Nurses´ perceptions of automated dispensing cabinets – an observational study and an online survey

Automated dispensing cabinets, ADCs, were introduced in the 1980s in the United States, since which time they have been increasingly used to automate and rationalise the medication process in hospitals and other health care facilities [1]. These medication storage systems decentralise the distribution of drugs near the patient and provide quick access to medicines for the nurse. ADCs have the potential to reduce medication errors and to improve the work efficiency of pharmacy and nursing staff [1‐5]. Barcode scanning, generally combined with ADCs, reduces the risk of errors both when drugs are removed from an ADC and when they are being placed in the cabinet. ADCs can also help to control illegal drug delivery for other than patient use. Furthermore, ADCs can help to account for medicine, billing and inventory management.

Kuopio University Hospital (KUH), Kuopio, Finland, a tertiary care hospital, has a catchment of 250,000 people, 90,000 annual patients and 20,000 annual operations. In May 2015, a new part of the hospital was completed and 32 ADCs (eMED ICON, NewIcon, Kuopio, Finland) were introduced there in the Operating Rooms of the Anaesthesia and Surgical Unit (OR), and the Intensive Care Unit (ICU). Most of KUH’s ADCs are placed into the wall structures of operating theatres and patient rooms using an innovative pass-through method [6]. This system allows the ADCs to be filled from outside the room and the medicines obtained inside the room. This is expected to reduce unnecessary movement into and out of the operating theatre during operations. Each ward has also a central ADC in the medication room, in which drugs that are seldom needed are stored.

Before collecting a medicine from the ADC, a user logs into the system. Light guidance helps to find the selected product. Each medicine package taken from a cabinet is documented by scanning its barcode to ensure that the right medicine has been taken. The system manages storage control and provides computer-controlled, real-time monitoring and tracking of medicine use and waste. Since the introduction of ADCs in KUH, the billing system has changed; nowadays wards pay only for the medicines they have used, and the medicines are owned by a pharmacy until they are removed from the ADC. The ADCs are restocked by pharmacy technicians.

Before introducing the ADCs in clinical use, the nursing staff could practise their use during several pilot phases. The idea of the pilot phases was to gather user experience, recognise problems and improve the usability of the ADCs. The pilot phase lasted 5 months in the OR and 8 months in the ICU. The most important change of ADCs, made based on the pilot phase, was the pass-through principle that allows nurses to use the ADC without disturbing the patient care activities.

Change management has an essential role in introducing ADC systems because the introduction of new systems causes often resistance to change [7]. The major challenges in introducing such systems successfully are usually more behavioural than technical. Individuals have to give up their familiar routines and invest their time and energy in learning the new system. The successful introduction of ADCs requires commitment and acceptance from employees, and resistance to change can restrict the system from working optimally.

Nurses are the end-users of ADCs, and their perceptions of ADCs are therefore important to survey. The aim of our study was to assess nurses´ perceptions of ADCs and the impacts of ADCs on nurses’ work. Our study hypothesis was that implementation of ADCs would decrease nurses’ time spent on dispensing and preparing medicines and that ADCs would be accepted smoothly by employees after pilot phases.

We conducted the study in KUH using direct observation of nurses both before (2014) and after (2016) the introduction of ADCs together with an online survey for nurses in 2017.

Time spent on dispensing and preparing medications decreased on average by half an hour per 8-h shift in the OR. The time saved was used on patient management and monitoring in the operating theatre during operations. The introduction of ADCs may have contributed to the faster collection of medicines as all the necessary medicines and associated supplies have been stocked in the ADCs of the operating theatres being available near the bedside. If some medicines lack in the ADC, nurses can collect them from the central ADC of the unit instead of collecting them from peripheral storage points, which reduces the number of steps taken by nursing staff. Especially in the OR standardised medications and well-organised storage of medicines in the unit are important principles in improving fluent workflow and safe medication process if installing the ADCs is not possible [8]. The surface area of the former ICU was remarkably smaller compared to the new unit, and the distances required for medicine and equipment collection were short, which may explain why the time spent on dispensing and preparing medications did not decrease in the ICU. One explaining factor for the difference between the OR and ICU could be also the presence of a whole-time ward pharmacist in the ICU before and after the installing the ADCs. In the OR, the pharmacy service has been part-time and mainly technical. The nurses in the OR were more involved in the pharmaceutical tasks (e.g. dispensing and reconstitution) compared to the situation in the ICU and thus, the ADCs streamlined their work more.

In general, the nurses were satisfied with ADCs and expressed they have made their work easier. This is consistent with the findings of Rochais et al. (2014) and Zaidan et al. (2016), who have investigated nurses´ perceptions of, and satisfaction with, the use of ADCs [9, 10].

Employees’ experiences in adapting to technological change were investigated by Sarnola et al. (2019) [11]. That study, which was carried out in KUH, revealed that work performance and efficiency-related (e.g. workflow, technology, training and ergonomics) positive factors enhanced employees’ ability and willingness to adapt to the change. Correspondingly negative factors which diminished employees’ ability to adapt were related to work performance but to individual-related factors (e.g. attitudes, knowledge and motivation) also. In this study, 90% of the respondents in the ICU were satisfied with the ADCs in general compared to 81% in the OR (Table 2). Nurses’ perceptions in the ICU were more positive than in the OR concerning the work performance related factors such as “easy to use” and “decreased movement” (Table 3). If nurses felt that the ADCs were beneficial, they adapted more easily to the change which could be seen in the ICU responses.

The introduction of new systems can cause resistance to change among staff at first, which can appear as non-compliance with instructions. In the present study the non-compliance with instructions was most apparent in the OR (Table 4). The observation established some deficiencies concerning the use of a barcode, and the results of the survey supported this finding.

The removal of a medicine was not always recorded, even though 95% of the nurses stated that they record it in 9–10 cases out of ten. The idea of recording is to ensure that the ADC always contains the appropriate quantities of medicines as the system manages stock control. It can be a risk to patient safety if an important product is lacking because someone has not recorded its removal. It also causes unnecessary work for pharmacy technicians. The problem is easily solved if everybody is motivated to comply with the instructions.

During the observation the nurses took medicines from the ADC when someone else was logged in, especially in the OR, and this was supported by the results of our survey. Work in an operating theatre is demanding, and the nurses have to scan all the time the patient, monitors, machines and infusions [8, 12]. In hectic situations when nurses are required to take medicines from cabinets immediately, they may consider logging in and recording time-consuming while their work is intensively focused to the patient monitoring. Based on the observations made in the present study, however, logging in the ADC does not take that much time, and in an emergency, logging can be overridden. Moreover, fewer than one-third of the respondents agreed that the log-in and identification process needed to access the ADC is time-consuming. This is supported by our measurements: the average time spent at the ADC on collecting a medicine is less than 16 s. One of the aims of the user recognition before medicine removal is to help resolve any unclear cases and to prevent medicine abuse by hospital staff [1, 13].

Trust is a significant factor in engaging employees in the management of change caused by automation [14, 15]. Reliable performance of the ADCs supports adaptive reliance on the new automation and the change is then considered trustworthy. The survey reveals (Tables 2 and 3) that the respondents in the ICU had a more positive attitude to the new automation meaning they had higher trust on it. In the OR, where the non-compliance and misuse of the ADCs were more prominent (Table 4), the respondents did not rely on practical performance of the ADCs that much which could cause a lack of confidence with the new technique. This can explain in the OR, why that many nurses did not comply with the instructions.

The reason why the nurses in the ICU were more satisfied with the ADCs and adapted better to the change than the nurses in the OR can be the difference in the extent of the pilot phase. In the ICU, the pilot period before the introduction of ADCs was more extensive and all nurses had the opportunity to practise the use of ADCs. The ICU nurses had also better possibilities to influence on the design and properties of the ADCs and to develop a new operational model. Not this kind of ample pilot phase was able to conduct in the OR.

Successful introduction of ADCs demands communication, support and the adequate training of users to a high standard [7]. In the present study, most of the respondents agreed that adequate training was given on how to use the ADC, which could explain nurses´ satisfaction. When the users are involved in the change from the very beginning, resistance to change can be managed and converted into commitment and enthusiasm.

The traffic into and out of the operating theatre decreased significantly. ADCs reduced the need to collect medicines or solutions from outside the operating theatre during an operation. This may improve patient safety; as the time used in collecting the products reduced, the time spent on patient monitoring and management increased. In addition, room traffic between the operating theatre and the corridor is thought to e.g. increase the risk of contaminants getting into the operating theatre [16].

Some previous studies indicate that ADCs reduce medication errors [3, 4, 17, 18]. In the present study a majority of the nurses were confident that the new system may improve patient safety. The most frequently mentioned features of ADCs that promote patient safety were barcode scanning, greater confidence that the right medicine has been taken, and the labels which the ADC automatically prints containing all necessary information about the medicine. The effects of ADCs on patient safety should be further evaluated. Based on the present study and earlier data [4, 19] ADCs can improve the medication process by bringing the medicines near the patients, offering real-time stock control and helping to ensure with barcode scanning that the right medicine has been retrieved. ADCs have also an essential role in building the closed loop medication system which allows the real-time documentation of medication and patient information [20, 21].

One of the main limitations of the present study was that the observation period was relatively short. Working days can differ a lot in terms of the number, length and challenge of operations. Thus, the comparison would have been more soundly based if there had been longer observation periods at both units. However, observation is time-consuming and demanding, and collecting a large amount of data is therefore challenging [22]. On the other hand, direct observation allows an objective view to be formed of the phenomenon being explored. According to Ampt et al. [23], observational work sampling is a more reliable method for obtaining an accurate reflection of the duties of nurses than self-reported work sampling [23]. An external observer can also notice any shortcomings more easily than persons who meet these phenomena daily.

Observational studies of this kind are subject to the Hawthorne effect, i.e. the presence of an observer may change the behaviour of the participants [23, 24]. Nurses may make greater efforts and act more carefully while being observed. On the other hand, they can be more nervous when they are aware, they are being observed. However, the observation was similar across the pre- and post-intervention periods, and thus the presence of an observer should have had only a minor impact on our study findings. This is supported by the study by Ampt et al. [23], in which feedback from nurses indicated that the presence of a researcher did not influence their behaviour that much.

The response rate of the survey was relatively low (23%) which is typical of this kind of survey [25]. Thus, the results may not necessarily represent the views of the entire study population. However, as over 80 nurses responded, we consider the results reliable. As nurses are the end-users of ADCs, their opinions and feedback are important, and this information can be utilised to develop ADC systems further.

The strength of our study is that the observation periods were timed both before and after the introduction of the ADCs, and that the observations were made in the same way and by the same observer at both times. The second observation period was timed 1 year after the introduction of ADCs to ensure the nurses had had enough time to familiarize themselves with the new technology and environment.

Our study focused on the nurses´ perceptions of ADCs and the effects of ADCs on nurses´ work and time management. In further studies, an investigation into economic impacts could provide important information regarding the costs and benefits of introducing ADCs. Also, the impacts of ADCs on patient safety could be examined by comparing medication error rates before and after the introduction of ADCs.

In general, nurses were satisfied with the ADCs and did not want to return to the old stock system. The attitudes towards ADCs were more positive and the compliance with instructions was better in the ICU than in the OR which can be explained by the more extensive pilot phase in the ICU. The introduction of ADCs decreased the time spent on dispensing and preparing medications in the OR. Thanks to the more efficient supply of medicines attributable to the ADCs, nurses had more time to focus on direct patient care. Traffic into and out of the operating theatre decreased significantly as there was less need to collect medicines from outside the operating theatre during operations. Based on our study, the introduction of ADCs is worth considering when hospitals and other health care facilities are planning to develop and reorganise the medication process. It is important to involve the users in the change and consider the needs of the users when designing automation systems.