Distributed cognition is a theory of human cognition that describes how information processing is dispersed across people and their workplace, their technologies, and their social organization and how information processing evolves over time.16 Essentially, distributed cognition describes how information is transformed and propagated throughout a system.17 It is one of a family of social cognitive theories known as situativity theory,18 all involving interactions between people, their environment, and the resources at hand.18
Social cognitive theories are increasingly popular in healthcare, and a recent special issue of the journal Diagnosis was devoted to considerations of how situativity theories (including distributed cognition) could be applied to understand and improve diagnosis.18 Principles of distributed cognition cross disciplinary boundaries and fall into three main categories: physical organization of work, information flow, and artifacts.17
The physical organization of work refers to the structure and context of care and the things that can be physically heard, seen, and accessed by the people doing the work. These all have a direct impact on cognition and will shape clinical reasoning, for better or worse.17 For example, nursing work is structured so that nurses have frequent patient interactions throughout a shift; that design gives nurses an advantage over physicians, whose interactions with a patient are likely to be less frequent.
This structure means that a nurse taking care of a patient is more likely than a physician to observe overt and many times more subtle clues, such as changes in vital signs, sensorium, or events such as active seizures, that will enhance the diagnostic process. In addition, the nurse is more likely to establish rapport with the patient and caregiver, thus being more likely to elicit additional historical or social details or clinical examination findings that may facilitate arriving at the correct diagnosis.
The physical organization of work influences how information flows throughout a system. Information flow itself is a specific category of distributed cognition because it defines the mechanism by which a system operates.17 At the most basic level, information flows through the process of communication, defined as an interpersonal process where shared understanding develops between communicators, to generate an effect or action.19,20
Communication breakdowns are consistently among the top system-related causes of diagnostic error, thus underscoring the importance of optimizing communication as a priority for improving diagnostic quality.5,21-24 In the ED, factors such as time pressure, numerous interruptions, and lack of a historical relationship with the patient form barriers to effective communication with patients.1 Nurses can help overcome these barriers because their relationship with patients/caregivers facilitates trust and information sharing.
Distributed cognition also maintains that to fully appreciate how information flows across people, places, and time, we need to understand all aspects of communication, from the mediums used to transmit information (e.g., pagers, telephone, face to face) to the type of communication used (e.g., verbal, nonverbal).
The final category of distributed cognition has to do with how artifacts are designed to support cognition.17 Artifacts refer to cognitive supports such as paper or electronic reminders and coordination tools, as well as such things as computers and software applications, including the electronic health record (EHR). For example, paper and electronic tools developed to facilitate handoffs between clinicians are a type of artifact.
Another artifact is the paper-based task sheet nurses frequently develop at the beginning of a shift. This sheet may include information such as medications that are due, when medication should be given, other therapies and treatments nurses are responsible for, and timing of all these treatments. Nurses often refer to these sheets as their “brain,” highlighting the link between artifact and cognition.25
Figure 1 displays the three principles of distributed cognition. When each principle is manifested independently, distributed cognition does not develop because no opportunity arises for input from another source. For example, a nurse assesses the patient upon initial presentation to the ED, demonstrating the physical organization of a nurse’s work, but without discussing assessment findings with another clinician or documenting findings in the EHR. Thus, distributed cognition will not occur.
The combination of all three principles results in distributed cognition. For example, as part of a newly established workflow, the nurse and physician go into a patient’s room together and jointly review new medication orders on the EHR before sending the patient home.
Figure 1. Principles of Distributed Cognition
