In MIRROR we support more reflective observations by care staff through the use of microblogging – in essence each member of care staff posts each observation in real-time using a microblogging tool. Here we describe the tools and approach applied in the first year of the project. We then outline our plan for a longer and wider trial scheduled for early 2012.

Microblogging as a Tool for Internal Communication

Microblogging allows users to post short updates. For example in Twitter these posts are known as tweets and can contain up to 140 characters. These messages appear in chronological order on the user’s public blog stream. Users can decide to ‘follow’ others and will then receive their messages. [2].
The use of microblogging as a tool for internal communication is summed up by Zhao and Rosson [3] as having potential for recreating the proverbial “water cooler” conversations and may play an important role for collaborative work and organisational innovation by providing support for “sharing of work relevant information among employees; coordination of group activities; creating potential collaboration opportunities; and social functions such as transmission of office culture and maintenance of common ground and a feeling of connectedness between co-workers” In MIRROR we intend to use the microblogging to improve sharing of work relevant information and collaborative work as well as improving the data capture processes for information about a residents daily activities, health, mental health and needs.

Recording Status Updates for Care Home Residents

More reflective observations about residents by care staff. It has long been a requirement for care staff to record the care they have delivered to an individual and the health status of that person at any point in time. When significant events occur this is a relatively obvious and straightforward activity. The member of care staff must ensure that the information is comprehensive and describes fully both what has occurred as well as the actions and tests undertaken as a result. In contrast, when considering the care of an individual with long term and chronic conditions who is relatively stable, there is an increased risk that care staff describe the current status of a resident as no change for a particular aspect of the condition or care provided, because it can be difficult to identify a very gradual change in the individual’s condition which may occur over a longer period. However it is vital to identify that gradual change in order to take effective action and amend the care provided. [1]

One current solution to achieve more effective recording of conditions and care is the framework captured in the acronym CART - recording that must be complete, accurate, relevant and timely. Staff are encouraged to use this acronym as a memory jogger to improve the quality of records of care, leading to replacement of statements such as the individual ate well by accurate statements of what was eaten at which meal and with or without assistance. However the effectiveness of CART relies on successful training and reinforcement to ensure that care staff record information with all four qualities.[1]

Furthermore the current acronym does not directly support reflection about current successful and less successful care so that good practices can be learned and poor practices avoided. Another current solution is to ask care staff to role play the investigator of a complaint about the care of a resident based on their own records. This reflection leads them to appreciate the paucity of information available from an incomplete record. However, this reflective practice has its limitations, and cannot be applied to support all of the care staff on a regular basis.[1]

Therefore, in MIRROR, we  are pursuing a different but complementary strategy based on the use of mobile devices running apps that enable care staff to record information about care in situ at the time that it is generated, thereby ensuring that the information is relevant, accurate and complete. In addition the apps support more reflective learning about the care that is given by encouraging the care staff to reflect on and record the information using a different structure designed to encourage reflection.

Each member of care staff is guided to write an observation in three parts: (i) the room number of the resident as his or her unique identifier; (ii) the observation made, and; (iii) his or her own reflection, encouraged by the prompt – what does this mean? This prompt was chosen based on discussions with care staff to encourage reflection in language familiar to most care staff. One example reflection in this format is: 23d: washed, brushed hair and provided breakfast but did not eat much. Need to look again at whether diet is right? Another is: 4: disruptive to other residents during lunch, and verbally abused staff. Need to talk to family about background issues. Care staff are prompted to use this reflection structure by a visual prompt attached to each mobile device. Care staff enter these observations directly in situ using the mobile device and Twitter app. [1]

Delivered through handheld devices and commercially available software

In MIRROR the microblogging tool is provided on an Apple iPod Touch locked to provide only the capabilities needed by care staff during a shift. The iPod Touch was chosen to be portable by care staff during a shift: it is only 4.4 inches tall, 2.3 inches wide, 0.28 inches wide and weighs only 100 grams. The shift supervisor monitors the posts on a dedicated desktop tool running on a laptop PC (TweetDeck in year one, and Yammer Desktop in year 2).

Using Twitter to Test Concept in Year One of MIRROR

In the first year of the project we ran a 3 day trial using restricted Twitter accounts. Twitter restricts each blog to a maximum length of 140 characters, thereby requiring the person who is blogging to reflect on the content and structure of each blog to ensure that it is complete and coherent, rather than provide a less structured monologue. It is this length restriction that we exploit in MIRROR to encourage care staff to reflect about the care being given. We then exploit other features of the microblogging app to share care staff observations in real-time to other staff using the same system to provide an overview of the care being given during a shift and redirect resources as needed. Unlike regular tweets that can be followed by members of the public, each observation is posted to a locked account that can only be accessed by the other devices being used by care staff and the shift supervisor. Each tweet can also be encrypted to ensure complete resident anonymity. Unlike the current process with paper notes, each observation is shared in real-time as shown on the right-hand side of Figure 1, thereby increasing communication between the care staff in the residential home and directing support to residents quickly.

The Next Step - Yammer

For the next phase we are implementing an enterprise microblogging tool called Yammer. Unlike Twitter, which is designed to be a tool to broadcast public posts that can be accessed by anyone on the web, Yammer is designed to be used internally within an organisation and is accessible only to members of that organisation. This provides a closed, encrypted network where carers can post observations and care notes for their residents. These posts will be monitored by the shift supervisor for patterns in resident behaviour and changes in mental or physical condition. The posts will also be incorporated into a daily or weekly summary for each resident, which the nurses and senior carers can use to track changes over time and to input into revisions of care plan for each resident.

References
[1] Karlsen, K.; Zachos, K.; Maiden, N.; Jones, S.; Turner, I.; Rose, M.; Pudney, K.; , "Supporting reflection and creative thinking by carers of older people with dementia," Pervasive Computing Technologies for Healthcare (PervasiveHealth), 2011 5th International Conference on , vol., no., pp.526-529, 23-26 May 2011
[2] Riemer, K., Richter, A. 2010. Tweet Inside: Microblogging in a Corporate Context. In Proceedings 23rd Bled eConference eTrust: Implications for the Individual, Enterprises and Society
[3] Zhao D., Rosson, M.B.,  2009. How and why people Twitter: the role that micro-blogging plays in informal communication at work. In Proceedings of the ACM 2009 international conference on Supporting group work (GROUP '09). ACM, New York, NY, USA, 243-252