Nursing process documentation systems in clinical routine--prerequisites and experiences

The Role of Nurse Managers in the Adoption of Health Information Technology: Findings From a Qualitative Study

OBJECTIVE

This study aims to investigate the role of nurse managers in supporting point-of-care nurses' health information technology (IT) use and identify strategies employed by nurse managers to improve adoption, while also gathering point-of-care nurses' perceptions of these strategies.

BACKGROUND

Nurse managers are essential in facilitating point-of-care nurses' use of health IT; however, the underlying phenomenon for this facilitation remains unreported.

METHODS

A qualitative descriptive study was conducted with 10 nurse managers and 14 point-of-care nurses recruited from a mental health hospital environment in Ontario, Canada. Inductive and deductive content analyses were used to analyze the semistructured interviews.

RESULTS

Nurse managers adopt the role of advocate, educator, and connector, using the following strategies: communicating system updates, demonstrating use of health IT, linking staff to resources, facilitating education, and providing IT oversight.

CONCLUSIONS

Nurse managers use a variety of strategies to support nurses' use of health IT. Future research should focus on the effectiveness of these strategies.

Accessing and sharing health information for post-discharge stroke care through a national health information exchange platform - a case study

BACKGROUND

Patients and citizens need access to their health information to get a retrospective as well as a prospective view on their care and rehabilitation processes. However, patients' health information is stored in several health information systems and interoperability problems often hamper accessibility. In Sweden a national health information exchange (HIE) platform has been developed that enables information exchange between different health information systems. The aim of this study is to explore the opportunities and limitations of accessing and interacting with important health information through the Swedish national HIE platform.

METHODS

A single case study approach was used for this study as an in-depth understanding of the subject was needed. A fictive patient case with a pseudo-name was created based on an interview with a stroke coordinator in Stockholm County. Information access through the national health information exchange platform and available service contracts and application programming interfaces were studied using different scenarios.

RESULTS

Based on the scenarios created in this study, patients would be able to access some health related information from their electronic health records using the national health information exchange platform. However, there is necessary information which is not retrievable as it is either stored in electronic health records and eHealth services which are not connected to the national health information exchange platform or there is no service contract developed for these types of information. In addition, patients are not able to share information with healthcare professionals.

CONCLUSION

The national Swedish HIE platform provides the building blocks needed to allow patients online access to their health information in a fragmented and distributed health system. However, more complex interaction scenarios allowing patients to communicate with their health care providers or to update their health related information are not yet supported. Therefore it is of great importance to involve patients throughout the design and evaluation of eHealth services on both national and local levels to ensure that their needs for interoperability and information exchange are met.

Individualization process of the standardized care plan in acute care hospitalization units: Study protocol

AIM

To understand the individualization process of the standardized care plan (SCP) that nurses design for hospitalized patients.

BACKGROUND

To apply the nursing process, it is advisable to use SCP to standardize the diagnosis, planning and evaluation stages. However, the fundamental element of this methodology is the individualization of the care plan.

DESIGN

A qualitative study, framed within the constructivist paradigm and applying the Grounded Theory method, in accordance with Strauss and Corbin's approach.

METHODS

Multicentre study. Theoretical sampling with maximum variation will be used. The data collection will consist of: in-depth individual interviews, participant observation, document analysis, focus group, and the questionnaires for Critical Thinking Assessment in relation to clinical practice and Nursing Competency Assessment for hospital nurses. The qualitative data will be analysed according to the constant comparative method of Strauss and Corbin's Grounded Theory, which involves performing open, axial and selective coding. The questionnaire results will be used to make a qualitative analysis that will consist of a triangulation between the level of critical thinking, level of expertise and record of the individualization process performed by the nurses. This protocol was approved in July 2015.

DISCUSSION

By knowing the possible stages used in the individualization of a SCP, together with the elements that facilitate or hinder said individualization and nurses' attitudes and experiences regarding this phenomenon, it could help direct improvement strategies in the standardization and individualization process. In addition to recommendations for teaching and research.

Nurses Education and Motivation Towards Nursing Documentation

Introduction: Nursing documentation is an integral part that cannot be separated from healthcare as a responsibility and accountability of nurses. High education and motivation are needed to achieve good nursing documentation. The aim of this study was to know the correlation between education and motivation of nurses towards Intensive Care nursing documentation.Methods: The design used was an analytical survey with a cross-sectional approach. The population was nurses in intensive care of Palembang BARI Hospital with as many as 46 nurses and 44 samples obtained with total sampling. Data were collected by questionnaire and observational and were analyzed by Chi-Square. Independent variables are education and motivation of nurses and the dependent variable is nursing documentation.Results: There was a correlation between education (p=0.035) and motivation (p=0.040) of nurses towards nursing documentation.Conclusion: High education and motivation of nurses influenced towards the quality of nursing education. The nursing manager of the hospital is recommended affording the opportunity to support human resources in the hospital, especially for nurses to participate in education, in accordance with the demands of legislation in nursing education, and to organize the training of nursing documentation.

Measuring the User Acceptance of a Web-based Nursing Documentation System

Objectives: The development of an ICNP web-based nursing documentation system, and its evaluation for its usability, and its user acceptance.

Methods: A web-based nursing documentation system was designed and implemented by using the Greek translation of ICNP beta 2 version nursing terminology. The system integrates the steps of nursing process for providing and documenting nursing care, while ICNP terminology is used for the description of nursing concepts. The system was evaluated by nurses in a computer laboratory. We measured the user interaction satisfaction mainly by using questionnaires and scenarios.

Results: The nurses who evaluated the system possessed adequate basic computer skills; but low-to-moderate experience in clinical or hospital information systems; and insufficient experience with nursing vocabularies, and especially ICNP. Overall, they were satisfied enough with the system’s usability and usefulness, while the acceptance level increased as the level of their training in computers, nursing process and ICNP was also increased. The integration and use in the system of predefined, or standardized, nursing concepts and care plans seems to increase the acceptance of the documentation system and also the ICNP.

Conclusion: The subjective satisfaction and response of the users towards the system is specified. The described system was evaluated under “laboratory conditions” and revealed some of its strong and weak points and some of the factors that influenced its success and acceptance by its users.

The Development of a Six Sigma–Based Ulcus Decubitus Prevention Model to Respond to Adverse Events

Introduction: Based on the number of incidences of Ulcus Decubitus in 2015 which was 2.4 ‰ and 1.59 ‰ in 2016, the incidences of Ulcus Decubitus is an indicator of patient safety. In one of the public hospitals in Surabaya, it showed that the achievement of a Ulcus Decubitus indicator had not been reached yet (the standard is 1.5 ‰ per year). One of the efforts that can be done to prevent the occurrence of ulcus decubitus is by way of Six Sigma-based ulcus decubitus prevention.Methods: The design of this research was an explanatory research study using a cross-sectional approach. The research respondents were nurses at Inpatient Wards (4 Rooms); 57 nurses via the Purposive Sampling technique. The research data was analysed with Partial Least Square (PLS)Results: Individual factors (Path Coefficient 0,200 t: 6,580), organisational factors (Path Coefficient 0,373 t: 9,278) and management factors (Path Coefficient 0.099 t: 2.184) are all significantly correlated with the Six Sigma-based Ulcus decubitus prevention.Conclusions: Individual, Organisational and Management factors are important factors in the Six Sigma-based Ulcus Decubitus prevention model. It needs advanced research to find out how much the influence of Six Sigma-based Ulcus Decubitus prevention implementation will decrease the incidences of Ulcus Decubitus.

The need for academic electronic health record systems in nurse education

The nursing profession has been slow to incorporate information technology into formal nurse education and practice. The aim of this study was to identify the use of academic electronic health record systems in nurse education and to determine student and faculty perceptions of academic electronic health record systems in nurse education. A quantitative research design with supportive qualitative research was used to gather information on nursing students' perceptions and nursing faculty's perceptions of academic electronic health record systems in nurse education. Eighty-three participants (21 nursing faculty and 62 students), from 5 nursing schools, participated in the study. A purposive sample of 9 nursing faculty was recruited from one university in the Midwestern United States to provide qualitative data for the study. The researcher-designed surveys (completed by faculty and students) were used for quantitative data collection. Qualitative data was taken from interviews, which were transcribed verbatim for analysis. Students and faculty agreed that academic electronic health record systems could be useful for teaching students to think critically about nursing documentation. Quantitative and qualitative findings revealed that academic electronic health record systems regarding nursing documentation could help prepare students for the future of health information technology. Meaningful adoption of academic electronic health record systems will help in building the undergraduate nursing students' competence in nursing documentation with electronic health record systems.

Challenges associated with the implementation of the nursing process: A systematic review

BACKGROUND

Nursing process is a scientific approach in the provision of qualified nursing cares. However, in practice, the implementation of this process is faced with numerous challenges. With the knowledge of the challenges associated with the implementation of the nursing process, the nursing processes can be developed appropriately. Due to the lack of comprehensive information on this subject, the current study was carried out to assess the key challenges associated with the implementation of the nursing process.

MATERIALS AND METHODS

To achieve and review related studies on this field, databases of Iran medix, SID, Magiran, PUBMED, Google scholar, and Proquest were assessed using the main keywords of nursing process and nursing process systematic review. The articles were retrieved in three steps including searching by keywords, review of the proceedings based on inclusion criteria, and final retrieval and assessment of available full texts.

RESULTS

Systematic assessment of the articles showed different challenges in implementation of the nursing process. Intangible understanding of the concept of nursing process, different views of the process, lack of knowledge and awareness among nurses related to the execution of process, supports of managing systems, and problems related to recording the nursing process were the main challenges that were extracted from review of literature.

CONCLUSIONS

On systematically reviewing the literature, intangible understanding of the concept of nursing process has been identified as the main challenge in nursing process. To achieve the best strategy to minimize the challenge, in addition to preparing facilitators for implementation of nursing process, intangible understanding of the concept of nursing process, different views of the process, and forming teams of experts in nursing education are recommended for internalizing the nursing process among nurses.

Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes

PURPOSE

To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment.

METHODS

This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated.

RESULTS

Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms).

CONCLUSIONS

Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

An evaluation of the implementation of a best practice guideline on tracheal suctioning in intensive care units

Aim  To minimise suctioning-induced complications in intensive care patients, it is crucial that nurses are able to perform the procedure safely and act in accord with research-based recommendations. This paper reports the process of developing, disseminating and implementing the best practice guideline and an evaluation of the process and outcomes of care during and following its implementation in intensive care units. Methods  The study was divided into four phases: (i) to develop the best practice guideline and plan strategies for its dissemination and implementation; (ii) to audit the current practice of nurses in the tracheal suctioning of patients in intensive care units with an artificial airway; (iii) to disseminate and implement the best practice guideline; and (iv) to evaluate the process as well as outcome of care following its implementation in intensive care units. Results  The pretest results indicate that gaps exist between actual nursing practice and recommendations based on research evidence. Most nurses performed the skills in accord with the best practice guideline, with 65% nurses scoring above the 70% level. The post-test audit results show that, overall, nurses demonstrated a good endotracheal suctioning technique, with 96% scoring above 75%, indicating an overall improvement in compliance with the guideline. A statistically significant difference was found between the pretest (73%) and post-test (89%) compliance scores (t = -7.67, P < 0.005). Conclusions  This implementation project highlights the importance of using a rigorous and systematic process to ensure the formal testing of an intervention. Some essential principles in implementing evidence are necessary, such as involving relevant staff and having a range of strategies and clear processes for implementation.

What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review

AIM

To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.

BACKGROUND

Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.

DESIGN

Systematic review.

METHOD

MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.

RESULTS

In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.

CONCLUSION

General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.

RELEVANCE TO CLINICAL PRACTICE

This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.

Nursing documentation for communicating and evaluating care

AIMS

To investigate the utility of electronic nursing documentation by exploring to what extent and for what purpose general practitioners use nursing documentation and to what extent and in which cases care unit managers use nursing documentation for quality development of care.

BACKGROUND

As health care includes multidisciplinary activities, communication about the care given is essential. To assure delivery of good and safe care, quality development is necessary. The main tool available for communication and quality development is the patient record. In many studies, nursing documentation has been found to be inadequate for this purpose.

DESIGN

This study had a cross-sectional descriptive design.

METHODS

Data were collected by postal questionnaires, one to the general practitioners (n = 544) and one to care unit managers (n = 82) in primary health care. Data were analysed by descriptive statistical and qualitative content analysis.

RESULTS

The general practitioners usually used the nursing record as the foremost source of information for treatment follow-up. The results, however, point out weaknesses and shortcomings in the nursing records, such as difficulties in finding important information because of a huge amount of routine notes. The care unit managers generally (74%) used the record for statistical purposes, while only half of them used it to evaluate care.

CONCLUSION

Nursing records need more clarity and need to be more prominent regarding specific nursing information to fulfil their purpose of transferring information and to constitute a base for quality development of care.

RELEVANCE TO CLINICAL PRACTICE

The results of this study can provide a part of a basis upon which a multi-professional patient record could be developed and which could also function as an alarm to managers at different levels to prioritize the development of nursing documentation.

Review: evaluating information systems in nursing

AIMS

To review existing nursing research on inpatient hospitals' information technology (IT) systems in order to explore new approaches for evaluation research on nursing informatics to guide further design and implementation of effective IT systems.

BACKGROUND

There has been an increase in the use of IT and information systems in nursing in recent years. However, there has been little evaluation of these systems and little guidance on how they might be evaluated.

METHODS

A literature review was conducted between 1995 and 2005 inclusive using CINAHL and Medline and the search terms 'nursing information systems', 'clinical information systems', 'hospital information systems', 'documentation', 'nursing records', 'charting'.

RESULTS

Research in nursing information systems was analysed and some deficiencies and contradictory results were identified which impede a comprehensive understanding of effective implementation. There is a need for IT systems to be understood from a wider perspective that includes aspects related to the context where they are implemented.

CONCLUSIONS

Social and organizational aspects need to be considered in evaluation studies and realistic evaluation can provide a framework for the evaluation of information systems in nursing.

RELEVANCE TO CLINICAL PRACTICE

The rapid introduction of IT systems for clinical practice urges evaluation of already implemented systems examining how and in what circumstances they work to guide effective further development and implementation of IT systems to enhance clinical practice. Evaluation involves more factors than just involving technologies such as changing attitudes, cultures and healthcare practices. Realistic evaluation could provide configurations of context-mechanism-outcomes that explain the underlying relationships to understand why and how a programme or intervention works.

Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation

AIMS AND OBJECTIVES

To describe the change in documentation of the nursing process in all inpatient wards in a 900-bed university hospital. Major research question was what are the differences between before and after implementation of documentation policy related to the steps of the nursing process?

BACKGROUND

Implementation of standardized languages has been shown to be difficult to accomplish in clinical practice. Patients are the source of data and their conditions, responses and well-being should be reflected in the nursing record. As such, nursing documentation can create the premises for the development of new knowledge in nursing and the improvement of nursing performance and can provide data and information necessary for nursing researchers to evaluate the quality of interventions and participate in the formulation of healthcare policy. This study is part of longitudinal project to prepare nurses for electronic documentation within the interdisciplinary health record and to improve documentation of nursing using standardized languages.

DESIGN AND METHOD

A cross-sectional study design was used: a pretest (n = 355 nursing records) for baseline status of nursing documentation, an intervention and a post-test (n = 349 nursing records) to obtain data on nursing documentation. The year-long intervention comprised planned work in groups, and educational and supporting efforts.

RESULTS

A statistically significant improvement was found in the use of Functional Health Patterns for documentation of nursing assessment, NANDA for nursing diagnoses and Nursing Interventions Classification for nursing interventions in documentation of daily nursing care for inpatients.

CONCLUSION

At all organizational levels intervention aimed at putting policy regarding documentation into clinical practice considerably improved daily use of standardized nursing languages. Relevance to clinical practice. Nurses need to use standardized language to document patient care data in the electronic health record and to demonstrate contributions to nursing care.

Information handling in the nursing discharge note

AIMS

The aim of this paper is twofold. Firstly, it describes hospital nurses' general use of the language function in the nursing discharge notes of patients who will require posthospital home health care. Secondly, it addresses the similarities and differences in completeness, structure and content between paper and electronic nursing discharge notes.

BACKGROUND

Previous research has identified gaps in the accuracy and relevance of information communicated between nurses working at different organizational levels.

DESIGN AND METHODS

A descriptive design with a text analysis framework was used.

RESULTS

The study shows that the text in the nursing discharge notes is information-dense and characterized by technical terms, although the nurses contextualized and individualized the content of the terms to clarify the message. Both similarities and differences were found in range and detail of the information nurses exchanged when they used paper or electronic discharge notes.

CONCLUSIONS

The use of structured and standardized templates helped nurses improve the completeness, structure and content of the information in the nursing discharge notes.

RELEVANCE TO CLINICAL PRACTICE

Whether paper or electronic documentation is used, the findings in this study highlight the challenges nurses encounter in ensuring continuity of care during patients' trajectory through the health system. The findings may help clarify the appropriateness of the content and language nurses use in the nursing discharge note as a communication medium. This study may also be helpful to nurses planning to use EPRs, as it illustrates some of the issues which should be clarified before this is implemented.

Nurses' information management at patients' discharge from hospital to home care

PURPOSE

The purpose of this paper is to explore and compare hospital and home care nurses' assessment of their information management at patients' discharge from hospital to home care before and after the hospital implemented an electronic nursing discharge note.

THEORY

This paper draws on the concept of inter-organizational continuity of care, and specifically addresses the contribution of the implementation of an electronic patient record (EPR).

METHODS

The study has a prospective descriptive design. A questionnaire addressing the information that hospital and home care nurses exchange when patients need continuing care after hospitalization was developed and used.

RESULTS

Hospital and home care nurses differed in the way they assessed the structures and content of the information they exchanged, both before and after the EPR implementation.

CONCLUSION AND DISCUSSION

There is a need to take account of the different organizational contexts within which the two nursing groups work. The organizational context (hospital versus home care) has implications for the nurses' assessment of the information they exchange. In further development of EPR, it is therefore essential to clarify the context-related information needs of the various health care provider groups as part of the commitment to patient safety.

The impact of electronic health records on time efficiency of physicians and nurses: a systematic review

A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.

Can evaluation studies benefit from triangulation? A case study

BACKGROUND

Information and communication technologies (ICTs) are increasingly being used in health care. Rigorous evaluations of ICT applications during both introduction and routine use are of great importance for decision makers and users. Within evaluation research, two main (and often rather distinct) traditions can be found: the objectivistic and the subjectivistic tradition.

METHODS

The theory of triangulation deals with the integration of methods and approaches as to conduct better evaluation studies. In evaluation research, triangulation in general means the multiple employment of various sources of data, observers, methods, and/or theories in investigations of the same phenomenon. We applied triangulation aspects in the analysis of the effects of a computer-based nursing documentation system.

RESULTS

We discuss, based on this case study, what benefits can be obtained from applying triangulation in an evaluation study. We show how both the validation of results and the completeness of results can be supported by triangulation.

DISCUSSION

The decision whether triangulation may be useful for a given research question, and how it may be correctly applied, requires-like other evaluation methods-intensive training and methodological experience. Medical informatics evaluation research may profit from this well-established theory.