Nurses' use of computerised clinical decision support systems: a case site analysis

The Effect of an Electronic Medical Record-Based Clinical Decision Support System on Adherence to Clinical Protocols in Inflammatory Bowel Disease Care: Interrupted Time Series Study

Background

Clinical decision support systems (CDSSs) embedded in electronic medical records (EMRs), also called electronic health records, have the potential to improve the adoption of clinical guidelines. The University of Alberta Inflammatory Bowel Disease (IBD) Group developed a CDSS for patients with IBD who might be experiencing disease flare and deployed it within a clinical information system in 2 continuous time periods.

Objective

This study aims to evaluate the impact of the IBD CDSS on the adherence of health care providers (ie, physicians and nurses) to institutionally agreed clinical management protocols.

Methods

A 2-period interrupted time series (ITS) design, comparing adherence to a clinical flare management protocol during outpatient visits before and after the CDSS implementation, was used. Each interruption was initiated with user training and a memo with instructions for use. A group of 7 physicians, 1 nurse practitioner, and 4 nurses were invited to use the CDSS. In total, 31,726 flare encounters were extracted from the clinical information system database, and 9217 of them were manually screened for inclusion. Each data point in the ITS analysis corresponded to 1 month of individual patient encounters, with a total of 18 months of data (9 before and 9 after interruption) for each period. The study was designed in accordance with the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) guidelines for health informatics evaluations.

Results

Following manual screening, 623 flare encounters were confirmed and designated for ITS analysis. The CDSS was activated in 198 of 623 encounters, most commonly in cases where the primary visit reason was a suspected IBD flare. In Implementation Period 1, before-and-after analysis demonstrates an increase in documentation of clinical scores from 3.5% to 24.1% (P<.001), with a statistically significant level change in ITS analysis (P=.03). In Implementation Period 2, the before-and-after analysis showed further increases in the ordering of acute disease flare lab tests (47.6% to 65.8%; P<.001), including the biomarker fecal calprotectin (27.9% to 37.3%; P=.03) and stool culture testing (54.6% to 66.9%; P=.005); the latter is a test used to distinguish a flare from an infectious disease. There were no significant slope or level changes in ITS analyses in Implementation Period 2. The overall provider adoption rate was moderate at approximately 25%, with greater adoption by nurse providers (used in 30.5% of flare encounters) compared to physicians (used in 6.7% of flare encounters).

Conclusions

This is one of the first studies to investigate the implementation of a CDSS for IBD, designed with a leading EMR software (Epic Systems), providing initial evidence of an improvement over routine care. Several areas for future research were identified, notably the effect of CDSSs on outcomes and how to design a CDSS with greater utility for physicians. CDSSs for IBD should also be evaluated on a larger scale; this can be facilitated by regional and national centralized EMR systems.

The effects of computerised decision support systems on nursing and allied health professional performance and patient outcomes: a systematic review and user contextualisation

Background

Computerised decision support systems (CDSS) are widely used by nurses and allied health professionals but their effect on clinical performance and patient outcomes is uncertain.

Objectives

Evaluate the effects of clinical decision support systems use on nurses', midwives' and allied health professionals' performance and patient outcomes and sense-check the results with developers and users.

Eligibility criteria

Comparative studies (randomised controlled trials (RCTs), non-randomised trials, controlled before-and-after (CBA) studies, interrupted time series (ITS) and repeated measures studies comparing) of CDSS versus usual care from nurses, midwives or other allied health professionals.

Information sources

Nineteen bibliographic databases searched October 2019 and February 2021.

Risk of bias

Assessed using structured risk of bias guidelines; almost all included studies were at high risk of bias.

Synthesis of results

Heterogeneity between interventions and outcomes necessitated narrative synthesis and grouping by: similarity in focus or CDSS-type, targeted health professionals, patient group, outcomes reported and study design.

Included studies

Of 36,106 initial records, 262 studies were assessed for eligibility, with 35 included: 28 RCTs (80%), 3 CBA studies (8.6%), 3 ITS (8.6%) and 1 non-randomised trial, a total of 1318 health professionals and 67,595 patient participants. Few studies were multi-site and most focused on decision-making by nurses (71%) or paramedics (5.7%). Standalone, computer-based CDSS featured in 88.7% of the studies; only 8.6% of the studies involved 'smart' mobile or handheld technology. Care processes - including adherence to guidance - were positively influenced in 47% of the measures adopted. For example, nurses' adherence to hand disinfection guidance, insulin dosing, on-time blood sampling, and documenting care were improved if they used CDSS. Patient care outcomes were statistically - if not always clinically - significantly improved in 40.7% of indicators. For example, lower numbers of falls and pressure ulcers, better glycaemic control, screening of malnutrition and obesity, and accurate triaging were features of professionals using CDSS compared to those who were not.

Evidence limitations

Allied health professionals (AHPs) were underrepresented compared to nurses; systems, studies and outcomes were heterogeneous, preventing statistical aggregation; very wide confidence intervals around effects meant clinical significance was questionable; decision and implementation theory that would have helped interpret effects - including null effects - was largely absent; economic data were scant and diverse, preventing estimation of overall cost-effectiveness.

Interpretation

CDSS can positively influence selected aspects of nurses', midwives' and AHPs' performance and care outcomes. Comparative research is generally of low quality and outcomes wide ranging and heterogeneous. After more than a decade of synthesised research into CDSS in healthcare professions other than medicine, the effect on processes and outcomes remains uncertain. Higher-quality, theoretically informed, evaluative research that addresses the economics of CDSS development and implementation is still required.

Future work

Developing nursing CDSS and primary research evaluation.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in Health and Social Care Delivery Research; 2023. See the NIHR Journals Library website for further project information.

Registration

PROSPERO [number: CRD42019147773].

Acceptance of clinical decision support system to prevent venous thromboembolism among nurses: an extension of the UTAUT model

Background

Venous thromboembolism has been a major public health problem and caused a heavy disease burden. Venous thromboembolism clinical decision support system was proved to have a positive influence on the prevention and management of venous thromboembolism. As the direct users, nurses' acceptance of this system is of great importance to support the successful implementation of it. However, there are few relevant studies to investigate nurses' acceptance and the associated factors are still unclear.

Objective

To investigate the determinant factors of nurses' acceptance of venous thromboembolism clinical decision support system with the modified Unified Theory of Acceptance and Use of Technology.

Methods

We designed a questionnaire based on the modified Unified Theory of Acceptance and Use of Technology and then a cross-sectional survey was conducted among nurses in a tertiary hospital in Nanjing, China. Statistically, a Structural Equation Modeling -Partial Least Squares path modeling approach was applied to examine the research model.

Results

A total of 1100 valid questionnaires were recycled. The modified model explained 74.7%, 83.0% and 86% of the variance in user satisfaction, behavioral intention and user behavior, respectively. The results showed that performance expectancy (β = 0.254, p = 0.000), social influence (β = 0.136, p = 0.047), facilitating conditions (β = 0.245, p = 0.000), self-efficacy (β = 0.121, p = 0.048) and user satisfaction (β = 0.193, p = 0.001) all had significant effects on nurses' intention. Although effort expectancy (β = 0.010, p = 0.785) did not have a direct effect on nurses' intention, it could indirectly influence nurses' intention with user satisfaction as the mediator (β = 0.296, p = 0.000). User behavior was significantly predicted by facilitating conditions (β = 0.298, p = 0.000) and user intention (β = 0.654, p = 0.001).

Conclusion

The research enhances our understanding of the determinants of nurses' acceptance of venous thromboembolism clinical decision support system. Among these factors, performance expectancy was considered as the top priority. It highlights the importance of optimizing system performance to fit the users' needs. Generally, the findings in our research provide clinical technology designers and administrators with valuable information to better meet users' requirements and promote the implementation of venous thromboembolism clinical decision support system.

Moral Sensitivity and Emotional Intelligence in Intensive Care Unit Nurses

Moral sensitivity helps individuals resolve moral dilemmas as a precursor to moral decision-making. Intensive care unit (ICU) nurses are at high risk for encountering moral dilemmas and should have the moral sensitivity to recognize moral issues. The activities of ICU nurses in moral decision-making are guided by moral sensitivity but are also based on emotional intelligence (EI). EI, be recognized as an integral part of moral sensitivity with long-standing theoretical foundations. It is necessary to explicate the true role of EI in moral sensitivity through empirical research. To measure the level of moral sensitivity of ICU nurses and determine the relationship between moral sensitivity and EI. We recruited 467 ICU nurses of ten hospitals from March to June 2021 in Hunan Province, China for a cross-sectional questionnaire survey. The moral sensitivity and EI were measured using the Moral Sensitivity Questionnaire-Revised Version into Chinese (MSQ-R-CV) and the Wong and Law Emotional Intelligence Scale-Version into Chinese (WLEIS-C). A self-report questionnaire covered sociodemographic characteristics. The average moral sensitivity score of ICU nurses was 39.41 ± 7.21. The average EI score was significantly positively correlated with the moral sensitivity score (p < 0.001). This study demonstrated that the moral sensitivities of ICU nurses were at medium levels. EI of ICU nurses can indeed affect their moral sensitivity, and the impact of each element of EI should be clarified for practical application.

Better safe than sorry: Registered nurses' strategies for handling difficult calls to emergency medical dispatch centres - An interview study

AIMS AND OBJECTIVES

To describe strategies employed by registered nurses for handling difficult calls to emergency medical dispatch centres.

BACKGROUND

At emergency medical dispatch centres, registered nurses encounter a range of difficult calls in their clinical practice. They often use clinical decision support systems, but these may be of limited help if the caller is for instance abusive or has limited language proficiency. Much can be learnt from strategies developed by registered nurses for handling difficult calls.

DESIGN

A descriptive qualitative study was conducted.

METHODS

A purposeful sample of 24 registered nurses from three different emergency medical dispatch centres were interviewed. The transcribed interviews were analysed using qualitative content analysis. The COREQ checklist was applied.

RESULTS

An overarching theme was established: "Using one's nursing competence and available resources for a safe outcome", based on three sub-themes: Use one's own professional and personal resources, Use resources within the organisation and Use external resources. The themes in turn consist of ten categories.

CONCLUSIONS

Registered nurses employed a range of strategies to deal with difficult calls, often in combination. They used their personal resources, resources within their own organisation, and collaboration partners to make safe triage decisions and use resources wisely. The effectiveness of these strategies, however, remains unknown. When registered nurses were unable to rule out a high-acuity condition, they used safety-netting and sent an ambulance. Evaluating current strategies and making strategies explicit could further improve the ability of nurses to handle difficult calls.

RELEVANCE TO CLINICAL PRACTICE

The strategies described by registered nurses for handling difficult calls to EMDCs included using a consecutive set of strategies. Some of the strategies seemed to be used deliberately, while others seemed tacit and applied in a routinised way. These strategies could potentially be useful for RNs working with telephone triage in different contexts.

The perspectives of Swedish registered nurses about managing difficult calls to emergency medical dispatch centres: a qualitative descriptive study

Background

Telephone triage at emergency medical dispatch centres is often challenging for registered nurses due to lack of visual cues, lack of knowledge about the patient, and time pressure – and making the right decision can be a matter of life and death. Some calls may be more difficult to handle, and more knowledge is needed about these calls to develop education and coping strategies. Therefore, the aim of this study was to describe the perspectives of registered nurses’ views about managing difficult calls to emergency medical dispatch centres.

Methods

A descriptive design with a qualitative inductive approach was used. Three dispatch centers in mid-Sweden were investigated, covering about 950,000 inhabitants and handling around 114,000 calls per year. Individual interviews were carried out with a purposeful sample of 24 registered nurses. Systematic text condensation was conducted.

Results

Seven themes were generated: calls with communication barriers, calls from agitated or rude callers, calls about psychiatric illness, calls from third parties, calls about rare or unclear situations, calls with unknown addresses and calls regarding immediate life-threatening conditions. There was a strong consensus among the registered nurses about which calls were experienced as difficult, with the exception of calls about immediate life-threatening conditions. Some registered nurses thought calls about immediate life-threatening conditions were easy to handle as they simply adhered to protocol, while others described these calls as difficult and were emotionally affected.

Conclusion

The registered nurses’ descriptions of difficult calls focused on the callers, while their own role, the organisational framework, and leadership were not mentioned. Many types of calls included difficulties, which could be related to the caller, their symptoms, or different circumstances. The registered nurses pointed to language barriers and rude, agitated callers as increasing problems. An investigation of actual emergency calls is warranted to examine the extent and nature of such calls.

"A catalyst for action": Factors for implementing clinical risk prediction models of infection in home care settings

OBJECTIVE

The study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow.

MATERIALS AND METHODS

This was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses' perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis.

RESULTS

Two themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings.

DISCUSSION

The findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action.

CONCLUSIONS

It is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.

Clinical Decision Support Systems for Pressure Ulcer Management: Systematic Review

BACKGROUND

The clinical decision-making process in pressure ulcer management is complex, and its quality depends on both the nurse's experience and the availability of scientific knowledge. This process should follow evidence-based practices incorporating health information technologies to assist health care professionals, such as the use of clinical decision support systems. These systems, in addition to increasing the quality of care provided, can reduce errors and costs in health care. However, the widespread use of clinical decision support systems still has limited evidence, indicating the need to identify and evaluate its effects on nursing clinical practice.

OBJECTIVE

The goal of the review was to identify the effects of nurses using clinical decision support systems on clinical decision making for pressure ulcer management.

METHODS

The systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. The search was conducted in April 2019 on 5 electronic databases: MEDLINE, SCOPUS, Web of Science, Cochrane, and CINAHL, without publication date or study design restrictions. Articles that addressed the use of computerized clinical decision support systems in pressure ulcer care applied in clinical practice were included. The reference lists of eligible articles were searched manually. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies.

RESULTS

The search strategy resulted in 998 articles, 16 of which were included. The year of publication ranged from 1995 to 2017, with 45% of studies conducted in the United States. Most addressed the use of clinical decision support systems by nurses in pressure ulcers prevention in inpatient units. All studies described knowledge-based systems that assessed the effects on clinical decision making, clinical effects secondary to clinical decision support system use, or factors that influenced the use or intention to use clinical decision support systems by health professionals and the success of their implementation in nursing practice.

CONCLUSIONS

The evidence in the available literature about the effects of clinical decision support systems (used by nurses) on decision making for pressure ulcer prevention and treatment is still insufficient. No significant effects were found on nurses' knowledge following the integration of clinical decision support systems into the workflow, with assessments made for a brief period of up to 6 months. Clinical effects, such as outcomes in the incidence and prevalence of pressure ulcers, remain limited in the studies, and most found clinically but nonstatistically significant results in decreasing pressure ulcers. It is necessary to carry out studies that prioritize better adoption and interaction of nurses with clinical decision support systems, as well as studies with a representative sample of health care professionals, randomized study designs, and application of assessment instruments appropriate to the professional and institutional profile. In addition, long-term follow-up is necessary to assess the effects of clinical decision support systems that can demonstrate a more real, measurable, and significant effect on clinical decision making.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42019127663; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=127663.

An overview of clinical decision support systems: benefits, risks, and strategies for success

Computerized clinical decision support systems, or CDSS, represent a paradigm shift in healthcare today. CDSS are used to augment clinicians in their complex decision-making processes. Since their first use in the 1980s, CDSS have seen a rapid evolution. They are now commonly administered through electronic medical records and other computerized clinical workflows, which has been facilitated by increasing global adoption of electronic medical records with advanced capabilities. Despite these advances, there remain unknowns regarding the effect CDSS have on the providers who use them, patient outcomes, and costs. There have been numerous published examples in the past decade(s) of CDSS success stories, but notable setbacks have also shown us that CDSS are not without risks. In this paper, we provide a state-of-the-art overview on the use of clinical decision support systems in medicine, including the different types, current use cases with proven efficacy, common pitfalls, and potential harms. We conclude with evidence-based recommendations for minimizing risk in CDSS design, implementation, evaluation, and maintenance.

Telephone nurses' use of a decision support system: An observational study

Telephone nurses give advice and support and make assessments based on verbal communication only. Web-based decision support systems are often used to increase patient safety and make medically correct assessments. The aim of the present this study was to describe factors affecting the use of a decision support system and experiences with this system among telephone nurses in Swedish primary health care. Observations and semistructured interviews were conducted. Six registered nurses with at least 1 year of experience of telephone nursing participated. Field notes and interviews were analyzed by qualitative content analysis. The main findings of the present this study were factors that decrease the decision support system use or promote deviation from decision support system use, factors that are positive for decision support system use and the decision support system complicates the work. Underuse and deviations from decision support systems can be a safety risk, because decisions are based on too little information. Further research with observations of telephone nurses' use of decision support systems is needed to develop both telephone nursing and decision support systems.

What maximizes the effectiveness and implementation of technology-based interventions to support healthcare professional practice? A systematic literature review

Background

Technological support may be crucial in optimizing healthcare professional practice and improving patient outcomes. A focus on electronic health records has left other technological supports relatively neglected. Additionally, there has been no comparison between different types of technology-based interventions, and the importance of delivery setting on the implementation of technology-based interventions to change professional practice. Consequently, there is a need to synthesise and examine intervention characteristics using a methodology suited to identifying important features of effective interventions, and the barriers and facilitators to implementation. Three aims were addressed: to identify interventions with a technological component that are successful at changing professional practice, to determine if and how such interventions are theory-based, and to examine barriers and facilitators to successful implementation.

Methods

A literature review informed by realist review methods was conducted involving a systematic search of studies reporting either: (1) behavior change interventions that included technology to support professional practice change; or (2) barriers and facilitators to implementation of technological interventions. Extracted data was quantitative and qualitative, and included setting, target professionals, and use of Behaviour Change Techniques (BCTs). The primary outcome was a change in professional practice. A thematic analysis was conducted on studies reporting barriers and facilitators of implementation.

Results

Sixty-nine studies met the inclusion criteria; 48 (27 randomized controlled trials) reported behavior change interventions and 21 reported practicalities of implementation. The most successful technological intervention was decision support providing healthcare professionals with knowledge and/or person-specific information to assist with patient management. Successful technologies were more likely to operationalise BCTs, particularly “instruction on how to perform the behavior”. Facilitators of implementation included aligning studies with organisational initiatives, ensuring senior peer endorsement, and integration into clinical workload. Barriers included organisational challenges, and design, content and technical issues of technology-based interventions.

Conclusions

Technological interventions must focus on providing decision support for clinical practice using recognized behavior change techniques. Interventions must consider organizational context, clinical workload, and have clearly defined benefits for improving practice and patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0661-3) contains supplementary material, which is available to authorized users.

Acceptability of Clinical Decision Support Interface Prototypes for a Nursing Electronic Health Record to Facilitate Supportive Care Outcomes

PURPOSE

To determine the acceptability, usefulness, and ease of use for four nursing clinical decision support interface prototypes.

METHODS

In a simulated hospital environment, 60 registered nurses (48 female; mean age = 33.7 ± 10.8; mean years of experience = 8.1 ± 9.7) participated in a randomized study with four study groups. Measures included acceptability, usefulness, and ease of use scales.

FINDINGS

Mean scores were high for acceptability, usefulness, and the ease of use for all four groups. Inexperienced participants (<1 year) reported higher perceived ease of use (p = .05) and perceived usefulness (p = .01) than those with experience of 1 year or more.

CONCLUSIONS

Participants completed the protocol and reported that all four interfaces, including the control (HANDS), were acceptable, easy to use, and useful.

IMPLICATIONS FOR NURSING KNOWLEDGE

Further study is warranted before clinical implementation within the electronic health record.

Perceived added value of a decision support App for formal caregivers in community-based dementia care

Aims and objectives

To gain insight into the perceived added value of a decision support App for district nurses and case managers intended to support a problem assessment and the provision of advices on possible solutions to facilitate ageing in place of people with dementia, and to investigate how they would implement the App in daily practice.

Background

District nurses and case managers play an important role in facilitating ageing in place of people with dementia (PwD). Detecting practical problems preventing PwD from living at home and advising on possible solutions is complex and challenging tasks for nurses and case managers. To support them with these tasks, a decision support App was developed.

Methods

A qualitative study using semi‐structured interviews was conducted. A photo‐elicitation method and an interview guide were used to structure the interviews. The data were analysed according to the principles of content analysis.

Results

In five interviews with seven district nurses and case managers, the added value was described in terms of five themes: (a) providing a broader/better overview of possible solutions; (b) providing a guideline/checklist for problem assessment and advice on solutions; (c) supporting an in‐depth problem assessment; (d) being a support tool for unexperienced case managers/district nurses; and (e) providing up‐to‐date information. The participants regarded the App as complementary to their current work procedure, which they would use in a flexible manner at different stages in the care continuum.

Conclusions

The participants valued both parts, the problem assessment and the overview of possible solutions. An important requisite for the usage would be that the content is continuously updated. Before implementation of the App can be recommended, an evaluation of its effectiveness regarding decision‐making should be conducted.

Relevance to clinical practice

This study underpins the need of nurses and case managers for decision support with regard to problem assessment and providing advices on possible solutions to facilitate ageing in place of PwD. There results also show the importance of listening to users experience and their perceived added value of decision support tools as this helps to explain the lack of statistically significant effects on quantitative outcome measure in contrast to a high willingness to use the App in a previous study.

Implementation and use of computerised clinical decision support (CCDS) in emergency pre-hospital care: a qualitative study of paramedic views and experience using Strong Structuration Theory

BACKGROUND

Computerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics' experience of the CCDS intervention and to identify factors affecting its implementation and use.

METHODS

We invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis.

RESULTS

Twenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were 'suitable' and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support.

CONCLUSION

Implementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective.

TRIAL REGISTRATION

ISRCTN Registry 10538608 . Registered 1 May 2007. Retrospectively registered.

Advancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD - an ethnographic study

Background

Telemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses’ reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses’ clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated.

Methods

In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis.

Results

When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: “the process of telemedicine nurses’ reasoning to assess health change” and “the influence of the telemedicine setting on nurses’ reasoning and decision-making processes”. An overall theme, termed “advancing beyond the system”, represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses’ clinical reasoning process.

Conclusion

In the telemedicine setting, when supported by a computerised decision support system, nurses’ reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses’ reasoning process. Nurses’ reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses’ reasoning process.

Exploring nurses’ reactions to electronic nursing documentation at the point of care

Purpose

The purpose of this paper is to investigate nurses’ attitudes, perceptions, and reactions to a new point-of-care information system for documenting nursing care.

Design/methodology/approach

A design science research methodology (DSRM) was used to examine the feasibility and usability of a novel nursing informatics solution in the context of acute hospital care. Data were collected using focus groups and non-participant observations. Analyses were guided by the theoretical lens of actor-network theory (ANT).

Findings

The findings unpack an understanding of the potential value of a new technology, rather than a binary understanding of positive or negative value. Using the ANT lens, the study reveals the dynamics of the nurse-technology relationships and consequent disruptions throughout the translation process. The findings highlight the central role of negotiation in the socio-technical construction of the hybrid actor-network during the implementation of new technology in acute hospital contexts.

Research limitations/implications

Further studies are needed to investigate the dynamics and complexity of the translation process that occurs during technology adoption, reactions of the involved actors to the emerging network and impacts on their role and work process.

Practical implications

Engaging nurses early during development and testing; aligning the new system’s functionality and interface with nurses’ interests and work practices; and supporting changes to clinical work process to enable an effective heterogeneous actor-network to emerge and become stable.

Originality/value

This study presents a novel use of ANT in a DSRM to understand an enterprise-wide system involving nurses and real clinical settings. The emerged actor-network provides insights into the translation process when nurses adapt to using new technology in their work.

Toward Meaningful Care Plan Clinical Decision Support: Feasibility and Effects of a Simulated Pilot Study

BACKGROUND

Clinical decision support (CDS) tools-with easily understood and actionable information, at the point of care-are needed to help registered nurses (RNs) make evidence-based decisions. Not clear are the optimal formats of CDS tools. Thorough, preclinical testing is desirable to avoid costly errors associated with premature implementation in electronic health records.

OBJECTIVE

The aims of this study were to determine feasibility of the protocol designed to compare multiple CDS formats and evaluate effects of numeracy and graph literacy on RN adoption of best practices and care planning time in a simulated environment.

METHODS

In this pilot study, 60 RNs were randomly assigned to one of four CDS conditions (control, text, text + graph, and text + table) and asked to adjust the plan of care for two patient scenarios over three shifts. Fourteen best practices were identified for the two patients and sent as suggestions with evidence to the three CDS groups. Best practice adoption rates, care planning time, and their relationship to the RN's numeracy and graph literacy scores were assessed.

RESULTS

CDS groups had a higher adoption rate of best practices (p < .001) across all shifts and decreased care planning time in shifts 2 (p = .01) and 3 (p = .02) compared with the control group. Higher numeracy and graph literacy were associated with shorter care planning times under text + table (p = .05) and text + graph (p = .01) conditions. No significant differences were found between the three CDS groups on adoption rate and care planning time.

DISCUSSION

This pilot study shows the feasibility of our protocol. Findings show preliminary evidence that CDS improves the efficiency and effectiveness of care planning decisions and that the optimal format may depend on individual RN characteristics. We recommend a study with sufficient power to compare different CDS formats and assess the impact of potential covariates on adoption rates and care planning time.

Telephone counselling by nurses in Norwegian primary care out-of-hours services: a cross-sectional study

Background

The primary care out-of-hours (OOH) services in Norway are characterized by high contact rates by telephone. The telephone contacts are handled by local emergency medical communication centres (LEMCs), mainly staffed by registered nurses. When assessment by a medical doctor is not required, the nurse often handles the contact solely by nurse telephone counselling. Little is known about this group of contacts. Thus, the aim of this study was to investigate characteristics of encounters with the OOH services that are handled solely by nurse telephone counselling.

Methods

Nurses recorded ICPC-2 reason for encounter (RFE) codes and patient characteristics of all patients who contacted six primary care OOH services in Norway during 2014. Descriptive statistics and frequency analyses were applied.

Results

Of all telephone contacts (n = 61,441), 23% were handled solely by nurse counselling. Fever was the RFE most frequently handled (7.3% of all nurse advice), followed by abdominal pain, cough, ear pain and general symptoms. Among the youngest patients, 32% of the total telephone contacts were resolved by nurse advice compared with 17% in the oldest age group. At night, 31% of the total telephone contacts were resolved solely by nurse advice compared with 21% during the day shift and 23% in the evening. The share of nurse advice was higher on weekdays compared to weekends (mean share 25% versus 20% respectively).

Conclusion

This study shows that nurses make a significant contribution to patient management in the Norwegian OOH services. The findings indicate which conditions nurses should be able to handle by telephone, which has implications for training and routines in the LEMCs. There is the potential for more nurse involvement in several of the RFEs with a currently low share of nurse counselling.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0651-z) contains supplementary material, which is available to authorized users.

Beyond guidelines: discretionary practice in face-to-face triage nursing

This article draws on ethnographic data from a Norwegian emergency primary care clinic (EPCC) to explore nurses' discretionary application of guidelines. Specifically, it analyses nurses' discretionary use of the Manchester Triage System (MTS) when performing face-to-face triage, that is, assessing the urgency of patients' complaints. The analysis shows how nurses assessed patients at odds with MTS prescriptions by collecting supplementary data, engaging in differential diagnostic and holistic reasoning, relying on emotion and intuition, and allowing colleagues and patients to influence their reasoning. The findings also show how nurses' reasoning led them to override guidelines both overtly and covertly. Based on this evidence, it is argued that nurses' assessments relied more on internalised 'triage mindlines' than on codified triage guidelines, although the MTS did function as a support system, checklist and system for supervisory control. The study complements existing research on standardisation in nursing by providing an in-depth analysis of nurses' methods for navigating guidelines and by detailing how deviations from those guidelines spring from their clinical reasoning. The challenges of imposing a managerial logic on professional labour are also highlighted, which is of particular relevance in light of the drive towards standardisation in modern healthcare.

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

Background

The implementation of robot-assisted surgery (RAS) can be challenging, with reports of surgical robots being underused. This raises questions about differences compared with open and laparoscopic surgery and how best to integrate RAS into practice.

Objectives

To (1) contribute to reporting of the ROLARR (RObotic versus LAparoscopic Resection for Rectal cancer) trial, by investigating how variations in the implementation of RAS and the context impact outcomes; (2) produce guidance on factors likely to facilitate successful implementation; (3) produce guidance on how to ensure effective teamwork; and (4) provide data to inform the development of tools for RAS.

Design

Realist process evaluation alongside ROLARR. Phase 1 – a literature review identified theories concerning how RAS becomes embedded into practice and impacts on teamwork and decision-making. These were refined through interviews across nine NHS trusts with theatre teams. Phase 2 – a multisite case study was conducted across four trusts to test the theories. Data were collected using observation, video recording, interviews and questionnaires. Phase 3 – interviews were conducted in other surgical disciplines to assess the generalisability of the findings.

Findings

The introduction of RAS is surgeon led but dependent on support at multiple levels. There is significant variation in the training provided to theatre teams. Contextual factors supporting the integration of RAS include the provision of whole-team training, the presence of handpicked dedicated teams and the availability of suitably sized operating theatres. RAS introduces challenges for teamwork that can impact operation duration, but, over time, teams develop strategies to overcome these challenges. Working with an experienced assistant supports teamwork, but experience of the procedure is insufficient for competence in RAS and experienced scrub practitioners are important in supporting inexperienced assistants. RAS can result in reduced distraction and increased concentration for the surgeon when he or she is supported by an experienced assistant or scrub practitioner.

Conclusions

Our research suggests a need to pay greater attention to the training and skill mix of the team. To support effective teamwork, our research suggests that it is beneficial for surgeons to (1) encourage the team to communicate actions and concerns; (2) alert the attention of the assistant before issuing a request; and (3) acknowledge the scrub practitioner’s role in supporting inexperienced assistants. It is beneficial for the team to provide oral responses to the surgeon’s requests.

Limitations

This study started after the trial, limiting impact on analysis of the trial. The small number of operations observed may mean that less frequent impacts of RAS were missed.

Future work

Future research should include (1) exploring the transferability of guidance for effective teamwork to other surgical domains in which technology leads to the physical or perceptual separation of surgeon and team; (2) exploring the benefits and challenges of including realist methods in feasibility and pilot studies; (3) assessing the feasibility of using routine data to understand the impact of RAS on rare end points associated with patient safety; (4) developing and evaluating methods for whole-team training; and (5) evaluating the impact of different physical configurations of the robotic console and team members on teamwork.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A Systematic Review of Nurses' Experiences With Unintended Consequences When Using the Electronic Health Record

In response to unprecedented financial government incentives, electronic health record (EHR) adoption has tripled since 2009. While EHR benefits are emphasized, research demonstrates that adoption may result in unintended consequences that nurse administrators can anticipate and mitigate. Unintended consequences are defined as unplanned effects, whether positive or negative. Little is known about nursing perceptions and experience of unintended consequences arising from EHR implementation, and nursing studies are minimal in comparison with research on experience among their interprofessional colleagues. The purpose of this article is to present the state of the science on nurses' experiences with unintended consequences of EHRs derived from a systematic review that includes 4 original studies. Findings demonstrate that nurses experience changes to workflow, must continually adapt to meet patient's needs in the context of imperfect EHR systems, and have difficulty accessing the information they need to make patient care decisions. Even so, most state they would not revert to paper records if given the choice. Implications for nurse administrators include the need for continual engagement with nurses along the continuum of EHR design, as well as the need to encourage nurses to speak up and acknowledge workflow changes that threaten patient safety or do not support work efficiency.

Use of Simulation to Study Nurses' Acceptance and Nonacceptance of Clinical Decision Support Suggestions

Our long-term goal was to ensure nurse clinical decision support works as intended before full deployment in clinical practice. As part of a broader effort, this pilot project explored factors influencing acceptance/nonacceptance of eight clinical decision support suggestions displayed in an electronic health record-based nursing plan of care software prototype. A diverse sample of 21 nurses participated in this high-fidelity clinical simulation experience and completed a questionnaire to assess reasons for accepting/not accepting the clinical decision support suggestions. Of 168 total suggestions displayed during the experiment (eight for each of the 21 nurses), 123 (73.2%) were accepted, and 45 (26.8%) were not accepted. The mode number of acceptances by nurses was seven of eight, with only two of 21 nurses accepting all. The main reason for clinical decision support acceptance was the nurse's belief that the suggestions were good for the patient (100%), with other features providing secondary reinforcement. Reasons for nonacceptance were less clear, with fewer than half of the subjects indicating low confidence in the evidence. This study provides preliminary evidence that high-quality simulation and targeted questionnaires about specific clinical decision support selections offer a cost-effective means for testing before full deployment in clinical practice.

Applying artificial intelligence technology to support decision-making in nursing: A case study in Taiwan

This study applied artificial intelligence to help nurses address problems and receive instructions through information technology. Nurses make diagnoses according to professional knowledge, clinical experience, and even instinct. Without comprehensive knowledge and thinking, diagnostic accuracy can be compromised and decisions may be delayed. We used a back-propagation neural network and other tools for data mining and statistical analysis. We further compared the prediction accuracy of the previous methods with an adaptive-network-based fuzzy inference system and the back-propagation neural network, identifying differences in the questions and in nurse satisfaction levels before and after using the nursing information system. This study investigated the use of artificial intelligence to generate nursing diagnoses. The percentage of agreement between diagnoses suggested by the information system and those made by nurses was as much as 87 percent. When patients are hospitalized, we can calculate the probability of various nursing diagnoses based on certain characteristics.

The effects of intervention on quality of telephone triage at an emergency unit in Finland: Nurses' perspective

AIMS AND OBJECTIVES

The aim of this study was to investigate the effects of a nurse training intervention on the assessment of patients' care needs in telephone triage at an emergency unit. The objective of this study was to generate information about nurse training that can be utilized when developing telephone triage and health care education.

BACKGROUND

With the growing number of patients coming into emergency departments and a lack of resources in healthcare, it would be valuable to determine an effective training intervention in telephone triage, particularly when assessing the training needs of nurses.

DESIGN

The study was quasi-experimental, with a pre- and post-test design.

METHODS

The data were collected from the nurses at the emergency department and joint emergency service of the Central Hospital in Northern Finland (baseline n = 28, post-test n = 26). The descriptive statistic, Fisher's χ(2) test and McNemar's test were used to analyse the data.

RESULTS

The intervention improved nurses' skills to evaluate patients' needs and health condition via the telephone triage. There was a statistically significant difference in the resources, knowledge, skills and attitudes of the nurses between the baseline and post-test measurements.

CONCLUSIONS

The nurse training intervention improved the quality of telephone triage.

RELEVANCE TO CLINICAL PRACTICE

Nurses should receive continuous training in telephone triage in order to maintain and reinforce their professional competence. When planning the training, the age and relevant work experience of the nurses should be taken into consideration as well, since the results indicate that they lead to variation in the nurses' competence.

Integrating computerized clinical decision support systems into clinical work: A meta-synthesis of qualitative research

PURPOSE

Computerized clinical decision support systems (CDSS) are an emerging means for improving healthcare safety, quality and efficiency, but meta-analyses findings are mixed. This meta-synthesis aggregates qualitative research findings as possible explanations for variable quantitative research outcomes.

INCLUSION CRITERIA

Qualitative studies published between 2000 and 2013 in English, involving physicians, registered and advanced practice nurses' experience of CDSS use in clinical practice were included.

SEARCH STRATEGY

PubMed and CINAHL databases were searched. Study titles and abstracts were screened against inclusion criteria. Retained studies were appraised against quality criteria. Findings were extracted iteratively from studies in the 4th quartile of quality scores. Two reviewers constructed themes inductively. A third reviewer applied the defined themes deductively achieving 92% agreement.

RESULTS

3798 unique records were returned; 56 met inclusion criteria and were reviewed against quality criteria. 9 studies were of sufficiently high quality for synthetic analysis. Five major themes (clinician-patient-system integration; user interface usability; the need for better 'algorithms'; system maturity; patient safety) were defined.

CONCLUSIONS

Despite ongoing development, CDSS remains an emerging technology. Lack of understanding about and lack of consideration for the interaction between human decision makers and CDSS is a major reason for poor system adoption and use. Further high-quality qualitative research is needed to better understand human-system interaction issues. These issues may continue to confound quantitative study results if not addressed.

Feasibility and impact of a computerised clinical decision support system on investigation and initial management of new onset chest pain: a mixed methods study

BACKGROUND

Clinical decision support systems (CDSS) can modify clinician behaviour, yet the factors influencing their effect remain poorly understood. This study assesses the feasibility and acceptability of a CDSS supporting diagnostic and treatment decisions for patients with suspected stable angina.

METHODS

Intervention The Optimising Management of Angina (OMA) programme includes a CDSS guiding investigation and medication decisions for clinicians managing patients with new onset stable angina, based on English national guidelines, introduced through an educational intervention. Design and participants A mixed methods study i. A study of outcomes among patients presenting with suspected angina in three chest pain clinics in England before and after introduction of the OMA programme. ii. Observations of clinic processes, interviews and a focus group with health professionals at two chest pain clinics after delivery of the OMA programme.

OUTCOMES

Medication and cardiovascular imaging investigations undertaken within six months of presentation, and concordance of these with the recommendations of the CDSS. Thematic analysis of qualitative data to understand how the CDSS was used.

RESULTS

Data were analysed for 285 patients attending chest pain clinics: 106 before and 179 after delivery of the OMA programme. 40 consultations were observed, 5 clinicians interviewed, and a focus group held after the intervention. The proportion of patients appropriate for diagnostic investigation who received one was 50 % (95 CI 34-66 %) of those before OMA and 59 % (95 CI 48-70 %) of those after OMA. Despite high use of the CDSS (84 % of consultations), observations and interviews revealed difficulty with data entry into the CDSS, and structural and practical barriers to its use. In the majority of cases the CDSS was not used to guide real-time decision making, only being consulted after the patient had left the room.

CONCLUSIONS

The OMA CDSS for the management of chest pain is not feasible in its current form. The CDSS was not used to support decisions about the care of individual patients. A range of barriers to the use of the CDSS were identified, some are easily removed, such as insufficient capture of cardiovascular risk, while others are more deeply embedded in current practice, such as unavailability of some investigations or no prescribing privileges for nurses.

Development and Implementation of the Clinical Decision Support System for Patients With Cancer and Nurses' Experiences Regarding the System

PURPOSE

The purpose of this study was to develop and implement the clinical decision support system (CDSS) for oncology nurses in the care of patients with cancer and to explore the nurses' experiences about the system.

METHODS

The study was conducted using a mixed-methods research design with 14 nurses working at a gynecological oncology clinic at a university hospital in Turkey.

FINDINGS

The nurses stated that they did not experience any problems during the implementation of the CDSS, and its usage facilitated the assessment of patients' needs and care management.

CONCLUSIONS

The results indicated that the CDSS supported the nurses' decision-making process about patients' needs and preparation of individual care plans.

PRACTICE IMPLICATIONS

The CDSS should be developed and implemented by the nurses working with patients with cancer. AMAÇ: Amaç kanser hastalarının bakımına yönelik klinik karar destek sistemi oluşturmak, uygulamak (KKDS) ve sistemi kullanan hemşirelerin deneyimlerini incelemektir. YÖNTEM: Çalışma kalitatif ve kantitatif araştırma yöntemleri kullanılarak Türkiyede'ki bir üniversite hastanesinin jinekolojik onkoloji servisinde çalışan 14 hemşire ile yürütülmüştür.

BULGULAR

Hemşireler KKDS'ni kullanırken herhangi bir sorun yaşamadıklarını ve sistemin hasta gereksinimlerini değerlendirmeyi ve bakım yönetimini kolaylaştırdığını belirtmişlerdir. SONUÇ: Bulgular hastanın gereksinimlerine karar verme sürecinde ve bireysel bakım planları hazırlamada KKDS'nin hemşireleri desteklediğini göstermektedir. HEMŞIRELIK UYGULAMALARI IÇIN ÖNERILER: Kanserli hastaların bakımına yönelik KKDS geliştirilebilir ve hemşireler tarafından klinikte kullanılabilir.

A comparison of calls subjected to a malpractice claim versus 'normal calls' within the Swedish healthcare direct: a case-control study

OBJECTIVES

The purpose of this study is to compare communication patterns in calls subjected to a malpractice claim with matched controls.

SETTING

In many countries, telephone advice nursing is patients' first contact with healthcare. Telenurses' assessment of callers' symptoms and needs are based on verbal communication only, and problems with over-triage and under-triage have been reported.

PARTICIPANTS

A total sample of all reported medical errors (n=33) during the period 2003-2010 within Swedish Healthcare Direct was retrieved. Corresponding calls were thereafter identified and collected as sound files from the manager in charge at the respective call centres. For technical reasons, calls from four of the cases were not possible to retrieve. For the present study, matched control calls (n=26) based on the patient's age, gender and main symptom presented by the caller were collected.

RESULTS

Male patients were in majority (n=16), and the most common reasons for calling were abdominal pain (n=10) and chest pain (n=5). There were statistically significant differences between the communication in the cases and controls: telenurses used fewer open-ended medical questions (p<0.001) in the cases compared to the control calls; callers provided telenurses with more medical information in the control calls compared to the cases (p=0.001); and telenurses used more facilitation and patient activation activities in the control calls (p=0.034), such as back-channel response (p=0.001), compared to the cases.

CONCLUSIONS

The present study shows that telenurses in malpractice claimed calls used more closed-ended questioning compared to those in control calls, who used more open-ended questioning and back-channel response, which provided them with richer medical descriptions and more information from the caller. Hence, these communicative techniques are important in addition to solid medical and nursing competence and sound decision aid systems.

Nurses' use of an integrated electronic health record: results of a case site analysis

PURPOSE

To explore how nurses use an integrated Electronic Health Record (EHR) in practice.

METHODS

A multi-site case study across two hospitals in Kaiser Permanente Northern California. Non-participant observation was used to explore nurses' use of the EHR, while semi-structured interviews with nurses and managers explored their perceptions of the EHR and how it affected their practice. Data were analyzed thematically using codes derived deductively from the literature and inductively from the data.

RESULTS

Key themes arising from the analysis suggest that the EHR changed various elements of the way nurses practiced. Introducing the EHR was thought to have improved communication, ease of access to information and the safety of medication administration processes. At an organizational level, there was variability in how the EHR was used to support care documentation and initiatives to improve the quality of care provided by nurses.

CONCLUSION

The EHR was perceived to improve efficiency, safety and communication by the majority of nurses who were interviewed. However, it is likely that a number of other factors such as individual nurse's characteristics and organizational culture influence how an EHR can be used effectively to improve outcomes for patients.

Evaluation of user interface and workflow design of a bedside nursing clinical decision support system

Background

Clinical decision support systems (CDSS) are important tools to improve health care outcomes and reduce preventable medical adverse events. However, the effectiveness and success of CDSS depend on their implementation context and usability in complex health care settings. As a result, usability design and validation, especially in real world clinical settings, are crucial aspects of successful CDSS implementations.

Objective

Our objective was to develop a novel CDSS to help frontline nurses better manage critical symptom changes in hospitalized patients, hence reducing preventable failure to rescue cases. A robust user interface and implementation strategy that fit into existing workflows was key for the success of the CDSS.

Methods

Guided by a formal usability evaluation framework, UFuRT (user, function, representation, and task analysis), we developed a high-level specification of the product that captures key usability requirements and is flexible to implement. We interviewed users of the proposed CDSS to identify requirements, listed functions, and operations the system must perform. We then designed visual and workflow representations of the product to perform the operations. The user interface and workflow design were evaluated via heuristic and end user performance evaluation. The heuristic evaluation was done after the first prototype, and its results were incorporated into the product before the end user evaluation was conducted. First, we recruited 4 evaluators with strong domain expertise to study the initial prototype. Heuristic violations were coded and rated for severity. Second, after development of the system, we assembled a panel of nurses, consisting of 3 licensed vocational nurses and 7 registered nurses, to evaluate the user interface and workflow via simulated use cases. We recorded whether each session was successfully completed and its completion time. Each nurse was asked to use the National Aeronautics and Space Administration (NASA) Task Load Index to self-evaluate the amount of cognitive and physical burden associated with using the device.

Results

A total of 83 heuristic violations were identified in the studies. The distribution of the heuristic violations and their average severity are reported. The nurse evaluators successfully completed all 30 sessions of the performance evaluations. All nurses were able to use the device after a single training session. On average, the nurses took 111 seconds (SD 30 seconds) to complete the simulated task. The NASA Task Load Index results indicated that the work overhead on the nurses was low. In fact, most of the burden measures were consistent with zero. The only potentially significant burden was temporal demand, which was consistent with the primary use case of the tool.

Conclusions

The evaluation has shown that our design was functional and met the requirements demanded by the nurses’ tight schedules and heavy workloads. The user interface embedded in the tool provided compelling utility to the nurse with minimal distraction.

Phase II Practice-based Evidence in Nutrition (PEN) evaluation: interviews with key informants

PURPOSE

Dietitians of Canada has collaborated with experts in knowledge translation and transfer, technology, and dietetic practice to develop and implement an innovative online decision-support system called Practice-based Evidence in Nutrition (PEN). A study was conducted to evaluate the perceived facilitators and barriers that enable dietitians to use or prevent them from using PEN.

METHODS

As part of the overall evaluation framework of PEN, a qualitative descriptive research design was used to address the research purpose. Individual, semi-structured telephone interviews with 17 key informants were completed, and the interview transcripts underwent qualitative content analysis.

RESULTS

Respondents identified several facilitators of and barriers to PEN use. Facilitators included specificity to dietetics, rigorous/expert review, easy accessibility, current content, credible/secure material, well-organized/easy-to-use material, material that is valuable to practice, and good value for money. Barriers included perceived high cost, fee structuring/cost to students, certain organizational aspects, and a perceived lack of training for pathway contributors.

CONCLUSIONS

This formative evaluation has indicated areas in which PEN could be improved and strategies to make PEN the standard for dietetic education and practice. Ensuring that PEN is meeting users' knowledge needs is of the utmost importance if dietitians are to remain on the cutting edge of scientific inquiry.

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

OBJECTIVES

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.

DESIGN

Interrupted time series analysis, 2003-2009.

SETTING

A large US not-for-profit integrated health care organization.

PARTICIPANTS

29 hospitals in Northern and Southern California.

INTERVENTION

An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.

MAIN OUTCOME MEASURES

Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).

RESULTS

EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).

CONCLUSIONS

The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.