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Ergonomics Product Development

of a Mobile Workstation for

Health Care

Risto Toivonen

Research Engineer

Finnish Institute of

Occupational Health

Topeliuksenkatu 41 a A.

FI-00250, Helsinki,

Finland

Risto.Toivonen@ttl.fi

Dong-Shik Choi

Researcher

Finnish Institute of

Occupational Health

Topeliuksenkatu 41 a A.

FI-00250, Helsinki,

Finland

Dong-Shik.Choi@ttl.fi

Nina Nevala

Team Leader, PhD

Finnish Institute of

Occupational Health

Topeliuksenkatu 41 a A.

FI-00250, Helsinki,

Finland

Nina.Nevala@ttl.fi

Abstract

The use of information and communication technologies is

increasing in health care, and patient information is being

transferred into electronic format. The aim of this study was

to test the ergonomics and usability of a mobile workstation

prototype in actual work situations. The mobile workstation

was tested by physicians (n=5) and nurses (n=3) during and

after hospital rounds. The study produced 19 requirements

for a usable product. The participants rated wheel function,

screen height, the mobility of the terminal, and the

adjustability of the terminal height as the best usability

features of the prototype. The keyboard level, the mouse

level, and the difficulty to install the computer into the

terminal were reported as the most important points in need

of improvement. The results of this study show that having

physicians and nurses make subjective judgments about the

usability of a mobile workstation adds value to its design.

Keywords

computer, design, health care, participatory ergonomics,

usability, user-centered design, computers on wheels

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Vol. 7, Issue 1, November 2011

Introduction

Physicians and nurses are highly mobile in their daily hospital routine, moving frequently

between wards, outpatient clinics, diagnostic and therapeutic departments, conference rooms,

and operating theaters (Ammenwerth, Buchauer, Bludau, & Haux, 2000). Health care

professionals need to request and enter information at different locations, for example, on their

daily ward round (Reuss, Menozzi, Büchi, Koller, & Krueger, 2004). Thus mobile technology is

becoming more important in modern health care. Mobile information and communication

systems in clinical routine have the potential to greatly improve communication, facilitate

information access, eliminate double documentation, and increase the quality of patient care in

the long run when an appropriate infrastructure is available (Ammenwerth et al., 2000;

Buchauer, Werner, & Haux, 1998).

The utilization of mobile technology increases treatment and diagnostic capabilities, but it also

increases the complexity of health care (Liljegren, 2006). Mobile devices may play an important

role in convincing health care staff to use and handle the volume and complexity of clinical data

by simplifying the integration of mobile devices into existing medical information systems

(Karahoca, Bayraktar, Tatoglu, & Karahoca, 2010). However, physicians have clear access

preferences when they interact with patient records during their daily rounds (Reuss et al.,

2004). Increasingly health care policy and decision makers are demanding evidence to justify

investments in health information systems (Kushniruk & Patel, 2004).

Various types of mobile devices are in use in health care. Personal digital assistants (PDAs),

tablet PCs, and laptops installed on mobile workstations are the devices most commonly

mentioned in the studies. Each of these devices clearly has strengths and weaknesses, which

should be taken into account when a decision is made about the method appropriate for helping

physicians and nurses interact with a number of electrical information systems during daily

routines. User preferences for these kinds of devices and the situations under which different

devices would be used have been studied in several papers (Andersen Lindgaard, Prgomet,

Creswick, & Westbrook, 2009).

Some studies have commented about the usability of mobile workstations, but even then the

focus was either on the information systems used by the mobile devices, the usability of the

user interfaces of the system, or the physical properties of the computers per se (Andersen et

al., 2009). However, a need for mobile workstations with better usability and ergonomics for

health care workers was reported in these same studies. The studies addressed questions about

the size of workstations, the ease of operation, and the mobility of the workstation (Junglas,

Abraham, & Ives, 2009), each of which is an important design factor that affects the usability

and ergonomics of a product.

In this paper we have used the terms usability and ergonomics side by side. According to

Pheasant (1996), the objective of ergonomics is to achieve the best possible match between a

product and its users in the context of the work task to be performed. On the other hand, the

SFS-EN ISO 9241-11 (1998) standard states that usability is the extent to which a product can

be used by specified users to achieve specified goals with effectiveness, efficiency, and

satisfaction in a specified context of use. Generally speaking, considering both usability and

ergonomics during the development of a medical device, and when medical technology is

purchased at hospitals, is considered to be increasingly important (Liljegren & Osvalder, 2004;

Martin, Norris, Murphy, & Crowe, 2008).

The aim of this study was to test the ergonomics and usability of a mobile workstation

prototype in real work situations. As this study was conducted as a part of a product

development process, an additional objective was to determine the most important ergonomic

design factors that need to be taken into account in the final and future mobile workstation

version. In this study neither the usability of the computer user interface nor the usability of the

electronic patient information system was included. To be able to fully utilize a mobile

workstation in a hospital environment requires that both the work processes and the

Information and Communication Technology (ICT) infrastructure have been adapted for this

new medical practice. In this study we wanted to investigate the use of the mobile workstation

in normal work situations and to collect user experience on the new mobile workstation model,

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Journal of Usability Studies

Vol. 7, Issue 1, November 2011

not the new way of working as such. Thus we selected users who already had some experience

with mobile workstations.

Materials and Methods

The following sections discuss the mobile workstation features, the procedure used in this study,

and the expert and participant evaluations of the workstation.

The Tested Mobile Workstation Prototype

The mobile workstation prototype was called SPARKe 54.1, as named by the prototype design

company—Spark Ergonomics Oy Ltd (see Figure 1). The workstation could be equipped with

either a laptop or a desktop computer. A laptop computer could be installed under the lockable

cover case and operated by an external keyboard and a mouse, or it could be laid on the cover.

For the external keyboard, there was a separate keyboard tray with a slide-out mouse tray and

mouse cubby (on the right side of the keyboard tray). The mouse tray on the cover of the cart

could be pulled out to the left or right of the cover. During the study only laptop computers

were used, and they were operated in both possible installation settings. Additional accessories

installed on the prototype were a storage basket and a rack for an additional battery.

Figure 1. Features of the tested mobile workstation: 1 - foot pedal for adjusting height, 2 -

storage basket, 3 - rack for an additional battery, 4 - keyboard tray, 5 - case for the computer,

6 - lockable cover for the case, 7 - higher mouse tray, 8 - combined mouse tray and mouse

cubby (lower mouse tray), 9 - lockable wheels (in front of the cart)

Procedure

This usability study was part of a product development process in which the expert evaluation

and the user study data were given to the company that developed the mobile workstation

prototype. Figure 2 illustrates the iterative design process. For the first phase of the study,

experts evaluated a mobile workstation prototype and provided feedback. The experts’ feedback

was integrated into the design of a redesigned mobile workstation prototype. The redesigned

prototype was tested during the second phase of the study, the user study phase. Participants

in the user study used the redesigned workstation prototype during one day in actual work

situations in a hospital.

The outcome of both the expert review and the user study was a list of requirements for a

usable, ergonomically designed mobile workstation. These requirements and feedback then

were given to the company that designed the mobile workstation.

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Vol. 7, Issue 1, November 2011

Usability Study

Implementation

Figure 2. Procedure used during the prototype usability study. The implementation was

performed by the prototype design company

Expert Evaluation

The process started with a 3-hour expert evaluation (Hignett, 1998) in which four experts in

both ergonomics and technical, design, health science, and physiotherapy participated. In this

hands-on session, the experts performed usage scenarios using the original prototype and

commented on its physical design characteristics and the operation of the prototype. One of the

experts acted as the chairman and led the discussion if needed. During the session, the experts

were able to evaluate the use of the mobile workstation in simulated work situations. A laptop

was placed on the prototype, but no hospital information system was available because the

focus was strictly on the physical aspects of the mobile workstation.

The experts' comments were collected during the session as a list of recommended

modifications. The mobile workstation developers then redesigned the prototype with the

experts’ recommendations in mind. The recommendations also served as a basis for the

questions raised in the user study phase.

User Study

The following sections discuss the participants and the methods used in the user evaluation

portion of the study.

Participants

The intended users of a mobile workstation are both nurses and physicians. The practice of who

operates the workstation during a round varies from ward to ward. In our study the participants

were five physicians (two men, three women) and three nurses (one man, two women), aged

20-41 years (Table 1), from two hospitals in the Helsinki region of Finland. They all were right-

handed and were accustomed to using a mobile workstation in their normal routine. They

worked an average of 8 hours a week with their wards workstation. The volunteer participants

gave their written consent to participate before the study began.

Expert Evaluation

Feedback

User study

Video-recorded think-aloud

Visual analogue scales (VAS)

System usability scales (SUS)

•

Criteria for the ergonomics and

usability of the mobile workstation

Feedback

Product

(Final implementation)

Redesign of the prototype

Redesign of the prototype

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Vol. 7, Issue 1, November 2011

Table 1. Background Factors of the Participants (N=8), Mean and Range

Variable

Mean

Range

Age (years)

33

20 - 41

Height (cm)

169

154 - 183

Weight (kg)

66

48 - 86

Experience in present work (years)

7

0.25 - 15

Experience in the use of any mobile workstation

(months)

11

1 - 36

Methods

The mobile workstation was tested during and after a hospital round in a hospital ward (Figure

3). A round consists of seeing all of the patients who are in the hospital under the care of the

physician who leads the round. There were two rounds in this study, and the number of patients

seen during rounds was between 15 and 20. One physician made the round individually; other

rounds had three participants (two physicians, one nurse). The activities performed included

reading the patient’s information on the screen and entering text about the patient’s status

using the keyboard. After the round, the video-recorded, think-aloud method was used to

further evaluate the usability of the mobile workstation prototype. The participants were asked

to report their thoughts as they used the prototype. We asked the following question to all

participants: "How should this product be developed further?"

Figure 3. A physician using a mobile workstation during a typical morning round.

Visual analogue scales (VAS) were used to determine the usability features of the mobile

workstation (Beauchamp, 1999; Lintula & Nevala, 2006; Nevala & Tamminen-Peter, 2004;

Price, McGrath, Rafii, & Buckingham, 1983). The VAS is a 100 mm long continuous line with

endpoints anchored by 0 (very poor) and 100 (very good). The VAS score is a measured

distance (expressed in millimeters) from the 0 scale point. The participants were asked to mark

on the line the point that indicated their evaluation of the feature. In addition, there was a

question that asked, “How would you like to see this mobile workstation be further developed?”

The 10-item System Usability Scale (SUS) was used to determine the subjective assessment of

the usability of the prototype (Brooke, 1996). It provided an easy-to-understand score from 0

(negative) to 100 (positive). The SUS is an effective, reliable, and inexpensive tool for

measuring the usability of a wide variety of products and services (Bangor, Kortum, & Miller,

2008; Bangor, Kortum, & Miller, 2009; Dumas, 2003; Sauro, 2011).

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Vol. 7, Issue 1, November 2011

Results

The following sections discuss the results of the expert evaluation and the user study, and the

list of criteria for optimal mobile workstation design.

Expert Evaluation

According to the group of experts, the functioning of the wheels, the height of the screen, the

mobility of the workstation, and the adjustability of the workstation height were the best

features of the prototype. The keyboard tray, the mouse tray, and the difficulty of installing the

laptop computer onto the workstation were reported as needing further development. The

evaluation showed that the design needed to be simplified (i.e., the height needed to be easier

to adjust, and the case for the computer needed to be redesigned). Table 2 lists the usability

requirements for any mobile workstation according to the experts.

Table 2. Expert Evaluators’ Usability Requirements for Mobile Workstations

Evaluator

Education

Usability Requirements

1

Master of sciences

(Eng.)

Adjustability of the angle and height of the screen,

possibility to install and remove the computer easily,

lockability, stability, easy to walk with the workstation

2

Master of sciences

(Design)

Immobility of the computer, keyboard, and mouse during

movement of the workstation; turnable wheels; available

accessories (e.g., holder for extra battery); lockable

wheels

3

Doctor of health

sciences, physiotherapist

Usable with a straight back, easy to get near the

computer, mouse can be used with both hands, mouse is

near the keyboard

4

Doctor of health

sciences, physiotherapist

Suitable for standing and sitting postures, equipped with

handles, cleanable, easily adjustable, possibility to

support arms

Before the user study, the mechanism to adjust the height of the workstation and the locking

mechanism of the laptop were redesigned.

User Study

This section reports the quantitative and subjective responses of the eight test participants after

using the workstation for rounds. The usability of the mobile workstation according to the mean

SUS index was 73 (SD 11.0). The SUS scores of the eight participants were the following: 90,

82.5 (n=2), 75, 72.5, 65, 62.5, and 52.5. There was no difference between the scores for the

nurses and physicians.

The results of the VAS ratings are presented in Figure 4. Movability, the functioning of the

wheels, the adjustability of the height, and the stability of the mobile workstation were the

highest rated factors. On the other hand, the combined keyboard and mouse tray feature (see

Figure 1) received the lowest scores. Some of the VAS ratings were heavily influenced by the

work practices that individual nurses and physicians had adopted in their ward and, therefore,

the ratings showed large variations. For example, some participants preferred the disinfection

bottle holder on the mobile workstation as was the case in their ward, while others thought a

bottle located by the patient's bed was enough.

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Vol. 7, Issue 1, November 2011

Figure 4. Perceived usability (VAS: 0=Very Poor, 100=Very Good) of the mobile workstation

according to the doctors and nurses (n=8; means, standard deviations)

In response to questions, the participants pointed out that the mobile workstation must be an

easy-to-use and sought-after tool for work, so that everyone would be able to make use of it

easily and effectively. The doctors and nurses stated that they would like to use the mobile

workstation because

"The use of the COW [computer on wheels; mobile workstation] seems very

convenient."

"It is nice to make the round alone—I talk more with the patient."

"I send the instructions for the nurses and physiotherapists directly to their electronic

work list."

"I have my own schedule."

All the participants were eager to comment on the usability of the new mobile workstation

model because previous mobile workstation models had shortcomings. Large variations in

specific VAS features clearly indicated that the basic workstation should have as simple a

construction as possible, but be equipped according to users' varying needs.

Criteria for the Ergonomics and Usability of the Mobile Workstation

Based on the findings of both the expert evaluation and the user study, we formulated the

following criteria for a usable and ergonomically designed mobile workstation. These same

criteria were taken as essential design points by the developers of the mobile workstation

prototype.

•

Small as possible

•

Usable for a mobile computer, separate keyboard, and mouse

•

Computer easily installed and removed

•

Lockable computer or laptop

•

Equipped with handles

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Vol. 7, Issue 1, November 2011

•

Computer, keyboard, and mouse stay immobile during workstation movement

•

Easily moved and equipped with wheels that turn and lock

•

Cleanable—no sharp corners

•

Extra equipment available if needed

•

Can be used when standing or sitting

•

Easy to get near the computer and stand with a straight back

•

Easy to adjust the height with one hand

•

Height adjustability between 80-120 cm

•

Angle of the screen adjustable

•

Mouse usable with both hands near the keyboard

•

Arms supportable during computer use

•

Easy to walk with the mobile workstation, i.e., the construction of the mobile

workstation does not interfere with movements of legs

•

Easy to learn how to use

•

Manual includes ergonomic instructions

In addition to data gathered from the expert evaluation and user study, the ErgoSHAPE method

(Launis & Lehtelä, 1992) was used to define the minimum range of adjustability for the height

to make it possible to work with the mobile workstation while either sitting or standing.

(ErgoSHAPE is a collection of human anthropometric models and ergonomic recommendations

for work place designers to be used with AutoCAD.) The recommended and minimum ranges for

the height adjustment for the mobile workstation are presented in Figure 5. A range of 80–

120 cm enabled even the shortest and the tallest workers (P5 or 5% of the population is shorter

than 80 cm / P95 or 5% of the population is taller than 120 cm) to work comfortably with the

mobile workstation, either while sitting on, for example, a saddle chair or while standing.

Figure 5. The recommended and minimum ranges for the height adjustability of the mobile

workstation

Discussion and Recommendation

Based on the expert evaluation and the user study, this study found 19 different criteria for the

ergonomics and usability of a mobile workstation. The most important ergonomic features of the

mobile workstation that needed improvement were the keyboard tray, the mouse tray, and the

procedure to install and lock the laptop computer to the workstation.

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Vol. 7, Issue 1, November 2011

In the future, more information and communication technologies will be used in health care. As

the market becomes more competitive, usability can be a key product differentiator and a

crucial factor in the purchase decision. The results showed that a mobile workstation must be an

easy-to-use and sought-after tool for work so that everyone is able to make use of it easily and

effectively. Nurses and physicians need both hands for the examination and care of their

patients, therefore, handheld computers are not practical. However, in the literature, no articles

were found concerning the ergonomics and usability of mobile workstations: Most of the

scientific literature pertained to information access in health care (Reuss et al., 2004), mobile

health care acceptance (Wu et al., 2007), handheld computers (Lapinsky, 2007), and

information technologies in patients' homes (Kaufman et al., 2003).

This study was planned in cooperation with researchers, manufacturers, and experienced health

care workers. As a result, it was possible to identify the work tasks generally performed with a

mobile workstation and to choose proper testing methods. The final mobile workstation was

developed using an iterative process that included expert evaluation and practical user

experience feedback and evaluation. In the expert evaluation, four experts in ergonomics

participated. The expert evaluation is a quick and cheap method for achieving broad coverage of

a whole product, but it typically misses some complex issues (Barrington, 2007). In the user

study, eight experienced physicians and nurses participated. It is known that the use of four to

eight participants can drive a useful iterative cycle: find serious problems, correct them, and

find more serious problems (Molich, 2010). According to Molich’s paper, the number and the

quality of evaluators affects the results more than the size of the participant group.

This study shows that the SUS index is suitable for products other than software user interfaces.

The SUS index was free, and easy to administer and use. In addition, the SUS scores can be

evaluated against emerging benchmarks (Bangor et al., 2008; Bangor et al., 2009; Sauro,

2011).

Practitioner’s Take Away

The results of this study suggest the following:

•

Usability tests can be carried out with doctors and nurses in real hospital situations.

•

SUS and VAS can be used quickly by end users when assessing the usability of a

product.

•

Subjective judgments made by end users in the work setting add value to the

judgments of experts, even when ergonomic factors are involved.

Acknowledgements

The authors wish to thank Martti Launis, Senior Expert, and Ritva Ketola, special researcher, for

their valuable comments during the expert evaluation. The authors would also like to thank the

volunteer physicians and nurses who made this project possible. Financial support was provided

by the Finnish Work Environment Fund.

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About the Authors

Risto Toivonen

Risto Toivonen, MSc

Tech, works as a

research engineer in the

Ergonomics and Usability

team of the Finnish

Institute of Occupational

Health in Helsinki.

Dong-Shik Choi

Dong-Shik Choi is a

Manager in KOSHA

(Korea Occupational

Safety and Health

Agency). He is working

as a visiting researcher

in the Ergonomics and

Usability team of the

Finnish Institute of

Occupational Health. He

holds a MS in

Ergonomics from the

Korea University.

Nina Nevala

Nina Nevala, PhD,

Adjunct Professor, is the

leader of the Ergonomics

and Usability team of the

Finnish Institute of

Occupational Health in

Helsinki. She received

her PhD from the

University of Jyväskylä.

Her research focuses on

the ergonomics,

usability, accessibility,

and accommodation of

workplaces.