Naturalistic animal behavior exhibits a strikingly complex organization in the temporal domain, with variability arising from at least three sources: hierarchical, contextual, and stochastic. What neural mechanisms and computational principles underlie such intricate temporal features? In this review, we provide a critical assessment of the existing behavioral and neurophysiological evidence for these sources of temporal variability in naturalistic behavior. Recent research converges on an emergent mechanistic theory of temporal variability based on attractor neural networks and metastable dynamics, arising via coordinated interactions between mesoscopic neural circuits. We highlight the crucial role played by structural heterogeneities as well as noise from mesoscopic feedback loops in regulating flexible behavior. We assess the shortcomings and missing links in the current theoretical and experimental literature and propose new directions of investigation to fill these gaps. Naturalistic animal behavior exhibits a striking amount of variability in the temporal domain . An indiThe second source of temporal variability stems from the different contexts in which a specific behavior can be performed. For example, reaction times to a delivered stimulus can be consistently faster when an animals is expecting it compared to slower reaction times when the stimulus is unexpected . ContextAfter controlling for all known contextual effects, an individual’s behavior still exhibits a large amount of residual temporal variability across repetitions of the same behavioral unit. This residual variability across repetitions can be quantified as a property of the distribution of movement durations, which is typically very skewed with an exponential tail , suggestThese three aspects of temporal variability  can all be observed in the naturalistic behavior of a single individual during their lifetime. Other sources of behavioral variability have also been investigated. Variability in movement execution and body posture  may origFrom this overview, we conclude that the temporal structure of naturalistic, self-initiated behavior can be decomposed along at least three axes of temporal variability : a largeNeural representation: How are self-initiated actions represented in the brain and how are they concatenated into behavioral sequences?Stochasticity: What neural mechanisms underlie the temporal variability observed in behavioral units across multiple repetitions within the same context?Context: How do contextual modulations affect the temporal variability in behavior, enabling flexibility in action timing and behavioral sequence structure?Hierarchy: How do neural circuits generate the vast hierarchy of timescales from milliseconds to minutes, hallmark of naturalistic behavior?The mechanistic approach we will review is based on the theory of metastable attractors , which iCaenorhabditis elegans  in rodents as part of a distributed network involved in motor planning in head-fixed mice  and contNeural patterns in M2 may represent attractors of the underlying recurrent circuit dynamics. Attractors are a concept in the theory of dynamical systems, defined as the set of states a system evolves to starting from a large set of initial conditions. The central feature of an attractor is that, if the system is perturbed slightly away from an attractor, it tends to return to it. Within the context of neural activity, an attractor is a persisting pattern of population activity where neurons fire at an approximately constant rate for an extended period of time (see Appendix 1 for models of attractor dynamics). Foundational work in head-fixed mice showed that licking preparatory activity in M2 during a delayed response task is encoded by choice-specific discrete attractors . AttractMetastable attractors can be concatenated into sequences, which can either be random, as observed during ongoing periods in sensory cortex , or highThe hypothesis that preparatory activity for upcoming actions is encoded in discrete attractors in M2 has been convincingly demonstrated using causal manipulations in head-fixed preparations in mice (see Appendix 1), although a causal test of this hypothesis in freely moving animals is currently lacking. A shortcoming of the metastable attractor model of action timing in The metastable attractor model assumes the existence of discrete units of behavior at the level of actions, although large variability in movement execution originating downstream of cortical areas may blur the distinction between the discrete behavioral units. The extent to which behavior can be interpreted as a sequence of discrete behavioral units or, rather, a superposition of continuously varying poses (see Appendix 1 for an in-depth discussion of this issue) is currently open for debate.At higher levels of the behavioral hierarchy, repetitions of the same behavioral sequence . However, a full quantitative understanding of the metastable regime is currently lacking. Such theory is within reach in the case of recurrent networks of continuous rate units. In circuits where metastable dynamics arises from low-dimensional correlated variability , dynamicOne important source of behavioral variability is phenotypic variability across different individuals with identical genetic profile, an important aspect of behavior in ethological and evolutionary light . StochasC. elegans : average duration; usage frequency; and transition probabilities between units. Moreover, context may also change the motor execution of a behavioral unit, for example, by improving the vigor of a certain movement upon learning or motivation. For each type of modulation, we will give several examples and review computational mechanisms that may explain them.The second source of temporal variability in naturalistic behavior arises from contextual modulations, which can be The distribution of self-initiated action durations typically exhibits large variability, whose characteristic timescale can be extracted from their average duration . The aveContextual changes in brain state may also be induced by varying levels of neuromodulators. In the self-initiated waiting task of Although the contextual modulations considered so far occur on a fast timescale of a few trials, they may also be the consequence of associative learning. In a lever press task, mice learned to adjust the average duration of the lever press to different criteria in three different conditions where lever presses were always rewarded regardless of duration or only rewarded if longer than 800 or 1600 ms. Within each of the three conditions, the distribution of action timing exhibited large temporal variability, yet the average duration was starkly different between the three criteria as the mice learned the different criteria . ReactioThe paramount role of contextual modulations in regulating action timing during naturalistic scenarios has been well documented. However, the neural mechanisms underlying these effects remain elusive. Results from head-fixed preparations revealed some possible explanations, which have the potential to generalize to the freely moving case. Within the paradigm of metastable attractors (see Appendix 3), the speed at which cortical activity encodes incoming stimuli can be flexibly controlled in a state-dependent manner by transiently changing the baseline level of afferent input currents to a local cortical circuit. These baseline changes may be driven by top-down projections from higher cortical areas or by neuromodulators. In a recurrent circuit exhibiting attractor dynamics, changes in baseline levels modulate the average transition times between metastable attractors . In thesAlthough it is not possible to measure potential wells directly in the brain, using mean field theory one can show that the height of these potential wells is directly proportional to the neuronal gain as measured by single-cell transfer functions . In particular, a decrease (increase) in pyramidal cells gain can lead to faster (slower) average action timing. This biologically plausible computational mechanism was proposed to explain the acceleration of sensory coding observed when gustatory stimuli are expected compared to when they are delivered as a surprise ; and theHow can a neural circuit learn to flexibly adjust its responses to stimuli or the timing of self-initiated actions? Theoretical work has established gain modulation as a general mechanism to flexibly control network activity in recurrent network models of motor cortex . IndividContextual modulations of temporal variability may affect other aspects of natural behavior beyond average action timing, such as the frequency of occurrence of an action (‘state usage’) or the transition probabilities between actions within a behavioral sequence . These eDuring ongoing periods, in the absence of a task, animal behavior features a large variety of actions and behavioral sequences . ExperimRecent studies have begun to shed light on the rules that may control how animals learn and execute behavioral sequences. These studies revealed various types of contextual modulations such as changes in the occurrence of single actions or in the transition probabilities between pairs of actions and proposed potential mechanisms underlying these effects. Biologically plausible models of mesoscopic neural circuits can generate complex sequential activity . In a reHow do animals learn context-dependent behavioral sequences? Within the framework of corticostriatal circuits, sequential activity patterns can be learned in an all-inhibitory circuit representing the striatum . LearninIt remains to clarify the exact extent to which the stochastic and contextual variability are independent sources. In principle, one could hypothesize that detailed knowledge and control of all experimental variables and behavioral state and their history might explain part of the trial-to-trial variability as contextual variability conditioned on these variables. For example, in the Marshmallow task about 10% of the temporal variability in waiting times could be attributed to a trial history effect, which relied on an intact medial prefrontal cortex and was abolished with its inactivation . MoreoveThe computational mechanisms discussed so far can separately account for some specific features of contextual modulations, but none of the existing models can account for all of them. Metastable attractor models, where an attractor/action dictionary can be established, explain how the large variability in action timing may arise from correlated neural noise driving transitions between attractors . These mequences . Two difequences  or a chaA promising model system to investigate the neural mechanisms of flexible motor sequences is songbirds. Canary songs consist of repeated syllables called phrases, and the ordering of these phrases follows long-range rules in which the choice of what to sing depends on the song structure many seconds prior . These lContextual modulations of behavior may occur on longer timescales as well, including those induced by circadian rhythms, hormones, and other changes in internal states; and they may span the whole lifetime of an individual, such as homeostasis and development. Social behavior provides another source of complex contextual modulations. We briefly address these different aspects of contextual modulations below.Internal states, such as hunger , and cirOther sources of contextual modulation of behavior may act on even longer timescales spanning the whole lifetime of an individual , such asAlthough most of the experiments discussed in this review entail the behavior of individual animals, contextual modulations of behavior are prominently observed in naturalistic assays comprising the interaction between pairs of animals, such as hunting and social behaviors. In the prey–capture paradigm, a mouse pursues, captures, and consumes live insect prey . Prey–caThe temporal organization of naturalistic behavior exhibits a clear hierarchical structure , where aC. elegans  may generate multiple timescales in sub-second range, from a few milliseconds to a few hundred milliseconds . AlthougTheoretical studies highlighted the central role played by recurrent synaptic couplings within a local circuit for generating long timescales emerging from the recurrent dynamics. Recurrent networks with random recurrent couplings can generate time-varying neural activity whose timescale may be tuned to very slow values at a critical point . Long tiTwo biologically plausible ingredients were shown to be sufficient to generate long timescales with temporal heterogeneity in their distributions: recurrent couplings realizing local functional neural clusters and heterogeneity in synaptic couplings. The first requirement of functional assemblies is a connectivity motif ubiquitously observed in biological circuits, namely, the fact that the strength of recurrent couplings decays with spatial distance between pairs of neurons, leading to the emergence of local functional assemblies of strongly coupled neurons . In recuEscherichia coli  generate metastable attractors representing upcoming actions . Other sThe structure of naturalistic behavior emerging on long timescales in the fruit fly is a hierarchical tree-like organization , which iThe model of nested basins of attractions proposed in


Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care. Almost every action within the medical setting either explicitly or implicitly contains two judgements, one ethical and one scientific, and there is constant interplay between what is technically possible and what is morally desirable”  is now the standard of care for an expanding number of pediatric and adult medical conditions. ECLS is commonly deployed to allow recovery from potentially reversible conditions, such as acute respiratory distress syndrome (ARDS) and shock; as a bridge to decision, when prognosis is uncertain; as a rescue therapy during cardiopulmonary arrest that is unresponsive to initial resuscitation measures; and as a bridge to transplant or destination therapy with mechanical circulatory support –5. Over Rapid technological advancements and the exponential expansion of ECLS utilization, as exemplified by the SARS-CoV-2 pandemic, are generating an increasing number of ethical and societal considerations –16. ClinSince its introduction nearly fifty years ago, ECLS has provided life-support to over 170,000 patients globally . ECLS isHistorically, the earliest clinical trial with ECLS failed to demonstrate improved survival in adults ; howeverOutcomes following ECLS vary with patient age and indication for support, ranging from >90% survival in neonates with meconium aspiration syndrome, 65% for all pediatric ECLS indications, 46% in adults with ARDS, to 30% in adults following cardiac arrest , 52. Whican.” However, within the context of a wide range of mortality rates, risks for severe morbidities, limited outcome data, and clinician ethical duty to save lives, ECLS clinicians are often faced with the extremely difficult medical and moral decision—“should we?” Unfortunately, there is little ethical guidance to assist bedside clinicians in making these complex decisions.As ECLS technology advances at a rapid pace, there are few technical limitations to offering ECLS as a potentially life saving intervention—therefore, “we The following hypothetical cases, based on an amalgam of actual clinical cases, highlight several important ethical dilemmas that arise in the provision of ECLS.Lily (pseudonym) was a 4-year-old girl found 90 minutes after being submerged in a cold-water lake. Rescuers initiated cardiopulmonary resuscitation at the scene. CPR (cardiopulmonary resuscitation) was provided for 30 minutes en route to the nearest community hospital with return of spontaneous circulation upon arrival. An adult cardiothoracic surgeon had recently established an adult ECLS program at this community hospital. Based on the possibility of neurologic recovery following cold water drowning, the medical team cannulated Lily onto ECLS despite minimal evidence of neurological function. Open chest cannulation was performed given that only adult-size ECLS cannulas were available. The child was then transported to a nearby quaternary academic pediatric center using a portable ECLS team. After rewarming to normothermia, Lily's physical examination revealed lack of neurologic function except for abnormal spontaneous respirations. Head CT revealed diffuse cerebral edema with loss of gray-white matter differentiation, concerning for devastating and likely irreversible neurologic injury. Based on the low likelihood of any neurologic recovery, the family and the medical team jointly decided to compassionately withdraw life support. Lily's parents wished to pursue organ donation and found significant meaning out of this tragedy when her liver and kidneys were successfully transplanted following a circulatory determination of death (DCDD) protocol.In this case, urgent medical decision making is complex and challenging when the potential risks and benefits are unpredictable, and there is substantial prognostic uncertainty. ECLS did not provide direct benefit to the child, however the utilization of this intense resource provided benefit to the family and society. The family had additional time to grieve the loss of their child and were given the opportunity to graciously offer the gift of organ donation.Betty (pseudonym) is a previously healthy obese unvaccinated 22-year-old woman who was critically ill with severe acute respiratory distress syndrome (ARDS) secondary to SARS-CoV-2 pneumonia complicated by secondary bacterial infection. Despite maximal support with mechanical ventilation, her oxygenation remained quite poor, and she was placed on venovenous ECLS on hospital day five. Due to limited clinical staff and ECLS pumps at the adult hospital during the pandemic, she was transferred from an adult facility to a pediatric ECLS center using a mobile ECLS transport team. While she remained on ECLS, the pediatric intensive care unit (PICU) reached capacity, and critically ill children were diverted to other community-based facilities. After four weeks of ongoing support via ECLS, she was ultimately decannulated. Due to severe deconditioning and lung disease, she remained in the PICU for an additional three weeks during which time a tracheotomy was performed, and she was transitioned to a portable ventilator.This case highlights the challenges and consequences of allocation of resource intense therapies during a pandemic. While rapid advancements in technology allow for portable ECLS, transferring this young adult patient to a pediatric facility consequently impacted the ability of the institution to provide specialized pediatric care to other pediatric patients.Proactive and explicit exploration through collaboration and research of ethical considerations that arise in clinical cases like these may mitigate potential risks and promote: (1) respect for the well-being and autonomy of patients, families, and staff; (2) optimization of patient outcomes while minimizing undue burdens for patients and families; and (3) responsible, equitable, and fair allocation of resources. Navigating complex and challenging questions that arise in ECLS will hopefully lead to improved quality of patient care through a better understanding of the ethical and societal considerations.To develop a research agenda to inform ethical guidance for clinicians and institutions in the utilization of ECLS, a multi-disciplinary team of pediatric specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single academic institution. Using an iterative consensus process, a broad range of research questions were collected and refined by the group over a series of monthly meetings for approximately 18 months. The broad list was refined by removing duplicates and then selecting questions according to the following criteria: (1) frequency of occurrence in ECLS; 2) uniqueness to ECLS; (3) urgency; (4) feasibility to study; and (5) potential to advance the practice of ECLS and improve quality of patient care. To create the research agenda, refined questions were categorized into the following themes: (1) scope and frequency of ethical dilemmas involving ECLS; (2) clinical decisions and ethical guidance to initiate, forgo, or discontinue ECLS; (3) approaches to optimize communication with and provide emotional support for families and clinical team members; and (4) research design and implementation in ECLS , 2. uniqueneA. Scope and Frequency of Ethical DilemmasEthical dilemmas are common in the provision of ECLS, as highlighted by the COVID-19 pandemic. However, few empirical data describe the nature and frequency of ethical issues that arise in ECLS. In order to identify solutions, the problems need to be clearly defined.What ethical dilemmas do clinicians and families experience in ECLS and how frequently do these arise?B. Clinical Decisions and Ethical Guidance to Initiate, Forgo, or Discontinue ECLSECLS decision-making is complex and influenced by a myriad of interacting forces at the bedside, the institution and in society. Decisions may be fraught with challenges and complexity due to the combination of several factors: (1) limited time frame for decision-making; (2) life and death circumstances; (3) large, multidisciplinary clinical teams with potential for differing opinions; (4) prognostic uncertainty; (5) potential for serious complications; (6) increasingly heterogenous patient populations with greater complexity in which ECLS is utilized; and (7) national and international guidelines based on expert opinion rather than clinical data. These challenging circumstances often lead to variability in decisions made by individual or relatively small groups of clinicians potentially resulting in the inconsistent use of ECLS  , 38, 39.1. Who DecidesWhat are existing decision-making models for ECLS and how do they lead to variability in use? What does shared medical decision making look like within the context of high urgency and high stakes decisions?What impact does including and excluding various clinical team members from the decision-making process have on: complexity of the decision-making process, quality of medical care, utilization of ECLS, job satisfaction of clinicians, and family support?What role does ECLS-specific training of clinical team members have on the decision-making process?Should ECLS ever be initiated or withdrawn against a family's wishes? If so, what are the morbidity and mortality thresholds for such decisions?2. How We DecideDo clinicians ever limit the use of ECLS based on perceived ethical barriers that are not empirically substantiated? If so, what are the perceived ethical barriers, and how should they be addressed?What biases and assumptions exist among the clinical team, institutions, and organizations that may impact how decisions are made?How are bedside decisions influenced by clinical outcome data, patient comorbidities, and institutional availability of ECLS resources?Why and how does ECLS utilization  vary between institutions or between clinical teams within an institution? What factors contribute to these variations in practices, and how can they be mitigated to ensure equitable care?What factors influence the decision to end life by withdrawing ECLS? How are these decisions made? How are conflicting opinions resolved?How does the urgency of the clinical situation impact clinician decision-making? How does this urgency impact the process of obtaining informed consent from patients and their surrogates?What role, if any, should ECLS center volume and experience play in determining which patient diagnoses are supported by ECLS?How should relatively scarce ECLS equipment and staff be allocated during conventional, contingency, and crisis standards of care?Are there clinical situations when E-CPR should be considered obligatory or prohibited? If so, how are these clinical situations determined and assessed?What is the appropriate level of training and experience needed to determine ECLS candidacy and initiate support? How does the advent of mobile ECLS influence these decisions?3. Use of Outcomes Data in ECLS Decision-MakingAre current outcome data adequate to drive or support decision-making in ECLS? What additional outcome data would improve decision-making?How do clinicians' personal values influence interpretation of outcome data and how does this lead to variability in use of ECLS?How do we determine appropriate morbidity and mortality thresholds for compelling or withholding ECLS?Are outcome data commonly used in decision making or are decisions based primarily on clinical experiences? How accurately do clinicians prognosticate?What are the most important long-term outcomes  for survivors of ECLS and their families? How should these outcomes influence bedside decision-making in ECLS?4. Societal Influence on Bedside Decision-MakingIs ECLS viewed by institutions and society as a conventional therapy  or as an extraordinary intervention  or both? How does this view influence ECLS utilization at the bedside?How do societal values and beliefs  influence the use of ECLS?Does society have an obligation to ensure equitable access to ECLS for all patients? For example, can individual institutions refuse to offer ECLS without obligation to transfer or should referral networks be required? Should ECLS centers of excellence be required to have mobile ECLS teams to improve equitable access?At the societal level, what factors should be included in the calculation of the costs and benefits  of ECLS? How should these factors be prioritized and who determines the prioritization paradigm? How should these analyses affect bedside decision-making?What role should ECLS play in organ donation for patients declared deceased based on neurologic criteria? Should ECLS be utilized to support organ donors who are declared deceased after circulatory death? What are the ethical implications of these practices?How does systemic racism potentially exacerbate health care disparities when considering utilization of ECLS?C. Communication and Emotional SupportA paucity of literature exists describing communication related to ECLS. The following questions seek to measure the quality of communication and to explore the influence that communication content and style has on patients and families and within the medical team.1. Patients and FamiliesCommunicating with patients and their families can be difficult in the critical care environment, especially under the stressful circumstances that often surround ECLS . EffectiHow do clinicians communicate with families regarding risks, benefits, alternative options, and outcomes of ECLS prior to initiating ECLS and during support? What are barriers and potential facilitators of optimal communication?How does the urgency of the clinical situation impact communication with families?Is the conventional model for “informed consent” applicable to the initiation of ECLS? Should informed consent be obtained for every ECLS encounter? Are there any modifications to the informed consent process that may improve communication and guide decision making for families?What is the optimal approach to support the family cognitively and emotionally during the decision-making process to initiate ECLS?How can clinicians balance hope and realistic expectations during communication with families when ECLS is initiated and throughout the course of ECLS?How does language used by clinicians impact the experiences of families and their decisions related to ECLS? How do clinicians' views of appropriateness of ECLS use influence their language? For families who speak a language other than English , how does the use of language interpreters impact the quality and accuracy of communication?What is the role of cultural navigators when navigating complex decisions regarding ECLS? How are cultural barriers that may arise in complex decision making identified and mitigated?What is the balance between resource utilization and family support when a family requests to continue ECLS after the recommendation has been made to discontinue life support?How should clinicians optimally provide psycho-social support for patients and their families both acutely and long-term when ECLS is utilized?2. Clinical TeamECLS requires a collaborative and multidisciplinary approach to patient care. Guidelines for ECLS based on expert opinion and experience rather than on clinical data may lead to disparate opinions among clinical team members. Unresolved discord among clinical team members may negatively impact quality of care and patient safety. Understanding and improving communication among clinical team members may help to reconcile these differences. Optimal communication may limit intramural discord, reduce individual moral distress, and thereby improve the quality of patient care. Understanding of the impact of communication among the clinical team requires investigation.How does verbal and non-verbal language used by ECLS teams bias the institutional culture surrounding the “appropriate” use of ECLS? How do institutional cultures and biases affect decision-making in ECLS?How does the interaction and communication among a diverse clinical team impact the experience of patients and their families, team performance, and clinical outcome?How should team leaders manage dissent among clinical team members?How does a lack of consensus among clinical team members affect the quality of patient care, patient emotional well-being, family members, clinical team, unit morale, and other unit patients?Should parents and/or surrogates be made aware of differing opinions within the clinical team? If so, what approach should be used?D. Clinical Research Design and ImplementationResearch in ECLS may be ethically challenging due to the complexity and intensity of the clinical circumstances. Additionally, because ECLS clinicians and researchers are typically one and the same, ambiguity between clinical and research practices of ECLS may exist. These overlapping relationships and the clinical context may unduly influence family expectations, decision-making, and participation in clinical research. Furthermore, designing optimal research studies to advance ECLS may be difficult given the life-threatening context, heterogeneity and complexity of clinical diagnoses, lack of standardized processes, and diversity of clinical opinions about effectiveness. The following questions should be addressed to optimize research practices in ECLS:How do the clinical context and provider relationships influence families' expectations, understanding, and willingness to participate in ECLS research?How do families experience participation in ECLS research?How do researchers ensure that patients and families are optimally protected during ECLS research and improve their experiences?How do provider views about benefit or futility of ECLS in a particular population influence provider endorsement of or participation in research studies in ECLS?In what contexts are randomized trials involving ECLS justified? What alternatives may be appropriate and under what conditions?Should the approach to clinical research in ECLS differ from other “life support therapies”?Seattle Ethics in ECLS Consortium identified and prioritized important ethical questions that warrant further empirical and normative research in the domains of societal decision-making, bedside decision-making, patient/family communication, medical team dynamics, and research ethics. Identifying ethical considerations in the delivery of ECLS is an initial step toward: (1) better understanding the ethical dilemmas encountered, (2) developing approaches to address these ethical dilemmas, and ultimately (3) improving the quality of medical care provided and support for families when utilizing ECLS.The The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.ML-N founded and led the SEE Consortium and conceptualized the initial manuscript. ML-N and JC co-facilitated the SEE Consortium discussions to develop the ECLS research agenda and drafted, revised, and approved the final manuscript as submitted. JC and JD performed background literature searches. HB, EBo, TB, JD, AD, DM, JR, JT, and BW all participated in the SEE Consortium, vetted the research questions, edited and approved the final manuscript. EBe vetted the research questions, edited and approved the final manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


N = 26) reported being highly satisfied with the training and reported a high degree of confidence in their ability to use VVC. Based on evaluation data and interview feedback, providers and clinic leaders were satisfied with group facilitation. Group facilitation may be a helpful tool in rapidly training clinical teams to implement and sustain video telemental health.Video telehealth experienced rapid growth throughout the COVID-19 pandemic in many healthcare sectors, including mental health. The Veterans Health Administration’s video telehealth platform, VA Video Connect, has been widely used to reach veterans who may have experienced difficulty accessing care, such as those living in rural areas or other barriers . Implementing VVC requires a multifaceted approach, including training providers on technical skills, increasing access to equipment for providers and veterans, and integrating VVC within the culture and processes of the clinic unit. Prior successful VVC implementation efforts in rural areas have focused on simultaneous one-on-one provider and leadership engagement using implementation facilitation (IF). However, given the rapid need for VVC expansion in light of limits and dangers associated with in-person care during the pandemic, our team developed group facilitation to increase the reach of VVC implementation through IF. Group facilitation combined training in technical and policy elements of VVC with IF with groups of providers from clinic units. This approach was designed to rapidly disseminate the necessary knowledge to conduct VVC combined with collaborative problem solving as a team to improve the ability of the clinical team to sustain VVC. Attendees were asked for feedback on the session through multiple choice and open-ended questions. Participants ( Video telehealth has experienced rapid growth throughout the COVID-19 pandemic, including for mental health , with a focus on learning the basics of the technology. However, to adapt rapidly to provider, patient, and system needs, VTH platforms are updated frequently. A particular gap in training in this rapidly changing system is that communications about these frequent updates take time to permeate all levels of a national healthcare system, and frontline providers may vary in their engagement with VVC communication.To address the needs of many providers, the VHA training is focused on providing information to reach general competence in using VVC, but it is not feasible for a training with such scope to be tailored to the myriad clinical contexts, especially during the rapidly changing context of virtual care during COVID-19. There are elements of VTH beyond skill-based learning that impact integration into clinical care. For example, providers who primarily work in the field with veterans experiencing homelessness have different VTH needs than providers transitioning patients from inpatient to outpatient care. Understandably, it is beyond the scope of broad, platform-focused training to allow providers to brainstorm solutions to potential barriers for seamless implementation of VTH in their clinic with fellow providers and administrative staff.Implementation facilitation (IF)  to facilitate grass-roots efforts to increase VVC use, while maintaining connection with national efforts and leadership priorities. Although this one-on-one method enabled strong partnerships and personalized facilitation . Second, group facilitation allowed clinical teams to work together in one meeting to receive training in implementing VVC, problem solve together on how to best incorporate it into their setting and population, and work through their unique barriers and facilitators as a team (versus isolated single providers and champions). This also allowed team members to support each other and build a culture of shared information and resources. Attendees also brainstormed how VVC could be implemented in their particular context and how to deploy and sustain VVC as a team. Third, it allowed clinical teams to be paired with ongoing support from external and internal facilitators.Thus far, our group has conducted 36 group facilitation sessions across nine sites from seven states. These sites were selected in partnership with VHA mental health leadership as sites that could benefit from a targeted implementation to increase use of VTH encounters. The PIVOT approach  to 5 . All questions are included in Table As a component of this ongoing quality-improvement work, attendees were invited to provide anonymous feedback through evaluation questionnaires. A total of 170 providers attended these sessions. Questionnaires evaluated attendees’ satisfaction with the training, confidence in using video telehealth, and anticipated barriers to implementing VVC. Evaluation was not required, and 26  attendees completed evaluation. Evaluation consisted of four multiple-choice questions and four open-ended questions. The multiple-choice questions were rated on Likert-type scales from 1  and rated the trainers as effective in conveying knowledge  and as engaging . Attendees generally rated confidence in their ability to use VVC as high .Overall, attendees were satisfied with the training approach  was particularly helpful. Responses illustrative of this theme included “The trainers made the training specific to what our group was needing” and “Responsiveness to specific questions.” Another theme from respondents was the appreciation of content on the technical use of VVC and implementation suggestions. Key comments included the statement “I loved that they talked about ways to implement VVC, for example with no shows. I also loved that they talked about things to share with veterans who are apprehensive.” Other comments were “Learned new things about how to streamline my VVC visits!” and “I liked that the presenters went over everything step by step.”Respondents also described barriers that they were experiencing or anticipate experiencing in their implementation of VVC. Such barriers included veterans’ access to equipment and sufficient high-speed internet access, patient familiarity/comfort with equipment or video calls, and scheduling concerns . An illustrative response was “Veterans that do not have internet or if they do internet speed does not support VVC.” Responses to the remaining two open-ended questions  had very few responses, and comments received largely focused on logistical elements of the training .This initial iteration of group-based IF for building capacity to deliver VTH care enabled the PIVOT implementation team to rapidly respond to site needs for both technical and clinical implementation training. These trainings were tailored to the needs and clinical contexts of providers and staff and had a broader reach than previous one-to-one facilitation models conducted by our team (Day et al., Recent work on IF in the context of virtual facilitation identified several key practice elements, including planning in advance, real-time communication, build relationships, engaging participants, and using a virtual room (Hartmann et al., The current evaluation must be considered in light of its limitations. First, the evaluation presented in this paper was initially designed for collection of feedback to improve the training in a quality improvement context. More rigorous, theoretically driven, formal evaluation is needed. This is especially the case for outcomes related to actual implementation of VVC beyond satisfaction. Furthermore, a relatively low number of those who attended the training completed the evaluation, reflecting those who were willing to share their feedback. More rigorous sampling is needed to avoid bias from such self-selection. Finally, the qualitative analysis in the current study was limited by lack of responses that precluded more rigorous forms of analysis.Implementing health technologies is a complex task. Clinicians, staff, and other end users of these technologies have multiple considerations and demands, with varied access to resources and implementation support. The added complexity of rapid implementation of VTH during the COVID-19 pandemic precipitated the need to empower large numbers of providers and staff to implement VVC in their facilities. Combining training in technology with IF allowed training that was feasible and acceptable for interprofessional mental health staff to quickly build capacity for expanded telehealth provision.


Gorilla gorilla) provides the opportunity to study the ecological-constraints model in the largest primate species. We investigated how two groups of western gorillas of differing sizes  in Central African Republic, responded to seasonal variation in fruit availability in terms of activity and diet. We used continuous focal animal sampling during periods of high (July–August 2011) and low (October 2011–January 2012) fruit availability, measured by monthly phenological scores. While diet diversity, resting and moving time did not differ between groups, overall the smaller group spent more time feeding than the larger group although this became less evident when fruit was more available. The smaller group was more frugivorous than the larger group. However, the larger group increased more steeply fruit consumption when fruit was more available, and incorporated more insects, young leaves and bark when fruit was less available, when compared to the smaller group. Up to a certain limit, the flexibility of large, seasonal frugivores to survive on a more folivorous diet may buffer the upper limit group size, suggesting deviation from the ecological-constraints model as in some folivores.The ecological-constraints model posits that living in larger groups is associated to higher travel costs and reduced nutritional intake due to within-group feeding competition setting upper group size limits. While this is critical for frugivorous mammals, the model is less ubiquitous for folivores who feed on more abundant and evenly distributed food. The seasonally frugivorous diet of western gorillas ( As a result, primary consumers face periods of preferred food abundance and food scarcity (e.g.9). Variation in food availability is thus expected to affect foraging habits and diet composition, in turn influencing also species’ dietary diversity (e.g.11). Consequently, different animal species have developed various strategies to optimize their energy budgets13. Many birds and ungulates migrate seasonally . Other species switch dietary choices to different food categories or to resources that are available year-round . They may vary the daily range and travelling time to optimize foraging effort . Primate species respond in different ways to such socio-ecological constraints. Most great apes show clear dietary variation and flexibility in response to seasonal fruit availability (e.g.41).Rainforests are characterized by seasonal and inter-annual variation in the availability of vegetative and reproductive plant parts  may be one strategy to cope with reduced food availability47. According to the ecological-constraints model51, many primate species alter diet, activity budgets and/or reduce group cohesion in order to stay successfully in large, stable groups. The ecological-constraints model posits that living in larger groups is associated to higher travel costs and reduced nutritional intake due to within-group feeding competition setting upper group size limits. This pattern is clear in most frugivorous primates, but the prediction power of the ecological constraints model is weak for most of folivorous primates living in small groups (folivore paradox:52). This is because food resources of folivores are generally more abundant and widely distributed54, enabling them to compensate for the increased nutritional requirements by foraging in non-rapidly depleted food patches. However, some folivores support the ecological constraints model by showing high scramble competition within large groups . Infanticide as a male reproductive strategy in some social mammals60 has been suggested as a possible factor explaining the lack of this relationship in other folivores, due to the high number of females with dependent infants and high influx of immigrating and extra-group males, a possible pressure limiting larger group size62. Similarly, predation risk, which may be higher for terrestrial and smaller bodied species, may also limit group size by constraining group spread to an upper limit51. Generally, large groups have greater group spread (e.g.63).For species living in stable and cohesive social units, within-group feeding competition may limit foraging efficiency depending on food patch size64. They are expected to deviate from the ecological-constraints model as, predicted by their body size, predation risk for adults is low but group cohesion is necessary to limit infanticide risk from extra-group males67. Western gorilla (Gorilla gorilla)’s ranging patterns, activity budgets and even their health and microbiome are strongly affected by seasonal changes in the environment75. As fruit availability increases (and so fruit consumption), western gorillas increase their traveling time and daily path length to locate fruit trees (western gorillas: e.g.77). In this framework, western gorillas are particularly interesting as they show a flexible diet and respond to seasonal variation in fruit availability by dramatically modifying their diet from mainly folivorous (> 70% of leaves) to mainly frugivorous . On the other extreme, the Virunga population of mountain gorillas (G. beringei beringei) are mainly herbivorous80 and have similar average group size to western gorillas . However, the maximum observed group size is double in mountain gorillas compared to western gorillas , raising the question of whether seasonal frugivory may set an upper limit for group size in western gorillas. The diet flexibility of western gorillas thus provides us with the opportunity to increase our understanding of the ecological-constraints model for large species that are not strictly frugivorous or folivorous.Gorillas are the most terrestrial of the great apes and also the largest living primatesHow  seasonal variation in food availability affects group size and composition of Critically Endangered western gorillas has yet to be investigated. Theoretically, during periods of fruit abundance, western gorillas may face two opposing pressures: the urge to travel and spread out in search of fruiting trees and reduce within-group feeding competition, and the need to maintain adequate group cohesion to avoid infanticide and predation risk . Thus, the need to seek a fine-tuned balance between these two pressures may limit group size in this seasonal frugivorous species.50].Here, we investigate the influence of group size on activity budget and diet of two groups of wild western gorillas, in terms of their response to seasonal variation in fruit availability. We predict that to minimise within-group feeding competition, the larger group will be a) less frugivorous than the smaller group, b) it will increase its travel time to locate either more or larger fruiting trees to meet its energy requirements . If the larger group has a less frugivorous diet in comparison to the smaller group, we predict c) it will compensate by increasing feeding time and diet diversity in order to meet energy requirements . When compared to the smaller group, the seasonal variation of young leaf and bark consumption of the larger group was higher. Since non-reproductive plant parts are generally less patchily distributed than fruit , their inclusion allows likely larger groups to maintain higher group cohesion, and potentially decrease infanticide and predation risks66. Being hind-gut fermenters (thanks to their large body size) like other large mammals, gorillas can extract from a folivorous diet a large quantity and diversity of macro- and micro-nutrients106. However, consumption of all leaves, mainly from shrubs, did not vary between groups and in relation to fruit availability, likely because they are always available and less nutritious than young leaves or insects.The larger group compensated the higher nutritional needs by changing the proportion of time spent feeding on other foods. One strategy is to incorporate lower quality food in the diet (as opposed to fruit) in order to meet the nutritional requirements of a larger group (ungulates:108), allowing many primate species to survive in seasonal environments (e.g.110). Our result contrasts with several studies showing increased insect exoskeleton remains in western gorilla faeces during the rainy (high fruit availability) season when termite mounds maybe easier to break/open (e.g.111). However, for larger groups, increasing insectivory while decreasing frugivory during the (dry) low fruit availability may be more profitable for maintaining group cohesion, since termite mounds are less dispersed than the few individual fruiting trees available .Another strategy of the larger group was to increase more insect consumption when fruit was scarce, when compared to the smaller group. Since the two study sites are only 10 km a part each other as a part of the same continuous forest, we do not expect this difference (occurring only when fruit availability was low) being the result of a different termite availability between the sites. Insects are highly nutritional food resources (e.g.112). Contrary to our predictions, group size did not affect the time spent moving in western gorillas (neither as main effect nor in association with fruit availability), contrary to what has been found for other primates113. In fact, western gorillas already incur additional costs for longer daily travel distance and time when feeding on fruit . These higher energetic costs are compensated by the high energetic content of fruit confirming the tendency of a previous study25. When feeding on fruit, they also likely increase group spread . The group spread may be more evident in the larger group, since decreased social cohesion and reduced synchronisation of animal activities may be associated to increased group size (e.g. ungulates:114). This is corroborated by the higher social activities found in the smaller group during the high fruit availability period, allowed by a higher group cohesion among group members, when compared to the larger group.Social mammals like primates and carnivores are expected to respond to increased group size by increasing travel time . Furthermore, in western gorillas where secondary female dispersal can occur multiple times, larger groups are one of the correlates of adult females transferring to other groups119. This may be the consequence of heightened infanticide and predation risk in larger groups, where group members need to spread further to feed on fruit114. Given the dietary flexibility, infanticide is likely a key pressure for limiting group size in this large-bodied seasonal frugivorous species rather than predation .In particular, group size was a limiting factor for frugivory during periods of low fruit availability, when western gorillas are more folivorous. Since the ecological-constraints model shows that within-group feeding competition sets the upper limit of group size for frugivoresShedding light on the drivers of the evolution of sociality and grouping patterns in our closest relatives, this study contributes to our knowledge on behavioural flexibility in relation to socioecological changes which can be relevant for human evolution.Supplementary Information 1.


Patient mobility is an evidenced-based physical activity intervention initiated during intensive care unit (ICU) admission and continued throughout hospitalization to maintain functional status, yet mobility is a complex intervention and not consistently implemented. Cognitive work analysis (CWA) is a useful human factors framework for understanding complex systems and can inform future technology design to optimize outcomes.The aim of this study is to understand the complexity and constraints of the ICU work environment as it relates to nurses carrying out patient mobility interventions, using CWA.We conducted a work domain analysis and completed an abstraction hierarchy using the CWA framework. Data from documents, observation (32 hours), and interviews with nurses (N=20) from 2 hospitals were used to construct the abstraction hierarchy.Nurses seek information from a variety of sources and integrate patient and unit information to inform decision-making. The completed abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The analysis identifies several opportunities for technology design to support nurse decision-making about patient mobility.Future interventions need to consider the complexity of the ICU environment and types of information nurses need to make decisions about patient mobility. Considerations for future system redesign include developing and testing clinical decision support tools that integrate critical patient and unit-level information to support nurses in making patient mobility decisions. Patient mobility is a critical intervention for intensive care unit (ICU) patients because hospital-acquired functional decline or a new loss in independently completing activities of daily living is a common complication of hospitalization, occurring in at least 50% of patients who require intensive care ,2. MobilPossible explanations for the lack of widespread implementation of mobility interventions into routine practice may include the fact that mobility guidelines are complex and challenging to implement and require thorough assessment to determine a patient’s stability and mobility status, team training and coordination to maintain safety and monitor equipment, and sufficient physical space for the patient, team, and equipment to complete activities. Mobility fits within several clinical practice domains, with physical therapists (PTs) or registered nurses (RNs) being most frequently involved in planning and implementing ICU mobility interventions . RNs andClinical decision support (CDS), or tools that integrate guideline recommendations with patient-specific information at the right time and at the point of care, has the potential to support the implementation of mobility guidelines into practice. CDS interventions are particularly relevant in ICU settings due to the large amounts of electronic health record (EHR) data generated and the need for time-critical decisions. CDS interventions to identify risk for clinical deterioration  and sepsWe propose examining mobility decision-making using human factors methods to understand the work environment in which mobility decisions are made. Human factors methods aim to understand interactions between humans and elements of a system to optimize outcomes ,25. The One approach that has been used effectively to study real-world decision-making and inform informatics-based interventions in health care is cognitive work analysis (CWA). CWA is a methodological 5-phase framework that includes analytic tools used for systematically identifying different constraints or limitations in a work environment . A fundaIn addition, results of CWA inform system redesign and support developing decision support tools that offer flexibility in complex and unpredictable settings . CWA haswhy something exists and a linkage to a lower level describes how a purpose or function exists in the work environment.Work domain analysis (WDA) is the foundational phase of CWA and focuses on understanding work environment purposes, constraints, and how the purpose(s) are achieved within the constraints of the work environment ,31. A reDespite increasing research on the benefits of ICU-based patient mobility interventions, routine implementation of mobility guidelines into clinical practice is inadequate. A greater understanding of the environment in which ICU nurses make patient mobility decisions is needed to inform the development of future interventions. Therefore, the aim of this study was to apply WDA to develop an understanding of the complex ICU work environment and identify constraints as they relate to nurses carrying out patient mobility interventions.In this descriptive study, WDA was used as an approach for data collection and analysis. A WDA was conducted using data from multiple sources and followed an iterative process of data collection and model development. The scope of the WDA was the ICU work environment in the context of nurses carrying out patient mobility interventions.The study was conducted in 2 adult ICUs at 2 different health systems in a Midwestern US city. The study ICUs were chosen because they had established interdisciplinary mobility programs. Both ICUs had implemented protocols for managing pain, agitation, delirium, and immobility, which included orders for nurses to advance patient mobility as tolerated and PT orders dependent upon the medical team. Mechanically ventilated patients were routinely mobilized out of bed to the chair by nurses and often walked with PTs or RNs before ICU discharge. Both sites had a well-established safe patient handling and mobility program with patient lift equipment provided in the unit and staff training in safe patient handling. In addition, both units had similar nursing characteristics  and each organization had obtained Magnet Recognition for high-quality nursing care. Site 1 was a 24-bed closed-model ICU in an academic tertiary care center, and site 2 was a 12-bed open-model ICU in an academically affiliated Veterans Administration hospital. Although site 2 had slightly lower patient acuity, both units routinely admitted a range of medical and postsurgical patients.Multiple data sources were chosen to understand the ICU work environment within the perspective of mobility practice.Organizational policies and published mobility guidelines were reviewed for relevance. Organizational policies were provided by nurse leaders at each site, and mobility guidelines were retrieved from PubMed. The following search terms were used: “guideline,” “intensive care units,” and “early mobility.” One researcher (AK) reviewed each document and extracted information related to the abstraction hierarchy levels.Nurse observations  were conducted at site 1 by 2 researchers (AK and another researcher) during normal routines of the first 4 hours of 2 separate shifts using a paper data collection tool. Both researchers observed the same nurse to capture communication, workflow, assessment, and coordination information to inform interview questions. Each nurse was interviewed within 1 week following the final observation.Semistructured interviews (N=20) were conducted using an interview guide . ParticiNurses with 6 months or greater of current ICU experience and working 20 hours or more each week were eligible to participate. A purposive sampling method was used to select nurses with a range of experience while including expert nurses who routinely engaged patients in mobility activities. Participants were recruited via advertisement and recruitment materials in the unit and by nurse managers providing contact information for expert nurses with experience mobilizing patients.The University of Wisconsin-Madison institutional review board and the Madison Veterans Administration Research and Development Committee approved the study .Data analysis and abstraction hierarchy development were conducted iteratively with the data collection process. Nurse observation data were summarized, and follow-up interview questions were generated after each observation. Interview data were coded using an inductive approach. Two investigators, one with expertise in critical care nursing (AK) and the other in hospital ambulation interventions and qualitative methods (BK), analyzed the interview data using inductive content analysis . InvestiThe abstraction hierarchy was developed by systematically and iteratively synthesizing data extracted from document review and subcategory and category codes from interview data. Steps from Naikar’s  9-step mTwenty nurses participated in the study . Participants had a range of 4 to 15 years of ICU experience, with a median of 7.8 years .Results of the WDA are presented by abstraction hierarchy level and shown in part in The functional or overall purpose of the ICU is to initially stabilize patients experiencing life-threating illness or injury and to provide high-quality care that improves outcomes for critically ill patients.Four values and priorities were identified: improve patient outcomes, maintain nurse safety, maintain nurse competence, and maximize unit throughput. Most nurses described organizational priorities that focused on improving patient quality and outcomes, such as preventing patient falls. Moreover, staff safety and maintaining competency were promoted, as most participants described organizational training and resources available to nurses for safely assisting patients with movement. Maintaining ICU throughput was an additional priority, as most nurses described the routine, rapid turnaround of admitting highly unstable patients, stabilizing patients, and then transferring patients as soon as they met criteria for a lower level of care.Six purpose-related functions were identified, which describe how the values and priorities are achieved.Situation awareness is recognition of unit activities and resources. Nurses described the need to assist with other unstable patients as a priority over patient mobility and increased activity on the unit limiting staffing resources to assist with mobility.Vigilance is monitoring a patient’s stability over the work shift. For example, participants described watching patient vital signs on the bedside monitor while assisting them with repositioning in the bed or assessing for improvement in ability to follow directions over time. Multiple shifts with a patient provided nurses with more time to know the patient. Nurses stated that they felt more confident to progress mobility on the second day of providing care, based upon their assessment of how the patient tolerated a lower level of mobility the day prior.Plan is the process of preparing for mobility interventions. Participants described multiple barriers that required clarification or adaptation before progressing mobility interventions. For example, nurses described time spent clarifying mobility orders with the medical team or asking family members about the type of assistive equipment a patient used prior to admission.Prevent complications is implementing interventions to avoid harm. For the most severely ill patients, when short-term survival is not known, nurses identified that the priority is to achieve and maintain physiologic stability. As patients stabilize, participants described implementing progressive mobility interventions to prevent functional decline.Individualize mobility progression is the process of assessing and determining the mobility goal for the shift. For patients that had not yet gotten out of bed in the ICU, nurses described spending considerable time assessing and synthesizing patient information to determine if the patient would tolerate out-of-bed mobility.Consult experienced colleague is identifying and communicating with another health care professional to inform the daily mobility goal. In some situations, nurses described talking with a nursing assistant to learn how the patient tolerated walking during a prior mobility session, whereas in other situations, nurses described talking with a PT for medically complex patients with weakness or unsteady balance, or it being their first time out of bed after bed rest.Nine object-related processes were identified and are presented in Twelve physical objects were identified and were grouped into components of human resources, equipment, and information sources. Physical objects describe how the object-related processes are implemented. Participants described human resources, primarily nursing assistants, other nurses and PTs, and mobility equipment, such as a walker, as necessary to support mobility interventions. Nurses used information from multiple sources to establish a mobility goal for the shift. Nurses described comparing current patient assessment information  and data from bedside monitors  to previous values to assess stability. Nurses also relied on peers during shift handoff reports and on patients or family members for verbal information.how the concept is achieved or carried out and moving from the bottom to a higher level in the abstraction hierarchy describes why a concept exists. For example, the object-related process of synthesizing information is connected to 10 physical objects, illustrating how nurses seek information from a variety of sources to inform mobility decision-making. Synthesizing information is also linked to 4 higher-level purposes, indicating why nurses integrate both patient and hospital unit information when making mobility decisions.Means-ends linkages were identified between levels in the abstraction hierarchy and are illustrated in Our WDA describes the complexity of the ICU work environment within the context of nurses carrying out patient mobility interventions. The abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The WDA identifies several opportunities for technology design and future study at the nurse level and unit level to support nurse decision-making about patient mobility.One key information need is to provide assessment information about patient stability to nurses. Nurses in this study described assessing the patient over the course of a shift or several shifts to individualize mobility progression, and nurses described information sources they used to determine patient stability for mobility. To improve the efficiency for nurses in seeking information about mobility decision-making, a trended display of patient stability for physiologic metrics that nurses currently use  from the EHR may support decision-making. A second key information need is to provide historic patient mobility information to nurses. Participants described using information about the patient’s past mobility activity to inform their planning for the shift and looking for this information in multiple places. There are valid numerical scales to quantify mobility status and to efficiently communicate the highest level of activity a patient has achieved ,35. A cuWe have identified information that may be amenable to technology-based interventions to support nurse decision-making for mobility in the ICU. Studies using WDA-informed information displays have demonstrated improved ability for ICU and emergency room nurses to detect patient changes when compared to use of the existing EHRs ,37. FromFindings from the WDA also demonstrate opportunities and recommendations for unit-level information needs. Using technology interface design to organize relevant patient and unit information may offer several benefits. For example, displaying patient and unit information simultaneously may assist with limited resource allocation by prioritizing patients who display a greater need for mobility, such as a patient that has a greater duration of immobility. A unit display may also support a unit culture of accountability for mobility progression, as each patient’s mobility status is visible to the ICU team. A unit-based display or dashboard of real-time EHR data for promoting guideline-based mechanical ventilation care has been found to improve interprofessional care coordination, communication, and patient outcomes . Future This study should be considered within the context of several limitations. First, the study was conducted in 2 medical-surgical ICUs at 2 academic medical centers. Therefore, our findings may not be generalizable to all ICUs, but we expect the findings to be transferrable to similar settings. Differences in patient population, unit culture or available resources, ICU type, such as specialty surgical ICUs or community-based ICUs, may change work environment barriers. In addition, both study ICUs had experience with implementing mobility interventions. Work environment constraints and nurse decision-making might look different depending upon the status of implementing mobility practices, unit culture, teamwork, and ICU resources. Finally, the study focused on the work environment from the perspective of nurses. Although nurses described communication and coordination with other health care providers, future work is needed to include data from patients, family members, and additional team members in the work environment. The WDA is by no means a complete representation of the ICU work environment within the context of mobility interventions. Future work should expand the analysis to other layers of CWA.One goal of the current study was to inform future system design to support the nurse in progressing patient mobility interventions. Therefore, our focus was on possible improvements in the work environment, such as information visibility, that could influence prototype designs as opposed to physical improvements in the work environment, such as reconfiguring the structural layout of the ICU room, which might be cost prohibitive.This WDA provided several important insights for understanding nurse decision-making about patient mobility within the context of the ICU work environment and identified opportunities for technology design to support decision-making. The results of this study identify strategies for integrating critical patient and unit-level information to inform patient mobility decisions. Future studies should investigate the acceptability and feasibility of interventions to support nurse decision-making about mobility interventions. This analysis demonstrates that interdependencies exist between patients, nurses, other members of the health care team, and unit resources. Therefore, multicomponent interventions that address constraints in the work environment, such as lack of human resources and nurse workload, are needed. Systems-based approaches to improve delivery of mobility and patient outcomes must include interventions that are based upon how nurses make these complex decisions within the work environment.CWA is a valuable framework for understanding the environment in which ICU nurses make patient mobility decisions and for identifying priorities to target with future CDS designs for supporting mobility decisions at the point of care. Findings from this study provide an understanding of how mobility decisions are made from the perspective of the ICU work environment and identify a need to consider the types of information nurses use to make knowledgeable and efficient patient mobility decisions.