The Digital Shadow in the ICU: An Interdisciplinary Narrative Review of Data Curation, Ethical Stress, and the Sociotechnical Workflow of Critical Care
Abstract
Background: The modern Intensive Care Unit (ICU) is a nexus of intensive, multi-source data generation, creating a vast "digital shadow" of the patient that exists alongside the formal medical record. The labor involved in curating this shadow—filtering, interpreting, and transcribing data from devices, labs, and observations—is largely hidden. Aim: This narrative review aims to examine how the invisible data-management practices of nurses, medical secretaries, and lab technicians shape the official narrative of critical illness, and to explore the resulting sociological and ethical implications for the care team. Methods: A comprehensive search of PubMed, CINAHL, Scopus, and Sociological Abstracts (2010-2024) was conducted, integrating literature from critical care, health informatics, science and technology studies (STS), and the sociology of work. Results: The review identifies a pervasive "curation gap" between raw data and the formal record. This gap is filled by distributed, often undervalued labor that distributes ethical stress, creates hierarchies of data credibility privileging technological over narrative knowledge, and can lead to communication fissures impacting care coordination. Conclusion: Recognizing and formally integrating the sociotechnical work of data curation is essential for humanizing ICU care, mitigating moral injury among staff, and designing EHRs that support, rather than obscure, collaborative sense-making.
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References
Adrien, O., Mohammad, A. K., Hugtenburg, J. G., Mccarthy, L. M., Priester-Vink, S., Visscher, R., ... & Karapinar-Carkıt, F. (2023). Prescribing cascades with recommendations to prevent or reverse them: a systematic review. Drugs & Aging, 40(12), 1085. https://doi.org/10.1007/s40266-023-01072-y
Botrugno, C. (2023). Law, religion and technology: the new “truth” on patient’s body and the ethical ambivalence of the digital clinical gaze. REVISTA DE DIREITO DA SAÚDE COMPARADO, 1, 8-20. https://hdl.handle.net/2158/1318431
Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P., Holden, R., & Gurses, A. P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied ergonomics, 45(1), 14-25. https://doi.org/10.1016/j.apergo.2013.04.023
Carayon, P., Wetterneck, T. B., Cartmill, R., Blosky, M. A., Brown, R., Hoonakker, P., ... & Walker, J. M. (2021). Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations. Journal of patient safety, 17(5), e429-e439. DOI: 10.1097/PTS.0000000000000358
Collins, S., Couture, B., Kang, M. J., Dykes, P., Schnock, K., Knaplund, C., ... & Cato, K. (2018, December). Quantifying and visualizing nursing flowsheet documentation burden in acute and critical care. In AMIA Annual Symposium Proceedings (Vol. 2018, p. 348). https://pubmed.ncbi.nlm.nih.gov/30815074/
Deb, S., & Claudio, D. (2015). Alarm fatigue and its influence on staff performance. IIE Transactions on Healthcare Systems Engineering, 5(3), 183-196. https://doi.org/10.1080/19488300.2015.1062065
Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. The Journal of clinical ethics, 20(4), 330-342. https://doi.org/10.1086/JCE200920406
Espay, A. J., Hausdorff, J. M., Sánchez‐Ferro, Á., Klucken, J., Merola, A., Bonato, P., ... & Movement Disorder Society Task Force on Technology. (2019). A roadmap for implementation of patient‐centered digital outcome measures in Parkinson's disease obtained using mobile health technologies. Movement Disorders, 34(5), 657-663. https://doi.org/10.1002/mds.27671
Hickman, E., Gillies, C., Khunti, K., & Seidu, S. (2023). Deprescribing, polypharmacy and prescribing cascades in older people with type 2 diabetes: a focused review. Journal of the Indian Institute of Science, 103(1), 191-204. https://doi.org/10.1007/s41745-022-00352-7
Hunt, L. M., Bell, H. S., Baker, A. M., & Howard, H. A. (2017). Electronic health records and the disappearing patient. Medical Anthropology Quarterly, 31(3), 403-421. https://doi.org/10.1111/maq.12375
Jedwab, R. M., Manias, E., Hutchinson, A. M., Dobroff, N., & Redley, B. (2022). Nurses’ experiences after implementation of an organization-wide electronic medical record: Qualitative descriptive study. JMIR nursing, 5(1), e39596. https://doi.org/10.2196/39596
Kang, M. J., Rossetti, S. C., Knaplund, C., Chang, F. Y., Schnock, K. O., Whalen, K., ... & Dykes, P. C. (2021). Nursing documentation variation across different medical facilities within an integrated healthcare system. CIN: Computers, Informatics, Nursing, 39(12), 845-850. DOI: 10.1097/CIN.0000000000000736
Keebler, J. R., Lazzara, E. H., Patzer, B. S., Palmer, E. M., Plummer, J. P., Smith, D. C., ... & Riss, R. (2016). Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes. Human factors, 58(8), 1187-1205. https://doi.org/10.1177/0018720816672309
Keenan, G. M., Yakel, E., Tschannen, D., & Mandeville, M. (2008). Documentation and the nurse care planning process. Patient safety and quality: An evidence-based handbook for nurses.
Kotecha, N., Shapiro, J. M., Cardasis, J., & Narayanswami, G. (2017). Reducing unnecessary laboratory testing in the medical ICU. The American journal of medicine, 130(6), 648-651. https://doi.org/10.1016/j.amjmed.2017.02.014
Lekan, D., McCoy, T. P., Jenkins, M., Mohanty, S., & Manda, P. (2022). Frailty and in-hospital mortality risk using EHR nursing data. Biological Research for Nursing, 24(2), 186-201. https://doi.org/10.1177/10998004211060541
Lindsay, M. R., & Lytle, K. (2022). Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Applied clinical informatics, 13(03), 711-719. DOI: 10.1055/a-1868-6431
Mainali, S., Merrill, A. E., & Krasowski, M. D. (2021). Frequency of icteric interference in clinical chemistry laboratory tests and causes of severe icterus. Practical laboratory medicine, 27, e00259. https://doi.org/10.1016/j.plabm.2021.e00259
Manojlovich, M., Hofer, T. P., & Krein, S. L. (2021). Advancing patient safety through the clinical application of a framework focused on communication. Journal of Patient Safety, 17(8), e732-e737. DOI: 10.1097/PTS.0000000000000547
Movahedi, A., Sadooghiasl, A., Ahmadi, F., & Vaismoradi, M. (2023). A grounded theory study of alarm fatigue among nurses in intensive care units. Australian Critical Care, 36(6), 980-988. https://doi.org/10.1016/j.aucc.2022.12.004
Muth, C., Blom, J. W., Smith, S. M., Johnell, K., Gonzalez‐Gonzalez, A. I., Nguyen, T. S., ... & Valderas, J. M. (2019). Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. Journal of internal medicine, 285(3), 272-288. https://doi.org/10.1111/joim.12842
Perkowski, C., Eldridge, B., Zurca, A. D., Demartini, T. K., Ceneviva, G. D., Williams, D., ... & Krawiec, C. (2022). Impact of pediatric intensive care unit preadmission huddle on perceptions of interprofessional communication about patient safety. Critical Care Nurse, 42(4), 55-67. https://doi.org/10.4037/ccn2022307
Ruppel, H., Funk, M., & Whittemore, R. (2018). Measurement of physiological monitor alarm accuracy and clinical relevance in intensive care units. American Journal of Critical Care, 27(1), 11-21. https://doi.org/10.4037/ajcc2018385
Ruppel, H., Dougherty, M., Bonafide, C. P., & Lasater, K. B. (2023). Alarm burden and the nursing care environment: a 213-hospital cross-sectional study. BMJ Open Quality, 12(4). https://doi.org/10.1136/bmjoq-2023-002342
Schapkaitz, E., & Mafika, Z. (2014). Critical value reporting: a survey of 36 clinical laboratories in South Africa. South African medical journal, 104(1), 65-67. Retrieved from https://www.ajol.info/index.php/samj/article/view/99854
Sheehan, P., Joy, A., Fleming, A., Vosper, H., & McCarthy, S. (2022). Human factors and patient safety in undergraduate healthcare education: a systematic review. Human factors in healthcare, 2, 100019. https://doi.org/10.1016/j.hfh.2022.100019
Silva, J. M., Durden, T. E., & Hirsch, A. (2023). Erasing inequality: Examining discrepancies between electronic health records and patient narratives to uncover perceived stigma and dismissal in clinical encounters. Social Science & Medicine, 323, 115837. https://doi.org/10.1016/j.socscimed.2023.115837
Sinha, A., Stevens, L. A., Su, F., Pageler, N. M., & Tawfik, D. S. (2021). Measuring electronic health record use in the pediatric ICU using audit-logs and screen recordings. Applied Clinical Informatics, 12(04), 737-744. DOI: 10.1055/s-0041-1733851
Sinsky, C. A., Rule, A., Cohen, G., Arndt, B. G., Shanafelt, T. D., Sharp, C. D., ... & Hribar, M. (2020). Metrics for assessing physician activity using electronic health record log data. Journal of the American Medical Informatics Association, 27(4), 639-643. https://doi.org/10.1093/jamia/ocz223
Star, S. L., & Strauss, A. (2016). 19 Layers of Silence, Arenas of Voice: The Ecology of Visible and Invisible Work. Boundary Objects and Beyond: Working with Leigh Star, 351.
Thomas, S. N., French, D., Jannetto, P. J., Rappold, B. A., & Clarke, W. A. (2022). Liquid chromatography–tandem mass spectrometry for clinical diagnostics. Nature Reviews Methods Primers, 2(1), 96. https://doi.org/10.1038/s43586-022-00175-x
Authors
Copyright (c) 2024 Hadi Munawer A Alotaibi, Hassan Husain Daghas, Majed Hifthallah Hakami, Yahia Abdullah Monawar Mubarak, Mariam Abdullah Alghamdi, Mohamad Bader Almotiry, Omar Mohammed Hawas Alruwaili, Norah Mohammed H Alruwaili, Ali Awwad Alharthi, Saeeda Hanen Sofyani, Ahmed Ghazi Alotaibi, Sultan Abdullah Alzahrani
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