situation awareness level 1). The situation awareness scores indicated that anesthesiologists seem not to perceive the environment well during endotracheal intubation.

APPLICATION

The SEEV model fit can be used to capture and assess situation awareness level 1. During endotracheal intubation, anesthesiologists should be supported by technology or staff to notice changes in the environment.

Investigating Cognitive Load in Energy Network Control Rooms: Recommendations for Future Designs

This study analyzed and explored the cognitive load of Australian energy market operators managing one of the longest inter-connected electrical networks in the world. Each operator uses a workstation with seven screens in an active control room environment, with a large coordination screen to show information and enable collaboration between different control centers. Cognitive load was assessed during both training scenarios and regular control room operations via the integration of subjective and physiological measures. Eye-tracking glasses were also used to analyze the operators gaze behavior. Our results indicate that different events (normal or unexpected), different participants for the same session, and different periods of one session all have varying degrees of cognitive load. The system design was observed to be inefficient in some situations and to have an adverse affect on cognitive load. In critical situations for instance, operator collaboration was high and the coordination screen was used heavily when collaborating between two control centers, yet integration with the system could be improved. Eye tracking data analysis showed that the layout of applications across the seven screens was not optimal for many tasks. Improved layout strategies, potential combination of applications, redesigning of certain applications, and linked views are all recommended for further exploration in addition to improved integration of procedures and linking alarms to visual cues.

Data in Context: How Digital Transformation Can Support Human Reasoning in Cyber-Physical Production Systems

In traditional production plants, current technologies do not provide sufficient context to support information integration and interpretation. Digital transformation technologies have the potential to support contextualization, but it is unclear how this can be achieved. The present article presents a selection of the psychological literature in four areas relevant to contextualization: information sampling, information integration, categorization, and causal reasoning. Characteristic biases and limitations of human information processing are discussed. Based on this literature, we derive functional requirements for digital transformation technologies, focusing on the cognitive activities they should support. We then present a selection of technologies that have the potential to foster contextualization. These technologies enable the modelling of system relations, the integration of data from different sources, and the connection of the present situation with historical data. We illustrate how these technologies can support contextual reasoning, and highlight challenges that should be addressed when designing human–machine cooperation in cyber-physical production systems.

Biosignal-Based Attention Monitoring to Support Nuclear Operator Safety-Relevant Tasks

In the main control room (MCR) of a nuclear power plant (NPP), the quality of an operator's performance can depend on their level of attention to the task. Insufficient operator attention accounted for more than 26% of the total causes of human errors and is the highest category for errors. It is therefore necessary to check whether operators are sufficiently attentive either as supervisors or peers during reactor operation. Recently, digital control technologies have been introduced to the operating environment of an NPP MCR. These upgrades are expected to enhance plant and operator performance. At the same time, because personal computers are used in the advanced MCR, the operators perform more cognitive works than physical work. However, operators may not consciously check fellow operators' attention in this environment indicating potentially higher importance of the role of operator attention. Therefore, remote measurement of an operator's attention in real time would be a useful tool, providing feedback to supervisors. The objective of this study is to investigate the development of quantitative indicators that can identify an operator's attention, to diagnose or detect a lack of operator attention thus preventing potential human errors in advanced MCRs. To establish a robust baseline of operator attention, this study used two of the widely used biosignals: electroencephalography (EEG) and eye movement. We designed an experiment to collect EEG and eye movements of the subjects who were monitoring and diagnosing nuclear operator safety-relevant tasks. There was a statistically significant difference between biosignals with and without appropriate attention. Furthermore, an average classification accuracy of about 90% was obtained by the k-nearest neighbors and support vector machine classifiers with a few EEG and eye movements features. Potential applications of EEG and eye movement measures in monitoring and diagnosis tasks in an NPP MCR are also discussed.

Uncovering the Value of a Historical Paper-Based Collaborative Artifact: The Nursing Unit's Kardex System

We identify useful functions and usability characteristics of a historical cognitive artifact used by nurses working in a hospital unit, the Kardex. By identifying aspects of a widely used artifact, we uncover opportunities to improve the usefulness of current systems for hospital nurses. We conducted semi-structured interviews with registered nurses about their prior experience with the Kardex. Questions included what elements of the Kardex are missing from their current electronic support. Memos were generated iteratively from interview transcript data and grouped into themes. Eighteen nurses from multiple clinical areas participated and had a median of 25–29 years of nursing experience. The themes were: (1) a status at a glance summary for each patient, (2) a prospective memory aid, (3) efficiency and ease of use, (4) updating information required to maintain value, (5) activity management, (6) verbal handover during shift-to-shift report, (7) narrative charting and personalized care, and (8) non-clinical care communication. Implications for digital support are to provide immediate, portable access to a standardized patient summary, support for nurses to manage their planned activities during a series of shifts, provide unstructured text fields for narrative charting, and to support adding informal notes for personalized care.

Human Performance Analysis of Processes for Retrieving Beidou Satellite Navigation System During Breakdown

Satellite navigation systems provide continuous, timely, and accurate signals of location, speed, and time to users all over the world. Although the running of these systems has become highly automated, the human operator is still vital for its continued operation, especially when certain equipment failures occur. In this paper, we examined 180 incidents of one particular type of equipment failure and the whole recovery process as recorded in the log files from a ground control center of the Beidou satellite navigation system. We extracted the information, including the technical description of the failure, the time when the fault occurred, the full recovery time, and the demographic information of the team members on the shift responsible for responding to the failure. We then transformed these information into the cognitive complexity of the task, time of day, shift handover period, and team skill composition. Multiple regression analysis showed that task complexity and shift handover were key predictors of recovery time. Time of day also influenced the recovery time, during midnight to 4 a.m., operators made longer responses. We also found that the fault handling processes could be improved if the team's most adept member is more skillful at that role than in other teams. We discussed the theoretical and practical implication of this study.

User-defined information sharing for team situation awareness and teamwork

Team members have different roles in various scenarios to maintain situation awareness. A collaborative system should therefore provide appropriate information to the appropriate person at an appropriate time. Considering the mismatch between the designed and actually used information, this paper proposed that users should define what information to share with their team-mates. Thirty-six participants, who formed eighteen teams, used both the traditional and user-defined shared displays to perform failure diagnosis on the context of nuclear power plants. The user-defined shared display exhibited shorter diagnosis time without significant difference in correctness. Information quality, instead of quantity, was positively correlated with team mutual awareness. This study provides empirical evidence that user-defined information sharing is effective at improving operator's diagnosis performance, so the users should be able to tailor the information based on requirements.Practitioner Summary: To support team situation awareness and teamwork, the present study proposed that users should define what information to share with their team-mates. The laboratory experiment shows that user-defined information sharing shortens operator diagnosis time without degrading correctness. Information quality appears more important than information quantity in enhancing team mutual awareness.

Workarounds to Intended Use of Health Information Technology: A Narrative Review of the Human Factors Engineering Literature

Objective To integrate and synthesize insights from recent studies of workarounds to the intended use of health information technology (HIT) by health care professionals. Background Systems are safest when the documentation of how work is done in policies and procedures closely matches what people actually do when they are working. Proactively identifying and managing workarounds to the intended use of technology, including deviations from expected workflows, can improve system safety. Method A narrative review of studies of workarounds with HIT was conducted to identify themes in the literature. Results Three themes were identified: (1) Users circumvented new additional steps in the workflow when using HIT, (2) interdisciplinary team members communicated via HIT in text fields that were intended for other purposes, and (3) locally developed paper-based and manual whiteboard systems were used instead of HIT to support situation awareness of individuals and groups; an example of a locally developed system was handwritten notes about a patient on a piece of paper folded up and carried in a nurse's pocket. Conclusion Workarounds were employed to avoid changes to workflow, enable interdisciplinary communication, coordinate activities, and have real-time portable access to summarized and synthesized information. Application Implications for practice include providing summary overview displays, explicitly supporting role-based communication and coordination through HIT, and reducing the risk to reputation due to electronic monitoring of individual performance.

Effects of integrated designs of alarm and process information on diagnosis performance in digital nuclear power plants

In the main control rooms of nuclear power plants (NPPs), operators frequently switch between alarm displays and system-information displays to incorporate information from different screens. In this study, we investigated two integrated designs of alarm and process information - integrating alarm information into process displays (denoted as Alarm2Process integration) and integrating process information into alarm displays (denoted as Process2Alarm integration). To analyse the effects of the two integration approaches and time pressure on the diagnosis performance, a laboratory experiment was conducted with ninety-six students. The results show that compared with the non-integrated case, Process2Alarm integration yields better diagnosis performance in terms of diagnosis accuracy, time required to generate correct hypothesis and completion time. In contrast, the Alarm2Process integration leads to higher levels of workload, with no improvement in diagnosis performance. The diagnosis performance of Process2Alarm integration was consistently better than that of Alarm2Process integration, regardless of the levels of time pressure. Practitioner Summary: To facilitate operator's synthesis of NPP information when performing diagnosis tasks, we proposed to integrate process information into alarm displays. The laboratory validation shows that the integration approach significantly improves the diagnosis performance for both low and high time-pressure levels.

Development and evaluation of a monitoring-aid system for a nuclear power plant in control room system manipulation

BACKGROUND

In an advanced nuclear power plant (NPP), the operators are responsible for monitoring a massive number of alarm parameters.

OBJECTIVE

To assist the operators, a monitoring-aid system (MAS), that applies four quality control chart methods, was proposed and evaluated.

METHODS

Two types of MAS, namely, text and graph marks, were proposed and compared with the original display. To validate the proposed MAS, 17 professional engineers and operators were invited to join an experiment. Two different system states, normal and abnormal, were simulated. The operators were asked to manipulate the system, monitor the critical parameters, search for operational procedures, and deal with other secondary tasks. The primary and secondary task performance and heart rate were measured. After each task was conducted, three subjective rating questionnaires, namely, mental workload, situation awareness, and preference ratings, were implemented for the proposed MAS and the original system.

RESULTS

With the assistance of the MAS, the alarm detection rate, secondary task performance, and subjective mental workload demonstrate significant improvements. The proposed MAS helps the operators monitor critical parameters.

CONCLUSIONS

Therefore, the MAS should be considered for implementation with the control panel to increase the safety of NPPs. Furthermore, the MAS could reduce the mental workload might decrease the health hazard of the operators.

Procedure and information displays in advanced nuclear control rooms: experimental evaluation of an integrated design

In the main control rooms of nuclear power plants, operators frequently have to switch between procedure displays and system information displays. In this study, we proposed an operation-unit-based integrated design, which combines the two displays to facilitate the synthesis of information. We grouped actions that complete a single goal into operation units and showed these operation units on the displays of system states. In addition, we used different levels of visual salience to highlight the current unit and provided a list of execution history records. A laboratory experiment, with 42 students performing a simulated procedure to deal with unexpected high pressuriser level, was conducted to compare this design against an action-based integrated design and the existing separated-displays design. The results indicate that our operation-unit-based integrated design yields the best performance in terms of time and completion rate and helped more participants to detect unexpected system failures. Practitioner Summary: In current nuclear control rooms, operators frequently have to switch between procedure and system information displays. We developed an integrated design that incorporates procedure information into system displays. A laboratory study showed that the proposed design significantly improved participants' performance and increased the probability of detecting unexpected system failures.

The Automation-by-Expertise-by-Training Interaction

OBJECTIVE

I introduce the automation-by-expertise-by-training interaction in automated systems and discuss its influence on operator performance.

BACKGROUND

Transportation accidents that, across a 30-year interval demonstrated identical automation-related operator errors, suggest a need to reexamine traditional views of automation.

METHOD

I review accident investigation reports, regulator studies, and literature on human computer interaction, expertise, and training and discuss how failing to attend to the interaction of automation, expertise level, and training has enabled operators to commit identical automation-related errors.

RESULTS

Automated systems continue to provide capabilities exceeding operators' need for effective system operation and provide interfaces that can hinder, rather than enhance, operator automation-related situation awareness. Because of limitations in time and resources, training programs do not provide operators the expertise needed to effectively operate these automated systems, requiring them to obtain the expertise ad hoc during system operations. As a result, many do not acquire necessary automation-related system expertise.

CONCLUSION

Integrating automation with expected operator expertise levels, and within training programs that provide operators the necessary automation expertise, can reduce opportunities for automation-related operator errors.

APPLICATION

Research to address the automation-by-expertise-by-training interaction is needed. However, such research must meet challenges inherent to examining realistic sociotechnical system automation features with representative samples of operators, perhaps by using observational and ethnographic research. Research in this domain should improve the integration of design and training and, it is hoped, enhance operator performance.

Cognitive engineering and health informatics: Applications and intersections

Cognitive engineering is an applied field with roots in both cognitive science and engineering that has been used to support design of information displays, decision support, human-automation interaction, and training in numerous high risk domains ranging from nuclear power plant control to transportation and defense systems. Cognitive engineering provides a set of structured, analytic methods for data collection and analysis that intersect with and complement methods of Cognitive Informatics. These methods support discovery of aspects of the work that make performance challenging, as well as the knowledge, skills, and strategies that experts use to meet those challenges. Importantly, cognitive engineering methods provide novel representations that highlight the inherent complexities of the work domain and traceable links between the results of cognitive analyses and actionable design requirements. This article provides an overview of relevant cognitive engineering methods, and illustrates how they have been applied to the design of health information technology (HIT) systems. Additionally, although cognitive engineering methods have been applied in the design of user-centered informatics systems, methods drawn from informatics are not typically incorporated into a cognitive engineering analysis. This article presents a discussion regarding ways in which data-rich methods can inform cognitive engineering.

Situation awareness acquired from monitoring process plants - the Process Overview concept and measure

We introduce Process Overview, a situation awareness characterisation of the knowledge derived from monitoring process plants. Process Overview is based on observational studies of process control work in the literature. The characterisation is applied to develop a query-based measure called the Process Overview Measure. The goal of the measure is to improve coupling between situation and awareness according to process plant properties and operator cognitive work. A companion article presents the empirical evaluation of the Process Overview Measure in a realistic process control setting. The Process Overview Measure demonstrated sensitivity and validity by revealing significant effects of experimental manipulations that corroborated with other empirical results. The measure also demonstrated adequate inter-rater reliability and practicality for measuring SA based on data collected by process experts. Practitioner Summary: The Process Overview Measure is a query-based measure for assessing operator situation awareness from monitoring process plants in representative settings.

Defining the methodological challenges and opportunities for an effective science of sociotechnical systems and safety

An important part of the application of sociotechnical systems theory (STS) is the development of methods, tools and techniques to assess human factors and ergonomics workplace requirements. We focus in this paper on describing and evaluating current STS methods for workplace safety, as well as outlining a set of six case studies covering the application of these methods to a range of safety contexts. We also describe an evaluation of the methods in terms of ratings of their ability to address a set of theoretical and practical questions (e.g. the degree to which methods capture static/dynamic aspects of tasks and interactions between system levels). The outcomes from the evaluation highlight a set of gaps relating to the coverage and applicability of current methods for STS and safety (e.g. coverage of external influences on system functioning; method usability). The final sections of the paper describe a set of future challenges, as well as some practical suggestions for tackling these.

PRACTITIONER SUMMARY

We provide an up-to-date review of STS methods, a set of case studies illustrating their use and an evaluation of their strengths and weaknesses. The paper concludes with a 'roadmap' for future work.

Communicating a Model-Based Energy Performance Indicator

Monitoring energy performance can help organizations make better efficiency investment and operational decisions. However, key energy performance indicators can be difficult to interpret because they blend effects of real system changes and statistical model behavior. We designed an explanatory energy model report for a commercial energy-monitoring product. The design was guided by a task analysis based on user observation, interviews, and designer participation. It was refined with usability heuristics, task walk-throughs, and tabletop discussions. Our collaborator is incorporating the design into its next product revision.

Inter-rater reliability of query/probe-based techniques for measuring situation awareness

Query- or probe-based situation awareness (SA) measures sometimes rely on process experts to evaluate operator actions and system states when used in representative settings. This introduces variability of human judgement into the measurements that require inter-rater reliability assessment. However, the literature neglects inter-rater reliability of query/probe-based SA measures. We recruited process experts to provide reference keys to SA queries in trials of a full-scope nuclear power plant simulator experiment to investigate the inter-rater reliability of a query-based SA measure. The query-based SA measure demonstrated only 'moderate' inter-rater reliability even though the queries were seemingly direct. The level of agreement was significantly different across pairs of experts who had different levels of exposure to the experiment. The results caution that inter-rater reliability of query/probe-based techniques for measuring SA cannot be assumed in representative settings. Knowledge about the experiment as well as the domain is critical to forming reliable expert judgements.

PRACTITIONER SUMMARY

When the responses of domain experts are treated as the correct answers to the queries or probes of SA measures used in representative or industrial settings, practitioners should take caution in assuming (or otherwise assess) inter-rater reliability of the situation awareness measures.

Automation and adaptation: Nurses' problem-solving behavior following the implementation of bar coded medication administration technology

The most common change facing nurses today is new technology, particularly bar coded medication administration technology (BCMA). However, there is a dearth of knowledge on how BCMA alters nursing work. This study investigated how BCMA technology affected nursing work, particularly nurses' operational problem-solving behavior. Cognitive systems engineering observations and interviews were conducted after the implementation of BCMA in three nursing units of a freestanding pediatric hospital. Problem-solving behavior, associated problems, and goals, were specifically defined and extracted from observed episodes of care. Three broad themes regarding BCMA's impact on problem solving were identified. First, BCMA allowed nurses to invent new problem-solving behavior to deal with pre-existing problems. Second, BCMA made it difficult or impossible to apply some problem-solving behaviors that were commonly used pre-BCMA, often requiring nurses to use potentially risky workarounds to achieve their goals. Third, BCMA created new problems that nurses were either able to solve using familiar or novel problem-solving behaviors, or unable to solve effectively. Results from this study shed light on hidden hazards and suggest three critical design needs: (1) ecologically valid design; (2) anticipatory control; and (3) basic usability. Principled studies of the actual nature of clinicians' work, including problem solving, are necessary to uncover hidden hazards and to inform health information technology design and redesign.

Review of computerized physician handoff tools for improving the quality of patient care

BACKGROUND

Computerized physician handoff tools (CHTs) are designed to allow distributed access and synchronous archiving of patient information via Internet protocols. However, their impact on the quality of physician handoff, patient care, and physician work efficiency have not been extensively analyzed.

METHODS

We searched MEDLINE, PUBMED, EMBASE, CINAHL, the Cochrane database for systematic reviews, and the Cochrane central register for clinical trials, from January 1960 to December 2011. We selected all articles that reported randomized controlled trials, controlled clinical trials, controlled before-after studies, and quasi-experimental studies of the use of CHTs for physician handoff for hospitalized patients. Relevant studies were evaluated independently for their eligibility for inclusion by 2 individuals in a 2-stage process.

RESULTS

The literature search identified 1026 citations of which 6 satisfied the inclusion criteria. One study was a randomized controlled trial, whereas 5 were controlled before-after studies. Two studies showed that using CHTs reduced adverse events and missing patients. Three studies demonstrated improved overall quality of handoff after CHT implementation. One study suggested that CHTs could potentially enhance work efficiency and continuity of care during physician handoff. Conflicting impacts on consistency of handoff were found in 2 studies.

CONCLUSIONS

The evidence that CHTs improve physician handoff and quality of hospitalized patient care is limited. CHT may improve the efficiency of physician work, reduce adverse events, and increase the completeness of physician handoffs. However, further evaluation using rigorous study designs is needed.

A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers

BACKGROUND

Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward.

METHODS

We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction.

RESULTS

During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently "lost" to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9±1.1, 8.1±1.0, and 7.9±1.7, respectively.

CONCLUSION

The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety.

The Four-Second Supervisor: Multi-Tasking Supervision and Its Support

Supervision is a broad term that covers a wide range of task environments and cognitive activities. Here, we describe one specific type called multi-tasking supervision. It involves rapidly assessing a set of distinct systems or situations and determining where attention is needed moment by moment. Multi-tasking supervision is a key component of many command and control, and other, tasks. This paper focuses on understanding the cognitive needs of multi-tasking supervision and developing support concepts for it. First, we place multi-tasking supervision within the context of other types of supervision. Next, we consider the types of tasks and work environments that are appropriate for multi-tasking supervision. Finally, we discuss computer display concepts for supporting multi-tasking supervision.

Can cultural differences lead to accidents? Team cultural differences and sociotechnical system operations

OBJECTIVE

I discuss cultural factors and how they may influence sociotechnical system operations.

BACKGROUND

Investigations of several major transportation accidents suggest that cultural factors may have played a role in the causes of the accidents. However, research has not fully addressed how cultural factors can influence sociotechnical systems.

METHOD

I review literature on cultural differences in general and cultural factors in sociotechnical systems and discuss how these differences can affect team performance in sociotechnical systems.

RESULTS

Cultural differences have been observed in social and interpersonal dimensions and in cognitive and perceptual styles; these differences can affect multioperator team performance.

CONCLUSION

Cultural factors may account for team errors in sociotechnical systems, most likely during high-workload, high-stress operational phases. However, much of the research on cultural factors has methodological and interpretive shortcomings that limit their applicability to sociotechnical systems.

APPLICATION

Although some research has been conducted on the role of cultural differences on team performance in sociotechnical system operations, considerable work remains to be done before the effects of these differences can be fully understood. I propose a model that illustrates how culture can interact with sociotechnical system operations and suggest avenues of future research. Given methodological challenges in measuring cultural differences and team performance in sociotechnical system operations, research in these systems should use a variety of methodologies to better understand how culture can affect multioperator team performance in these systems.

Interruptions in healthcare: theoretical views

BACKGROUND

Researchers in healthcare have begun to investigate interruptions extensively, given evidence for the adverse effects of work interruptions in other domains and given the highly interruptive hospital environment. In this paper, we reviewed literature on interruptions in critical care and medication dispensing settings in search of evidence for a relationship between interruptions and adverse events.

METHODS

The literature search included the databases MEDLINE, CINAHL+Pre CINHAL, Health Sources: Nursing Academic Edition, EMBASE, PsycINFO, ISI Web of Science and Ergonomics Abstracts. The paper titles and abstracts were subsequently reviewed. After the initial search, we reviewed paper titles and abstracts to define the subset for review.

RESULTS

We currently lack evidence in healthcare of the extent to which interruptions lead to adverse effects. The lack of evidence may be due to the descriptive rather than causal nature of most studies, the lack of theory motivating investigations of the relationship, the fact that healthcare is a complex and varied domain, and inadequate conceptualizations of accident aetiology. We identify two recent accident theories in which the relationship between activity and medical errors is complex, indicating that even when it is sought, causal evidence is hard to find.

DISCUSSION

Future research on interruptions in healthcare settings should focus on the following. First, prospective memory research and distributed cognition can provide a theoretical background for understanding the impact of interruptions and so could provide guidance for future empirical research on interruptions and the planning of actions in healthcare. Second, studying how interruptions are successfully rather than unsuccessfully overcome may better help us understand their effects. Third, because interruptions almost always have positive and adverse effects, more appropriate dependent variables could be chosen.

Proactive Process Control Monitoring using Trends

Proactive monitoring involves, in part, the effective use of time-based information such as Trends. In the oil and chemical industries, the benefits of a proactive approach include less down-time, fewer alarm-flooding stresses, and maximized product output. This report aims to describe the effective use of trend displays by examining how expert Distributed Control System (DCS) operators monitored and visualized trends proactively. We found two preferences for trend display layouts, suggesting a lack of design guidelines and understanding towards optimum trend usage performance in the industry. The decision process in proactive monitoring is discussed, along with the attributes that define an expert trends user.

Human factors contributions to knowledge elicitation

OBJECTIVE

The objective of this article is to lay out contributions of human factors to knowledge elicitation (KE) methodology.

BACKGROUND

The background is historical, dating to about 1985, and involves the convergence of expert systems with applied psychology and cognitive psychology.

METHOD

The method is a literature review, focusing on past issues of Human Factors.

RESULTS

Human factors researchers have contributed significantly to KE methodology. However, KE methodology "belongs to" a number of communities of practice and has applications that transcend individual disciplines.

CONCLUSION

Knowledge elicitation, thought of as a kind of cognitive task analysis, grows in importance with the increasing use of information technology to form complex sociotechnical work systems and the increasing importance of expertise to knowledge-based organizations.

APPLICATION

I discuss some open issues for further research and methodological investigation.

Uncovering the requirements of cognitive work

OBJECTIVE

In this article, the author provides an overview of cognitive analysis methods and how they can be used to inform system analysis and design.

BACKGROUND

Human factors has seen a shift toward modeling and support of cognitively intensive work (e.g., military command and control, medical planning and decision making, supervisory control of automated systems). Cognitive task analysis and cognitive work analysis methods extend traditional task analysis techniques to uncover the knowledge and thought processes that underlie performance in cognitively complex settings.

METHODS

The author reviews the multidisciplinary roots of cognitive analysis and the variety of cognitive task analysis and cognitive work analysis methods that have emerged.

RESULTS

Cognitive analysis methods have been used successfully to guide system design, as well as development of function allocation, team structure, and training, so as to enhance performance and reduce the potential for error.

CONCLUSIONS

A comprehensive characterization of cognitive work requires two mutually informing analyses: (a) examination of domain characteristics and constraints that define cognitive requirements and challenges and (b) examination of practitioner knowledge and strategies that underlie both expert and error-vulnerable performance. A variety of specific methods can be adapted to achieve these aims within the pragmatic constraints of particular projects.

APPLICATION

Cognitive analysis methods can be used effectively to anticipate cognitive performance problems and specify ways to improve individual and team cognitive performance (be it through new forms of training, user interfaces, or decision aids).

Human processes of control: tracing the goals and strategies of control room teams

This study utilized a process tracing methodology to analyse the goals and strategies of control room teams in dealing with an unpredicted plant disturbance. The human processes of control used by operators and their supervisors, and interactions between them, were analysed during phases of detection, diagnosis, and control of a small plant leak. Five control room teams were videotaped tackling this simulated scenario on a full-scale simulator. The results found substantial differences both within and between teams in how the goals of monitoring and implementing procedures during the detection phase, and problem-solving and plant control during the diagnosis phase were achieved. The temporal patterning of the activities associated with these goals revealed that the teams used different strategies. The training implications of these findings are discussed, in particular with respect to the control room supervisor who had a pivotal role.

Evolvable work-centred support systems for command and control: creating systems users can adapt to meet changing demands

Military command and control (C2) organizations are complex socio-technical systems which must constantly adapt to meet changing operational requirements. We describe our experiences in developing a work-centred support system (WCSS) to aid weather forecasting and monitoring in a military airlift C2 organization as an illustrative case. As part of the development process we conducted field observations both before and after introduction of the WCSS in their operations centre. A striking finding was the constant changes that operations personnel faced (changes in goals and priorities, changes in scale of operations, changes in team roles and structure, and changes in information sources and systems). We describe the changes in workplace demands that we observed and the modifications we needed to make to the WCSS in response. For today's fielded systems, it is seldom possible to make changes that are responsive to users' changing requirements in a timely manner. We argue for the need to incorporate facilities that enable users to adapt their systems to the changing requirements of work and point to some promising directions towards evolvable work-centred support systems.