There is an extreme health workforce shortage in Eastern, Central, and Southern Africa. Shortage of eye care workers impedes effective implementation of prevention of blindness programs. The World Health Organization has identified education, partnership, leadership, financing, and policy as intertwined interventions that are critical to resolving this crisis on the long term.The VISION 2020 LINK between the College of Ophthalmology of Eastern, Central, and Southern Africa and the Royal College of Ophthalmologists in the United Kingdom aims to increase the quantity and quality of eye care training in East, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, curriculum development for residents in ophthalmology and ophthalmic clinical officers, continuous professional development (CPD), and mentoring program for young ophthalmologists. This study examined how education and partnership can be linked to improve eye care, through an evaluation of this north-south link based on its own targets and established frameworks to guide north-south links.An exploratory qualitative case study design was used. Twenty-nine link representatives were recruited through purposive sampling and snowballing. Face-to-face interviews were conducted using a semi-structured interview schedule that incorporated the components of a successful link from an existing framework. Documents pertaining to the link were also examined. Thematic analysis was used for data analysis.The findings revealed that the perception to the contribution of the link to eye care in the region is generally positive. Process indicators showed that the targets in three strategic objectives of the link have been achieved. Framework-based evaluation also showed that the link is successful. Mutual learning and development of friendships were the most commonly identified success factors. Inadequate awareness of the link by college members is a key challenge.The study concludes that the link is active and evolving and has achieved most of its targets. Further developments should be directed to influence health system strengthening in Eastern, Central, and Southern Africa more strategically. The study recommends expansion of the scope of collaboration to involve multiple health system building blocks. The World Health Report  demonstrThe World Health Organization (WHO) human resource for health action plan  identifiHealth links are formalized long-term voluntary partnerships between counterpart health organizations in the United Kingdom and developing countries (DC), whose primary purpose is to build capacity in the DC through targeted training . The numThe VISION 2020 LINKS program was launched in 2004 by the International Centre for Eye Health, for the purpose of capacity building for eye care in Africa . This prA few studies have investigated the contribution made by health links , 6–11. HNational Health Service (NHS) [Africa Unit [As the need to examine the success of links has gained prominence, frameworks for such an evaluation have also been developed. There are three published frameworks, all specifically designed to evaluate United Kingdom-Africa partnerships. The ce (NHS)  describece (NHS)  and the ce (NHS) . The Africa Unit  has in tica Unit  listed 1The LINK was launched in 2008 by a memorandum between the East African College of Ophthalmologists (EACO), which is the predecessor to COECSA, and the Royal College of Ophthalmologists, United Kingdom. COECSA was subsequently formed in 2012 upon the merger between EACO and the Ophthalmological Society of Eastern Africa (OSEA). The COECSA-RCOphth VISION 2020 LINK aims to increase the quantity and quality of eye care training in Eastern, Central, and Southern Africa through a focus on five strategic areas: fellowship examination for ophthalmologists, training the trainers, development of harmonized curricula for training residents in ophthalmology and ophthalmic clinical officers, online continuous professional development (CPD) program, and a mentoring program for young ophthalmologists. The LINK is supported by a grant from the Department for International Development (DFID) through the Tropical Health Education Trust (THET).The eight countries involved in the LINK at the time of the study were Burundi, Ethiopia, Kenya, Malawi, Rwanda, Tanzania, Uganda, and Zambia. All the countries face a severe shortage of health workers, including eye health workers. Training programs for ophthalmologists and ophthalmic clinical officers are already established in all the countries except Rwanda and Burundi. The training programs, however, are heterogeneous in curriculum content and delivery. The first phase of implementation of the LINK was from 2010 to 2012, and it was initiated with three ECSA countries . The second phase was 2013–2014 and involved eight countries. Additional countries plan to join COECSA in the near future, such as South Sudan.An extensive literature search was conducted to provide an in-depth understanding of health links. In addition, preliminary discussions were held with the COECSA president and with the VISION 2020 LINKS manager to gain an insight into the genesis of the COECSA-RCOphth LINK. Subsequently, a study protocol was developed for a qualitative case study. The study was designed in accordance with the principles of the Helsinki Declaration  and the Data was collected between May and July 2014. Twelve LINK coordinators (one from each ECSA country and three from the United Kingdom) were initially identified from the VISION 2020 LINK office (purposive sampling) and contacted by email to arrange for face-to-face interviews. Nineteen additional link representatives were identified at these interviews through snowballing . Semi-structured interviews were conducted in the United Kingdom and in ECSA. The main topics covered in the interview were the implementation of the LINK, contribution of the LINK to capacity building in ECSA, and the progress in the strategic objectives. The framework for evaluation of links proposed by Eastwood et al.  was incoInterviews were conducted in English and audio recorded. Participants gave written informed consent. Link-related documents were also examined to provide triangulation. Data analysis was done using thematic analysis.Twenty-nine of the 31 people contacted consented and were available for interview (94% response rate). The other two consented but were unavailable due to competing commitments. Both of them were from COECSA, one was an ophthalmologist while the other was a manager. Twenty-three of those interviewed (79% of respondents) were ophthalmologists while the other 21% were managers and non-ophthalmologist health workers. Seventeen per cent were from the United Kingdom while 83% were from ECSA region. The majority of the participants had been involved in both phase I and phase 2 of this LINK. However, their period of involvement ranged from 1 year to the entire period of the LINK.Participants generally perceived the LINK positively and identified themselves, peers, institutions, or countries as beneficiaries of the LINK. The benefits were in the form of training, examinations, workshops, or exchange visits to the partner country. Link documents (reports) that were examined captured similarly positive feedback from residents and ophthalmologists regarding improved teaching and examination methods. Several themes related to capacity development were identified and were classified into three levels: personal, institutional, and country and regional level Fig. . At the At the institutional level, training institutions for Master of Medicine  and ophthalmic clinical officers (OCO) have had harmonized curricula developed. The trainers for M.Med have also received training in teaching and assessment skills under the “train the trainers” (TTT) program. New assessment methods have been adopted such as the objective structured clinical examination (OSCE) to replace the traditional long and short case method. The structured viva examination method has been maintained.At the country level, capacity has been developed in the areas of clinical guideline development, curriculum development, and examiner training. At the regional level, continuous professional development (CPD) occurs at the annual scientific congress. The fellowship examination runs annually, and a total of 31 ophthalmologists had taken it by 2013. Thirty-seven examiners for this examination have also been trained, 36 from the eight countries  and one from South Sudan which has intention to join COECSA.My overall opinion is that the LINK is going well and should continue. Although for us from (names country) the membership in COECSA is very new, we have learnt that working together brings change (COECSA participant)It is rewarding to see that much progress has been made and there are tangible outputs (United Kingdom participant)The perception of the participants to the contribution of the LINK was generally positive. For example:The fellowship examination started with the LINK in 2010. It has run every year since then, and we now have a pool of COECSA examiners (COECSA participant)The fellowship examination began in 2010, and the number of candidates registering increased progressively Table . Thirty-Trainers in the training institutions have been trained through the LINK Table . The traExams are the shining signature of the LINK (COECSA participant)Or approach to assessment of students in residency has changed drastically, and the assessments are now more objective…previously examinations were conducted inappropriately but we changed following many trainings that were facilitated by RCOphth (COECSA participant)The participants felt that this training had changed practice in teaching and assessment:The examination area was seen to be the most successful among the five objectives. One of the reasons attributed to this success was the enthusiasm of the examination leads, which gave this objective “a big driving force” (RCOphth participant).Curriculum development has helped us to set standards in COECSA through use of a harmonized curriculum (COECSA participant)The LINK’s target was to develop two new curricula I am not sure how far we are with the plans for online CPD, but we need to have a platform for it, and to develop our own online resources in future (COECSA participant)Although some progress had been made towards making CPD available in the region, online CPD was not available Table .Table 7PThere was significant inequity in the availability of CPD opportunities, with the ophthalmologists who work in the cities and in training institutions being advantaged and those in rural areas remaining disadvantaged. The most common reasons given for delay in implementing online CPD was the high cost of equipment and software, the lack of a CPD strategy, and the difficulty in entrenching the CPD concept.I am not young but one of my colleagues attended the first Young Ophthalmologists Forum at Kigali in 2013 and another meeting in Dar…and is now extremely motivated, …even taking up leadership positions here(COECSA participant)Progress in this objective mainly occurred in phase 2 of the LINK, during which the Young Ophthalmologists Forum (YOF) held two forums and 24 ophthalmologists received leadership training. The leadership training, and the motivation arising from it, was the key reference made in relation to this objective:It depends on how actively the individual demonstrates readiness to be involved. I am a young ophthalmologist and I am fully involved. I have not experienced any lack of opportunity and I have not heard of any complaint (COECSA participant)Although some participants indicated that young ophthalmologists felt alienated and lacked opportunities for participation, other participants did not concur:Table There was marked congruence in the perception on the benefits of the LINK, as identified by partners from both the United Kingdom and ECSA.It is about sharing experiences and learning … it is not just copying directly from RCOphth and replicating it in COECSA (United Kingdom participant)Support and friendship is very good…now when I get an email from (name of a counterpart in COECSA) I can identify with the situation as they express it … this is because I have the experience of that context now (United Kingdom participant)For me the LINK has created professional space …I am inspired to work even though resources are limited (COECSA participant)The profile of the college (COECSA) and training institutions has been raised. In Kigali congress we had ministerial presence and this means there is recognition (United Kingdom participant)Participants referred to increase in personal and institutional capacity, development of friendships and networks, cross-cultural awareness, motivation to change practice of training, increased teamwork, raising the profile of ophthalmology, and the opportunity for mentoring relationships. However, the most commonly identified benefits were shared learning and development of friendship:COECSA members also cited the benefit of affiliate membership to RCOphth being access to journals and CPD materials from RCOphth.Like the benefits, the challenges did not show variation by collaborating partner or by country. However, one challenge that was articulated in only one ECSA country is the lack of involvement of ophthalmologists in private practice in LINK activities. Participants from the seven other ECSA countries indicated that in their countries, those in private practice were fully involved or that in some countries, no ophthalmologists were exclusively engaged in private practice.Keep in mind that the broader the link, the more the parties in the partnership, a kind of scramble results and you may not get what you wish. This does not occur when you are dealing with a specific hospital to hospital link, as you are not competing with others in the team (COECSA participant)Inadequate awareness of the LINK by college members in both the United Kingdom and ECSA was the leading recognized challenge. In addition, the multi-country nature of the partnership also carries some unease:The other challenges are listed in Table Participants identified the areas of improvement in the LINK. While the specific suggestions by the north and south partners differ, they cut across the phases of planning, implementation, and evaluation of the LINK Table .Table 10Resolution WHA 59.23 of the World Health Assembly (2006) focuses on scaling up of health worker production. It calls on both developed and developing countries to engage urgent, sustained, and innovative action to address this crisis. Such action includes capacity building for the health workforce. This need is a motivating factor for institutions to engage in strategic institutional, national, regional, and international collaboration. The Baguley et al. study  and the The main shortcoming of the qualitative study methodology is the potential for response, reporting, and social desirability bias. We tried to address this by involving participants from both the United Kingdom and ECSA partners to provide a balanced view. Triangulation of sources of data also ensured internal validity. The evaluation of the success of the LINK was limited to a focus on the way the LINK is run, as health impact or economic evaluation were beyond the scope of the study. Although the case study is a unique health link, comparability of findings with other links is feasible because specified frameworks for evaluation were used.Capacity has been built at micro, meso and macro levels. The first phase of the link concentrated on building individual capacity of trainers and of training institutions for M.Med residency and OCO training. The second phase was marked by a transition from institutional to country focus, and the number of countries in the LINK has increased from three to eight. Skills development has been the main avenue for building capacity. The specific skills have included leadership, teaching, assessment, and curriculum and clinical guidelines development, a feature that is also noted in other links .The LINK achieved the targets that had been set for three of its five objectives, namely fellowship examination, training the trainers, and curriculum development. One of the factors considered responsible for the success is in the area of examinations is that the personalities at the lead in ECSA have been a strong driving force, by virtue of demonstrating strong leadership and commitment to agreed goals. This is not a unique finding as other studies have shown that such individuals contribute significantly to initiating links or making them successful , 20. TheSimilarly, although only two forums for leadership training for young ophthalmologists had been held, it had generated a lot of motivation and also willingness to take up new roles. Viewed from the concept of health system strengthening, the LINK has influenced leadership capability, which relates to the stewardship or governance building block of health systems.  Some parThe LINK was on target in the curriculum development objective. It is worth noting that the two curricula were developed jointly by the partners, and not just replicated from RCOphth. This ensures that the curriculum is relevant to the COECSA context. Previous research on health links between the United Kingdom and Africa provides evidence that failure to take this precaution may render a curriculum irrelevant to the intended user .Although the residency and OCO training programs in COECSA are heterogenous in terms of organization and duration, the new harmonized curriculum can be applied across the institutions. It allows for flexibility and meets the needs of diverse COECSA institutions. Training institutions can adopt the curriculum in totality or adopt portions of it, subject to a set minimum criteria, which gives flexibility to member institutions. Only one paper has previously explicitly documented the importance of flexibility and creativity in partnerships .The process by which health professionals keep updated to meet the needs of patients, the health service, and their own professional development. It includes the continuous acquisition of new knowledge, skills, and attitudes to enable competent practiceContinuing professional development is an important intervention for building capacity in human resource for health. Peck et al.  have defOnline CPD had not yet been implemented in the LINK as targeted and access to regular CPD remained very variable. Ophthalmologists working in rural areas and outside teaching institutions were relatively disadvantaged, yet they see the bulk of the patients and are also more prone to professional isolation. This is a mismatch between the availability of CPD and the pattern of the need for it. The LINK must strive to break the mismatch rather than aggravate it, for links have been known to build disparities . The hinProgress regarding the Young Ophthalmologists Forum occurred in phase 2 of the partnership, and 24 young ophthalmologists benefited from leadership training. Although the mentoring program was still being developed, participants reported that the leadership training had generated motivation . Motivating young ophthalmologists might help to avoid decline in enthusiasm as the partnership proceeds, a potential risk that was identified in the initial grant for the LINK. Mentoring young ophthalmologists, together with access to subspecialty training as participants suggested, has potential to impact both the service delivery and the leadership and governance building blocks of health systems. This is an important avenue for the LINK to go beyond focusing on just one building block, the health workforce (capacity building).mutual learning and the development of friendship with counterparts, leading to personal satisfaction [The benefits, challenges, and suggestions identified in this study are wide, and they align to the findings in other literature , 10, 20.The LINK faces a number of challenges Table , most ofSome literature documents that building relationships, especially in the early stages of partnership, is the most daunting and time-consuming challenge to partnerships . This woSuccess of a link can be assessed from many angles. This LINK can be considered successful based on the Eastwood et al. framework  and alsosustainability, as the trainees will use this skill for the rest of the career in training and will train successors. However, it does not address sustainability of funding for LINK activities, which depend on grants. Sustainability is a principle that is also emphasized by the NHS [At the strategy level, the LINK was established through a memorandum of understanding that specified mutually agreed objectives. The LINK has also embraced joint planning, even in proposal writing for funding. Strategic planning is a best practice that is similarly articulated by the African Unit framework . The vis the NHS  and Afri the NHS  framewormutual accountability and shared responsibility which are also emphasized by the NHS [ownership, shared roles, and strong commitment from junior and senior staff.At the operational level, the link has embraced regular contact between individuals involved in the partnership, bilateral annual visits, and in-country training activities. These practices strengthen liaison, communication, local ownership, and commitment to the partnership. There is strong commitment to the LINK by the presidents and chief executives of the two colleges, deducible from their participation in activities such as the annual congress. Participants mentioned using personal time for LINK activities, which further implies commitment. There are LINK coordinators in each of the eight countries involved in the partnership and in each of the committees responsible for various activities such as curriculum development or examinations. These committees have shared leadership from both partners. This is a reflection of  the NHS . DFID fo the NHS . The Afr the NHS  similarlAlthough the LINK has demonstrated a level of achievement of ownership, participants from both partners also identified insufficient ownership as a challenge. This might suggest that there are different domains of ownership, and only a part of them have been satisfied, but this study did not seek to investigate these domains.institutional infrastructure is not visible in COECSA as it is a “young college” that is still developing its structures. The need for strengthening monitoring and evaluation was raised in the suggestions for improvement .Expansion of scope of collaboration is the next step; COECSA participants expressed the need for expansion of collaboration to include joint research, subspecialty training within the region, training for the editorial team of the scientific journal, mobilization of resources and appropriate technology, and sourcing equipment for eye care. The link can foster additional north-south VISION 2020 hospital twinning links, which several hospitals are seeking. It can also foster south-south interdependency between ECSA countries as they can synergistically leverage on each other’s capabilities and goodwill.Future research may include an evaluation of the impact of the LINK on the training of ophthalmologists, for example, through a survey of a cohort of newly graduated ophthalmologists. An impact of the LINK on prevention of blindness may also be appropriate, though attribution of effect to the LINK may be challenging. An economic evaluation would identify if the LINK is a cost-effective way of addressing the human resource challenges in the ECSA region.


Intensive care information systems (ICIS) are continuously evolving to meet the ever changing information needs of intensive care units (ICUs), providing the backbone for a safe, intelligent and efficient patient care environment. Although beneficial for the international advancement in building smart environments to transform ICU services, knowledge about the contemporary development of ICIS worldwide, their usage and impacts is limited. This study aimed to fill this knowledge gap by researching the development and implementation of an ICIS in a Chinese hospital, nurses’ use of the system, and the impact of system use on critical care nursing processes and outcomes.This descriptive case study was conducted in a 14-bed Respiratory ICU in a tertiary hospital in Beijing. Participative design was the method used for ICU nurses, hospital IT department and a software company to collaboratively research and develop the ICIS. Focus group discussions were conducted to understand the subjective perceptions of the nurses toward the ICIS. Nursing documentation time and quality were compared before and after system implementation. ICU nursing performance was extracted from the annual nursing performance data collected by the hospital.A participative design process was followed by the nurses in the ICU, the hospital IT staff and the software engineers in the company to develop and implement a highly useful ICIS. Nursing documentation was fully digitized and was significantly improved in quality and efficiency. The wrong data, missing data items and calculation errors were significantly reduced. Nurses spent more time on direct patient care after the introduction of the ICIS. The accuracy and efficiency of medication administration was also improved. The outcome was improvement in ward nursing performance as measured by ward management, routine nursing practices, disinfection and isolation, infection rate and mortality rate.Nurses in this ICU unit in China actively participated in the ICIS development and fully used the system to document care. Introduction of the ICIS led to significant improvement in quality and efficiency in nursing documentation, medication order transcription and administration. It allowed nurses to spend more time with patients to improve quality of care. These led to improvement in overall nursing performance. Further study should investigate how the ICIS system contributes to the improvement in decision making of ICU nurses and intensivists. With rate up to 70%, failure of health information technology (HIT) project is a widespread, significant problem . The “deThe first intensive care unit (ICU) in China was established in Beijing in 1982 . AlthougAlthough only a “young” speciality in the family of hospital health care, the processes of intensive care nursing have been steadily improving, as have other specialties in Chinese hospitals. The driving force has been the government health reform program  underpinTranslation of knowledge into rational care is as essential and pressing as the development of new diagnostic or therapeutic devices, and is arguably even more important . HoweverDespite its importance, Lapinsky et al. found the use of fully integrated intensive care information systems (ICIS) was still not common in 2008 ; only 46Several authors have suggested that computerised nursing information systems are among the optimal choices to improve nursing care in ICUs , 12. BosTo date there is no refereed paper reporting ICIS development, implementation, usage and impact from Asian countries including China. The international research community have no knowledge about whether and how ICIS is introduced and used by nurses in China, and what are the impacts of Chinese nurses’ use of ICIS on their work practices and performance. Lack of this knowledge is a serious impediment for the international advancement of intensive care as a medical specialty and ICIS as an effective tool to support intensive care services.Critical care research in China is still in its infancy . AlthougThe goal of participatory design is to establish a more human, creative and effective relationship between the actors involved in technology’s design and its use so as to generate a user-friendly digital ecosystem . The parThe organizational contexts are important for the success of participatory design projects . These iThe nature of participation can be conceptualised in three dimensions: (1) access to relevant information , (2) theMany participatory design methods have been developed, such as cooperative experimental systems development method, prototyping experiments, and work-oriented design. Cooperative experimental systems development method is characterized by a focus on active user involvement throughout the entire development process . PrototyTools and techniques are needed to facilitate designers to learn the everyday work practices of potential users, for workers to learn about the technical options, and for both to connect current and future work practices with envisioned new technologies. The useful tools and techniques for work analysis include visualization, reviewing written materials, questionnaires, interviews and ethnographic techniques . VisualiThe tools and techniques for system design include scenarios, mock-ups, simulations of the relation between work and technology, future workshops, design games, case-based prototyping and cooperative prototyping , 30. TheThe case study site is the 14-bed respiratory ICU in the Department of Pulmonary & Critical Care Medicine in 307th Hospital of PLA in Beijing, China. The hospital is a tertiary hospital with 1500 beds. The Respiratory ICU was established in 2009, the same year intensive care was recognised as a medical specialty by the Chinese Ministry of Health. In total, there were 27 nurses in the specialty. The demographic profiles of the nurses are listed in Table The first author, who was the Director of Nursing (DON) in the ICU, expressed her wish of introducing certain information system to reduce the burden of nursing documentation, and to “return nurses to patients” with the Chief Information Officer (CIO) in the hospital in 2012. After initial market research including site visits to two hospitals in Beijing with sophisticated IT systems and discussions with various HIT vendors, YQ, CB and the CIO came to the conclusion that there was no readily available ICIS that could meet the needs of the ICU nursing. The team had to develop an ICIS onsite.The project team was coordinated by then CIO in the hospital. YQ was responsible to provide domain knowledge and resources, five nurses (22%) in the unit  participated in the project team. A manager in the company led the technical team. The team members included one to two software engineers in the Department of Biomedical Engineering in the hospital, all of the authors for the paper except SQ and PY, and three to eight software engineers from the company at the various software development stages.As the initiator of the ICIS development, the nursing team was actively driving the development, providing the engineers with access to the ICU knowledge and resources. An engineer could conduct ethnographic observation in the ICU upon informing the DON and without disturbance to the unit operation. Excited by the opportunity of leading the development of ICIS innovation in China, the CIO was highly enthusiastic, allocated one to two biomedical engineers in the Department of Biomedical Engineering in the hospital to the project, as well as the office space for use by the engineers in the company for software development. Motivated by the opportunity to enter the market of ICIS, the management in the company made the strategic decision to invest resources in building the ICIS, using the hospital ICU as an experiment and test site. With the appropriate administrative position in the organization, the CIO acted as the general manager for the project.Therefore, a shared goal that united the three collaborating partners together was producing a high quality ICIS to strengthen the position of nurses in their efforts to improve working conditions and quality of work life. The initial nursing requirement for the system was automating the nursing documentation system, real-time data capture from numerous ICT equipment, and automatic generation of the one-page 24-h special nursing care form.The common goal motivated the team to communicate, negotiate, compromise and collaborate in the participative design process. To solve the challenge of ambiguity of requirements and difficulty in understanding the view point of each other, the engineers and the nurses really collaborated to understand each other. Patience, collegiality, and trust led to high morale, mutual learning and development.The nursing team provided the requirements for the system, including the nursing documentation forms and data, the information flow and its accordance with nursing work processes and exchange mechanism with other hospital information systems in the other departments.With better knowledge of the work practices of nurses, experience of automating hospital work and cost associated with the automation, the biomedical engineers in the hospital drove the requirements capture and analysis, and the translation of nursing needs to the language of the software developers in the company.The team regularly had participatory design meetings at the Department of Biomedical Engineering in the hospital in the late afternoon for one to three hours. Any idea, issue or suggestion was discussed, the information related to the project was transparently shared in these meetings. Each individual team member took an independent position on the problems. After discussion, the final decision was a rational choice based on the analysis of various scenarios, weighing pros and cons of each scenario.This stage was quickly gone through in one-month time. The CIO and two biomedical engineers in the hospital regularly visited the ICU unit, having meetings with the DON and the nurses to understand the nurses’ work activities, purposes, procedures, routines, technologies used, and information exchange with other departments using other hospital information systems.The biomedical engineers in the hospital used the ethnographic techniques such as observing nursing work, reviewing written documents, and communicating with nurses to understand the everyday work activities and actions of nurses and to gain insights into nurses’ tacit knowledge.They learned nursing care processes and actions; first what nurses did, then divided the nursing actions into modules and understood each action in a module. They recorded the action, its rationale, and relationship with other actions or parameters; e.g., the relationship between medication orders and patient’s health conditions. Based on the learning, they produced the requirements documentation.The whole team worked together, either in the ICU or in the Biomedical Engineering Department, to understand and prioritize work organisation and to agree on the technical solutions. The team would discuss the documented requirements. To balance the speed of development and the quality of software, the requirements were prioritised according to the sequence of information flow and usage rate, i.e., how many users would use a function. The functions with high usage rate were given higher priority for automation.Tools such as diagrams, drawings and nursing scenarios were often used to visualize and analyse the model of patient journey and information flow, the relationship between technology and work in these meetings and to develop shared views on nursing work and how the ICIS could be best designed to support the nursing work.The participating nurses learned about the technical options through direct discussions with engineers in the participatory design meetings, trialling on the prototype system and referencing with their experience of using other common software applications such as Microsoft Word and online activities.The system development methods included cooperative experimental systems development method, prototyping experiments and work-oriented design.The first version of the prototype was quickly produced in two-month time, in February 2013. As the product was a direct translation of paper records to electronic records, the nurses did not see it as what they expected, i.e., an automatic system that would help nurses to manage information. It was completely abandoned because nurses did not see it as usable. This experience taught the engineering team that automation was not a simple replication of manual process, but the best possible automation of information flow and output.An incremental, modular development was conducted to ensure quality control for each step of patient journey. A module was centred on satisfying the information needs for each step of patient journey, such as patient admission, allocation of bed and medication order. Only after a module was built, and has satisfactorily passed unit test and user test, would the development progress to the next module.Between February and September 2013, the ICIS was incrementally used to record the information for one patient by a nurse in the project team. The nurse recorded the patient information both on paper and in the ICIS and checked the conformance between the two types of records. The trial rolled from one patient to the second and third. Only after all the deficits were ironed out and the software functionality and workflow met the needs of ICU nursing, was the system fully implemented in the unit in September 2013. The system was fully integrated into practice by December 2013.The onsite engineer provided training to all nurses on usage of the system. This full-time, onsite support was continued until July 2014. This had enabled any usage problems to be resolved promptly on site, any technical glitches to be ironed out quickly and the functionality of the system to be continuously improved. The nurses involved in piloting the system also acted as trainers and champions to provide peer support to the other nurses.There was strict procedure to follow on functional change and documentation. System was only upgraded after thorough testing to ensure error free. Installation of the upgraded system was usually conducted at mid-night on week days, avoiding the peak usage period of weekends and Mondays.Pre- and post-implementation comparison was conducted. The outcome data collected were documentation time versus direct patient care time, auditing of paper vs electronic nursing records, and annual hospital nursing performance data.Pre-implementation data collection was conducted between May and September 2013, before the ICIS was implemented in the ICU. The documentation time was acquired through self-reporting by nurses in the day shift, from 8 am to 8 pm. In consideration of the frequent occurrence of emergencies, an intrinsic feature of ICUs, a nurse was given five months to record their own documentation time and direct patient care time per shift, then reported the average time over five months to the Director of Nursing (DON) in the unit.The post-implementation data was collected during March to August 2014, five months after implementation of the ICIS, when most nurses were sufficiently experienced to use the ICIS confidently.The nursing records were audited by the Director of Nursing (DON) as part of the routine nursing documentation quality control process in the hospital. Ten to fourteen nursing records were audited randomly every day to identify missing data, missing data items, calculation errors and legibility. Missing data items were identified by a comparison of a patient’s records in a day with that of previous days.Before the ICIS introduction, YQ audited 500 paper-based nursing records in July to August 2013. After the ICIS was fully implemented, she audited 450 electronic nursing records in May to June 2014 again, as part of the routine procedure of quality assurance.Nursing performance in each ward was formally evaluated by a quality assurance committee on annual basis as an important nursing quality assurance mechanism in the hospital. Six areas were assessed: ward management, routine practice, disinfection and isolation, nursing documentation, infection rate and mortality rate. Each area was measured in several domains. Each domain was, again, measured by several tangible items, each was assigned a score. The total score of all items in all domains in an area was 100. For example, the area of disinfection and isolation was measured by four domains: hand hygiene, sterilised goods management, clinical item usage and management, and ventilator usage and management. The domain of hand hygiene was again measured by five items: (1) A clear sign to notify the procedure of hand hygiene and completeness of supplies for hand wash at the sink, 1 mark; (2) Antiseptic agent to be placed close to the entrance of the monitoring ward, 1 mark; (3) Nurses were fluent with the six-step hand wash procedure, 1 mark; (4) Washing hands promptly, washing or antiseptic disinfection before and after contact with a patient, 3 marks; and (5) Correct usage of various gloves, 1 mark. Likewise, other domains were also measured by the specific, measurable items. With a standardised, reasonably rigorous method of data collection, the annual nursing performance data provided a useful indicator of changes in nursing care quality that might be related to the introduction of the ICIS.The study was approved by the Institutional Review Board of Affiliated Hospital of Academy of Military Medical Sciences.The system had the following functionality: 1) Seamless integration with the hospital information system (HIS), picture archiving and communication system (PACS), laboratory information system (LIS) and electronic medical records (EMR); (2) Automatic collection and recording of data from bed-side monitoring devices and respirators via a centralised transmitter; (3) Extraction of physician order entries from the HIS; (4) Bar-code verification of a patient’s identity and the medication to be administered for preventing medication errors; (5) Generation of line charts of patient vital signs; (6) Automatic generation of a daily one-page, 24-h “Critical Care Chart”; (7) Provision of an interface for nurses to enter patient intake and discharge records, body temperature, nursing records and medication management records. Figure  SeamlessThe data captured from the monitoring devices included blood pressure, heart rate, breathing, transcutaneous oxygen saturation, ventilator output, blood gas analysis parameters, and various intake and output statistics. The system automatically conducted blood gas analysis, calculated oxygenation index, hemofiltration and fluid intake and output balance. The interval of data collection is one minute. The numerical data were presented in a one-page, easy-to-read intuitive diagram called a Critical Care Chart see Fig. .Fig. 2ICThere were 20 types of quantitative evaluation of clinical effects built into the ICIS. The critical disease assessment model in the ICIS included acute care physiology and chronic disease evaluation (APACHE II score), sequential organ exhaustion evaluation system (SOFA score), and comprehensive assessment of multiple organ dysfunction (MODS score).Abnormal data captured from various monitoring devices, such as blood pressure outside normal range, or out of range data entry, were automatically identified and alerted to nurses by the ICIS. For example, the abnormal data collected from an electrocardiography would be colour-coded to draw the attention of nurses to the need for further assessment. Nurses were alerted to the depth of entrance of endotracheal intubation, if longer than the total length of the tube by a pop-up window for further validation.It is common that 10 to 20 medications are prescribed to a patient in the ICU. In the ICIS, in order to standardise the process of medication administration, each medication in a physician order entry was automatically classified as a long-term or temporary medication by the period of medication. Long-term medications were further classified by the method of administration into three types: (1) oral medication, (2) minor treatment, such as oxygen and cardiopulmonary suctioning, and (3) injection, including intravenous and intramuscular injection.In accordance with the characteristics of nursing in the ICU, specific forms and charts were designed in the ICIS to present real-time changes in vital signs. These included an observational chart of vital signs, critical patient records, critical nursing charts, various assessment forms and medication administration forms. The database was established to collect, integrate, analyse and export data to the end users, nurses. The system also provided search functions for all the data in the database. The data searched can be stored in an Excel spreadsheet.The system was used in three major functional areas of nursing: data capture and entry, information output and medication administration. Nurses used mobile terminals on cart and desktop computers to access data electronically. After introduction of the ICIS, paper was no longer used by nurses in the ICU. The nurses who participated in the focus group discussions all expressed satisfaction with the ICIS and the way it was implemented, grateful for the support received from the onsite engineer. One nurse reported “The system was used to full. The engineers provided all the functions in accordance with our requirements. We also used all these functions.” They all stated that whenever they had any problem using the system, the problem was solved promptly.The major benefits of the ICIS were improved quality and efficiency of nursing documentation, accuracy and efficiency of medication administration and overall nursing service quality and efficiency.Errors often occurred when nurses were required to hand write and draw diagrams to present the monitoring data. These could lead to inaccurate assessment of the condition of a critically ill patient. Using the ICIS, 100% accurate monitoring data were automatically generated; improving the accuracy of patient assessment.Measured by the indicators of quality of nursing documentation including wrong data, missing data items, wrong calculations and legibility, the quality of electronic records significantly outperformed paper records. The rate of wrong data was reduced from 7.5% in the paper records to 1.6% in the electronic records. The rate of missing data dropped from 18.5% in the paper to 3.7% in the electronic records. The rate of wrong calculation decreased from 16.8% to 2.8%. The electronic records were completely legible, whereas 110 illegible data items were corrected in the paper records  per 12 h shift to complete nursing documentation. Using the ICIS, the documentation time was significantly reduced to 2.05 h .According to the self-reported time usage data, using the paper records, a nurse would spend 3.80 h  on bed-side nursing tasks. After using the ICIS, a nurse spent 21.95 h  on bed-side nursing tasks , an increase of 1.75 h in a 24-h period.When using the paper records, in a 24-h period, a nurse spent 20.20 h (Using the ICIS, the whole process of medication administration was automated via barcode technology, including order transcription from the HIS system, verification and administration.According to the clinical guideline, an order entry by a doctor first needed to be transcribed by a nurse to the nursing chart, then to be validated by the second nurse. Only after the two nurses both signed the medication chart to signal completion of the medication validation process could the order entry be sent to the pharmacy for dispensing.In a doctor’s prescription, the dosage was recorded as the total amount of medication for a day. As a medicine was often needed to be administered several times for a patient in a day, it required a nurse to calculate the dosage for each medication, a source of calculation error.As the ICIS directly populated the order entry data from the HIS, it eliminated the process of order transcription, an error prone process. The ICIS automatically presented the number of times that a medicine needed to be administered based on pattern analysis of medication administration for the common types of medicine. This provided an intuitive interface for a nurse to enter the dosage data. The nurse was also given the flexibility of changing administration time and dosage according to own discretion. Therefore, after implementation of the ICIS, the whole process of medication administration was automated and standardised. The error rate in transcription of medication prescription was believed to be reduced.The ICIS also helped nurses to prioritize nursing treatment by the automatic classification of medications. For example, if a medication was placed in the temporary category, it signalled to a nurse that this medication had to be administered at the correct time. Long-term medication needed to be administered in order, at a fixed time interval, whereas administration of minor treatments, such as shoulder massage or oral hygiene care, could be done after the completion of oral medication and injection. Therefore, the nurses felt that they spent less time and less mental load on medication administration.Data output from the ICIS was in various intuitive diagrams and charts, much more intuitive and convenient for a nurse to monitor and accurately understand the disease change process. The nurses reported that the saved time was used to observe the changes in a patient’s psycho-social status and to provide more personal care to the patients. The amount of oral hygiene, personal care and physiotherapy treatment to the patients was also increased after using the ICIS.The study unit had always enjoyed high performance ratings in all mandatory nursing quality audit areas in the annual hospital nursing service evaluation Table . The quaKnowledge about the contemporary development of the ICIS worldwide, their usage and impacts on nursing services is beneficial for international advancement in building smart environments to transform ICU services in different healthcare context. This case study contributes new knowledge about how nurses contribute to the participatory design of an ICIS to support critical care nursing in a Chinese hospital. It describes the development and functionality of the ICIS, the nursing team’s use of the system, and the impact of system use on critical nursing care processes and outcomes. Both objective, performance evidence and nurses’ perceptions were gathered to provide a pre- and post-implementation comparison of quality and efficiency of nursing documentation, quality and efficiency of medication management, and impact on quality of nursing services.Carayon et al.  find thaThe success of the system, including its fit with nursing work processes and information needs was ensured by a committed, sustained collaboration in research and development of the ICIS by the ICU nurses, the hospital IT department and the software company developing the system. Once more, this case study proves that the active participation of the intended users in HIT design facilitates good design . This efSimilar to findings by Bosman , 17 and Serious medication errors are common in hospitals and often occur during the process of order transcription and medication administration . Heavy nStandardisation of the order transcription and medication administration process was another mechanism that had led to the reduction of medication administration error in the ICU, as suggested by the previous study . AlthougThe organization of nursing work in the study unit was improved with the automation of nursing documentation, particularly monitoring data collection, medication order transcription and management. The tasks that are markers of good nursing care, such as oral hygiene and skin care, teaching, and comforting patients , were inThe limitation of the study was that only one ICU was studied to provide a bird’s eye view of the introduction of the ICIS in a Chinese hospital. A comparison of medication error rate before and after the implementation of the ICIS could provide useful, direct evidence about the effect of the ICIS on medication error, a key potential benefit of digitisation of ICU work. The improvement in nursing care quality cannot be fully attributed to the introduction of the ICIS. From its inception in 2009, only a few nursing staff left the ICU. Five-year daily hands-on nursing practice had led to a steady progress in team building, communication, improvement in individual nursing expertise, capacity and skill in intensive care nursing; an important contributor to the steady improvement in nursing performance.Management of daily activities in ICU is challenging; ICU intensivists and nurses often need to make immediate ad hoc decisions to enable the optimal flow of activities . TherefoParticipatory design was a useful model for the nurses, the hospital IT department and the software company to collaboratively research and develop a user-centred, intelligent ICU environment. Use of the ICIS had brought benefits including improving quality and efficiency of nursing documentation, accuracy and efficiency of medication administration, overall improvement in nursing service quality, and improvement in working conditions and quality of work life for the nurses. Further research can be focused on understanding how to enhance the functionality of the ICIS to support decision making of intensivists and nurses, and nursing performance measurement in ICU.


The evolution of the Internet of Things leads to new opportunities for the contemporary notion of smart offices, where employees can benefit from automation to maximize their productivity and performance. However, although extensive research has been dedicated to analyze the impact of workers’ emotions on their job performance, there is still a lack of pervasive environments that take into account emotional behaviour. In addition, integrating new components in smart environments is not straightforward. To face these challenges, this article proposes an architecture for emotion aware automation platforms based on semantic event-driven rules to automate the adaptation of the workplace to the employee’s needs. The main contributions of this paper are: (i) the design of an emotion aware automation platform architecture for smart offices; (ii) the semantic modelling of the system; and (iii) the implementation and evaluation of the proposed architecture in a real scenario. One of ly work” .A large body of research has been carried out on the impact that emotions have on decision making , health Emotion Aware AmI (AmE) extends the notion of intelligent environments to detect, process and adapt intelligent environments to users’ emotional state, exploiting theories from psychology and social sciences for the analysis of human emotional context. Considering emotions in the user context can improve customization of services in AmI scenarios and help users to improve their emotional intelligence . Howeverhttps://ifttt.com/) or Zapier (https://zapier.com/). These systems, so-called Task Automation Services (TASs) [A popular approach to interconnect and personalize both IoT and Internet services is the use of Event-Condition-Action (ECA) rules, also known as trigger–action rules . Severals (TASs) , are typs (TASs) ,15, thesThis work proposes a solution that consists in an emotion aware automation platform that enables the automated adaption of smart office environments to the employee’s needs. This platform allows workers to easily create and configure their own automation rules, resulting in a significant improvement of their productivity and performance. A semantic model for the emotion aware TASs based on the Evented Web (EWE)  ontologyThe rest of this paper is organized as follows. Firstly, an overview about the related work in smart offices, emotion regulation and semantic technologies is given in This section describes the background and related work for the architecture proposed in this paper. First, an overview of related work in AmE and specifically in smart offices is given in a kind of AmI environment facilitating human emotion experiences by providing people with proper emotion services instantly”. This notion aims at fostering the development of emotion-aware services in pervasive AmI environments.The term AmE was coined by Zhou et al. . AmE is AmE are usually structured in three building blocks ,17: emotEmotion sensing is the process of gathering affective data using sensors or auto-reporting techniques. There exists many potential sensor sources, including speech, video, mobile data [Emotion analysis module applies emotion recognition techniques , as well as ensemble of different information sources from the same mode .Algorithms to predict emotions based on facial expressions are mature and considered accurate. Currently, there are two main techniques to realize facial expression recognition depending on its way of extracting feature data: appearance-based features, or geometry-based features . Both teEmotion recognition from speech analysis is an area that is gaining momentum in recent years . Speech Physiological signals are another data source for recognizing people’s emotions . The ideEmotion regulation consists in the modification of processes involved in the generation or manifestation of emotion , and resXin et al. ,55 demonWith regard to music, several studies ,58 show The commented studies show that the adaptation of ambient light colour and music are considerable solutions for regulating emotions in a smart office environment, as this adaptation may improve workers’ mood and increase their productivity and efficiency.Semantic representation considerably improves interoperability and scalability of the system, as it provides a rich machine-readable format that can be understood, reasoned about, and reused.what they are exchanging (concepts and their relationship), but also how they represent this information (representation formats and models). Moreover, although these two aspects need to be in synchrony, they are not unambiguously coupled: knowing how data are encoded does not suffice to know what real concepts the refer to, and vice versa.To exchange information between independent systems, a set of common rules need to be established, such as expected formats, schemas and expected behaviour. These rules usually take the form of an API (application programming interface). In other words, systems need not only to define The semantic approach addresses this issue by replacing application-centric ad-hoc models and representation formats with a formal definition of the concepts and relationships. These definitions are known as ontologies or vocabularies. Each ontology typically represents one domain in detail, and they borrow concepts from one another whenever necessary . SystemsThis work merges two domains: rule-based systems and emotions. We will explore the different options for semantic representation in each domain.There are plenty of options for modelling and implementing rule-based knowledge, such as RuleML , Semantihttps://www.w3.org/2001/sw/wiki/TopBraid)) and N3 Logic (EYE (http://eulersharp.sourceforge.net/)).EWE  is a vocChannel, Event, Action and Rule. The class Channel defines individuals that either generate Events, provide Actions, or both. In the smart office context, sensors and actuators such as an emotion detector or a smart light are described as channels, which produce events or provide actions. The class Event defines a particular occurrence of a process, and allows users to describe under which conditions should rules be triggered. These conditions are the configuration parameters, and are modelled as input parameters. Event individuals are generated by a certain channel, and usually provide additional details. These additional details are modelled as output parameters, and can be used within rules to customize actions. The recognition of sadness generated by the emotion detector sensor is an example of entity that belongs to this class. The class Action defines an operation provided by a channel that is triggered under some conditions. Actions provides effects whose nature depends on itself, and can be configured to react according to the data collected from an event by means of input parameters. Following the smart office context mentioned above, to change the light colour is an example of action generated by the smart light channel. Finally, the class Rule defines an ECA, triggered by an event that produces the execution of an action. An example of rule is: “If sadness is detected, then change the light colour”.Four major classes make up the core of EWE: There are also different options for emotion representation. EmotionML  is one oMoreover, the Onyx model provides a model for emotion conversion, and a set of existing conversions between well known models. Including conversion as part of the model enables the integration of data using different models. Two examples of this would be working with emotion readings from different providers, or fusing information from different modalities , which typically use different models. It also eases a potential migration to a different model in the future.In addition, Onyx has been extended to cover multimodal annotations ,78. LastEmotion, EmotionAnalysis and EmotionSet. They relate to each other in the following way: an EmotionAnalysis process annotates a given entity  with an EmotionSet, and an EmotionSet is in turn comprised of one or more Emotions. Due to the provenance information, it is possible to track the EmotionAnalysis that generated the annotation.There are three main concepts in the Onyx ontology that are worth explaining, as they are used in the examples in following sections. They are: With the purpose of applying a semantic layer to the emotion aware automation system, several vocabularies and relationships between ontologies have been designed. This enables the semantic modelling of all entities in the smart office environment. ewe:Rule) are modelled using EWE ontology [ewe:Event) and actions (ewe:Action) are generated by certain channels. In the proposed architecture, there are different channels that either generate events, provide actions, or both. The class ewe:Channel has been subclassed to provide an emotional channel class (emo:Channel), which is responsible for generating events and actions related to the emotion recognition and regulation. From this class, the channels emo:EmotionSensor and emo:EmotionRegulator have been defined. The former is responsible for generating events related to the emotion detection, while the later is responsible for providing certain actions that have the purpose of regulating the emotion. These two classes group all sensors and actuators able to detect or regulate emotions, but should be subclassed by classes representing each device concretely. In addition, events and actions may have parameters. The emo:EmotionDetected event has as Parameter the detected emotion. Emotions are modelled using Onyx [onyx:Emotion.Automation rules  the song to be played, while the action of change ambient colour has as parameter the colour to which the light must change. In addition, all these actions are also represented as therapies using Human Stress Ontology (HSO) ontology [hso:Therapy has been subclassed. To give a better idea of how specific Channels, Events and Actions have been modelled; The ontology , so hso:An example of event and action instances with grounded parameters, which are based on the concepts defined in the listing given above, is presented in sad emotion detection and produces the action of changing ambient colour to green  and its pre-processing. With this purpose, the input analyzer is connected with the mentioned sensors, and the received data are sent to the recognizer module. The recognizer module receives data captured by the input analyzer. It consists in a pipeline with several submodules that perform different analysis depending on the source of the information. In the proposed architecture, there are three sub-modules: emotion recognizer, context recognizer and web recognizer. The emotion recognizer module provides functions for extracting emotions by means of real time recognition of facial expression, speech and text analysis, and biometric data monitoring; the context recognizer provides functions for extracting context data from sensors ; and the web recognizer provides functions for extracting information from Internet services. Once data have been extracted, they are sent to the semantic modelling module. The main role of semantic modelling is the application of a semantic layer  where users can easily create, remove or edit rules. The GUI connects with the rule administration module, which is responsible for handling the corresponding changes in the repositories. There are two repositories in the platform: rule repository, where information about rules and channels is stored; and emotion regulation policies repository. The policies are sets of rules which aim to regulate the emotion intensity in different contexts. In the smart office context proposed, they are intended to regulate negative emotions to maximize productivity. The rules may be aimed towards automating aspects such as: ambient conditionsto improve the workers’ comfort; work related tasks to improve efficiency; or the rules could adjust work conditions to improve productivity. Some examples of these rules are presented below:(a)If stress level of a worker is too high, then reduce his/her task number. When a very high stress level in a worker has been detected, this rule proposes reducing his/her workload to achieve that his/her stress level falls and his/her productivity rises.(b)If temperature rises above 30 °C, then turn on the air conditioning. To work at high level of temperatures may result in workers’ stress, so this rule proposes to automatically control this temperature in order to prevent high levels of stress.(c)If average stress level of workers is too high, then play relaxing music. If most workers have a high stress value, the company productivity will significantly fall. Thus, this rule proposes to play relaxing music in order to reduce the stress level of workers.To enable the configuration and management of automation rules, the platform provides a In addition, the company human resources department may implement their own emotion regulation policies to adjust the system to their own context. The system adapts rules based on channel description. Rule adaptation is based on identifying if the smart environment includes the channels used by a certain rule. The system detects available channels of the same channel class used by the rule and request confirmation from the user to included the “adapted rule”. This enables the adaptation of rules to different channel providers, which can be physical sensors  or internet services . The EWE ontology allows us this adaptation by mean of OWL2 punning mechanism for attaching properties to channels .events manager module, which sends them to the rule engine to be evaluated along with the stored rules. The rule engine module is a semantic engine reasoner [events manager and the load of rules that are stored in the repository. When a new event is captured and the available rules are loaded, the reasoner runs the ontology model inferences and the actions based on the incoming events and the automation rules are drawn. These actions are sent to the action trigger, which connects to the corresponding channels to perform the actions.With regards to event reception, these are captured by the reasoner  based onhttps://crossbar.io/), and IoT Middleware that provides both REST-through Web Application Messaging Protocol (WAMP)- and Message Queuing Telemetry Transport (MQTT) interfaces.The semantic integration of sensors and services is done based on the notion of adapters ,84, whichttp://n3.restdesc.org/). Several sensors and services have already been integrated into EWETasker suitable for the smart office use case. In particular, EWETasker supports indoor and temperature sensors (Estimote bluetooth beacons (https://estimote.com)), smart object sensor (Estimote bluetooth stickers), electronic door control based on Arduino, video emotion sensors (based on Emotion Research Lab), social network emotion sensor (Twitter), and mobile-phone sensors . With regards to corporate services, several services oriented to software consultancy firms have been integrated for collaboration  and software development (Restyaboard Scrum board (http://www.restya.com), GitHub (https://github.com) and Slack (https://slack.com)).Finally, the implementation of this architecture, called EWETasker, was made using PHP for the server, HTML/JavaScript for the web client (including the GUI), and Android SDK for a mobile client. The implementation was based on N3 technology and EYE reasoning engine . This module provides facial mood detection and emotional metrics that are fed to the automation system. This module is an implementation that performs emotion classification in two main steps: (i) it makes use of Histogram of Oriented Gradients (HOG) features that are used to train with a SVM classifier in order to localize face position in the image; and (ii) the second step consists in a normalization process of the face image, followed by a Multilayer Perceptron that implements the emotion classification. Emotion Research reports 98% accuracy in emotion recognition tasks.Emotion Research software (A camera (Gucee HD92) feeds the video to the emotion recognizer submodule.Room lighting (WS2812B LED strip controlled by WeMos ESP8266 board) is used as an actuator on the light level of the room, with the possibility of using several lighting patterns.Google Chromecast  transmitLG TV 49UJ651V is used for displaying images.Google Home is used for communicating with the user. In this experiment, the system can formulate recommendations to the user.The material used for this experiment is varied, as the proposed automation system needs several devices to properly function. Regarding the deployment of the automation system, the TAS ran in a commodity desktop computer, with sufficient CPU and memory for its execution. The same environment was prepared for the emotion recognizer system. For the sensors and actuators, the following were used:https://www.mozilla.org/en-US/firefox/desktop/).Participants accessed the web HTML-based interface using a desktop computer with the Firefox browser . We used a set of 20 questions of similar difficulty that have been designed so that any participant can answer them within 30 s. The use of a web-based interface allowed us to programmatically perform the session, and to record metrics associated with the experiment.The workflow of the experiment is as follows. Each participant’s session is divided into two parts. In each part of the session half of the task questions are sequentially prompted to the participant by the examiner system. Simultaneously, the automation system is fed with the information provided by the different sensors that are continually monitoring the participant emotional state. The experiment finishes when all the questions have been answered. In addition, a questionnaire is given to the participants just after the sessions concludes. These questions are oriented to offer the participant’s view of the system. The raised questions are summarized in The workflow of the system in the context of the experiment is as follows. While the participant is performing the task, the emotion sensor is continuously monitoring the participant’s emotional state. The emotion sensor uses the camera as information input, while the Google Home is used when the user communicates with the system. This emotion-aware data are sent to the TAS, which allows the system the have continuous reports. The TAS receives, processes, and forwards these events to the N3 rule engine. Programmed rules are configured to detect changes in the participant emotional state, acting accordingly. As an example, a shift of emotion, such as the change from happy to sad, is detected by the rule engine which triggers the relaxation actions. If a certain emotion regulation rule is activated, the corresponding action is then triggered through the communication to the action trigger module, which causes the related actuators to start its functioning. The configured actions are aimed at relaxing and regulating the emotion of the participant, so that the performance in the experiment task is improved, as well as the user satisfaction. The actions configured for this experiment are: (i) relaxation recommendations done by the Google Home, such as a recommendation to take a brief walk for two minutes; (ii) lighting patterns using coloured lights that slowly change its intensity and colour; and (iii) relaxing imagery and music that are shown to the user via the TV. A diagram of this deployment is shown in While the participants are performing the proposed task, the actions of the automation system are controlled. During half of each session, the automation is deactivated, while, during the other half, the action module is enabled. With this, we can control the environmental changes performed by the automation system, allowing its adaptation at will.Another interesting aspect that could be included is the integration of learning policies based on employee’s emotional state. A related work that models learning policies and their integration with Enterprise Linked Data is detailed in .The experiment was a within-subject design. As previously stated, the controlled factor is the use of the automation system, which has two levels, activated and not activated. The automation use factor is counterbalanced using a Latin square so that the participants are divided into two groups. One group performs the first half of the session without the automation system, while, for the second half of the session, the system is used. The other group performs the task inversely.p = 0.015 < 0.05). These results support H1 and H2, concluding that users feel more inclined to use the adaptation system rather than performing the task without adaptation.To tackle Hypothesis 1 and Hypothesis 2, Questions 1 and 2 were analyzed. Regarding Question 1, 18 respondents declared that the section with the adaptation system enabled was the most relaxing for them. In contrast, seven users claimed that for them the most relaxing section of the experiment was that without the adaptation system. The results from Question 1 suggest that users prefer to use the adaptation system, although it seems that this is not the case for all the users. Regarding the Question 2, results show that the average in the adaptation part (3.5) is higher than with no adaptation whatsoever (2.5), as shown in p = 2.96 × 10−6 < 0.05). As expected, Hypothesis 3 receives experimental support, indicating that the use of the automation system can improve the performance of the user in a certain task, as perceived by the users.Following, Question 3 addressed Hypothesis 3. The analysis of the results of this question reveals that users point higher the usefulness of the environment adaptation for the completion of the task, as shown in p = 0.0002 < 0.05). With regard to Question 5, the average for the satisfaction with the adapted environment is 3.83; in contrast, the satisfaction with the no adaptation environment is 2.17, as shown in p = 1.02 × 10−10 < 0.05). Attending to this, users seem to consider the adaptation system for their personal workspace, and at the same time, they exhibit a higher satisfaction with an adapted work environment. These data indicate that Hypothesis 4 is true, and that users positively consider the use of the adaptation system.In relation to Hypothesis 4, both Questions 4 and 5 are aimed to check its validity. As can be seen in This paper presents the architecture of an emotion aware automation platform based on semantic event-driven rules, to enable the automated adaption of the workplaces to the need of the employees. The proposed architecture allows users to configure their own automation rules based on their emotions to regulate these emotions and improve their wellbeing and productivity. In addition, the architecture is based on semantic event-driven rules, so this article also describes the modelling of all components of the system, thus enabling data interoperability and portability of automations. Finally, the system was implemented and evaluated in a real scenario.Through the experimentation, we verified a set of hypotheses. In summary: (i) using the proposed automation system helps to regulate the emotional state of users; (ii) adaptations of the automation system do not interrupt the workflow of users; (iii) the proposed system improves user performance in a work environment; and, finally, (iv) the system increases user satisfaction. These results encourage the use and improvement of this kind of automation systems, as they seem to provide users with a number of advantages, such as regulation of stress and emotions, and personalized work spaces.As future work, there are many lines that can be followed. One of these lines is the application of the proposed system to other scenarios different from smart offices. The high scalability offered by the developed system facilitates the extension of both the architecture and the developed tools with the purpose of giving a more solid solution to a wider range of scenarios. Currently, we are working on its application to e-learning and e-commerce scenarios. In addition, another line of future work is the recognition of the activity, as it is useful to know the activity related to the detected emotion of the user.Furthermore, we also plan to develop a social simulator system based on emotional agents to simplify the test environment. This system will enable testing different configurations and automations of the smart environment before implementing them in a real scenario, resulting in an important reduction of costs and efforts in the implementation.


Active commuting could contribute to increasing physical activity. The objective of this study was to characterise patterns of active commuting to and from schools in children and adolescents in Chile. A total of 453 Chilean children and adolescents aged between 10 and 18 years were included in this study. Data regarding modes of commuting and commuting distance was collected using a validated questionnaire. Commuting mode was classified as active commuting  or non-active commuting . Commuting distance expressed in kilometres was categorised into six subgroups . Car commuting was the main mode for children  and adolescents . Whereas public bus commuting was the main transport used by adolescents to return from school. Only 11.0% and 24.8% of children and adolescents, respectively, walk to school. The proportion of children and adolescents who engage in active commuting was lower in those covering longer distances compared to a short distance. Adolescents walked to and from school more frequently than children. These findings show that non-active commuting was the most common mode of transport and that journey distances may influence commuting modes in children and adolescents. During the last decade, physical activity levels have decreased  whilst sActive commuting, especially in children and adolescents, has been suggested as a feasible way of increasing their overall physical levels . WalkingAlthough there is increasing evidence regarding active commuting behaviours in children and adolescents, most of this evidence has been generated from developed countries, such as Canada, U.S., Australia and European countries ,14,15,16This cross-sectional study was conducted in the urban city of Valparaiso in Chile. The sample is non-probabilistic and intentional. A total of 421 students (168 children and 253 adolescents) aged between 10 and 18 years old  were included in this study. These participants belonged to three public and two private schools from the Valparaíso region.http://profith.ugr.es/paco). This questionnaire has been validated in Spanish population [The mode of commuting to and from school was measured using a questionnaire for children and adolescents developed by the University of Granada (Spain) through the project “PACO: pedalea y anda al colegio”  and the 2004 Helsinky statement.® version 21 . A p-value (<0.05) was set as significant in all analyses.The results are presented as means and standard deviations for continuous variables and as a prevalence rate for categorical variables. For analysis purposes, the sample was stratified into groups by sex and age for both children and adolescents. Differences in commuting mode between gender (boys vs. girls), age (children vs. adolescents) and commuting route (to school vs. from school) were assessed using the Chi-square test. Differences for commuting distance by age and commuting mode were also investigated using Chi-square test. All statistical analyses were performed using the statistical program SPSSThe modes of commuting to and from school for both children and adolescents are shown in p < 0.001). They also reported a lower use of car commuting and a higher use of public transport when compared to children. Interestingly, children commuted more by motorcycle (in the company of their parents) than adolescents (p < 0.001), while neither children nor adolescents used bicycles as a prominent mode of commuting to school.The modes of commuting between children and adolescents were statistically different, except for the metro or train commuting. Adolescents reported walking more frequently than children (Differences between the modes of commuting by route of commuting (to and from school) are shown in The commuting distances from home to school in children and adolescents are shown in The main findings of this study indicate that car commuting is the most popular commuting mode in both children  and adolescents . Most adolescents, however, used the public bus to return from school. Interestingly, walking was the only active mode used, with no participants reporting cycling to or from school. The proportion of walking commuters is higher in adolescents than in children. As expected, the percentage of both children and adolescents who walk to school was higher for those who commute short distances. It is worthy of note that this is the first study addressing patterns of different commuting modes in young Chilean students, which reinforces the need for more research on this subject.Less than 10% of children and around 25% of adolescents reported commuting by walking in the present study. These results are lower than those reported by other developed countries such as Spain where 62.4% of schoolchildren walked or cycled to school , or BelgInterestingly, none of the participants included in this study reported cycling to or from school. Similarly, in Spain, only 0.5% of students cycle to school . HoweverOur results show that car commuting is the most popular mode of commuting for both children and adolescents. However, adolescents reported using public bus as the second most common mode of commuting from school to home. These data show the increasing level of independent mobility that adolescents have when compared to children. In addition, the use of public transport also implies some form of active commuting ,25, and This study revealed that more than 35% of children and adolescents live more than 5 km away from school and only 20% of children live less than 0.5 km away. These findings may suggest that long distances between home and school is one of the main limitations in the promotion of active commuting behaviours in children and adolescents. An Australian study  reportedGiven that schools are far from residential areas, developing catchment areas policies to reduce distances and promote active commuting could bring the Chilean context closer to that of other countries in Europe. These results provide several insights that should be further analysed and improved on within the Chilean society. The main issue is that parents in Chile travel more than an hour on a daily basis to take their children to private schools—which are considered to be more qualified than the public schools located closer to family homes. This trend negatively affects the promotion of active commuting to school, since longer distances often force families to use their cars. It would be helpful to promote active commuting by improving governmental policies that ensure safety and reduce barriers to active commuting. Furthermore, it may help society to tackle the high inactivity and alarming childhood and adolescent obesity rate in Chile.The main strengths of this study are that this is the first study to describe the modes of commuting in Chilean children and adolescents, and that it provides reliable data originating from the questionnaire. Limitations are the low number of total participants, the low heterogeneity of the Chilean cities included in the sample, and the self-reported distance from home to school.The most common mode of commuting in children and adolescents from Valparaiso is the car, and the rate of walking was lower than in other European and North American countries. This study shows higher independent mobility in adolescents  when compared to children. In addition, the long distance from home to school appears to be a main barrier in the promotion of active modes of commuting among the Chilean school children. These results provide unique information on active commuting patterns in school children which could be used to inform public health authorities for the promotion and facilitation of active commuting in children and adolescents. This, in turn, could have important implications for health during adulthood.


Auditory hallucinations are defined as the abnormal perception of sound in the absence of an external auditory stimulus. Musical hallucinations constitute a complex type of auditory hallucination characterized by perception of melodies, music, or songs. Musical hallucinations are infrequent and have been described in 0.16% of a general hospital population. The auditory hallucinations are popularly associated with psychiatric disorders or degenerative neurological diseases but there may be other causes in which the patient evolves favorably with treatment. With this clinical case we want to stress the importance of knowing the causes of musical hallucinations due to the unpredictable social consequences that they can have. An auditory hallucination is defined as an abnormal perception of sound in the absence of an external auditory stimulus. Auditory hallucinations can be simple  or complex . Musical Hallucination (MH) constitutes a complex type of auditory hallucination in which the perception of said hallucination can be in the form of melodies, music or songs.As figures in the scientific literature, Emmanuel Régis (a French psychiatrist), was the first to mention musical hallucinations in 1881). But it was not until some 50 years later, in 1932, when the difference between musical hallucinations of organic or psychotic origins was established. Since then sets of cases have been published and some studies, in spite of which the prevalence of musical hallucinations cannot be clearly defined; it is believed that approximately 0.16% of the population of a general hospital [881. But The MH can be of different origin. They have been linked to psychiatric illnesses such as the cases of schizophrenia, depression or obsessive-compulsive disorders. However, itis not in the psychiatric environment where they are more prevalent. The organic MH are prevalent above all in patients with neurological pathologies, whether these be cerebral lesions , epilepsy of the temporal lobe, Parkinson's, infectious processes of the central nervous system, etc. They are also produced in patients with severe hearing loss constituting the auditory Charles Bonnet Syndrome (CBS). They can be produced as a side effect of some medications  and have also been observed in hepatic transplants. And sometimes it's difficult to know its etiology .There is no specific treatment; the majority of cases in which treatment has been effective depended on the resolution of the underlying cause. We present the case of a woman who came in for a consult due to musical hallucinations in which the correct diagnosis and treatment allow the patient to have personal autonomy avoiding institutionalization for her condition.81-year-old woman with a history of hypertension treated via Enalapril and dyslipidemia treated via diet. She had been evaluated some years ago by an otorhinolaryngologist and was diagnosed with bilateral hypoacusis, which was severe in the right ear and moderate in the left ear, where she had a hearing aid.Four months prior to the consult, the patient had her first episode of MH. It consisted of childhood songs, which she had learned and liked . She heard them in her left ear, which was the only one that still retained partial audition with a hearing aid. She had not heard anything with her right ear for several years. The songs could last for hours and did not bother her; she assumed they came from the outside environment.It was noted that the patient did not have any previous incidents of psychiatric illness, she had not shown symptoms of cognitive deterioration, and she had no changes in her regular treatment; she lived alone and was independent in her daily life. After the patient’s symptoms began, her family was worried about with the possibility that she had a psychiatric or neurological illness; following a consult with her general practitioner the patient was given treatment with sertraline. The family also started considering the possibility of sending her to a nursing home believing that she was showing signs of the onset of dementia.In the neurological examination, aside from the hypoacusis, the patient did not present with alterations of interest and, in her cognitive evaluation, the tests were within normal ranges .Because of the presence of MH, the patient was evaluated by psychiatry, which did not encounter any pathology.In the tests performed: analytical, Holter EEG, and MRI of her brain, only diffuse cerebral atrophy was identified in the image study, and there were no other points of interest. The audiometry test noted a moderate loss of neurosensory hearing in the left ear and severe loss in the right.Once diagnosed with auditory hallucinations secondary to sensory deprivation, she was placed on carbamazepine (200 mg every 8 hours). About 15 days later there was a partial improvement of the clinic: the music came less frequently, although of equal intensity. After explaining the symptoms to the patient and her family, she continued living alone and having personal autonomyMusical hallucinations are an infrequent type of auditory hallucination. MH can be simple or complex. Simple MH (tinnitus), includes a wide range of sounds . Complex musical hallucinations refer to more elaborate sounds as music or songs or speech and those are the ones we will discuss in this article .1): advanced age, female sex (up to 70-80% in some cases), presence of auditory deficit, social isolation, treatment with certain pharmaceuticals, presence of cerebral atrophy in image studies, and psychiatric pathology [There are various risk factors associated with the presence of MH (Table athology .2), MH are divided into five groups: secondary to auditory deprivation [In relation to the etiology (Table rivation , focal crivation , 6, 7, privation , epilepsrivation , and secrivation . Auditorrivation . The phyrivation . They arrivation , 4.Treatment , 13 for In this case we want to stress the importance of knowing the causes of MH and reassure the patients and family, as hallucinations are popularly associated with psychiatric disorders or degenerative neurological diseases. A misdiagnosis and incorrect treatment can, on the one hand, distress the patients and their family, and on the other, have unpredictable social consequences.


It is now widely accepted that an innate immune system exists within the brain and plays an important role in both physiological and pathological processes ,2. This In general, pathological conditions are associated with elevated levels of neuroimmune factors in the brain, whereas low levels of neuroimmune factors are found in the normal brain. For example, elevated levels of neuroimmune factors in the brain have been reported for a number of conditions including brain injury, infection, neurodegenerative and psychiatric disorders, and drug abuse ,5,6. ConNeuroimmune factors, like their counterpart in the periphery, produce their biological actions through interactions with cognate membrane receptor systems that translate the chemical signal through the intervention of intracellular signaling pathways. These signaling systems are complex and many have yet to be fully elucidated. Of importance is that during pathological conditions, typically multiple signaling factors are simultaneously present in the cellular environment and may activate different signaling pathways on the same cell. These intracellular pathways may interact, a complexity that is a challenge to understanding the mechanisms responsible for the biological actions associated with a particular brain condition and the development of specific therapeutic strategies. In this Special Issue, recent advances in an understanding of the neuroimmune system of the brain and the actions of neuroimmune factors are presented for ten areas under study; most areas are associated with pathological conditions. Together, these studies are illustrative of the breadth and status of the field, the experimental approaches being employed, and areas for future research.The review by Gruol  summarizTransgenic mice that express elevated levels of IL-6 in the brain through increased astrocyte expression are also used in studies reported in the original article by Erta et al. . TransgeThe review by Mukandala et al.  summarizMori et al.  review tParkinson’s disease is also a topic of the review by Grimmig et al. . This reThree original articles in this Special Issue focus on the role of neuroimmune factors in the actions of drugs of abuse on the brain. Recent studies have revealed that several abused drugs, including alcohol and morphine, induce glial cells of the brain, primarily astrocytes and microglia, to secrete neuroimmune factors ,12,13. MThe original article by Marshall et al.  reports Chang et al.  report eThe review article by Liu et al.  focuses Nizamutdinov and Shapiro  provide