electronic nursing documentation: Topics by Science.gov

Sample records for electronic nursing documentation

The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study.

PubMed

Wang, Ning; Yu, Ping; Hailey, David

2015-08-01

The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated. To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans. A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study. There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes. The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
The Storied Experiences of Registered Nurses' Transition from Paper to Electronic Nursing Documentation

ERIC Educational Resources Information Center

Smith, Jeff S.

2010-01-01

This narrative inquiry was designed to bring to life the storied experiences of registered nurses who have transitioned from paper to electronic nursing documentation and to provide a foundation for others who may be preparing to implement electronic documentation and wish to consider the significance of these nurses' stories of change in their…
Improving the Quality of Electronic Documentation in Critical Care Nursing

ERIC Educational Resources Information Center

Stevens, Brent

2017-01-01

Electronic nursing documentation systems can facilitate complete, accurate, timely documentation practices, but without effective policies and procedures in place, a gap in practice exists and quality of care may be impacted. This systematic review of literature examined current evidence regarding electronic nursing documentation quality. General…
Implementation of standardized nomenclature in the electronic medical record.

PubMed

Klehr, Joan; Hafner, Jennifer; Spelz, Leah Mylrea; Steen, Sara; Weaver, Kathy

2009-01-01

To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation.
Quality of nursing documentation: Paper-based health records versus electronic-based health records.

PubMed

Akhu-Zaheya, Laila; Al-Maaitah, Rowaida; Bany Hani, Salam

2018-02-01

To assess and compare the quality of paper-based and electronic-based health records. The comparison examined three criteria: content, documentation process and structure. Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organised within the system known as the electronic health records. Nursing documentation must be completed at the highest standards, to ensure the safety and quality of healthcare services. However, the evidence is not clear on which one of the two forms of documentation (paper-based versus electronic health records is more qualified. A retrospective, descriptive, comparative design was used to address the study's purposes. A convenient number of patients' records, from two public hospitals, were audited using the Cat-ch-Ing audit instrument. The sample size consisted of 434 records for both paper-based health records and electronic health records from medical and surgical wards. Electronic health records were better than paper-based health records in terms of process and structure. In terms of quantity and quality content, paper-based records were better than electronic health records. The study affirmed the poor quality of nursing documentation and lack of nurses' knowledge and skills in the nursing process and its application in both paper-based and electronic-based systems. Both forms of documentation revealed drawbacks in terms of content, process and structure. This study provided important information, which can guide policymakers and administrators in identifying effective strategies aimed at enhancing the quality of nursing documentation. Policies and actions to ensure quality nursing documentation at the national level should focus on improving nursing knowledge, competencies, practice in nursing process, enhancing the work environment and nursing workload, as well as strengthening the capacity building of nursing practice to improve the quality of nursing care and patients' outcomes. © 2017 John Wiley & Sons Ltd.
[Support of the nursing process through electronic nursing documentation systems (UEPD) – Initial validation of an instrument].

PubMed

Hediger, Hannele; Müller-Staub, Maria; Petry, Heidi

2016-01-01

Electronic nursing documentation systems, with standardized nursing terminology, are IT-based systems for recording the nursing processes. These systems have the potential to improve the documentation of the nursing process and to support nurses in care delivery. This article describes the development and initial validation of an instrument (known by its German acronym UEPD) to measure the subjectively-perceived benefits of an electronic nursing documentation system in care delivery. The validity of the UEPD was examined by means of an evaluation study carried out in an acute care hospital (n = 94 nurses) in German-speaking Switzerland. Construct validity was analyzed by principal components analysis. Initial references of validity of the UEPD could be verified. The analysis showed a stable four factor model (FS = 0.89) scoring in 25 items. All factors loaded ≥ 0.50 and the scales demonstrated high internal consistency (Cronbach's α = 0.73 – 0.90). Principal component analysis revealed four dimensions of support: establishing nursing diagnosis and goals; recording a case history/an assessment and documenting the nursing process; implementation and evaluation as well as information exchange. Further testing with larger control samples and with different electronic documentation systems are needed. Another potential direction would be to employ the UEPD in a comparison of various electronic documentation systems.
The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home.

PubMed

Munyisia, Esther N; Yu, Ping; Hailey, David

2011-02-01

To date few studies have compared nursing home caregivers' perceptions about the quality of information and benefits of nursing documentation in paper and electronic formats. With the increased interest in the use of information technology in nursing homes, it is important to obtain information on the benefits of newer approaches to nursing documentation so as to inform investment, organisational and care service decisions in the aged care sector. This study aims to investigate caregivers' perceptions about the quality of information and benefits of nursing documentation before and after the introduction of an electronic documentation system in a nursing home. A self-administered questionnaire survey was conducted three months before, and then six, 18 and 31 months after the introduction of an electronic documentation system. Further evidence was obtained through informal discussions with caregivers. Scores for questionnaire responses showed that the benefits of the electronic documentation system were perceived by the caregivers as provision of more accurate, legible and complete information, and reduction of repetition in data entry, with consequential managerial benefits. However, caregivers' perceptions of relevance and reliability of information, and of their communication and decision-making abilities were perceived to be similar either using an electronic or a paper-based documentation system. Improvement in some perceptions about the quality of information and benefits of nursing documentation was evident in the measurement conducted six months after the introduction of the electronic system, but were not maintained 18 or 31 months later. The electronic documentation system was perceived to perform better than the paper-based system in some aspects, with subsequent benefits to management of aged care services. In other areas, perceptions of additional benefits from the electronic documentation system were not maintained. In a number of attributes, there were similar perceptions on the two types of systems. Copyright Â© 2010 Elsevier Ireland Ltd. All rights reserved.
Implementation of a next-generation electronic nursing records system based on detailed clinical models and integration of clinical practice guidelines.

PubMed

Min, Yul Ha; Park, Hyeoun-Ae; Chung, Eunja; Lee, Hyunsook

2013-12-01

The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system. A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system. The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines. An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
Using an Educational Electronic Documentation System to Help Nursing Students Accurately Identify Nursing Diagnoses

ERIC Educational Resources Information Center

Pobocik, Tamara J.

2013-01-01

The use of technology and electronic medical records in healthcare has exponentially increased. This quantitative research project used a pretest/posttest design, and reviewed how an educational electronic documentation system helped nursing students to identify the accurate related to statement of the nursing diagnosis for the patient in the case…
The need for academic electronic health record systems in nurse education.

PubMed

Chung, Joohyun; Cho, Insook

2017-07-01

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. Copyright © 2017. Published by Elsevier Ltd.
The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric Intensive Care Unit.

PubMed

Panesar, Rahul S; Albert, Ben; Messina, Catherine; Parker, Margaret

2016-01-01

The Situation, Background, Assessment, Recommendation (SBAR) handoff tool is designed to improve communication. The effects of integrating an electronic medical record (EMR) with a SBAR template are unclear. The research team hypothesizes that an electronic SBAR template improves documentation and communication between nurses and physicians. In all, 84 patient events were recorded from 542 admissions to the pediatric intensive care unit. Three time periods were studied: (a) paper documentation only, (b) electronic documentation, and (c) electronic documentation with an SBAR template. Documentation quality was assessed using a 4-point scoring system. The frequency of event notes increased progressively during the 3 study periods. Mean quality scores improved significantly from paper documentation to EMR free-text notes and to electronic SBAR-template notes, as did nurse and attending physician notification. The implementation of an electronic SBAR note is associated with more complete documentation and increased frequency of documentation of communication among nurses and physicians. © The Author(s) 2014.
Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings.

PubMed

Lavin, Mary Ann; Harper, Ellen; Barr, Nancy

2015-04-14

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs. Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome electronic processes. This article describes the views of nurses shared by members of the Nursing Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR concerns with Information Technology (IT) staff and vendors and to take their place at the table when nursing-related IT decisions are made. In this article, we describe the experiential-reflective reasoning and action model used to understand staff nurses' perspectives, share committee reflections and recommendations for improving both documentation and documentation technology, and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing issues include medication safety, documentation and standards of practice, and EHR efficiency. IT concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.
Teaching home care electronic documentation skills to undergraduate nursing students.

PubMed

Nokes, Kathleen M; Aponte, Judith; Nickitas, Donna M; Mahon, Pamela Y; Rodgers, Betsy; Reyes, Nancy; Chaya, Joan; Dornbaum, Martin

2012-01-01

Although there is general consensus that nursing students need knowledge and significant skill to document clinical findings electronically, nursing faculty face many barriers in ensuring that undergraduate students can practice on electronic health record systems (EHRS). External funding supported the development of an educational innovation through a partnership between a home care agency staff and nursing faculty. Modules were developed to teach EHRS skills using a case study of a homebound person requiring wound care and the Medicare-required OASIS documentation system. This article describes the development and implementation of the module for an upper-level baccalaureate nursing program located in New York City. Nursing faculty are being challenged to develop creative and economical solutions to expose nursing students to EHRSs in nonclinical settings.
A systematic approach to baseline assessment of nursing documentation and enterprise-wide prioritization for electronic conversion.

PubMed

Dykes, Patricia C; Spurr, Cindy; Gallagher, Joan; Li, Qi; Ives Erickson, Jeanette

2006-01-01

An important challenge associated with making the transition from paper to electronic documentation systems is achieving consensus regarding priorities for electronic conversion across diverse groups. In our work we focus on applying a systematic approach to evaluating the baseline state of nursing documentation across a large healthcare system and establishing a unified vision for electronic conversion. A review of the current state of nursing documentation across PHS was conducted using structured tools. Data from this assessment was employed to facilitate an evidence-based approach to decision-making regarding conversion to electronic documentation at local and PHS levels. In this paper we present highlights of the assessment process and the outcomes of this multi-site collaboration.
Electronic Nursing Documentation: Patient Care Continuity Using the Clinical Care Classification System (CCC).

PubMed

Whittenburg, Luann; Meetim, Aunchisa

2016-01-01

An innovative nursing documentation project conducted at Bumrungrad International Hospital in Bangkok, Thailand demonstrated patient care continuity between nursing patient assessments and nursing Plans of Care using the Clinical Care Classification System (CCC). The project developed a new generation of interactive nursing Plans of Care using the six steps of the American Nurses Association (ANA) Nursing process and the MEDCIN^® clinical knowledgebase to present CCC coded concepts as a natural by-product of a nurse's documentation process. The MEDCIN^® clinical knowledgebase is a standardized point-of-care terminology intended for use in electronic health record systems. The CCC is an ANA recognized nursing terminology.
Metrics for Electronic-Nursing-Record-Based Narratives: cross-sectional analysis.

PubMed

Kim, Kidong; Jeong, Suyeon; Lee, Kyogu; Park, Hyeoun-Ae; Min, Yul Ha; Lee, Joo Yun; Kim, Yekyung; Yoo, Sooyoung; Doh, Gippeum; Ahn, Soyeon

2016-11-30

We aimed to determine the characteristics of quantitative metrics for nursing narratives documented in electronic nursing records and their association with hospital admission traits and diagnoses in a large data set not limited to specific patient events or hypotheses. We collected 135,406,873 electronic, structured coded nursing narratives from 231,494 hospital admissions of patients discharged between 2008 and 2012 at a tertiary teaching institution that routinely uses an electronic health records system. The standardized number of nursing narratives (i.e., the total number of nursing narratives divided by the length of the hospital stay) was suggested to integrate the frequency and quantity of nursing documentation. The standardized number of nursing narratives was higher for patients aged ≥ 70 years (median = 30.2 narratives/day, interquartile range [IQR] = 24.0-39.4 narratives/day), long (≥ 8 days) hospital stays (median = 34.6 narratives/day, IQR = 27.2-43.5 narratives/day), and hospital deaths (median = 59.1 narratives/day, IQR = 47.0-74.8 narratives/day). The standardized number of narratives was higher in "pregnancy, childbirth, and puerperium" (median = 46.5, IQR = 39.0-54.7) and "diseases of the circulatory system" admissions (median = 35.7, IQR = 29.0-43.4). Diverse hospital admissions can be consistently described with nursing-document-derived metrics for similar hospital admissions and diagnoses. Some areas of hospital admissions may have consistently increasing volumes of nursing documentation across years. Usability of electronic nursing document metrics for evaluating healthcare requires multiple aspects of hospital admissions to be considered.
Metrics for Electronic-Nursing-Record-Based Narratives: Cross-sectional Analysis

PubMed Central

Kim, Kidong; Jeong, Suyeon; Lee, Kyogu; Park, Hyeoun-Ae; Min, Yul Ha; Lee, Joo Yun; Kim, Yekyung; Yoo, Sooyoung; Doh, Gippeum

2016-01-01

Summary Objectives We aimed to determine the characteristics of quantitative metrics for nursing narratives documented in electronic nursing records and their association with hospital admission traits and diagnoses in a large data set not limited to specific patient events or hypotheses. Methods We collected 135,406,873 electronic, structured coded nursing narratives from 231,494 hospital admissions of patients discharged between 2008 and 2012 at a tertiary teaching institution that routinely uses an electronic health records system. The standardized number of nursing narratives (i.e., the total number of nursing narratives divided by the length of the hospital stay) was suggested to integrate the frequency and quantity of nursing documentation. Results The standardized number of nursing narratives was higher for patients aged 70 years (median = 30.2 narratives/day, interquartile range [IQR] = 24.0–39.4 narratives/day), long (8 days) hospital stays (median = 34.6 narratives/day, IQR = 27.2–43.5 narratives/day), and hospital deaths (median = 59.1 narratives/day, IQR = 47.0–74.8 narratives/day). The standardized number of narratives was higher in “pregnancy, childbirth, and puerperium” (median = 46.5, IQR = 39.0–54.7) and “diseases of the circulatory system” admissions (median = 35.7, IQR = 29.0–43.4). Conclusions Diverse hospital admissions can be consistently described with nursing-document-derived metrics for similar hospital admissions and diagnoses. Some areas of hospital admissions may have consistently increasing volumes of nursing documentation across years. Usability of electronic nursing document metrics for evaluating healthcare requires multiple aspects of hospital admissions to be considered. PMID:27901174
Interdisciplinary collaboration and the electronic medical record.

PubMed

Green, Shayla D; Thomas, Joan D

2008-01-01

To examine interdisciplinary collaboration via electronic medical records (EMRs) with a focus on physicians' perception of nursing documentation. Quality improvement project using a survey instrument. Tertiary care pediatric hospital. Thirty-seven physicians. Physicians perceptions of nursing documentation after EMR implementation Physicians desire nursing documentation with greater clarity and additional information. Physicians indicate checklists alone for patient assessment and intervention data are insufficient for effective nurse/physician collaboration. Narrative nursing summaries are invaluable references that guide medical treatment decisions. Physicians see detailed assessments and well-described interventions of nurses' as critical to their ability to effectively practice medicine. Health care technology is called to develop EMRs that enable nurses to document detailed patient data in a swift and straightforward manner. Joint collaboration between nurses, physicians, and technology specialists is recommended to develop effective EMR systems.
Testing a Nursing-Specific Model of Electronic Patient Record documentation with regard to information completeness, comprehensiveness and consistency.

PubMed

von Krogh, Gunn; Nåden, Dagfinn; Aasland, Olaf Gjerløw

2012-10-01

To present the results from the test site application of the documentation model KPO (quality assurance, problem solving and caring) designed to impact the quality of nursing information in electronic patient record (EPR). The KPO model was developed by means of consensus group and clinical testing. Four documentation arenas and eight content categories, nursing terminologies and a decision-support system were designed to impact the completeness, comprehensiveness and consistency of nursing information. The testing was performed in a pre-test/post-test time series design, three times at a one-year interval. Content analysis of nursing documentation was accomplished through the identification, interpretation and coding of information units. Data from the pre-test and post-test 2 were subjected to statistical analyses. To estimate the differences, paired t-tests were used. At post-test 2, the information is found to be more complete, comprehensive and consistent than at pre-test. The findings indicate that documentation arenas combining work flow and content categories deduced from theories on nursing practice can influence the quality of nursing information. The KPO model can be used as guide when shifting from paper-based to electronic-based nursing documentation with the aim of obtaining complete, comprehensive and consistent nursing information. © 2012 Blackwell Publishing Ltd.
Using an educational electronic documentation system to help nursing students accurately identify patient data.

PubMed

Pobocik, Tamara

2015-01-01

This quantitative research study used a pretest/posttest design and reviewed how an educational electronic documentation system helped nursing students to identify the accurate "related to" statement of the nursing diagnosis for the patient in the case study. Students in the sample population were senior nursing students in a bachelor of science nursing program in the northeastern United States. Two distinct groups were used for a control and intervention group. The intervention group used the educational electronic documentation system for three class assignments. Both groups were given a pretest and posttest case study. The Accuracy Tool was used to score the students' responses to the related to statement of a nursing diagnosis given at the end of the case study. The scores of the Accuracy Tool were analyzed, and then the numeric scores were placed in SPSS, and the paired t test scores were analyzed for statistical significance. The intervention group's scores were statistically different from the pretest scores to posttest scores, while the control group's scores remained the same from pretest to posttest. The recommendation to nursing education is to use the educational electronic documentation system as a teaching pedagogy to help nursing students prepare for nursing practice. © 2014 NANDA International, Inc.

Nurses' Perceptions of Nursing Care Documentation in the Electronic Health Record

ERIC Educational Resources Information Center

Jensen, Tracey A.

2013-01-01

Electronic health records (EHRs) will soon become the standard for documenting nursing care. The EHR holds the promise of rapid access to complete records of a patient's encounter with the healthcare system. It is the expectation that healthcare providers input essential data that communicates important patient information to support quality…
Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO.

PubMed

Müller-Staub, Maria; Lunney, Margaret; Odenbreit, Matthias; Needham, Ian; Lavin, Mary Ann; van Achterberg, Theo

2009-04-01

This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed. Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation. A qualitative design was used for instrument development. Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalized into items and eight experts assessed face and content validity of the Q-DIO. Criteria were developed and operationalized into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88.25% agreement for the scores assigned to the 29 items of the Q-DIO. The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended. Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.
Evaluation of a System of Electronic Documentation for the Nursing Process

PubMed Central

de Oliveira, Neurilene Batista; Peres, Heloisa Helena Ciqueto

2012-01-01

The objective of this study is to evaluate the functional performance and the technical quality of an electronic documentation system designed to document the data of the Nursing Process. The Model of Quality will be the one established by the ISO/IEC 25010. Such research will allow the spreading of the knowledge of an emerging area, thus adding a further initiative to the growing efforts made in the information technology area for health and nursing. PMID:24199110
Computer-based nursing documentation in nursing homes: A feasibility study.

PubMed

Yu, Ping; Qiu, Yiyu; Crookes, Patrick

2006-01-01

The burden of paper-based nursing documentation has led to increasing complaints and decreasing job satisfaction amongst aged-care workers in Australian nursing homes. The automation of nursing documentation has been identified as one of the possible strategies to address this issue. A major obstacle to the introduction of IT solutions, however, has been a prevailing doubt concerning the ability and/or the willingness of aged-care workers to accept such innovation. This research investigates the attitudes of aged-care workers towards adopting IT innovation. Questionnaire survey were conducted in 13 nursing homes around the Illawarra and Sydney regions in Australia. The survey found that an unexpected 89.3% of participants supported the strategy of introducing electronic nursing documentation systems into residential aged-care facilities. 94.3% of them would use such a system depending on circumstances. Despite a shortage of computers in the workplace, which is a major barrier, this research provides strong evidence that care workers in residential aged-care facilities are willing to accept electronic nursing documentation practice and the uptake of information technology in residential aged-care is feasible in Australia.
Development and evaluation of nursing user interface screens using multiple methods.

PubMed

Hyun, Sookyung; Johnson, Stephen B; Stetson, Peter D; Bakken, Suzanne

2009-12-01

Building upon the foundation of the Structured Narrative Electronic Health Record (EHR) model, we applied theory-based (combined Technology Acceptance Model and Task-Technology Fit Model) and user-centered methods to explore nurses' perceptions of functional requirements for an electronic nursing documentation system, design user interface screens reflective of the nurses' perspectives, and assess nurses' perceptions of the usability of the prototype user interface screens. The methods resulted in user interface screens that were perceived to be easy to use, potentially useful, and well-matched to nursing documentation tasks associated with Nursing Admission Assessment, Blood Administration, and Nursing Discharge Summary. The methods applied in this research may serve as a guide for others wishing to implement user-centered processes to develop or extend EHR systems. In addition, some of the insights obtained in this study may be informative to the development of safe and efficient user interface screens for nursing document templates in EHRs.
EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes.

PubMed

OʼBrien, Ann; Weaver, Charlotte; Settergren, Theresa Tess; Hook, Mary L; Ivory, Catherine H

2015-01-01

The phenomenon of "data rich, information poor" in today's electronic health records (EHRs) is too often the reality for nursing. This article proposes the redesign of nursing documentation to leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing care across the continuum. The principles consider the need to optimize nurses' documentation efficiency while contributing to knowledge generation. The nursing process must be supported by EHRs through integration of best care practices: seamless workflows that display the right tools, evidence-based content, and information at the right time for optimal clinical decision making. Design of EHR documentation must attain a balance that ensures the capture of nursing's impact on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes "death by data entry." In 2014, a group of diverse informatics leaders from practice, academia, and the vendor community formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our health care system moves toward reimbursement on the basis of quality outcomes and prevention, the value of nursing data in this business proposition will become a key differentiator for health care organizations' economic success.
Time-motion analysis of clinical nursing documentation during implementation of an electronic operating room management system for ophthalmic surgery.

PubMed

Read-Brown, Sarah; Sanders, David S; Brown, Anna S; Yackel, Thomas R; Choi, Dongseok; Tu, Daniel C; Chiang, Michael F

2013-01-01

Efficiency and quality of documentation are critical in surgical settings because operating rooms are a major source of revenue, and because adverse events may have enormous consequences. Electronic health records (EHRs) have potential to impact surgical volume, quality, and documentation time. Ophthalmology is an ideal domain to examine these issues because procedures are high-throughput and demand efficient documentation. This time-motion study examines nursing documentation during implementation of an EHR operating room management system in an ophthalmology department. Key findings are: (1) EHR nursing documentation time was significantly worse during early implementation, but improved to a level near but slightly worse than paper baseline, (2) Mean documentation time varied significantly among nurses during early implementation, and (3) There was no decrease in operating room turnover time or surgical volume after implementation. These findings have important implications for ambulatory surgery departments planning EHR implementation, and for research in system design.
Time-Motion Analysis of Clinical Nursing Documentation During Implementation of an Electronic Operating Room Management System for Ophthalmic Surgery

PubMed Central

Read-Brown, Sarah; Sanders, David S.; Brown, Anna S.; Yackel, Thomas R.; Choi, Dongseok; Tu, Daniel C.; Chiang, Michael F.

2013-01-01

Efficiency and quality of documentation are critical in surgical settings because operating rooms are a major source of revenue, and because adverse events may have enormous consequences. Electronic health records (EHRs) have potential to impact surgical volume, quality, and documentation time. Ophthalmology is an ideal domain to examine these issues because procedures are high-throughput and demand efficient documentation. This time-motion study examines nursing documentation during implementation of an EHR operating room management system in an ophthalmology department. Key findings are: (1) EHR nursing documentation time was significantly worse during early implementation, but improved to a level near but slightly worse than paper baseline, (2) Mean documentation time varied significantly among nurses during early implementation, and (3) There was no decrease in operating room turnover time or surgical volume after implementation. These findings have important implications for ambulatory surgery departments planning EHR implementation, and for research in system design. PMID:24551402
Development of the Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument to assess paper-based and electronic resident records.

PubMed

Wang, Ning; Björvell, Catrin; Hailey, David; Yu, Ping

2014-12-01

To develop an Australian nursing documentation in aged care (Quality of Australian Nursing Documentation in Aged Care (QANDAC)) instrument to measure the quality of paper-based and electronic resident records. The instrument was based on the nursing process model and on three attributes of documentation quality identified in a systematic review. The development process involved five phases following approaches to designing criterion-referenced measures. The face and content validities and the inter-rater reliability of the instrument were estimated using a focus group approach and consensus model. The instrument contains 34 questions in three sections: completion of nursing history and assessment, description of care process and meeting the requirements of data entry. Estimates of the validity and inter-rater reliability of the instrument gave satisfactory results. The QANDAC instrument may be a useful audit tool for quality improvement and research in aged care documentation. © 2013 ACOTA.
Evaluation of Evidence-Based Nursing Pain Management Practice

PubMed Central

Song, Wenjia; Eaton, Linda H.; Gordon, Debra B.; Hoyle, Christine; Doorenbos, Ardith Z.

2014-01-01

Background It is important to ensure that cancer pain management is based on the best evidence. Nursing evidence-based pain management can be examined through an evaluation of pain documentation. Aims This study aimed to (a) modify and test an evaluation tool for nursing cancer pain documentation, and (b) describe the frequency and quality of nursing pain documentation in one oncology unit via electronic medical system. Design and Setting A descriptive cross-sectional design was used for this study at an oncology unit of an academic medical center in the Pacific Northwest. Methods Medical records were examined for 37 adults hospitalized during April and May of 2013. Nursing pain documentations (N = 230) were reviewed using an evaluation tool modified from the Cancer Pain Practice Index to consist of 13 evidence-based pain management indicators, including pain assessment, care plan, pharmacologic and nonpharmacologic interventions, monitoring and treatment of analgesic side effects, communication with physicians, and patient education. Individual nursing documentation was assigned a score from 0 (worst possible) to 13 (best possible), to reflect the delivery of evidence-based pain management. Results The participating nurses documented 90% of the recommended evidence-based pain management indicators. Documentation was suboptimal for pain reassessment, pharmacologic interventions, and bowel regimen. Conclusions The study results provide implications for enhancing electronic medical record design and highlight a need for future research to understand the reasons for suboptimal nursing documentation of cancer pain management. For the future use of the data evaluation tool, we recommend additional modifications according to study settings. PMID:26256215
Danish Perioperative Nurses' Documentation: A Complex, Multifaceted Practice Connected With Unit Culture and Nursing Leadership.

PubMed

Søndergaard, Susanne F; Lorentzen, Vibeke; Sørensen, Erik E; Frederiksen, Kirsten

2017-07-01

Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses' level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses' documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses' documentation practices and that a tailored EHR may improve documentation practices. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Evaluation of Evidence-based Nursing Pain Management Practice.

PubMed

Song, Wenjia; Eaton, Linda H; Gordon, Debra B; Hoyle, Christine; Doorenbos, Ardith Z

2015-08-01

It is important to ensure that cancer pain management is based on the best evidence. Nursing evidence-based pain management can be examined through an evaluation of pain documentation. The aim of this study was to modify and test an evaluation tool for nursing cancer pain documentation, and describe the frequency and quality of nursing pain documentation in one oncology unit via the electronic medical system. A descriptive cross-sectional design was used for this study at an oncology unit of an academic medical center in the Pacific Northwest. Medical records were examined for 37 adults hospitalized during April and May 2013. Nursing pain documentations (N = 230) were reviewed using an evaluation tool modified from the Cancer Pain Practice Index to consist of 13 evidence-based pain management indicators, including pain assessment, care plan, pharmacologic and nonpharmacologic interventions, monitoring and treatment of analgesic side effects, communication with physicians, and patient education. Individual nursing documentation was assigned a score ranging from 0 (worst possible) to 13 (best possible), to reflect the delivery of evidence-based pain management. The participating nurses documented 90% of the recommended evidence-based pain management indicators. Documentation was suboptimal for pain reassessment, pharmacologic interventions, and bowel regimen. The study results provide implications for enhancing electronic medical record design and highlight a need for future research to understand the reasons for suboptimal nursing documentation of cancer pain management. For the future use of the data evaluation tool, we recommend additional modifications according to study settings. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting.

PubMed

Juvé-Udina, Maria-Eulàlia; Pérez, Esperanza Zuriguel; Padrés, Núria Fabrellas; Samartino, Maribel Gonzalez; García, Marta Romero; Creus, Mònica Castellà; Batllori, Núria Vila; Calvo, Cristina Matud

2014-01-01

This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology. An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review. Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans. The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care. The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care. © 2013 Sigma Theta Tau International.
Integration of clinical research documentation in electronic health records.

PubMed

Broach, Debra

2015-04-01

Clinical trials of investigational drugs and devices are often conducted within healthcare facilities concurrently with clinical care. With implementation of electronic health records, new communication methods are required to notify nonresearch clinicians of research participation. This article reviews clinical research source documentation, the electronic health record and the medical record, areas in which the research record and electronic health record overlap, and implications for the research nurse coordinator in documentation of the care of the patient/subject. Incorporation of clinical research documentation in the electronic health record will lead to a more complete patient/subject medical record in compliance with both research and medical records regulations. A literature search provided little information about the inclusion of clinical research documentation within the electronic health record. Although regulations and guidelines define both source documentation and the medical record, integration of research documentation in the electronic health record is not clearly defined. At minimum, the signed informed consent(s), investigational drug or device usage, and research team contact information should be documented within the electronic health record. Institutional policies should define a standardized process for this integration in the absence federal guidance. Nurses coordinating clinical trials are in an ideal position to define this integration.
An Electronic Nursing Patient Care Plan Helps in Clinical Decision Support.

PubMed

Wong, C M; Wu, S Y; Ting, W H; Ho, K H; Tong, L H; Cheung, N T

2015-01-01

Information technology can help to improve health care delivery. The utilisation of informatics principle enhances the quality of nursing practices through improved communication, documentation and efficiency. The Nursing Profession constitutes 34% of the total workforce in the Hong Kong Hospital Authority (HA) and includes 21,000 nurses in 2012. To enhance the quality of care and patient safety in both hospitals and community care setting, it is essential that an integrated electronic decision support system for nurses is designed to track documentation and support care or service including observations, decisions, actions and outcomes throughout the care process at each point-of-care. The Patient Care Plan project was set up to achieve these objectives. The Project adheres to strict documentation information architecture to ensure data sharing is freely available. Preliminary results showed very promising improvement in clinical care.
Integration of Evidence into a Detailed Clinical Model-based Electronic Nursing Record System

PubMed Central

Park, Hyeoun-Ae; Jeon, Eunjoo; Chung, Eunja

2012-01-01

Objectives The purpose of this study was to test the feasibility of an electronic nursing record system for perinatal care that is based on detailed clinical models and clinical practice guidelines in perinatal care. Methods This study was carried out in five phases: 1) generating nursing statements using detailed clinical models; 2) identifying the relevant evidence; 3) linking nursing statements with the evidence; 4) developing a prototype electronic nursing record system based on detailed clinical models and clinical practice guidelines; and 5) evaluating the prototype system. Results We first generated 799 nursing statements describing nursing assessments, diagnoses, interventions, and outcomes using entities, attributes, and value sets of detailed clinical models for perinatal care which we developed in a previous study. We then extracted 506 recommendations from nine clinical practice guidelines and created sets of nursing statements to be used for nursing documentation by grouping nursing statements according to these recommendations. Finally, we developed and evaluated a prototype electronic nursing record system that can provide nurses with recommendations for nursing practice and sets of nursing statements based on the recommendations for guiding nursing documentation. Conclusions The prototype system was found to be sufficiently complete, relevant, useful, and applicable in terms of content, and easy to use and useful in terms of system user interface. This study has revealed the feasibility of developing such an ENR system. PMID:22844649
Defining and incorporating basic nursing care actions into the electronic health record.

PubMed

Englebright, Jane; Aldrich, Kelly; Taylor, Cathy R

2014-01-01

To develop a definition of basic nursing care for the hospitalized adult patient and drive uptake of that definition through the implementation of an electronic health record. A team of direct care nurses, assisted by subject matter experts, analyzed nursing theory and regulatory requirements related to basic nursing care. The resulting list of activities was coded using the Clinical Care Classification (CCC) system and incorporated into the electronic health record system of a 170-bed community hospital. Nine basic nursing care activities were identified as a result of analyzing nursing theory and regulatory requirements in the framework of a hypothetical "well" patient. One additional basic nursing care activity was identified following the pilot implementation in the electronic health record. The pilot hospital has successfully passed a post-implementation regulatory review with no recommendations related to the documentation of basic patient care. This project demonstrated that it is possible to define the concept of basic nursing care and to distinguish it from the interdisciplinary, problem-focused plan of care. The use of the electronic health record can help clarify, document, and communicate basic care elements and improve uptake among nurses. This project to define basic nursing care activities and incorporate into the electronic health record represents a first step in capturing meaningful data elements. When fully implemented, these data could be translated into knowledge for improving care outcomes and collaborative processes. © 2013 Sigma Theta Tau International.
Documentation of psychotropic PRN medication administration: An evaluation of electronic health records compared with paper charts and verbal reports.

PubMed

Martin, Krystle; Ham, Elke; Hilton, Zoe

2018-05-12

To describe the documentation of pro re nata (PRN) medication for anxiety, and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process. The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., De Marinis, Piredda, Pascarella et al., 2009) and considerable information missing (e.g., Marinis et al., 2010). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker, Lovell, & Harris, 2008). The project was a mixed method, two-phase study that collected data from two sites. In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice. Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration. We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation. Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be done through training, using structured report templates, and switching to electronic databases. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Evaluation of Nursing Documentation Completion of Stroke Patients in the Emergency Department: A Pre-Post Analysis Using Flowsheet Templates and Clinical Decision Support.

PubMed

Richardson, Karen J; Sengstack, Patricia; Doucette, Jeffrey N; Hammond, William E; Schertz, Matthew; Thompson, Julie; Johnson, Constance

2016-02-01

The primary aim of this performance improvement project was to determine whether the electronic health record implementation of stroke-specific nursing documentation flowsheet templates and clinical decision support alerts improved the nursing documentation of eligible stroke patients in seven stroke-certified emergency departments. Two system enhancements were introduced into the electronic record in an effort to improve nursing documentation: disease-specific documentation flowsheets and clinical decision support alerts. Using a pre-post design, project measures included six stroke management goals as defined by the National Institute of Neurological Disorders and Stroke and three clinical decision support measures based on entry of orders used to trigger documentation reminders for nursing: (1) the National Institutes of Health's Stroke Scale, (2) neurological checks, and (3) dysphagia screening. Data were reviewed 6 months prior (n = 2293) and 6 months following the intervention (n = 2588). Fisher exact test was used for statistical analysis. Statistical significance was found for documentation of five of the six stroke management goals, although effect sizes were small. Customizing flowsheets to meet the needs of nursing workflow showed improvement in the completion of documentation. The effects of the decision support alerts on the completeness of nursing documentation were not statistically significant (likely due to lack of order entry). For example, an order for the National Institutes of Health Stroke Scale was entered only 10.7% of the time, which meant no alert would fire for nursing in the postintervention group. Future work should focus on decision support alerts that trigger reminders for clinicians to place relevant orders for this population.
Cognitive analyses of a paper medical record and electronic medical record on the documentation of two nursing tasks: patient education and adherence assessment of insulin administration.

PubMed Central

Rinkus, Susan M.; Chitwood, Ainsley

2002-01-01

The incorporation of electronic medical records into busy physician clinics has been a major development in the healthcare industry over the past decade. Documentation of key nursing activities, especially when interacting with patients who have chronic diseases, is often lacking or missing from the paper medical record. A case study of a patient with diabetes mellitus was created. Well established methods for the assessment of usability in the areas of human-computer interaction and computer supported cooperative work were employed to compare the nursing documentation of two tasks in a commercially available electronic medical record (eRecord) and in a paper medical record. Overall, the eRecord was found to improve the timeliness and quality of nursing documentation. With certain tasks, the number of steps to accomplish the same task was higher, which may result in the perception by the end user that the tool is more complex and therefore difficult to use. Recommendations for the eRecord were made to expand the documentation of patient teaching and adherence assessment and to incorporate web technology for patient access to medical records and healthcare information. PMID:12463905

Impact of an electronic health record operating room management system in ophthalmology on documentation time, surgical volume, and staffing.

PubMed

Sanders, David S; Read-Brown, Sarah; Tu, Daniel C; Lambert, William E; Choi, Dongseok; Almario, Bella M; Yackel, Thomas R; Brown, Anna S; Chiang, Michael F

2014-05-01

Although electronic health record (EHR) systems have potential benefits, such as improved safety and quality of care, most ophthalmology practices in the United States have not adopted these systems. Concerns persist regarding potential negative impacts on clinical workflow. In particular, the impact of EHR operating room (OR) management systems on clinical efficiency in the ophthalmic surgery setting is unknown. To determine the impact of an EHR OR management system on intraoperative nursing documentation time, surgical volume, and staffing requirements. For documentation time and circulating nurses per procedure, a prospective cohort design was used between January 10, 2012, and January 10, 2013. For surgical volume and overall staffing requirements, a case series design was used between January 29, 2011, and January 28, 2013. This study involved ophthalmic OR nurses (n = 13) and surgeons (n = 25) at an academic medical center. Electronic health record OR management system implementation. (1) Documentation time (percentage of operating time documenting [POTD], absolute documentation time in minutes), (2) surgical volume (procedures/time), and (3) staffing requirements (full-time equivalents, circulating nurses/procedure). Outcomes were measured during a baseline period when paper documentation was used and during the early (first 3 months) and late (4-12 months) periods after EHR implementation. There was a worsening in total POTD in the early EHR period (83%) vs paper baseline (41%) (P < .001). This improved to baseline levels by the late EHR period (46%, P = .28), although POTD in the cataract group remained worse than at baseline (64%, P < .001). There was a worsening in absolute mean documentation time in the early EHR period (16.7 minutes) vs paper baseline (7.5 minutes) (P < .001). This improved in the late EHR period (9.2 minutes) but remained worse than in the paper baseline (P < .001). While cataract procedures required more circulating nurses in the early EHR (mean, 1.9 nurses/procedure) and late EHR (mean, 1.5 nurses/procedure) periods than in the paper baseline (mean, 1.0 nurses/procedure) (P < .001), overall staffing requirements and surgical volume were not significantly different between the periods. Electronic health record OR management system implementation was associated with worsening of intraoperative nursing documentation time especially in shorter procedures. However, it is possible to implement an EHR OR management system without serious negative impacts on surgical volume and staffing requirements.
Integrating traditional nursing service orientation content with electronic medical record orientation.

PubMed

Harton, Brenda B; Borrelli, Larry; Knupp, Ann; Rogers, Necolen; West, Vickie R

2009-01-01

Traditional nursing service orientation classes at an acute care hospital were integrated with orientation to the electronic medical record to blend the two components in a user-friendly format so that the learner is introduced to the culture, processes, and documentation methods of the organization, with an opportunity to document online in a practice domain while lecture and discussion information is fresh.
Hospital Nurses' Work Activity in a Technology-Rich Environment: A Triangulated Quality Improvement Assessment.

PubMed

Higgins, Linda W; Shovel, Judith A; Bilderback, Andrew L; Lorenz, Holly L; Martin, Susan C; Rogers, Debra J; Minnier, Tamra E

The aim of this project was to describe hospital nurses' work activity through observations, nurses' perceptions of time spent on tasks, and electronic health record time stamps. Nurses' attitudes toward technology and patients' perceptions and satisfaction with nurses' time at the bedside were also examined. Activities most frequently observed included documenting in and reviewing the electronic health record. Nurses' perceptions of time differed significantly from observations, and most patients rated their satisfaction with nursing time as excellent or good.
Use of Narrative Nursing Records for Nursing Research

PubMed Central

Park, Hyeoun-Ae; Cho, InSook; Ahn, Hee-Jung

2012-01-01

To explore the usefulness of narrative nursing records documented using a standardized terminology-based electronic nursing records system, we conducted three different studies on (1) the gaps between the required nursing care time and the actual nursing care time, (2) the practice variations in pressure ulcer care, and (3) the surveillance of adverse drug events. The narrative nursing notes, documented at the point of care using standardized nursing statements, were extracted from the clinical data repository at a teaching hospital in Korea and analyzed. Our findings were: the pediatric and geriatric units showed relatively high staffing needs; overall incidence rate of pressure ulcer among the intensive-care patients was 15.0% and the nursing interventions provided for pressure-ulcer care varied depending on nursing units; and at least one adverse drug event was noted in 53.0% of the cancer patients who were treated with cisplatin. A standardized nursing terminology-based electronic nursing record system allowed us to explore answers to different various research questions. PMID:24199111
Applying language technology to nursing documents: pros and cons with a focus on ethics.

PubMed

Suominen, Hanna; Lehtikunnas, Tuija; Back, Barbro; Karsten, Helena; Salakoski, Tapio; Salanterä, Sanna

2007-10-01

The present study discusses ethics in building and using applications based on natural language processing in electronic nursing documentation. Specifically, we first focus on the question of how patient confidentiality can be ensured in developing language technology for the nursing documentation domain. Then, we identify and theoretically analyze the ethical outcomes which arise when using natural language processing to support clinical judgement and decision-making. In total, we put forward and justify 10 claims related to ethics in applying language technology to nursing documents. A review of recent scientific articles related to ethics in electronic patient records or in the utilization of large databases was conducted. Then, the results were compared with ethical guidelines for nurses and the Finnish legislation covering health care and processing of personal data. Finally, the practical experiences of the authors in applying the methods of natural language processing to nursing documents were appended. Patient records supplemented with natural language processing capabilities may help nurses give better, more efficient and more individualized care for their patients. In addition, language technology may facilitate patients' possibility to receive truthful information about their health and improve the nature of narratives. Because of these benefits, research about the use of language technology in narratives should be encouraged. In contrast, privacy-sensitive health care documentation brings specific ethical concerns and difficulties to the natural language processing of nursing documents. Therefore, when developing natural language processing tools, patient confidentiality must be ensured. While using the tools, health care personnel should always be responsible for the clinical judgement and decision-making. One should also consider that the use of language technology in nursing narratives may threaten patients' rights by using documentation collected for other purposes. Applying language technology to nursing documents may, on the one hand, contribute to the quality of care, but, on the other hand, threaten patient confidentiality. As an overall conclusion, natural language processing of nursing documents holds the promise of great benefits if the potential risks are taken into consideration.
[The electronic use of the NANDA-, NOC- and NIC- classifications and implications for nursing practice].

PubMed

Bernhart-Just, Alexandra; Hillewerth, Kathrin; Holzer-Pruss, Christina; Paprotny, Monika; Zimmermann Heinrich, Heidi

2009-12-01

The data model developed on behalf of the Nursing Service Commission of the Canton of Zurich (Pflegedienstkommission des Kantons Zürich) is based on the NANDA nursing diagnoses, the Nursing Outcome Classification, and the Nursing Intervention Classification (NNN Classifications). It also includes integrated functions for cost-centered accounting, service recording, and the Swiss Nursing Minimum Data Set. The data model uses the NNN classifications to map a possible form of the nursing process in the electronic patient health record, where the nurse can choose nursing diagnoses, outcomes, and interventions relevant to the patient situation. The nurses' choice is guided both by the different classifications and their linkages, and the use of specific text components pre-defined for each classification and accessible through the respective linkages. This article describes the developed data model and illustrates its clinical application in a specific patient's situation. Preparatory work required for the implementation of NNN classifications in practical nursing such as content filtering and the creation of linkages between the NNN classifications are described. Against the background of documentation of the nursing process based on the DAPEP(1) data model, possible changes and requirements are deduced. The article provides a contribution to the discussion of a change in documentation of the nursing process by implementing nursing classifications in electronic patient records.
A nursing-specific model of EPR documentation: organizational and professional requirements.

PubMed

von Krogh, Gunn; Nåden, Dagfinn

2008-01-01

To present the Norwegian documentation KPO model (quality assurance, problem solving, and caring). To present the requirements and multiple electronic patient record (EPR) functions the model is designed to address. The model's professional substance, a conceptual framework for nursing practice is developed by examining, reorganizing, and completing existing frameworks. The model's methodology, an information management system, is developed using an expert group. Both model elements were clinically tested over a period of 1 year. The model is designed for nursing documentation in step with statutory, organizational, and professional requirements. Complete documentation is arranged for by incorporating the Nursing Minimum Data Set. A systematic and comprehensive documentation is arranged for by establishing categories as provided in the model's framework domains. Consistent documentation is arranged for by incorporating NANDA-I Nursing Diagnoses, Nursing Intervention Classification, and Nursing Outcome Classification. The model can be used as a tool in cooperation with vendors to ensure the interests of the nursing profession is met when developing EPR solutions in healthcare. The model can provide clinicians with a framework for documentation in step with legal and organizational requirements and at the same time retain the ability to record all aspects of clinical nursing.
Electronic implementation of national nursing standards--NANDA, NOC and NIC as an effective teaching tool.

PubMed

Allred, Sharon K; Smith, Kevin F; Flowers, Laura

2004-01-01

With the increased interest in evidence-based medicine, Internet access and the growing emphasis on national standards, there is an increased challenge for teaching institutions and nursing services to teach and implement standards. At the same time, electronic clinical documentation tools have started to become a common format for recording nursing notes. The major aim of this paper is to ascertain and assess the availability of clinical nursing tools based on the NANDA, NOC and NIC standards. Faculty at 20 large nursing schools and directors of nursing at 20 hospitals were interviewed regarding the use of nursing standards in clinical documentation packages, not only for teaching purposes but also for use in hospital-based systems to ensure patient safety. A survey tool was utilized that covered questions regarding what nursing standards are being taught in the nursing schools, what standards are encouraged by the hospitals, and teaching initiatives that include clinical documentation tools. Information was collected on how utilizing these standards in a clinical or hospital setting can improve the overall quality of care. Analysis included univariate and bivariate analysis. The consensus between both groups was that the NANDA, NOC and NIC national standards are the most widely taught and utilized. In addition, a training initiative was identified within a large university where a clinical documentation system based on these standards was developed utilizing handheld devices.
Transforming Clinical Documentation in EHRs for 2020: Recommendations from University of Minnesota's Big Data Conference Working Group.

PubMed

Weaver, Charlotte; O'Brien, Ann

2016-01-01

In 2014, a group of diverse informatics leaders from practice, academia, and the software industry formed to address how best to transform electronic documentation to provide knowledge at the point of care and to deliver value to front line nurses and nurse leaders. This presentation reports the recommendations from this Working Group geared towards a 2020 framework. The recommendations propose redesign to optimize nurses' documentation efficiency while contributing to knowledge generation and attaining a balance that ensures the capture of nursing's impact on safety, quality, yet minimizes "death by data entry."
Quality of Electronic Nursing Records: The Impact of Educational Interventions During a Hospital Accreditation Process.

PubMed

Nomura, Aline Tsuma Gaedke; Pruinelli, Lisiane; da Silva, Marcos Barragan; Lucena, Amália de Fátima; Almeida, Miriam de Abreu

2018-03-01

Hospital accreditation is a strategy for the pursuit of quality of care and safety for patients and professionals. Targeted educational interventions could help support this process. This study aimed to evaluate the quality of electronic nursing records during the hospital accreditation process. A retrospective study comparing 112 nursing records during the hospital accreditation process was conducted. Educational interventions were implemented, and records were evaluated preintervention and postintervention. Mann-Whitney and χ tests were used for data analysis. Results showed that there was a significant improvement in the nursing documentation quality postintervention. When comparing records preintervention and postintervention, results showed a statistically significant difference (P < .001) between the two periods. The comparison between items showed that most scores were significant. Findings indicated that educational interventions performed by nurses led to a positive change that improved nursing documentation and, consequently, better care practices.
A survey of nursing documentation, terminologies and standards in European countries

PubMed Central

Thoroddsen, Asta; Ehrenberg, Anna; Sermeus, Walter; Saranto, Kaija

2012-01-01

A survey was carried out to describe the current state of art in the use of nursing documentation, terminologies, standards and education. Key informants in European countries were targeted by the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO). Replies were received from key informants in 20 European countries. Results show that the nursing process was most often used to structure nursing documentation. Many standardized nursing terminologies were used in Europe with NANDA, NIC, NOC and ICF most frequently used. In 70% of the countries minimum requirements were available for electronic health records (EHR), but nursing not addressed specifically. Standards in use for nursing terminologies and information systems were lacking. The results should be a major concern to the nursing community in Europe. As a European platform, ACENDIO can play a role in enhancing standardization activities, and should develop its role accordingly. PMID:24199130
Nurses' Experiences of an Initial and Reimplemented Electronic Health Record Use.

PubMed

Chang, Chi-Ping; Lee, Ting-Ting; Liu, Chia-Hui; Mills, Mary Etta

2016-04-01

The electronic health record is a key component of healthcare information systems. Currently, numerous hospitals have adopted electronic health records to replace paper-based records to document care processes and improve care quality. Integrating healthcare information system into traditional nursing daily operations requires time and effort for nurses to become familiarized with this new technology. In the stages of electronic health record implementation, smooth adoption can streamline clinical nursing activities. In order to explore the adoption process, a descriptive qualitative study design and focus group interviews were conducted 3 months after and 2 years after electronic health record system implementation (system aborted 1 year in between) in one hospital located in southern Taiwan. Content analysis was performed to analyze the interview data, and six main themes were derived, in the first stage: (1) liability, work stress, and anticipation for electronic health record; (2) slow network speed, user-unfriendly design for learning process; (3) insufficient information technology/organization support; on the second stage: (4) getting used to electronic health record and further system requirements, (5) benefits of electronic health record in time saving and documentation, (6) unrealistic information technology competence expectation and future use. It concluded that user-friendly design and support by informatics technology and manpower backup would facilitate this adoption process as well.
Identification of pseudobulbar affect symptoms in the nursing home setting: Development and assessment of a screening tool.

PubMed

Allen, Carrie; Zarowitz, Barbara; O'Shea, Terrence; Peterson, Edward; Yonan, Charles; Waterman, Fanta

Pseudobulbar Affect (PBA) is a neurologic condition characterized by involuntary outbursts of crying and/or laughing disproportionate to patient mood or social context. Although an estimated 9% of nursing home residents have symptoms suggestive of PBA, they are not routinely screened. Our goal was to develop an electronic screening tool based upon characteristics common to nursing home residents with PBA identified through medical record data. Nursing home residents with PBA treated with dextromethorphan hydrobromide/quinidine sulfate (n = 140) were compared to age-, gender-, and dementia-diagnosis-matched controls without PBA or treatment (n = 140). Comparative categories included diagnoses, medication use and symptom documentation. Using a multivariable regression and best decision rule analysis, we found PBA in nursing home residents was associated with chart documentation of uncontrollable crying, presence of a neurologic disorder (e.g., Parkinson's disease), or by the documented presence of at least 2 of the following: stroke, severe cognitive impairment, and schizophrenia. Based on these risk factors, an electronic screening tool was created. Copyright © 2017 Elsevier Inc. All rights reserved.
77 FR 72865 - Announcement of Requirements and Registration for “Mobilizing Data for Pressure Ulcer Prevention...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-06

...'s electronic documentation systems require nurses to enter oversimplified text narratives or check... the healthcare continuum while reducing health care costs. A mobile health app would support nurses... appropriate nursing knowledge, nurses achieve the ability to track changes in patient status and to exchange...
Identification of Nursing Diagnosis-Outcome-Intervention Linkages for Inpatients in the Obstetrics Department Nursing Unit in South Korea.

PubMed

Yang, Min Ji; Kim, Hye Young; Ko, Eun; Kim, Hyun Kyung

2017-09-08

To identify the NANDA-I-NOC-NIC (NNN) linkages for inpatients of the obstetrics nursing unit using electronic nursing records. In this retrospective, descriptive survey, the electronic nursing records for 220 adult patients aged ≥18 years who were discharged after obstetrics nursing unit were analyzed. The 7 most frequent nursing diagnoses were found to be associated with 9 nursing outcomes and 26 nursing interventions. Herein, the list of nursing diagnoses was observed to comprise the safety/protection domain, the list of nursing outcomes the physiological health domain, and the list of nursing interventions the physiological: complex domain. This result can contribute to improving the nursing quality and will help continuing education and documentation system refinement. © 2017 NANDA International, Inc.
Nurses' perceptions of the impact of electronic health records on work and patient outcomes.

PubMed

Kossman, Susan P; Scheidenhelm, Sandra L

2008-01-01

This study addresses community hospital nurses' use of electronic health records and views of the impact of such records on job performance and patient outcomes. Questionnaire, interview, and observation data from 46 nurses in medical-surgical and intensive care units at two community hospitals were analyzed. Nurses preferred electronic health records to paper charts and were comfortable with technology. They reported use of electronic health records enhanced nursing work through increased information access, improved organization and efficiency, and helpful alert screens. They thought use of the records hindered nursing work through impaired critical thinking, decreased interdisciplinary communication, and a high demand on work time (73% reported spending at least half their shift using the records). They thought use of electronic health records enabled them to provide safer care but decreased the quality of care. Administrative implications include involving bedside nurses in system choice, streamlining processes, developing guidelines for consistent documentation quality and location, increasing system speed, choosing hardware that encourages bedside use, and improving system information technology support.
Examining Evidence-Based Content Related to Hospital Acquired Pressure Ulcer Prevention in Paper and Electronic Health Records

ERIC Educational Resources Information Center

Jaekel, Camilla M.

2012-01-01

Although there have been great advancements in the Electronic Health Record (EHR), there is a dearth of rigorous research that examines the relationship between the use of electronic documentation to capture nursing process components and the impact of consistent documentation on patient outcomes (Daly, Buckwalter & Maas, 2002; Gugerty, 2006;…
Impact of Adoption of a Comprehensive Electronic Health Record on Nursing Work and Caring Efficacy.

PubMed

Schenk, Elizabeth; Schleyer, Ruth; Jones, Cami R; Fincham, Sarah; Daratha, Kenn B; Monsen, Karen A

2018-04-23

Nurses in acute care settings are affected by the technologies they use, including electronic health records. This study investigated the impacts of adoption of a comprehensive electronic health record by measuring nursing locations and interventions in three units before and 12 months after adoption. Time-motion methodology with a handheld recording platform based on Omaha System standardized terminology was used to collect location and intervention data. In addition, investigators administered the Caring Efficacy Scale to better understand the effects of the electronic health record on nursing care efficacy. Several differences were noted after the electronic health record was adopted. Nurses spent significantly more time in patient rooms and less in other measured locations. They spent more time overall performing nursing interventions, with increased time in documentation and medication administration, but less time reporting and providing patient-family teaching. Both before and after electronic health record adoption, nurses spent most of their time in case management interventions (coordinating, planning, and communicating). Nurses showed a slight decrease in perceived caring efficacy after adoption. While initial findings demonstrated a trend toward increased time efficiency, questions remain regarding nurse satisfaction, patient satisfaction, quality and safety outcomes, and cost.
Personal Information Management for Nurses Returning to School.

PubMed

Bowman, Katherine

2015-12-01

Registered nurses with a diploma or an associate's degree are encouraged to return to school to earn a Bachelor of Science in Nursing degree. Until they return to school, many RNs have little need to regularly write, store, and retrieve work-related papers, but they are expected to complete the majority of assignments using a computer when in the student role. Personal information management (PIM) is a system of organizing and managing electronic information that will reduce computer clutter, while enhancing time use, task management, and productivity. This article introduces three PIM strategies for managing school work. Nesting is the creation of a system of folders to form a hierarchy for storing and retrieving electronic documents. Each folder, subfolder, and document must be given a meaningful unique name. Numbering is used to create different versions of the same paper, while preserving the original document. Copyright 2015, SLACK Incorporated.
Nurses' perceptions of e-portfolio use for on-the-job training in Taiwan.

PubMed

Tsai, Pei-Rong; Lee, Ting-Ting; Lin, Hung-Ru; Lee-Hsieh, Jane; Mills, Mary Etta

2015-01-01

Electronic portfolios can be used to record user performance and achievements. Currently, clinical learning systems and in-service education systems lack integration of nurses' clinical performance records with their education or training outcomes. For nurses with less than 2 years' work experience (nursing postgraduate year), use of an electronic portfolio is essential. This study aimed to assess the requirements of using electronic portfolios in continuing nursing education for clinical practices. Fifteen nurses were recruited using a qualitative purposive sampling approach between April 2013 and May 2013. After obtaining participants' consent, data were collected in a conference room of the study hospital by one-on-one semistructured in-depth interviews. Through data analyses, the following five main themes related to electronic learning portfolios were identified: instant access to in-service education information, computerized nursing postgraduate year training manual, diversity of system functions and interface designs, need for sufficient computers, and protection of personal documents. Because electronic portfolios are beginning to be used in clinical settings, a well-designed education information system not only can meet the needs of nurses but also can facilitate their learning progress.

An ontology model for nursing narratives with natural language generation technology.

PubMed

Min, Yul Ha; Park, Hyeoun-Ae; Jeon, Eunjoo; Lee, Joo Yun; Jo, Soo Jung

2013-01-01

The purpose of this study was to develop an ontology model to generate nursing narratives as natural as human language from the entity-attribute-value triplets of a detailed clinical model using natural language generation technology. The model was based on the types of information and documentation time of the information along the nursing process. The typesof information are data characterizing the patient status, inferences made by the nurse from the patient data, and nursing actions selected by the nurse to change the patient status. This information was linked to the nursing process based on the time of documentation. We describe a case study illustrating the application of this model in an acute-care setting. The proposed model provides a strategy for designing an electronic nursing record system.
Implementation of a documentation model comprising nursing terminologies--theoretical and methodological issues.

PubMed

von Krogh, Gunn; Nåden, Dagfinn

2008-04-01

To describe and discuss theoretical and methodological issues of implementation of a nursing services documentation model comprising NANDA nursing diagnoses, Nursing Intervention Classification and Nursing Outcome Classification terminologies. The model is developed for electronic patient record and was implemented in a psychiatric hospital on an organizational level and on five test wards in 2001-2005. The theory of Rogers guided the process of innovation, whereas the implementation procedure of McCloskey and Bulecheck combined with adult learning principals guided the test site implementation. The test wards managed in different degrees to adopt the model. Two wards succeeded fully, including a ward with high percentage of staff with interdisciplinary background. Better planning regarding the impact of the organization's innovative aptitude, the innovation strategies and the use of differentiated methods regarding the clinician's individual premises for learning nursing terminologies might have enhanced the adoption to the model. To better understand the nature of barriers and the importance of careful planning regarding the implementation of electronic patient record elements in nursing care services, focusing on nursing terminologies. Further to indicate how a theory and specific procedure can be used to guide the process of implementation throughout the different levels of management.
Barriers and facilitators to electronic documentation in a rural hospital.

PubMed

Whittaker, Alice A; Aufdenkamp, Marilee; Tinley, Susan

2009-01-01

The purpose of the study was to explore nurses' perceptions of barriers and facilitators to adoption of an electronic health record (EHR) in a rural Midwestern hospital. This study was a qualitative, descriptive design. The Staggers and Parks Nurse-Computer Interaction Framework was used to guide directed content analysis. Eleven registered nurses from oncology and medical-surgical units were interviewed using three semistructured interview questions. Predetermined codes and operational definitions were developed from the Staggers and Parks framework. Narrative data were analyzed by each member of the research team and group consensus on coding was reached through group discussions. Participants were able to identify computer-related, nurse-related, and contextual barriers and facilitators to implementation of EHR. In addition, two distinct patterns of perceptions and acceptance were identified. The Staggers and Parks Nurse-Computer Interaction framework was found to be useful in identifying computer, nurse, and contextual characteristics that act as facilitators or barriers to adoption of an EHR system. Acceptance and use of an EHR are enhanced when barriers are managed and facilitators are supported. Understanding and management of facilitators and barriers to EHR adoption may impact nurses' ability to provide and document nursing care.
Women's health nursing in the context of the National Health Information Infrastructure.

PubMed

Jenkins, Melinda L; Hewitt, Caroline; Bakken, Suzanne

2006-01-01

Nurses must be prepared to participate in the evolving National Health Information Infrastructure and the changes that will consequently occur in health care practice and documentation. Informatics technologies will be used to develop electronic health records with integrated decision support features that will likely lead to enhanced health care quality and safety. This paper provides a summary of the National Health Information Infrastructure and highlights electronic health records and decision support systems within the context of evidence-based practice. Activities at the Columbia University School of Nursing designed to prepare nurses with the necessary informatics competencies to practice in a National Health Information Infrastructure-enabled health care system are described. Data are presented from electronic (personal digital assistant) encounter logs used in our Women's Health Nurse Practitioner program to support evidence-based advanced practice nursing care. Implications for nursing practice, education, and research in the evolving National Health Information Infrastructure are discussed.
Initial Steps toward Validating and Measuring the Quality of Computerized Provider Documentation

PubMed Central

Hammond, Kenric W.; Efthimiadis, Efthimis N.; Weir, Charlene R.; Embi, Peter J.; Thielke, Stephen M.; Laundry, Ryan M.; Hedeen, Ashley

2010-01-01

Background: Concerns exist about the quality of electronic health care documentation. Prior studies have focused on physicians. This investigation studied document quality perceptions of practitioners (including physicians), nurses and administrative staff. Methods: An instrument developed from staff interviews and literature sources was administered to 110 practitioners, nurses and administrative staff. Short, long and original versions of records were rated. Results: Length transformation did not affect quality ratings. On several scales practitioners rated notes less favorably than administrators or nurses. The original source document was associated with the quality rating, as was tf·idf, a relevance statistic computed from document text. Tf·idf was strongly associated with practitioner quality ratings. Conclusion: Document quality estimates were not sensitive to modifying redundancy in documents. Some perceptions of quality differ by role. Intrinsic document properties are associated with staff judgments of document quality. For practitioners, the tf·idf statistic was strongly associated with the quality dimensions evaluated. PMID:21346983
A Phenomenological Exploration of Nurses' Perceptions of the Effect of Electronic Documentation on Healing Relationships

ERIC Educational Resources Information Center

Bradley, Sharon Lee

2011-01-01

The qualitative phenomenological study was an exploration of nurses' perceptions of the effect of information technology on healing relationships between nurses and patients. Extensive advancements in health care information technology have developed over the last decade, and have affected the health care environment. The increased time and…
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

PubMed

Keenan, Gail; Yakel, Elizabeth; Dunn Lopez, Karen; Tschannen, Dana; Ford, Yvonne B

2013-01-01

To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement. This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices. Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication. The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan.
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information

PubMed Central

Yakel, Elizabeth; Dunn Lopez, Karen; Tschannen, Dana; Ford, Yvonne B

2013-01-01

Objective To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement. Design This was a qualitative study of a sample of eight medical–surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices. Results Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication. Conclusion The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan. PMID:22822042
A Nursing Intelligence System to Support Secondary Use of Nursing Routine Data

PubMed Central

Rauchegger, F.; Ammenwerth, E.

2015-01-01

Summary Background Nursing care is facing exponential growth of information from nursing documentation. This amount of electronically available data collected routinely opens up new opportunities for secondary use. Objectives To present a case study of a nursing intelligence system for reusing routinely collected nursing documentation data for multiple purposes, including quality management of nursing care. Methods The SPIRIT framework for systematically planning the reuse of clinical routine data was leveraged to design a nursing intelligence system which then was implemented using open source tools in a large university hospital group following the spiral model of software engineering. Results The nursing intelligence system is in routine use now and updated regularly, and includes over 40 million data sets. It allows the outcome and quality analysis of data related to the nursing process. Conclusions Following a systematic approach for planning and designing a solution for reusing routine care data appeared to be successful. The resulting nursing intelligence system is useful in practice now, but remains malleable for future changes. PMID:26171085
The effect of the electronic medical record on nurses' work.

PubMed

Robles, Jane

2009-01-01

The electronic medical record (EMR) is a workplace reality for most nurses. Its advantages include a single consolidated record for each person; capacity for data interfaces and alerts; improved interdisciplinary communication; and evidence-based decision support. EMRs can add to work complexity, by forcing better documentation of previously unrecorded data and/or because of poor design. Well-designed and well-implemented computerized provider order entry (CPOE) systems can streamline nurses' work. Generational differences in acceptance of and facility with EMRs can be addressed through open, healthy communication.
Operationalizing the Student Electronic Portfolio for Doctoral Nursing Education.

PubMed

Willmarth-Stec, Melissa; Beery, Teresa

2015-01-01

There is an increasing trend toward use of the electronic portfolio (e-portfolio) in Doctor of Nursing Practice programs. E-portfolios can provide documentation of competencies and achievement of program outcomes while showcasing a holistic view of the student achievement. Implementation of the e-portfolio requires careful decision making concerning software selection, set-up, portfolio components, and evaluation. The purpose of this article is to describe the implementation of an e-portfolio in a Doctor of Nursing Practice program and provide lessons learned during the implementation stage.
Developing a prenatal nursing care International Classification for Nursing Practice catalogue.

PubMed

Liu, L; Coenen, A; Tao, H; Jansen, K R; Jiang, A L

2017-09-01

This study aimed to develop a prenatal nursing care catalogue of International Classification for Nursing Practice. As a programme of the International Council of Nurses, International Classification for Nursing Practice aims to support standardized electronic nursing documentation and facilitate collection of comparable nursing data across settings. This initiative enables the study of relationships among nursing diagnoses, nursing interventions and nursing outcomes for best practice, healthcare management decisions, and policy development. The catalogues are usually focused on target populations. Pregnant women are the nursing population addressed in this project. According to the guidelines for catalogue development, three research steps have been adopted: (a) identifying relevant nursing diagnoses, interventions and outcomes; (b) developing a conceptual framework for the catalogue; (c) expert's validation. This project established a prenatal nursing care catalogue with 228 terms in total, including 69 nursing diagnosis, 92 nursing interventions and 67 nursing outcomes, among them, 57 nursing terms were newly developed. All terms in the catalogue were organized by a framework with two main categories, i.e. Expected Changes of Pregnancy and Pregnancy at Risk. Each category had four domains, representing the physical, psychological, behavioral and environmental perspectives of nursing practice. This catalogue can ease the documentation workload among prenatal care nurses, and facilitate storage and retrieval of standardized data for many purposes, such as quality improvement, administration decision-support and researches. The documentations of prenatal care provided data that can be more fluently communicated, compared and evaluated across various healthcare providers and clinic settings. © 2016 International Council of Nurses.
Medication order communication using fax and document-imaging technologies.

PubMed

Simonian, Armen I

2008-03-15

The implementation of fax and document-imaging technology to electronically communicate medication orders from nursing stations to the pharmacy is described. The evaluation of a commercially available pharmacy order imaging system to improve order communication and to make document retrieval more efficient led to the selection and customization of a system already licensed and used in seven affiliated hospitals. The system consisted of existing fax machines and document-imaging software that would capture images of written orders and send them from nursing stations to a central database server. Pharmacists would then retrieve the images and enter the orders in an electronic medical record system. The pharmacy representatives from all seven hospitals agreed on the configuration and functionality of the custom application. A 30-day trial of the order imaging system was successfully conducted at one of the larger institutions. The new system was then implemented at the remaining six hospitals over a period of 60 days. The transition from a paper-order system to electronic communication via a standardized pharmacy document management application tailored to the specific needs of this health system was accomplished. A health system with seven affiliated hospitals successfully implemented electronic communication and the management of inpatient paper-chart orders by using faxes and document-imaging technology. This standardized application eliminated the problems associated with the hand delivery of paper orders, the use of the pneumatic tube system, and the printing of traditional faxes.
Conversion of school nurse policy and procedure manual to electronic format.

PubMed

Randall, Joellyn; Knee, Rachel; Galemore, Cynthia

2006-10-01

Policy and procedure manuals are essential to establishing standards of practice and ensuring quality of care to students and families. The Olathe District Schools (Kansas) Technology Department created the Virtual File Cabinet to provide online access to employee policies, school board policies, forms, and other documents. A task force of school nurses was formed to convert the nursing department's policies, procedures, protocols, and forms from hard copy to electronic format and make them available on the district's Virtual File Cabinet. Having the policy and procedure manuals in electronic format allows for quick access and ease in updating information, thereby guaranteeing the school nurses have access to the most current information. Cost savings were realized by reducing the amount of paper and staff time needed to copy, collate, and assemble materials.
Evidence-based use of electronic clinical tracking systems in advanced practice registered nurse education: an integrative review.

PubMed

Branstetter, M Laurie; Smith, Lynette S; Brooks, Andrea F

2014-07-01

Over the past decade, the federal government has mandated healthcare providers to incorporate electronic health records into practice by 2015. This technological update in healthcare documentation has generated a need for advanced practice RN programs to incorporate information technology into education. The National Organization of Nurse Practitioner Faculties created core competencies to guide program standards for advanced practice RN education. One core competency is Technology and Information Literacy. Educational programs are moving toward the utilization of electronic clinical tracking systems to capture students' clinical encounter data. The purpose of this integrative review was to evaluate current research on advanced practice RN students' documentation of clinical encounters utilizing electronic clinical tracking systems to meet advanced practice RN curriculum outcome goals in information technology as defined by the National Organization of Nurse Practitioner Faculties. The state of the science depicts student' and faculty attitudes, preferences, opinions, and data collections of students' clinical encounters. Although electronic clinical tracking systems were utilized to track students' clinical encounters, these systems have not been evaluated for meeting information technology core competency standards. Educational programs are utilizing electronic clinical tracking systems with limited evidence-based literature evaluating the ability of these systems to meet the core competencies in advanced practice RN programs.
Perioperative nurses' attitudes toward the electronic health record.

PubMed

Yontz, Laura S; Zinn, Jennifer L; Schumacher, Edward J

2015-02-01

The adoption of an electronic health record (EHR) is mandated under current health care legislation reform. The EHR provides data that are patient centered and improves patient safety. There are limited data; however, regarding the attitudes of perioperative nurses toward the use of the EHR. The purpose of this project was to identify perioperative nurses' attitudes toward the use of the EHR. Quantitative descriptive survey was used to determine attitudes toward the electronic health record. Perioperative nurses in a southeastern health system completed an online survey to determine their attitudes toward the EHR in providing patient care. Overall, respondents felt the EHR was beneficial, did not add to the workload, improved documentation, and would not eliminate any nursing jobs. Nursing acceptance and the utilization of the EHR are necessary for the successful integration of an EHR and to support the goal of patient-centered care. Identification of attitudes and potential barriers of perioperative nurses in using the EHR will improve patient safety, communication, reduce costs, and empower those who implement an EHR. Copyright © 2015 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Data Integrity: Beware of Viruses

ERIC Educational Resources Information Center

Bergren, Martha Dewey

2004-01-01

School nurses and health office employees are the creators and caretakers of legal documentation. School nurses have an ethical and legal obligation to protect the integrity of electronic student health records. Although there are many threats to data integrity, from inadequate hardware to electrical surges, one of the most pervasive threats to…
Integrated information systems for electronic chemotherapy medication administration.

PubMed

Levy, Mia A; Giuse, Dario A; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K

2011-07-01

Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations.
The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.

PubMed

Poissant, Lise; Pereira, Jennifer; Tamblyn, Robyn; Kawasumi, Yuko

2005-01-01

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.
The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review

PubMed Central

Poissant, Lise; Pereira, Jennifer; Tamblyn, Robyn; Kawasumi, Yuko

2005-01-01

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. PMID:15905487

Electronic reminders improve procedure documentation compliance and professional fee reimbursement.

PubMed

Kheterpal, Sachin; Gupta, Ruchika; Blum, James M; Tremper, Kevin K; O'Reilly, Michael; Kazanjian, Paul E

2007-03-01

Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting. We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders. A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement. The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.
Developing a Nursing Database System in Kenya

PubMed Central

Riley, Patricia L; Vindigni, Stephen M; Arudo, John; Waudo, Agnes N; Kamenju, Andrew; Ngoya, Japheth; Oywer, Elizabeth O; Rakuom, Chris P; Salmon, Marla E; Kelley, Maureen; Rogers, Martha; St Louis, Michael E; Marum, Lawrence H

2007-01-01

Objective To describe the development, initial findings, and implications of a national nursing workforce database system in Kenya. Principal Findings Creating a national electronic nursing workforce database provides more reliable information on nurse demographics, migration patterns, and workforce capacity. Data analyses are most useful for human resources for health (HRH) planning when workforce capacity data can be linked to worksite staffing requirements. As a result of establishing this database, the Kenya Ministry of Health has improved capability to assess its nursing workforce and document important workforce trends, such as out-migration. Current data identify the United States as the leading recipient country of Kenyan nurses. The overwhelming majority of Kenyan nurses who elect to out-migrate are among Kenya's most qualified. Conclusions The Kenya nursing database is a first step toward facilitating evidence-based decision making in HRH. This database is unique to developing countries in sub-Saharan Africa. Establishing an electronic workforce database requires long-term investment and sustained support by national and global stakeholders. PMID:17489921
Measuring Nursing Care Time and Tasks in Long-Term Services and Supports: One Size Does Not Fit All

PubMed Central

Sochalski, Julie A.; Foust, Janice B.; Zubritsky, Cynthia D.; Hirschman, Karen B.; Abbott, Katherine M.; Naylor, Mary D.

2015-01-01

Background Although nursing care personnel comprise the majority of staff in long-term care services and supports (LTSS), a method for measuring the provision of nursing care has not yet been developed. Purpose/Methods We sought to understand the challenges of measuring nursing care across different types of LTSS using a qualitative approach that included the triangulation of data from three unique sources. Results Six primary challenges to measuring nursing care across LTSS emerged: level of detail about time of day, amount of time, or type of tasks varied by type of nursing and organization; time and tasks were documented in clinical records and administrative databases; data existed both on paper and electronically; several sources of information were needed to create the fullest picture of nursing care; data was inconsistently available for contracted providers; documentation of informal caregiving was unavailable. Differences were observed for assisted living facilities and home and community based services compared to nursing homes and across organizations within a setting. A commonality across settings and organizations was the availability of an electronically stored care plan specifying individual needs but not necessarily how these would be met. Conclusions The findings demonstrate the variability of data availability and specificity across three distinct LTSS settings. This study is an initial step toward establishing a process for measuring the provision of nursing care across LTSS to be able to explore the range of nursing care needs of LTSS recipients and how these needs are fulfilled. PMID:22902975
Assessing usage patterns of electronic clinical documentation templates.

PubMed

Vawdrey, David K

2008-11-06

Many vendors of electronic medical records support structured and free-text entry of clinical documents using configurable templates. At a healthcare institution comprising two large academic medical centers, a documentation management data mart and a custom, Web-accessible business intelligence application were developed to track the availability and usage of electronic documentation templates. For each medical center, template availability and usage trends were measured from November 2007 through February 2008. By February 2008, approximately 65,000 electronic notes were authored per week on the two campuses. One site had 934 available templates, with 313 being used to author at least one note. The other site had 765 templates, of which 480 were used. The most commonly used template at both campuses was a free text note called "Miscellaneous Nursing Note," which accounted for 33.3% of total documents generated at one campus and 15.2% at the other.
Development of the electronic health records for nursing education (EHRNE) software program.

PubMed

Kowitlawakul, Yanika; Wang, Ling; Chan, Sally Wai-Chi

2013-12-01

This paper outlines preliminary research of an innovative software program that enables the use of an electronic health record in a nursing education curriculum. The software application program is called EHRNE, which stands for Electronic Heath Record for Nursing Education. The aim of EHRNE is to enhance student's learning of health informatics when they are working in the simulation laboratory. Integrating EHRNE into the nursing curriculum exposes students to electronic health records before they go into the workplace. A qualitative study was conducted using focus group interviews of nine nursing students. Nursing students' perceptions of using the EHRNE application were explored. The interviews were audio-taped and transcribed verbatim. The data was analyzed following the Colaizzi (1978) guideline. Four main categories that related to the EHRNE application were identified from the interviews: functionality, data management, timing and complexity, and accessibility. The analysis of the data revealed advantages and limitations of using EHRNE in the classroom setting. Integrating the EHRNE program into the curriculum will promote students' awareness of electronic documentation and enhance students' learning in the simulation laboratory. Preliminary findings suggested that before integrating the EHRNE program into the nursing curriculum, educational sessions for both students and faculty outlining the software's purpose, advantages, and limitations were needed. Following the educational sessions, further investigation of students' perceptions and learning using the EHRNE program is recommended. Copyright © 2012 Elsevier Ltd. All rights reserved.
Staff experiences within the implementation of computer-based nursing records in residential aged care facilities: a systematic review and synthesis of qualitative research.

PubMed

Meißner, Anne; Schnepp, Wilfried

2014-06-20

Since the introduction of electronic nursing documentation systems, its implementation in recent years has increased rapidly in Germany. The objectives of such systems are to save time, to improve information handling and to improve quality. To integrate IT in the daily working processes, the employee is the pivotal element. Therefore it is important to understand nurses' experience with IT implementation. At present the literature shows a lack of understanding exploring staff experiences within the implementation process. A systematic review and meta-ethnographic synthesis of primary studies using qualitative methods was conducted in PubMed, CINAHL, and Cochrane. It adheres to the principles of the PRISMA statement. The studies were original, peer-reviewed articles from 2000 to 2013, focusing on computer-based nursing documentation in Residential Aged Care Facilities. The use of IT requires a different form of information processing. Some experience this new form of information processing as a benefit while others do not. The latter find it more difficult to enter data and this result in poor clinical documentation. Improvement in the quality of residents' records leads to an overall improvement in the quality of care. However, if the quality of those records is poor, some residents do not receive the necessary care. Furthermore, the length of time necessary to complete the documentation is a prominent theme within that process. Those who are more efficient with the electronic documentation demonstrate improved time management. For those who are less efficient with electronic documentation the information processing is perceived as time consuming. Normally, it is possible to experience benefits when using IT, but this depends on either promoting or hindering factors, e.g. ease of use and ability to use it, equipment availability and technical functionality, as well as attitude. In summary, the findings showed that members of staff experience IT as a benefit when it simplifies their daily working routines and as a burden when it complicates their working processes. Whether IT complicates or simplifies their routines depends on influencing factors. The line between benefit and burden is semipermeable. The experiences differ according to duties and responsibilities.
Integrated Information Systems for Electronic Chemotherapy Medication Administration

PubMed Central

Levy, Mia A.; Giuse, Dario A.; Eck, Carol; Holder, Gwen; Lippard, Giles; Cartwright, Julia; Rudge, Nancy K.

2011-01-01

Introduction: Chemotherapy administration is a highly complex and distributed task in both the inpatient and outpatient infusion center settings. The American Society of Clinical Oncology and the Oncology Nursing Society (ASCO/ONS) have developed standards that specify procedures and documentation requirements for safe chemotherapy administration. Yet paper-based approaches to medication administration have several disadvantages and do not provide any decision support for patient safety checks. Electronic medication administration that includes bar coding technology may provide additional safety checks, enable consistent documentation structure, and have additional downstream benefits. Methods: We describe the specialized configuration of clinical informatics systems for electronic chemotherapy medication administration. The system integrates the patient registration system, the inpatient order entry system, the pharmacy information system, the nursing documentation system, and the electronic health record. Results: We describe the process of deploying this infrastructure in the adult and pediatric inpatient oncology, hematology, and bone marrow transplant wards at Vanderbilt University Medical Center. We have successfully adapted the system for the oncology-specific documentation requirements detailed in the ASCO/ONS guidelines for chemotherapy administration. However, several limitations remain with regard to recording the day of treatment and dose number. Conclusion: Overall, the configured systems facilitate compliance with the ASCO/ONS guidelines and improve the consistency of documentation and multidisciplinary team communication. Our success has prompted us to deploy this infrastructure in our outpatient chemotherapy infusion centers, a process that is currently underway and that will require a few unique considerations. PMID:22043185
Effectiveness of a computerised system of patient education in clinical practice: a longitudinal nested cohort study.

PubMed

Su, Chia-Hsien; Li, Tsai-Chung; Cho, Der-Yang; Ma, Wei-Fen; Chang, Yu-Shan; Lee, Tsung-Han; Huang, Li-Chi

2018-05-03

Developing electronic health record information systems is an international trend for promoting the integration of health information and enhancing the quality of medical services. Patient education is a frequent intervention in nursing care, and recording the amount and quality of patient education have become essential in the nursing record. The aims of this study are (1): to develop a high-quality Patient Education Assessment and Description Record System (PEADRS) in the electronic medical record (2); to examine the effectiveness of the PEADRS on documentation and nurses' satisfaction (3); to facilitate communication and cooperation between professionals. A quasi-experimental design and random sampling will be used. The participants are nurses who are involved in patient education by using traditional record or the PEADRS at a medical centre. A prospective longitudinal nested cohort study will be conducted to compare the effectiveness of the PEADRS, including (1): the length of nursing documentation (2); satisfaction with using the PEADRS; and (3) the benefit to professional cooperation. Patient privacy will be protected according to Electronic Medical Record Management Practices of the hospital. This study develops a patient education digital record system, which would profit the quality of clinical practice in health education. The results will be published in peer-reviewed journals and will be presented at scientific conferences. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
The Impact of an Integrated Electronic Health Record Adoption on Nursing Care Quality.

PubMed

Walker-Czyz, AnneMarie

2016-01-01

The purpose of this study was to measure the impact of an integrated electronic health record (EHR) innovation adoption on the quality of nursing care delivered, including hospital-acquired falls, hospital-acquired pressure ulcers, ventilator-associated pneumonia (VAP), central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and costs measured in nursing hours. The impact on quality, cost, and nurse satisfaction measured in turnover rates before, during, and after implementation of EHR tools was also investigated. Little is known about the adoption patterns of computerized documentation by nursing and the effects on the practice environment. A quantitative, retrospective analysis using interrupted time series model of a large data set was conducted in a 431-bed urban hospital, with 10 medical surgical units and 2 critical care units. The research was constructed using the Diffusion of Innovations (DOI) theory. Incorporating electronic, evidenced-based practice (EBP) tools into bedside nurse's workflow promotes decision making at the point of care that may improve quality with no negative impact on direct cost. The data revealed that total falls, CAUTI, and CLABSI rates were positively impacted after the implementation of an integrated EHR. Hospital-acquired pressure ulcer and VAP rates were negatively impacted at the implementation period followed by a significant positive rate reduction that surpassed the preimplementation period. Cost indicators, measured in hours per patient day and overtime, were negatively impacted during the implementation period followed by a return to baseline. Nurse turnover had a significant increase from the preimplementation to postimplementation period and failed to return to baseline. This study confirms that nurses have the ability to positively impact the quality of patient care through successful innovation adoption related to the use of EBP computerized documentation tools at the bedside. This study further clarified the practice environment of nurses during DOI.
Nursing constraint models for electronic health records: a vision for domain knowledge governance.

PubMed

Hovenga, Evelyn; Garde, Sebastian; Heard, Sam

2005-12-01

Various forms of electronic health records (EHRs) are currently being introduced in several countries. Nurses are primary stakeholders and need to ensure that their information and knowledge needs are being met by such systems information sharing between health care providers to enable them to improve the quality and efficiency of health care service delivery for all subjects of care. The latest international EHR standards have adopted the openEHR approach of two-level modelling. The first level is a stable information model determining structure, while the second level consists of constraint models or 'archetypes' that reflect the specifications or clinician rules for how clinical information needs to be represented to enable unambiguous data sharing. The current state of play in terms of international health informatics standards development activities is providing the nursing profession with a unique opportunity and challenge. Much work has been undertaken internationally in the area of nursing terminologies and evidence-based practice. This paper argues that to make the most of these emerging technologies and EHRs we must now concentrate on developing a process to identify, document, implement, manage and govern our nursing domain knowledge as well as contribute to the development of relevant international standards. It is argued that one comprehensive nursing terminology, such as the ICNP or SNOMED CT is simply too complex and too difficult to maintain. As the openEHR archetype approach does not rely heavily on big standardised terminologies, it offers more flexibility during standardisation of clinical concepts and it ensures open, future-proof electronic health records. We conclude that it is highly desirable for the nursing profession to adopt this openEHR approach as a means of documenting and governing the nursing profession's domain knowledge. It is essential for the nursing profession to develop its domain knowledge constraint models (archetypes) collaboratively in an international context.
Implementation of Improvements in an Electronic Documentation Nursing Process System Structured on NANDA-I, NOC and NIC (NNN) Classification.

PubMed

Peres, Heloísa; Cruz, Diná; Tellez, Michelle; de Cássia Gengo E Silva, Rita; Ortiz, Diley; Diogo, Regina; Ortiz, Dóris R

2016-01-01

The aim of this study was to present the experience of a teaching hospital with the implementation of improvements to an electronic documentation system of the nursing process (PROCEnf-USP®). The improvements were based on functional performance and technical quality of the system. It was adopted Scrum^™ method for version control PROCEnf-USP® by enabling agility, flexibility and possibility of integration between development and users. The PROCEnf-USP® has been used since 2009 and has professional and academic environments. The current version lets you generate reports and supports decisions about diagnoses, outcomes and interventions. It is provided the use of indicators to monitor results and registration at the point of care. The establishment of important.
Managing the Security of Nursing Data in the Electronic Health Record

PubMed Central

Samadbeik, Mahnaz; Gorzin, Zahra; Khoshkam, Masomeh; Roudbari, Masoud

2015-01-01

Background: The Electronic Health Record (EHR) is a patient care information resource for clinicians and nursing documentation is an essential part of comprehensive patient care. Ensuring privacy and the security of health information is a key component to building the trust required to realize the potential benefits of electronic health information exchange. This study was aimed to manage nursing data security in the EHR and also discover the viewpoints of hospital information system vendors (computer companies) and hospital information technology specialists about nursing data security. Methods: This research is a cross sectional analytic-descriptive study. The study populations were IT experts at the academic hospitals and computer companies of Tehran city in Iran. Data was collected by a self-developed questionnaire whose validity and reliability were confirmed using the experts’ opinions and Cronbach’s alpha coefficient respectively. Data was analyzed through Spss Version 18 and by descriptive and analytic statistics. Results: The findings of the study revealed that user name and password were the most important methods to authenticate the nurses, with mean percent of 95% and 80%, respectively, and also the most significant level of information security protection were assigned to administrative and logical controls. There was no significant difference between opinions of both groups studied about the levels of information security protection and security requirements (p>0.05). Moreover the access to servers by authorized people, periodic security update, and the application of authentication and authorization were defined as the most basic security requirements from the viewpoint of more than 88 percent of recently-mentioned participants. Conclusions: Computer companies as system designers and hospitals information technology specialists as systems users and stakeholders present many important views about security requirements for EHR systems and nursing electronic documentation systems. Prioritizing of these requirements helps policy makers to decide what to do when planning for EHR implementation. Therefore, to make appropriate security decisions and to achieve the expected level of protection of the electronic nursing information, it is suggested to consider the priorities of both groups of experts about security principles and also discuss the issues seem to be different between two groups of participants in the research. PMID:25870490
Managing the security of nursing data in the electronic health record.

PubMed

Samadbeik, Mahnaz; Gorzin, Zahra; Khoshkam, Masomeh; Roudbari, Masoud

2015-02-01

The Electronic Health Record (EHR) is a patient care information resource for clinicians and nursing documentation is an essential part of comprehensive patient care. Ensuring privacy and the security of health information is a key component to building the trust required to realize the potential benefits of electronic health information exchange. This study was aimed to manage nursing data security in the EHR and also discover the viewpoints of hospital information system vendors (computer companies) and hospital information technology specialists about nursing data security. This research is a cross sectional analytic-descriptive study. The study populations were IT experts at the academic hospitals and computer companies of Tehran city in Iran. Data was collected by a self-developed questionnaire whose validity and reliability were confirmed using the experts' opinions and Cronbach's alpha coefficient respectively. Data was analyzed through Spss Version 18 and by descriptive and analytic statistics. The findings of the study revealed that user name and password were the most important methods to authenticate the nurses, with mean percent of 95% and 80%, respectively, and also the most significant level of information security protection were assigned to administrative and logical controls. There was no significant difference between opinions of both groups studied about the levels of information security protection and security requirements (p>0.05). Moreover the access to servers by authorized people, periodic security update, and the application of authentication and authorization were defined as the most basic security requirements from the viewpoint of more than 88 percent of recently-mentioned participants. Computer companies as system designers and hospitals information technology specialists as systems users and stakeholders present many important views about security requirements for EHR systems and nursing electronic documentation systems. Prioritizing of these requirements helps policy makers to decide what to do when planning for EHR implementation. Therefore, to make appropriate security decisions and to achieve the expected level of protection of the electronic nursing information, it is suggested to consider the priorities of both groups of experts about security principles and also discuss the issues seem to be different between two groups of participants in the research.
Evaluation of the functional performance and technical quality of an Electronic Documentation System of the Nursing Process.

PubMed

de Oliveira, Neurilene Batista; Peres, Heloisa Helena Ciqueto

2015-01-01

To evaluate the functional performance and the technical quality of the Electronic Documentation System of the Nursing Process of the Teaching Hospital of the University of São Paulo. exploratory-descriptive study. The Quality Model of regulatory standard 25010 and the Evaluation Process defined under regulatory standard 25040, both of the International Organization for Standardization/International Electrotechnical Commission. The quality characteristics evaluated were: functional suitability, reliability, usability, performance efficiency, compatibility, security, maintainability and portability. The sample was made up of 37 evaluators. in the evaluation of the specialists in information technology, only the characteristic of usability obtained a rate of positive responses of less than 70%. For the nurse lecturers, all the quality characteristics obtained a rate of positive responses of over 70%. The staff nurses of the medical and surgical clinics with experience in using the system) and staff nurses from other units of the hospital and from other health institutions (without experience in using the system) obtained rates of positive responses of more than 70% referent to the functional suitability, usability, and security. However, performance efficiency, reliability and compatibility all obtained rates below the parameter established. the software achieved rates of positive responses of over 70% for the majority of the quality characteristics evaluated.
Definition, structure, content, use and impacts of electronic health records: a review of the research literature.

PubMed

Häyrinen, Kristiina; Saranto, Kaija; Nykänen, Pirkko

2008-05-01

This paper reviews the research literature on electronic health record (EHR) systems. The aim is to find out (1) how electronic health records are defined, (2) how the structure of these records is described, (3) in what contexts EHRs are used, (4) who has access to EHRs, (5) which data components of the EHRs are used and studied, (6) what is the purpose of research in this field, (7) what methods of data collection have been used in the studies reviewed and (8) what are the results of these studies. A systematic review was carried out of the research dealing with the content of EHRs. A literature search was conducted on four electronic databases: Pubmed/Medline, Cinalh, Eval and Cochrane. The concept of EHR comprised a wide range of information systems, from files compiled in single departments to longitudinal collections of patient data. Only very few papers offered descriptions of the structure of EHRs or the terminologies used. EHRs were used in primary, secondary and tertiary care. Data were recorded in EHRs by different groups of health care professionals. Secretarial staff also recorded data from dictation or nurses' or physicians' manual notes. Some information was also recorded by patients themselves; this information is validated by physicians. It is important that the needs and requirements of different users are taken into account in the future development of information systems. Several data components were documented in EHRs: daily charting, medication administration, physical assessment, admission nursing note, nursing care plan, referral, present complaint (e.g. symptoms), past medical history, life style, physical examination, diagnoses, tests, procedures, treatment, medication, discharge, history, diaries, problems, findings and immunization. In the future it will be necessary to incorporate different kinds of standardized instruments, electronic interviews and nursing documentation systems in EHR systems. The aspects of information quality most often explored in the studies reviewed were the completeness and accuracy of different data components. It has been shown in several studies that the use of an information system was conducive to more complete and accurate documentation by health care professionals. The quality of information is particularly important in patient care, but EHRs also provide important information for secondary purposes, such as health policy planning. Studies focusing on the content of EHRs are needed, especially studies of nursing documentation or patient self-documentation. One future research area is to compare the documentation of different health care professionals with the core information about EHRs which has been determined in national health projects. The challenge for ongoing national health record projects around the world is to take into account all the different types of EHRs and the needs and requirements of different health care professionals and consumers in the development of EHRs. A further challenge is the use of international terminologies in order to achieve semantic interoperability.
Effect of electronic report writing on the quality of nursing report recording

PubMed Central

Heidarizadeh, Khadijeh; Rassouli, Maryam; Manoochehri, Houman; Tafreshi, Mansoureh Zagheri; Ghorbanpour, Reza Kashef

2017-01-01

Background and Aim Recording performed nursery actions is one of the main chores of nurses. The findings have shown that recorded reports are not qualitatively valid. Since electronic reports can be regarded as a base to write reports, this study aims at determining the effect of utilizing electronic nursing reports on the quality of the records. Methods This quasi-experimental study was conducted with the aim of applying an electronic system of nursing recording in the heart department of Shahid Rahimi Medical Center, Lorestan University of Medical Science. The samples were nursing reports on the hospitalized patients in the heart department, the basis of complete enumeration (census) during the fall of 2014. The subjects were sixteen employed nurses. To do the study, the software of nursing records was set based on the Clinical Care Classification system (CCC). The research’s tool was the checklist of the Standards of Nursing Documentation. Results The findings indicated that before and after the intervention, the amount of reports’ adaption with the written standards, respectively, was (21.8%) and (71.3%), and the most complete recording was medicine status (58%) and (100%). The worst complete recording before the intervention, acute changes was (99.1%) and nursing processes was (78%) and after, the medicine status, intake and output status and patient’s education (100%); while the nursing report structure was regarded in all cases (100%). The results showed that there is a significant difference in the quality of reporting before and after using CCC (p<0.001). Conclusions Since the necessary parameters for recording a standard report do exist in electronic reporting (CCC), from one point, nurses are reminded to record the necessary parts and from the other point, the system does not allow the user to shut it down unless the necessary parameters are recorded. For this reason, the quality of recorded reports with electronic reporting improves. PMID:29238481
Electronic mail communication--management strategies.

PubMed

Strasser, Patricia B

2003-12-01

Electronic communication has come a long way in the past 30 years. It will no doubt continue to improve and remain the primary communication vehicle for businesses. Occupational health nurses, like other business professionals, must use email to their advantage to improve their practice. However, electronic mail communication must be managed in the same manner as records and documents produced in any form or media.
An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records.

PubMed

Müller-Staub, Maria; de Graaf-Waar, Helen; Paans, Wolter

2016-11-01

Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.
Automatic generation of nursing narratives from entity-attribute-value triplet for electronic nursing records system.

PubMed

Min, Yul Ha; Park, Hyeoun-Ae; Lee, Joo Yun; Jo, Soo Jung; Jeon, Eunjoo; Byeon, Namsoo; Choi, Seung Yong; Chung, Eunja

2014-01-01

The aim of this study is to develop and evaluate a natural language generation system to populate nursing narratives using detailed clinical models. Semantic, contextual, and syntactical knowledges were extracted. A natural language generation system linking these knowledges was developed. The quality of generated nursing narratives was evaluated by the three nurse experts using a five-point rating scale. With 82 detailed clinical models, in total 66,888 nursing narratives in four different types of statement were generated. The mean scores for overall quality was 4.66, for content 4.60, for grammaticality 4.40, for writing style 4.13, and for correctness 4.60. The system developed in this study generated nursing narratives with different levels of granularity. The generated nursing narratives can improve semantic interoperability of nursing data documented in nursing records.
Effects of using mobile device-based academic electronic medical records for clinical practicum by undergraduate nursing students: A quasi-experimental study.

PubMed

Choi, Mona; Lee, HyeongSuk; Park, Joon Ho

2018-02-01

The academic electronic medical record (AEMR) system is applied with the expectation that nursing students will be able to attain competence in healthcare decision-making and nursing informatics competencies. However, there is insufficient evidence regarding the advantage of applying mobile devices to clinical practicum. This study aimed to examine the effect of an experiment that introduced a mobile AEMR application for undergraduate nursing students in their practicum. A quasi-experimental design was used. The subjects were 75 third-year nursing students enrolled in clinical practicum and were divided into an experimental (practicum with AEMR) and a control (conventional practicum) group. Nursing informatics competencies, critical thinking disposition, and satisfaction with clinical practicum were measured before and after the clinical practicum for each group. The usability of the AEMR application was also examined for the experimental group after the experiment. After the experiment, the experimental group showed a significant increase in the informatics knowledge domain of nursing informatics competencies in the post-test. The difference in critical thinking between the experimental and control groups was not statistically significant. Regarding satisfaction with the clinical practicum, the experimental group exhibited a significantly higher level of satisfaction in "preparation of a diagnostic test or laboratory test and understanding of the results" and "nursing intervention and documentation" than the control group. Students who participated in the practicum using the AEMR application considered it useful. The AEMR application was an effective educational method for practicing the immediate documentation of students' observations and interventions and was available at the patients' bedsides. To improve critical thinking, it is necessary to apply a variety of approaches when solving clinical problems. Copyright © 2017 Elsevier Ltd. All rights reserved.

Best practices in nursing homes. Clinical supervision, management, and human resource practices.

PubMed

Dellefield, Mary Ellen

2008-07-01

Human resource practices including supervision and management are associated with organizational performance. Evidence supportive of such an association in nursing homes is found in the results of numerous research studies conducted during the past 17 years. In this article, best practices related to this topic have been culled from descriptive, explanatory, and intervention studies in a range of interdisciplinary research journals published between 1990 and 2007. Identified best practices include implementation of training programs on supervision and management for licensed nurses, certified nursing assistant job enrichment programs, implementation of consistent nursing assignments, and the use of electronic documentation. Organizational barriers and facilitators of these best practices are described. Copyright 2009, SLACK Incorporated.
An observational study of the accuracy and completeness of an anesthesia information management system: recommendations for documentation system changes.

PubMed

Wilbanks, Bryan A; Moss, Jacqueline A; Berner, Eta S

2013-08-01

Anesthesia information management systems must often be tailored to fit the environment in which they are implemented. Extensive customization necessitates that systems be analyzed for both accuracy and completeness of documentation design to ensure that the final record is a true representation of practice. The purpose of this study was to determine the accuracy of a recently installed system in the capture of key perianesthesia data. This study used an observational design and was conducted using a convenience sample of nurse anesthetists. Observational data of the nurse anesthetists'delivery of anesthesia care were collected using a touch-screen tablet computer utilizing an Access database customized observational data collection tool. A questionnaire was also administered to these nurse anesthetists to assess perceived accuracy, completeness, and satisfaction with the electronic documentation system. The major sources of data not documented in the system were anesthesiologist presence (20%) and placement of intravenous lines (20%). The major sources of inaccuracies in documentation were gas flow rates (45%), medication administration times (30%), and documentation of neuromuscular function testing (20%)-all of the sources of inaccuracies were related to the use of charting templates that were not altered to reflect the actual interventions performed.
Intermittent Auscultation for Intrapartum Fetal Heart Rate Surveillance: American College of Nurse-Midwives.

PubMed

2015-01-01

Fetal heart rate surveillance is a standard component of intrapartum care. The fetal heart rate can be evaluated using intermittent auscultation or electronic fetal monitoring. Research that has compared these 2 strategies found them to be equivalent with respect to long-term neonatal outcomes. The purpose of this clinical bulletin by the American College of Nurse-Midwives is to review the evidence for use of intermittent auscultation and provide recommendations for intermittent auscultation technique, interpretation, and documentation. © 2015 by the American College of Nurse-Midwives.
Back to the future: An online OSCE Management Information System for nursing OSCEs.

PubMed

Meskell, Pauline; Burke, Eimear; Kropmans, Thomas J B; Byrne, Evelyn; Setyonugroho, Winny; Kennedy, Kieran M

2015-11-01

The Objective Structured Clinical Examination (OSCE) is an established tool in the repertoire of clinical assessment methods in nurse education. The use of OSCEs facilitates the assessment of psychomotor skills as well as knowledge and attitudes. Identified benefits of OSCE assessment include development of students' confidence in their clinical skills and preparation for clinical practice. However, a number of challenges exist with the traditional paper methodology, including documentation errors and inadequate student feedback. To explore electronic OSCE delivery and evaluate the benefits of using an electronic OSCE management system. To explore assessors' perceptions of and attitudes to the computer based package. This study was conducted using electronic software in the management of a four station OSCE assessment with a cohort of first year undergraduate nursing students delivered over two consecutive years (n=203) in one higher education institution in Ireland. A quantitative descriptive survey methodology was used to obtain the views of the assessors on the process and outcome of using the software. OSCE documentation was converted to electronic format. Assessors were trained in the use of the OSCE management software package and laptops were procured to facilitate electronic management of the OSCE assessment. Following the OSCE assessment, assessors were invited to evaluate the experience. Electronic software facilitated the storage and analysis of overall group and individual results thereby offering considerable time savings. Submission of electronic forms was allowed only when fully completed thus removing the potential for missing data. The feedback facility allowed the student to receive timely evaluation on their performance and to benchmark their performance against the class. Assessors' satisfaction with the software was high. Analysis of assessment results can highlight issues around internal consistency being moderate and examiners variability. Regression analysis increases fairness of result calculations. Copyright © 2015. Published by Elsevier Ltd.
Evolution and revision of the Perioperative Nursing Data Set.

PubMed

Petersen, Carol; Kleiner, Cathy

2011-01-01

The Perioperative Nursing Data Set (PNDS) is a nursing language that provides standardized terminology to support perioperative nursing practice. The PNDS represents perioperative nursing knowledge and comprises data elements and definitions that demonstrate the nurse's influence on patient outcomes. Emerging issues and changes in practice associated with the PNDS standardized terminology require ongoing maintenance and periodic in-depth review of its content. Like each new edition of the Perioperative Nursing Data Set, the third edition, published in 2010, underwent content validation by numerous experts in clinical practice, vocabulary development, and informatics. The goal of this most recent edition is to enable the perioperative nurse to use the PNDS in a meaningful manner, as well as to promote standardization of PNDS implementation in practice, both in written documentation and the electronic health record. Copyright © 2011 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Big Data and Perioperative Nursing.

PubMed

Westra, Bonnie L; Peterson, Jessica J

2016-10-01

Big data are large volumes of digital data that can be collected from disparate sources and are challenging to analyze. These data are often described with the five "Vs": volume, velocity, variety, veracity, and value. Perioperative nurses contribute to big data through documentation in the electronic health record during routine surgical care, and these data have implications for clinical decision making, administrative decisions, quality improvement, and big data science. This article explores methods to improve the quality of perioperative nursing data and provides examples of how these data can be combined with broader nursing data for quality improvement. We also discuss a national action plan for nursing knowledge and big data science and how perioperative nurses can engage in collaborative actions to transform health care. Standardized perioperative nursing data has the potential to affect care far beyond the original patient. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis.

PubMed

Dowding, Dawn W; Turley, Marianne; Garrido, Terhilda

2012-01-01

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes. Interrupted time series analysis, 2003-2009. A large US not-for-profit integrated health care organization. 29 hospitals in Northern and Southern California. An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools. 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). 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). 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.
IT adoption of clinical information systems in Austrian and German hospitals: results of a comparative survey with a focus on nursing

PubMed Central

2010-01-01

Background IT adoption is a process that is influenced by different external and internal factors. This study aimed 1. to identify similarities and differences in the prevalence of medical and nursing IT systems in Austrian and German hospitals, and 2. to match these findings with characteristics of the two countries, in particular their healthcare system, and with features of the hospitals. Methods In 2007, all acute care hospitals in both countries received questionnaires with identical questions. 12.4% in Germany and 34.6% in Austria responded. Results The surveys revealed a consistent higher usage of nearly all clinical IT systems, especially nursing systems, but also PACS and electronic archiving systems, in Austrian than in German hospitals. These findings correspond with a significantly wider use of standardised nursing terminologies and a higher number of PC workstations on the wards (average 2.1 PCs in Germany, 3.2 PCs in Austria). Despite these differences, Austrian and German hospitals both reported a similar IT budget of 2.6% in Austria and 2.0% in Germany (median). Conclusions Despite the many similarities of the Austrian and German healthcare system there are distinct differences which may have led to a wider use of IT systems in Austrian hospitals. In nursing, the specific legal requirement to document nursing diagnoses in Austria may have stimulated the use of standardised terminologies for nursing diagnoses and the implementation of electronic nursing documentation systems. Other factors which correspond with the wider use of clinical IT systems in Austria are: good infrastructure of medical-technical devices, rigorous organisational changes which had led to leaner processes and to a lower length of stay, and finally a more IT friendly climate. As country size is the most pronounced difference between Germany and Austria it could be that smaller countries, such as Austria, are more ready to translate innovation into practice. PMID:20122275
Design of the SGML-based electronic patient record system with the use of object-oriented analysis methods.

PubMed

Kuikka, E; Eerola, A; Porrasmaa, J; Miettinen, A; Komulainen, J

1999-01-01

Since a patient record is typically a document updated by many users, required to be represented in many different layouts, and transferred from place to place, it is a good candidate to be represented structured and coded using the SGML document standard. The use of the SGML requires that the structure of the document is defined in advance by a Document Type Definition (DTD) and the document follows it. This paper represents a method which derives an SGML DTD by starting from the description of the usage of the patient record in medical care and nursing.
Vital sign documentation in electronic records: The development of workarounds.

PubMed

Stevenson, Jean E; Israelsson, Johan; Nilsson, Gunilla; Petersson, Goran; Bath, Peter A

2018-06-01

Workarounds are commonplace in healthcare settings. An increase in the use of electronic health records has led to an escalation of workarounds as healthcare professionals cope with systems which are inadequate for their needs. Closely related to this, the documentation of vital signs in electronic health records has been problematic. The accuracy and completeness of vital sign documentation has a direct impact on the recognition of deterioration in a patient's condition. We examined workflow processes to identify workarounds related to vital signs in a 372-bed hospital in Sweden. In three clinical areas, a qualitative study was performed with data collected during observations and interviews and analysed through thematic content analysis. We identified paper workarounds in the form of handwritten notes and a total of eight pre-printed paper observation charts. Our results suggested that nurses created workarounds to allow a smooth workflow and ensure patients safety.
A ward-based time study of paper and electronic documentation for recording vital sign observations.

PubMed

Wong, David; Bonnici, Timothy; Knight, Julia; Gerry, Stephen; Turton, James; Watkinson, Peter

2017-07-01

To investigate time differences in recording observations and an early warning score using traditional paper charts and a novel e-Obs system in clinical practice. Researchers observed the process of recording observations and early warning scores across 3 wards in 2 university teaching hospitals immediately before and after introduction of the e-Obs system. The process of recording observations included both measurement and documentation of vital signs. Interruptions were timed and subtracted from the measured process duration. Multilevel modeling was used to compensate for potential confounding factors. In all, 577 nurse events were observed (281 paper, 296 e-Obs). The geometric mean time to take a complete set of vital signs was 215 s (95% confidence interval [CI], 177 s-262 s) on paper, and 150 s (95% CI, 130 s-172 s) electronically. The treatment effect ratio was 0.70 (95% CI, 0.57-0.85, P < .001). The treatment effect ratio in ward 1 was 0.37 (95% CI, 0.26-0.53), in ward 2 was 0.98 (95% CI, 0.70-1.38), and in ward 3 was 0.93 (95% CI, 0.66-1.33). Introduction of an e-Obs system was associated with a statistically significant reduction in overall time to measure and document vital signs electronically compared to paper documentation. The reductions in time varied among wards and were of clinical significance on only 1 of 3 wards studied. Our results suggest that introduction of an e-Obs system could lower nursing workload as well as increase documentation quality. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com
Evidence-based practice and related information literacy skills of nurses in Singapore: an exploratory case study.

PubMed

Mokhtar, Intan Azura; Majid, Shaheen; Foo, Schubert; Zhang, Xue; Theng, Yin-Leng; Chang, Yun-Ke; Luyt, Brendan

2012-03-01

Increased demand for medical or healthcare services has meant that nurses are to take on a more proactive and independent role intending to patients, providing basic treatment and deciding relevant clinical practice. This, in turn, translates into the need for nurses to be able to translate research and evidence into their practice more efficiently and effectively. Hence, competencies in looking for, evaluating, synthesizing and applying documented information or evidence-based practice becomes crucial. This article presents a quantitative study that involved more than 300 nurses from a large government hospital in Singapore. A self-reporting questionnaire was developed to collect data pertaining to evidence-based practice and activities, including those that demonstrate information literacy competencies. Results seem to suggest that the nurses preferred to use print and human information sources compared to electronic information sources; were not proactive in looking up research or evidence-based information and, instead, preferred such information to be fed to them; and that they perceived they lacked the ability to evaluate research papers or effectively search electronic information related to nursing or evidence-based practice. It was also found that more than 80% of the nurses have not had any training related to evidence-based practice.
Development of electronic medical record charting for hospital-based transfusion and apheresis medicine services: Early adoption perspectives

PubMed Central

Levy, Rebecca; Pantanowitz, Liron; Cloutier, Darlene; Provencher, Jean; McGirr, Joan; Stebbins, Jennifer; Cronin, Suzanne; Wherry, Josh; Fenton, Joseph; Donelan, Eileen; Johari, Vandita; Andrzejewski, Chester

2010-01-01

Background: Electronic medical records (EMRs) provide universal access to health care information across multidisciplinary lines. In pathology departments, transfusion and apheresis medicine services (TAMS) involved in direct patient care activities produce data and documentation that typically do not enter the EMR. Taking advantage of our institution's initiative for implementation of a paperless medical record, our TAMS division set out to develop an electronic charting (e-charting) strategy within the EMR. Methods: A focus group of our hospital's transfusion committee consisting of transfusion medicine specialists, pathologists, residents, nurses, hemapheresis specialists, and information technologists was constituted and charged with the project. The group met periodically to implement e-charting TAMS workflow and produced electronic documents within the EMR (Cerner Millenium) for various service line functions. Results: The interdisciplinary working group developed and implemented electronic versions of various paper-based clinical documentation used by these services. All electronic notes collectively gather and reside within a unique Transfusion Medicine Folder tab in the EMR, available to staff with access to patient charts. E-charting eliminated illegible handwritten notes, resulted in more consistent clinical documentation among staff, and provided greater realered. However, minor updates and corrections to documents as well as select work re-designs were required for optimal use of e-charting-time review/access of hemotherapy practices. No major impediments to workflow or inefficiencies have been encount by these services. Conclusion: Documentation of pathology subspecialty activities such as TAMS can be successfully incorporated into the EMR. E-charting by staff enhances communication and helps promote standardized documentation of patient care within and across service lines. Well-constructed electronic documents in the EMR may also enhance data mining, quality improvement, and biovigilance monitoring activities. PMID:20805955
Color-Coded Labels Cued Nurses to Adhere to Central Line Connector Change.

PubMed

Morrison, Theresa Lynch; Laney, Christina; Foglesong, Jan; Brennaman, Laura

2016-01-01

This study examined nurses' adherence to policies regarding needleless connector changes using a novel, day-of-the-week, color-coded label compared with usual care that relied on electronic medical record (EMR) documentation. This was a prospective, comparative study. The study was performed on 4 medical-surgical units in a seasonally fluctuating, 715-bed healthcare system composed of 2 community hospitals. Convenience sample was composed of adults with central lines hospitalized for 4 or more days. At 4-day intervals, investigators observed bedside label use and EMR needleless connector change documentation. Control patients received standard care-needleless connector change with associated documentation in the EMR. Intervention patients, in addition to standard care, had a day-of-the-week, color-coded label placed on each needleless connector. To account for clustering within unit, multinomial logistic regression models using survey sampling methodology were used to conduct Wald χ tests. A multinominal odds ratio and 95% confidence interval (CI) provided an estimate of using labels that were provided on units relative to usual care documentation of needleless connector change in the EMR. In 335 central line observations, the units with labels (n = 205) had a 321% increase rate of documentation of needleless connector change in the EMR (odds ratio, 4.21; 95% CI, 1.76-10.10; P = .003) compared with the usual care control patients. For units with labels, when labels were present, placement of labels on needleless connectors increased the odds that nurses documented connector changes per policy (4.72; 95% CI, 2.02, 10.98; P = .003). Day-of-the-week, color-coded labels cued nurses to document central line needleless connector change in the EMR, which increased adherence to the needleless connector change policy. Providing day-of-the-week, color-coded needleless connector labels increased EMR documentation of timely needleless connector changes. Timely needleless connector changes may lower the incidence of central line-associated bloodstream infection.
XML technologies for the Omaha System: a data model, a Java tool and several case studies supporting home healthcare.

PubMed

Vittorini, Pierpaolo; Tarquinio, Antonietta; di Orio, Ferdinando

2009-03-01

The eXtensible markup language (XML) is a metalanguage which is useful to represent and exchange data between heterogeneous systems. XML may enable healthcare practitioners to document, monitor, evaluate, and archive medical information and services into distributed computer environments. Therefore, the most recent proposals on electronic health records (EHRs) are usually based on XML documents. Since none of the existing nomenclatures were specifically developed for use in automated clinical information systems, but were adapted to such use, numerous current EHRs are organized as a sequence of events, each represented through codes taken from international classification systems. In nursing, a hierarchically organized problem-solving approach is followed, which hardly couples with the sequential organization of such EHRs. Therefore, the paper presents an XML data model for the Omaha System taxonomy, which is one of the most important international nomenclatures used in the home healthcare nursing context. Such a data model represents the formal definition of EHRs specifically developed for nursing practice. Furthermore, the paper delineates a Java application prototype which is able to manage such documents, shows the possibility to transform such documents into readable web pages, and reports several case studies, one currently managed by the home care service of a Health Center in Central Italy.
Transforming to a computerized system for nursing care: organizational success within Magnet idealism.

PubMed

Lindgren, Carolyn L; Elie, Leslie G; Vidal, Elizabeth C; Vasserman, Alex

2010-01-01

In reaching the goal for standardized, quality care, a not-for-profit healthcare system consisting of seven institutional entities is transforming nursing practice guidelines, patient care workflow, and patient documents into electronic, online, real-time modalities for use across departments and all healthcare delivery entities of the system. Organizational structure and a strategic plan were developed for the 2-year Clinical Transformation Project. The Siemens Patient Care Document System was adopted and adapted to the hospitals' documentation and information needs. Two fast-track sessions of more than 100 nurses and representatives from other health disciplines were held to standardize assessments, histories, care protocols, and interdisciplinary plans of care for the top 10 diagnostic regulatory groups. Education needs of the users were addressed. After the first year, a productive, functional system is evidenced. For example, the bar-coded Medication Administration Check System is in full use on the clinical units of one of the hospitals, and the other institutional entities are at substantial stages of implementation of Patient Care Documentation System. The project requires significant allocation of personnel and financial resources for a highly functional informatics system that will transform clinical care. The project exemplifies four of the Magnet ideals and serves as a model for others who may be deciding about launching a similar endeavor.
Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a two-year study.

PubMed

Ammenwerth, Elske; Mansmann, Ulrich; Iller, Carola; Eichstädter, Ronald

2003-01-01

The documentation of the nursing process is an important but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems such as low quality of documentation are reported. It is unclear whether computer-based documentation systems can reduce these problems and which factors influence their acceptance by users. We introduced a computer-based nursing documentation system on four wards of the University Hospitals of Heidelberg and systematically evaluated its preconditions and its effects in a pretest-posttest intervention study. For the analysis of user acceptance, we concentrated on subjective data drawn from questionnaires and interviews. A questionnaire was developed using items from published questionnaires and items that had to be developed for the special purpose of this study. The quantitative results point to two factors influencing the acceptance of a new computer-based documentation system: the previous acceptance of the nursing process and the previous amount of self-confidence when using computers. On one ward, the diverse acceptance scores heavily declined after the introduction of the nursing documentation system. Explorative qualitative analysis on this ward points to further success factors of computer-based nursing documentation systems. Our results can be used to assist the planning and introduction of computer-based nursing documentation systems. They demonstrate the importance of computer experience and acceptance of the nursing process on a ward but also point to other factors such as the fit between nursing workflow and the functionality of a nursing documentation system.
[Interrelationship among "NANDA, NOC and NIC". A pilot study and an evaluation of a nursing document].

PubMed

Gomez de Segura Navarro, Carlota; Esain Larrambe, Ainhoa; Tina Majuelo, Pilar; Guembe Ibáñez, Irene; Fernández Perea, Laura; Narvaiza Solís, M Jesús

2006-01-01

(a) to determine the effectiveness of a nursing document which integrates nursing diagnoses, nursing treatments/actions (NIC), and results (NOC); (b) to verify the application of the aforementioned document in a hospitalization unit. A descriptive, transversal and observational study. Nursing documents (NANDA, NIC and NOC taxonomies). PHASES: 1st: analysis of the content in the nursing documentation for 23 pneumonic patients: Selection of nursing diagnoses and the most frequent interdependent problems. 2nd: Selection of results and nursing treatment/actions. 3rd: Elaboration of the document and a description of the Likert scales to define the state of the indicators for each result. 4th: A pilot study of the document applied to 12 patients. the application of the document permits one to identify the real status of a patient; to establish specific objectives; to improve the recording of data; to observe the effectiveness of treatment; to include educational activities; to give greater continuity and quality to a treatment plan.
The effects of the application of SIMPRO on the completeness and time efficiency of nursing documentation in the outpatient instalation at Dompet Dhuafa Hospital Parung

NASA Astrophysics Data System (ADS)

Dwisatyadini, M.; Hariyati, R. T. S.; Afifah, E.

2018-03-01

Nursing documentation is clinical information that has a vital role in nursing services. The nursing process includes assessment, diagnosis, intervention, implementation, and evaluation. The purpose of this study was to determine the effects of the application of SIMPRO on the completeness and the efficiency of nursing documentation in the outpatient installation at Dompet Dhuafa Hospital Parung. This study used quantitative method with pre experimental (pre and posttest without control group) design. The mean of the documentation completeness marks before the application of SIMPRO was 1.87 (SD 0.922), and after SIMPRO was applied increased to 3.61 (0.588). This increase indicated an improvement of the nursing documentation completeness after the implementation of SIMPRO. The mean of time needed by nurses in documenting the nursing care before the application of SIMPRO was 476.13 seconds (SD 78.896). The mean of documenting time decreased more than a half after the application of SIMPRO which was 202.52 seconds (SD 196.723). SIMPRO made a nurse easier to take a decision analysis and decision support system to nursing care plan and documentation.
E-documentation as a process management tool for nursing care in hospitals.

PubMed

Rajkovic, Uros; Sustersic, Olga; Rajkovic, Vladislav

2009-01-01

Appropriate documentation plays a key role in process management in nursing care. It includes holistic data management based on patient's data along the clinical path with regard to nursing care. We developed an e-documentation model that follows the process method of work in nursing care. It assesses the patient's status on the basis of Henderson's theoretical model of 14 basic living activities and is aligned with internationally recognized nursing classifications. E-documentation development requires reengineering of existing documentation and facilitates process reengineering. A prototype solution of an e-nursing documentation, already being in testing process at University medical centres in Ljubljana and Maribor, will be described.

What big size you have! Using effect sizes to determine the impact of public health nursing interventions.

PubMed

Johnson, K E; McMorris, B J; Raynor, L A; Monsen, K A

2013-01-01

The Omaha System is a standardized interface terminology that is used extensively by public health nurses in community settings to document interventions and client outcomes. Researchers using Omaha System data to analyze the effectiveness of interventions have typically calculated p-values to determine whether significant client changes occurred between admission and discharge. However, p-values are highly dependent on sample size, making it difficult to distinguish statistically significant changes from clinically meaningful changes. Effect sizes can help identify practical differences but have not yet been applied to Omaha System data. We compared p-values and effect sizes (Cohen's d) for mean differences between admission and discharge for 13 client problems documented in the electronic health records of 1,016 young low-income parents. Client problems were documented anywhere from 6 (Health Care Supervision) to 906 (Caretaking/parenting) times. On a scale from 1 to 5, the mean change needed to yield a large effect size (Cohen's d ≥ 0.80) was approximately 0.60 (range = 0.50 - 1.03) regardless of p-value or sample size (i.e., the number of times a client problem was documented in the electronic health record). Researchers using the Omaha System should report effect sizes to help readers determine which differences are practical and meaningful. Such disclosures will allow for increased recognition of effective interventions.
Sources of information used to support quality use of medicines: findings from a national survey of nurse practitioners in Australia.

PubMed

Buckley, Thomas; Stasa, Helen; Cashin, Andrew; Stuart, Meg; Dunn, Sandra V

2015-02-01

The purpose of this study was to investigate the sources, both print and electronic formats, which Australian nurse practitioners (NPs) currently use to obtain information regarding quality use of medicines (QUM). An additional aim was to document NPs' preferences for continuing education in relation to QUM. A national electronic survey of Australian NPs was conducted in 2007 and again in 2010. Eighty percent of respondents accessed information on QUM from professional literature, which may include scholarly journal articles, reports, and independent publications. There was a decrease in the percentage of respondents who obtained information from drug industry representatives. NPs prefer to receive medicines information in an electronic form, rather than a paper-based version, and over the time period more NPs are utilizing electronic sources rather than paper. These findings provide important insights into medical information products for the developers who may be able to use these results to ensure that their products meet the needs of NP clinicians. Additionally, the finding that NPs prefer to receive their continuing information related to medicines in electronic format, but also highly value conference proceedings, may help to inform future planning of NP education needs in relation to QUM. ©2014 American Association of Nurse Practitioners.
Use of and attitudes to a hospital information system by medical secretaries, nurses and physicians deprived of the paper-based medical record: a case report.

PubMed

Laerum, Hallvard; Karlsen, Tom H; Faxvaag, Arild

2004-10-16

Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians. We have used questionnaires and interviews to assess and compare frequency of use of the HIS for essential tasks, task performance and user satisfaction among medical secretaries, nurses and physicians. The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images. Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS.
Use of and attitudes to a hospital information system by medical secretaries, nurses and physicians deprived of the paper-based medical record: a case report

PubMed Central

Lærum, Hallvard; Karlsen, Tom H; Faxvaag, Arild

2004-01-01

Background Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians. Methods We have used questionnaires and interviews to assess and compare frequency of use of the HIS for essential tasks, task performance and user satisfaction among medical secretaries, nurses and physicians. Results The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images. Conclusions Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS. PMID:15488150
A professional curriculum vitae will open career doors.

PubMed

Harper, D S

1999-01-01

In today's challenging healthcare environment, it is essential for nurse practitioners to be able to describe themselves professionally on paper to compete for practice and academic opportunities. Nurse practitioners are competing with physician assistants as well as physicians for primary and acute care positions. A carefully compiled curriculum vitae will present the individual in the best light possible to help open career doors and enhance chances of success. Preparing a curriculum vitae will serve to highlight relevant professional accomplishments, whatever the setting, toward the fulfillment of professional goals. This article reviews the current professional print and electronic literature on preparing a curriculum vitae to assist the nurse practitioner in developing this vital document.
Conversion of School Nurse Policy and Procedure Manual to Electronic Format

ERIC Educational Resources Information Center

Randall, Joellyn; Knee, Rachel; Galemore, Cynthia

2006-01-01

Policy and procedure manuals are essential to establishing standards of practice and ensuring quality of care to students and families. The Olathe District Schools (Kansas) Technology Department created the Virtual File Cabinet to provide online access to employee policies, school board policies, forms, and other documents. A task force of school…
The Effects of a Web-Based Nursing Process Documentation Program on Stress and Anxiety of Nursing Students in South Korea.

PubMed

Lee, Eunjoo; Noh, Hyun Kyung

2016-01-01

To examine the effects of a web-based nursing process documentation system on the stress and anxiety of nursing students during their clinical practice. A quasi-experimental design was employed. The experimental group (n = 110) used a web-based nursing process documentation program for their case reports as part of assignments for a clinical practicum, whereas the control group (n = 106) used traditional paper-based case reports. Stress and anxiety levels were measured with a numeric rating scale before, 2 weeks after, and 4 weeks after using the web-based nursing process documentation program during a clinical practicum. The data were analyzed using descriptive statistics, t tests, chi-square tests, and repeated-measures analyses of variance. Nursing students who used the web-based nursing process documentation program showed significant lower levels of stress and anxiety than the control group. A web-based nursing process documentation program could be used to reduce the stress and anxiety of nursing students during clinical practicum, which ultimately would benefit nursing students by increasing satisfaction with and effectiveness of clinical practicum. © 2015 NANDA International, Inc.
Simulation for emergency nurses (SIREN): A quasi-experimental study.

PubMed

Boyde, Mary; Cooper, Emily; Putland, Hannah; Stanton, Rikki; Harding, Christie; Learmont, Ben; Thomas, Clare; Porter, Jade; Thompson, Andrea; Nicholls, Louise

2018-06-05

Within nursing education, simulation has been recognised as an effective learning strategy. Embedding simulation within clinical units has the potential to enhance patient safety and improve clinical outcomes. However it is important to evaluate the effectiveness of this educational technique to support the actual value and effectiveness. This study aimed to implement and evaluate an innovative simulation experience for registered nurses. A high-fidelity simulation focusing on nursing assessment was conducted with 50 Registered Nurses in an Emergency Department (ED) at a large tertiary referral hospital. Two questionnaires were completed pre and post simulation to assess anxiety related to participating in the simulation, and self-efficacy in patient assessment. Participant satisfaction and self-confidence in learning was assessed post simulation. Additionally a documentation audit from the patient's electronic chart was completed to review documentation entries before and after participation in the simulation. Anxiety scores decreased significantly from pre (M = 38.56, SD = 9.87) to post (M = 33.54, SD = 8.99), t(49) = 4.273, p < 0.001. There was a statistically significant increase in self-efficacy scores from pre (M = 195.16, SD = 28.09) to post (M = 214.12, SD =25.77), t(49) = 5.072, p < 0.001. ED nurses were highly satisfied with their simulation training and they were in agreement with the statements about self-confidence in learning. There was a statistically significant increase in two components of the documentation scores; initial clinical handover increased from pre (M = 7.88, SD = 1.76) to post (M = 8.79, SD =1.22), t(41) = 3.41, p < 0.001 and indicators of urgent illness increased from pre (M = 7.33, SD = 1.95) to post (M = 8.10, SD = 1.45), t(41) =2.27, p = 0.028. This study has demonstrated that a high fidelity simulation decreased participants' anxiety, increased self-efficiency in patient assessment, and improved documentation in patient records. Additionally ED nurses were highly satisfied with the simulation training. Copyright © 2018 Elsevier Ltd. All rights reserved.
Institutional and economic influences on quality of nursing documentation.

PubMed

Parker, L E; Wells, K B; Buchanan, J L; Benjamin, B

1994-01-01

This study evaluates the quality of nursing documentation within the hospital record for a particularly vulnerable group of patients, the depressed aged. Specifically, the effects of prospective payment, unit type, hospital type, and nurse staffing levels on nursing documentation within hospital charts were assessed.
The relationship among pressure ulcer risk factors, incidence and nursing documentation in hospital-acquired pressure ulcer patients in intensive care units.

PubMed

Li, Dan

2016-08-01

To explore the quality/comprehensiveness of nursing documentation of pressure ulcers and to investigate the relationship between the nursing documentation and the incidence of pressure ulcers in four intensive care units. Pressure ulcer prevention requires consistent assessments and documentation to decrease pressure ulcer incidence. Currently, most research is focused on devices to prevent pressure ulcers. Studies have rarely considered the relationship among pressure ulcer risk factors, incidence and nursing documentation. Thus, a study to investigate this relationship is needed to fill this information gap. A retrospective, comparative, descriptive, correlational study. A convenience sample of 196 intensive care units patients at the selected medical centre comprised the study sample. All medical records of patients admitted to intensive care units between the time periods of September 1, 2011 through September 30, 2012 were audited. Data used in the analysis included 98 pressure ulcer patients and 98 non-pressure ulcer patients. The quality and comprehensiveness of pressure ulcer documentation were measured by the modified European Pressure Ulcer Advisory Panel Pressure Ulcers Assessment Instrument and the Comprehensiveness in Nursing Documentation instrument. The correlations between quality/comprehensiveness of pressure ulcer documentation and incidence of pressure ulcers were not statistically significant. Patients with pressure ulcers had longer length of stay than patients without pressure ulcers stay. There were no statistically significant differences in quality/comprehensiveness scores of pressure ulcer documentation between dayshift and nightshift. This study revealed a lack of quality/comprehensiveness in nursing documentation of pressure ulcers. This study demonstrates that staff nurses often perform poorly on documenting pressure ulcer appearance, staging and treatment. Moreover, nursing documentation of pressure ulcers does not provide a complete picture of patients' care needs that require nursing interventions. The implication of this study involves pressure ulcer prevention and litigable risk of nursing documentation. © 2016 John Wiley & Sons Ltd.
E-nursing documentation as a tool for quality assurance.

PubMed

Rajkovic, Vladislav; Sustersic, Olga; Rajkovic, Uros

2006-01-01

The article presents the results of a project with which we describe the reengineering of nursing documentation. Documentation in nursing is an efficient tool for ensuring quality health care and consequently quality patient treatment along the whole clinical path. We have taken into account the nursing process and patient treatment based on Henderson theoretical model of nursing that consists of 14 basic living activities. The model of new documentation enables tracing, transparency, selectivity, monitoring and analyses. All these factors lead to improvements of a health system as well as to improved safety of patients and members of nursing teams. Thus the documentation was developed for three health care segments: secondary and tertiary level, dispensaries and community health care. The new quality introduced to the documentation process by information and communication technology is presented by a database model and a software prototype for managing documentation.
Failures in communication through documents and documentation across the perioperative pathway.

PubMed

Braaf, Sandra; Riley, Robin; Manias, Elizabeth

2015-07-01

To explore how communication failures occur in documents and documentations across the perioperative pathway in nurses' interactions with other nurses, surgeons and anaesthetists. Documents and documentation are used to communicate vital patient and procedural information among nurses, and in nurses' interactions with surgeons and anaesthetists, across the perioperative pathway. Previous research indicates that communication failure regularly occurs in the perioperative setting. A qualitative study was undertaken. The study was conducted over three hospitals in Melbourne, Australia. One hundred and twenty-five healthcare professionals from the disciplines of surgery, anaesthesia and nursing participated in the study. Data collection commenced in January 2010 and concluded in October 2010. Data were generated through 350 hours of observation, two focus groups and 20 semi-structured interviews. A detailed thematic analysis was undertaken. Communication failure occurred owing to a reliance on documents and documentation to transfer information at patient transition points, poor quality documents and documentation, and problematic access to information. Institutional ruling practices of professional practice, efficiency and productivity, and fiscal constraint dominated the coordination of nurses', surgeons' and anaesthetists' communication through documents and documentation. These governing practices configured communication to be incongruous with reliably meeting safety and quality objectives. Communication failure occurred because important information was sometimes buried in documents, insufficient, inaccurate, out-of-date or not verbally reinforced. Furthermore, busy nurses were not always able to access information they required in a timely manner. Patient safety was affected, which led to delays in treatment and at times inadequate care. Organisational support needs to be provided to nurses, surgeons and anaesthetists so they have sufficient time to complete, locate, and read documents and documentation. Infrastructure supporting communication technologies should be implemented to enable the rapid retrieval, entry, and dispersion of information. © 2015 John Wiley & Sons Ltd.
Implementation of nursing process in clinical settings: the case of three governmental hospitals in Ethiopia, 2017.

PubMed

Semachew, Ayele

2018-03-13

The purpose of this survey was to evaluate the implementation of the nursing process at three randomly selected governmental hospitals found in Amhara Region North West Ethiopia. From the total 338 reviewed documents, 264 (78.1%) have a nursing process format attached with the patient's profile/file, 107 (31.7%) had no nursing diagnosis, 185 (54.7%) of nurses stated their plan of care based on priority, 173 (51.2%) of nurses did not document their interventions based on plan and 179 (53.0%) of nurses did not evaluate their interventions. The overall implementation of nursing process among Felege Hiwot Referal hospital, Debretabor general hospital and Finoteselam general hospitals were 49.12, 68.18, and 69.42% respectively. Nursing professionals shall improve documentation required in implementing the nursing process. Nursing managers (matron, ward heads) shall supervise the overall implementation of nursing process. Hospital nursing services managers (matrons) shall arrange and facilitate case presentations by the nursing staffs which focus on documentation and updates on nursing process. Hospitals need to establish and support nursing process coordinating staff in their institution.
Measuring Clinical Decision Support Influence on Evidence-Based Nursing Practice.

PubMed

Cortez, Susan; Dietrich, Mary S; Wells, Nancy

2016-07-01

To measure the effect of clinical decision support (CDS) on oncology nurse evidence-based practice (EBP). . Longitudinal cluster-randomized design. . Four distinctly separate oncology clinics associated with an academic medical center. . The study sample was comprised of randomly selected data elements from the nursing documentation software. The data elements were patient-reported symptoms and the associated nurse interventions. The total sample observations were 600, derived from a baseline, posteducation, and postintervention sample of 200 each (100 in the intervention group and 100 in the control group for each sample). . The cluster design was used to support randomization of the study intervention at the clinic level rather than the individual participant level to reduce possible diffusion of the study intervention. An elongated data collection cycle (11 weeks) controlled for temporary increases in nurse EBP related to the education or CDS intervention. . The dependent variable was the nurse evidence-based documentation rate, calculated from the nurse-documented interventions. The independent variable was the CDS added to the nursing documentation software. . The average EBP rate at baseline for the control and intervention groups was 27%. After education, the average EBP rate increased to 37%, and then decreased to 26% in the postintervention sample. Mixed-model linear statistical analysis revealed no significant interaction of group by sample. The CDS intervention did not result in an increase in nurse EBP. . EBP education increased nurse EBP documentation rates significantly but only temporarily. Nurses may have used evidence in practice but may not have documented their interventions. . More research is needed to understand the complex relationship between CDS, nursing practice, and nursing EBP intervention documentation. CDS may have a different effect on nurse EBP, physician EBP, and other medical professional EBP.
Clinical care costing method for the Clinical Care Classification System.

PubMed

Saba, Virginia K; Arnold, Jean M

2004-01-01

To provide a means for calculating the cost of nursing care using the Clinical Care Classification System (CCCS). Three CCCS indicators of care components, actions, and outcomes in conjunction with Clinical Care Pathways (CCPs). The cost of patient care is based on the type of action time multiplied by care components and nursing costs. The CCCM for the CCCS makes it possible to measure and cost out clinical practice. The CCCM may be used with CCPs in the electronic patient medical record. The CCPs make it easy to track the clinical nursing care across time, settings, population groups, and geographical locations. Collected data may be used many times, allowing for improved documentation, analysis, and costing out of care.
An Audit of Nursing Documentation at Three Public Hospitals in Jamaica.

PubMed

Lindo, Jascinth; Stennett, Rosain; Stephenson-Wilson, Kayon; Barrett, Kerry Ann; Bunnaman, Donna; Anderson-Johnson, Pauline; Waugh-Brown, Veronica; Wint, Yvonne

2016-09-01

Nursing documentation provides an important indicator of the quality of care provided for hospitalized patients. This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica. This cross-sectional study audited a multilevel stratified sample of 245 patient records from three type B hospitals. An audit instrument which assessed nursing documentation of client history, biological data, client assessment, nursing standards, discharge planning, and teaching facilitated data collection. Descriptive statistics were conducted using IBM SPSS, Version 19 (IBM Inc., Armonk, NY, USA). Records from three hospitals (Hospital 1, n = 119, 48.6%; Hospital 2, n = 56, 22.9%; Hospital 3, n = 70, 28.6%) were audited. Documented evidence of the patient's chief complaint (81.6%), history of present illness (78.8%), past health (79.2%), and family health (11.0%) were noted; however, less than a third of the dockets audited recorded adequate assessment data (e.g., occupation or living accommodations of patients). The audit noted 90% of records had a physical assessment completed within 24 hr of admission and entries timed, dated, and signed by a nurse. Less than 5% of dockets had evidence of patient teaching, and 13.5% had documented evidence of discharge planning conducted within 72 hr of admission. This study highlights the weakness in nursing documentation and the need for increased training and continued monitoring of nursing documentation at the hospitals studied. Additional research regarding the factors that affect nursing documentation practice could prove useful. The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process. © 2016 Sigma Theta Tau International.
An observational study to assess an electronic point-of-care wound documentation and reporting system regarding user satisfaction and potential for improved care.

PubMed

Florczak, Beth; Scheurich, Anne; Croghan, John; Sheridan, Philip; Kurtz, Debra; McGill, William; McClain, Bonny

2012-03-01

The integration of information technology into daily patient care potentially provides a means to standardize care and enable continuous quality improvement through improved communication among care teams. A 2-month observational study was conducted on 38 residents with pressure ulcers at a 51-bed skilled nursing facility to rate the Ease of Use and Wound Management Effectiveness of a point-of-care electronic wound documentation system. Nine nurses evaluated the use of handheld "smart phone" devices equipped with a digital camera to document pressure ulcer assessment and treatment at point of care. Ease of Use (five items) was scored on a 5-point Likert scale (5 = very easy); Wound Management Effectiveness (eight items) was scored on a 5-point Likert scale (5 = very effective). Statistically significant mean changes in nurses' ratings were found for baseline compared to 2-month follow-up by paired t-test. Ease of Use ratings across the five criteria increased from an overall mean of 3.3 at baseline to 4.7 at follow-up (P = 0.5), while Wound Management Effectiveness increased from an overall mean of 3.3 at baseline to 4.4 at follow-up (P = 0.5) . The greatest gains for single items were reviewing wound progress (mean difference = 2.35; P = 0.000) and recognizing changes in wound status (mean difference = 1.78; P = 0.001) within the Ease of Use and Wound Management Effectiveness scales, respectively. The smallest change occurred in reading charts and notes (mean difference = 0.89) and ability to determine resident's risk level (mean difference = 0.39). Further research is needed to assess use of a wound documentation system in this and other settings, as well as to ascertain validity and reliability.
Strategies for Effectively Documenting Sexual Orientation and Gender Identity in Electronic Health Record.

PubMed

Frangella, Julia; Otero, Carlos; Luna, Daniel

2018-01-01

In this communication we identify strategies for effectively documenting Sexual Orientation and Gender Identity in Electronic Health Records. For this review a multidisciplinary group composed by three physicians, a nurse, an engineer and a lawyer analyzed the evidence in bibliography related to the topic and summarized the results. After analyzing the information, we summarized and classified them into three major topics: To request, to store and to display and access to the information. How to standardize those data and where data specifically will be populated in EHRs have not been answered yet. The target of all of these efforts should be: to be sensitive with the needs of the patient and to ensure high quality of care.
Testing of Triggers by Data Mining of Epilepsy Patients' Structured Nursing Records.

PubMed

Kinnunen, Ulla-Mari; Kivekäs, Eija; Paananen, Pekka; Kälviäinen, Reetta; Saranto, Kaija

2016-01-01

Epilepsies are neurological disorders with many different etiologies, symptoms and prognoses. Care for epilepsy patients should be uniform, homogeneous and optimized to avoid unnecessary hospitalizations or even worse outcomes. FinCC-based structured nursing documentation facilitates analyzing patient profiles and populations, developing care processes, nursing documentation, decision-making, and data reuse. This research aimed to determine the potential for finding possible risks for epilepsy patients' health and well-being from the structured nursing data with defined triggers for epilepsy patients. The research data included structured documentation of nursing diagnoses of and interventions for adult epilepsy patients (n = 100) at one neurological ward in a university hospital in 2009-2013. The results showed that nurses documented abundantly, and all triggers were mostly found. The study results will be reviewed by the neurological ward nurses to assess the FinCC and highlight the importance of documentation.
An Analysis of Community Health Nurses Documentation: The Best Approach to Computerization

PubMed Central

Chalmers, M.

1988-01-01

The study explored and analyzed the actual patient-related documentation performed by a sample of community health nurses working in voluntary home health agencies. The outcome of the study was a system flow chart of that documentation and included: common components of the documentation, where in the existing systems they are recorded, when they are recorded by the nurse and why they are used by the nurses and administrative personnel in the agencies. The flow chart is suitable for use as a prototype for the development of a computer software package for the computerization of the patient-related documentation by community health nurses. General System and communication theories were used as a framework for this study. A thorough analysis of the documenation resulted in a complete and exhaustive explication of the documentation by community health nurses, as well as the identification of what parts of that documentation lend themselves most readily to computerization and what areas, if any, may not readily adapt to computerization.

A survey of user acceptance of electronic patient anesthesia records

PubMed Central

Jin, Hyun Seung; Lee, Suk Young; Jeong, Hui Yeon; Choi, Soo Joo; Lee, Hye Won

2012-01-01

Background An anesthesia information management system (AIMS), although not widely used in Korea, will eventually replace handwritten records. This hospital began using AIMS in April 2010. The purpose of this study was to evaluate users' attitudes concerning AIMS and to compare them with manual documentation in the operating room (OR). Methods A structured questionnaire focused on satisfaction with electronic anesthetic records and comparison with handwritten anesthesia records was administered to anesthesiologists, trainees, and nurses during February 2011 and the responses were collected anonymously during March 2011. Results A total of 28 anesthesiologists, 27 trainees, and 47 nurses responded to this survey. Most participants involved in this survey were satisfied with AIMS (96.3%, 82.2%, and 89.3% of trainees, anesthesiologists, and nurses, respectively) and preferred AIMS over handwritten anesthesia records in 96.3%, 71.4%, and 97.9% of trainees, anesthesiologists, and nurses, respectively. However, there were also criticisms of AIMS related to user-discomfort during short, simple or emergency surgeries, doubtful legal status, and inconvenient placement of the system. Conclusions Overall, most of the anesthetic practitioners in this hospital quickly accepted and prefer AIMS over the handwritten anesthetic records in the OR. PMID:22558502
Registered nurses' decision-making regarding documentation in patients' progress notes.

PubMed

Tower, Marion; Chaboyer, Wendy; Green, Quentine; Dyer, Kirsten; Wallis, Marianne

2012-10-01

To examine registered nurses' decision-making when documenting care in patients' progress notes. What constitutes effective nursing documentation is supported by available guidelines. However, ineffective documentation continues to be cited as a major cause of adverse events for patients. Decision-making in clinical practice is a complex process. To make an effective decision, the decision-maker must be situationally aware. The concept of situation awareness and its implications for making safe decisions has been examined extensively in air safety and more recently is being applied to health. The study was situated in a naturalistic paradigm. Purposive sampling was used to recruit 17 registered nurses who used think-aloud research methods when making decisions about documenting information in patients' progress notes. Follow-up interviews were conducted to validate interpretations. Data were analysed systematically for evidence of cues that demonstrated situation awareness as nurses made decisions about documentation. Three distinct decision-making scenarios were illuminated from the analysis: the newly admitted patient, the patient whose condition was as expected and the discharging patient. Nurses used mental models for decision-making in documenting in progress notes, and the cues nurses used to direct their assessment of patients' needs demonstrated situation awareness at different levels. Nurses demonstrate situation awareness at different levels in their decision-making processes. While situation awareness is important, it is also important to use an appropriate decision-making framework. Cognitive continuum theory is suggested as a decision-making model that could support situation awareness when nurses made decisions about documenting patient care. Because nurses are key decision-makers, it is imperative that effective decisions are made that translate into safe clinical care. Including situation awareness training, combined with employing cognitive continuum theory as a decision-making framework, provides a powerful means of guiding nurses' decision-making. © 2012 Blackwell Publishing Ltd.
Effects of increased nurses' workload on quality documentation of patient information at selected Primary Health Care facilities in Vhembe District, Limpopo Province.

PubMed

Shihundla, Rhulani C; Lebese, Rachel T; Maputle, Maria S

2016-05-13

Recording of information on multiple documents increases professional nurses' responsibilities and workload during working hours. There are multiple registers and books at Primary Health Care (PHC) facilities in which a patient's information is to be recorded for different services during a visit to a health professional. Antenatal patients coming for the first visit must be recorded in the following documents: tick register; Prevention of Mother-ToChild Transmission (PMTCT) register; consent form for HIV and AIDS testing; HIV Counselling and Testing (HCT) register (if tested positive for HIV and AIDS then this must be recorded in the Antiretroviral Therapy (ART) wellness register); ART file with an accompanying single file, completion of which is time-consuming; tuberculosis (TB) suspects register; blood specimen register; maternity case record book and Basic Antenatal Care (BANC) checklist. Nurses forget to record information in some documents which leads to the omission of important data. Omitting information might lead to mismanagement of patients. Some of the documents have incomplete and inaccurate information. As PHC facilities in Vhembe District render twenty four hour services through a call system, the same nurses are expected to resume duty at 07:00 the following morning. They are expected to work effectively and when tired a nurse may record illegible information which may cause problems when the document is retrieved by the next person for continuity of care. The objective of this study was to investigate and describe the effects of increased nurses' workload on quality documentation of patient information at PHC facilities in Vhembe District, Limpopo Province. The study was conducted in Vhembe District, Limpopo Province, where the effects of increased nurses' workload on quality documentation of information is currently experienced. The research design was explorative, descriptive and contextual in nature. The population consisted of all nurses who work at PHC facilities in Vhembe District. Purposive sampling was used to select nurses and three professional nurses were sampled from each PHC facility. An in-depth face-to-face interview was used to collect data using an interview guide. PHC facilities encountered several effects due to increased nurses' workload where incomplete patient information is documented. Unavailability of patient information was observed, whilst some documented information was found to be illegible, inaccurate and incomplete. Documentation of information at PHC facilities is an evidence of effective communication amongst professional nurses. There should always be active follow-up and mentoring of the nurses' documentation to ensure that information is accurately and fully documented in their respective facilities. Nurses find it difficult to cope with the increased workload associated with documenting patient information on the multiple records that are utilized at PHC facilities, leading to incomplete information. The number of nurses at facilities should be increased to reduce the increased workload.
Consensus Statement of Standards for Interventional Cardiovascular Nursing Practice.

PubMed

White, Kevin; Macfarlane, Heather; Hoffmann, Bernadette; Sirvas-Brown, Helene; Hines, Kathryn; Rolley, John Xavier; Graham, Sandi

2018-05-01

Interventional cardiovascular nursing is a critical care nursing specialty providing complex nursing interventions to patients prone to clinical deterioration, through the combined risks of the pathophysiology of their illness and undergoing technically complex interventional cardiovascular procedures. No guidelines were identified worldwide to assist health care providers and educational institutions in workforce development and education guidelines to minimise patients' risk of adverse events. The Interventional Nurses Council (INC) developed a definition and scope of practice for interventional cardiac nursing (ICN's) in 2013. The INC executive committee established a working party of seven representatives from Australia and New Zealand. Selection was based on expertise in interventional cardiovascular nursing and experience providing education and mentoring in the clinical and postgraduate environment. A literature search of the electronic databases Science Direct, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Health Source was performed, using the search terms: clinical deterioration, ST elevation myocardial infarction, vital signs, primary percutaneous coronary intervention, PCI, AMI, STEMI, acute coronary syndrome, peri-procedural care, unstable angina, PCI complications, structural heart disease, TAVI, TAVR, cardiac rhythm management, pacing, electrophysiology studies, vascular access, procedural sedation. Articles were limited to the cardiac catheterisation laboratory and relevance to nursing based outcomes. Reference lists were examined to identify relevant articles missed in the initial search. The literature was compared with national competency standards, quality and safety documents and the INC definition and scope of practice. Consensus of common themes, a taxonomy of education and seven competency domains were achieved via frequent teleconferences and two face-to-face meetings. The working party finalised the standards on 14 July 2017, following endorsement from the CSANZ, INC, Heart Rhythm Council, CSANZ Quality Standards Committee and the Australian College of Critical Care Nurses (ACCCN). The resulting document provides clinical practice and education standards for interventional cardiac nursing practice. Copyright © 2017. Published by Elsevier B.V.
Evidence for the Existing American Nurses Association-Recognized Standardized Nursing Terminologies: A Systematic Review

PubMed Central

Tastan, Sevinc; Linch, Graciele C. F.; Keenan, Gail M.; Stifter, Janet; McKinney, Dawn; Fahey, Linda; Dunn Lopez, Karen; Yao, Yingwei; Wilkie, Diana J.

2014-01-01

Objective To determine the state of the science for the five standardized nursing terminology sets in terms of level of evidence and study focus. Design Systematic Review. Data sources Keyword search of PubMed, CINAHL, and EMBASE databases from 1960s to March 19, 2012 revealed 1,257 publications. Review Methods From abstract review we removed duplicate articles, those not in English or with no identifiable standardized nursing terminology, and those with a low-level of evidence. From full text review of the remaining 312 articles, eight trained raters used a coding system to record standardized nursing terminology names, publication year, country, and study focus. Inter-rater reliability confirmed the level of evidence. We analyzed coded results. Results On average there were 4 studies per year between 1985 and 1995. The yearly number increased to 14 for the decade between 1996–2005, 21 between 2006–2010, and 25 in 2011. Investigators conducted the research in 27 countries. By evidence level for the 312 studies 72.4% were descriptive, 18.9% were observational, and 8.7% were intervention studies. Of the 312 reports, 72.1% focused on North American Nursing Diagnosis-International, Nursing Interventions Classification, Nursing Outcome Classification, or some combination of those three standardized nursing terminologies; 9.6% on Omaha System; 7.1% on International Classification for Nursing Practice; 1.6% on Clinical Care Classification/Home Health Care Classification; 1.6% on Perioperative Nursing Data Set; and 8.0% on two or more standardized nursing terminology sets. There were studies in all 10 foci categories including those focused on concept analysis/classification infrastructure (n = 43), the identification of the standardized nursing terminology concepts applicable to a health setting from registered nurses’ documentation (n = 54), mapping one terminology to another (n = 58), implementation of standardized nursing terminologies into electronic health records (n = 12), and secondary use of electronic health record data (n = 19). Conclusions Findings reveal that the number of standardized nursing terminology publications increased primarily since 2000 with most focusing on North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification. The majority of the studies were descriptive, qualitative, or correlational designs that provide a strong base for understanding the validity and reliability of the concepts underlying the standardized nursing terminologies. There is evidence supporting the successful integration and use in electronic health records for two standardized nursing terminology sets: (1) the North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification set; and (2) the Omaha System set. Researchers, however, should continue to strengthen standardized nursing terminology study designs to promote continuous improvement of the standardized nursing terminologies and use in clinical practice. PMID:24412062
Nurses using futuristic technology in today's healthcare setting.

PubMed

Wolf, Debra M; Kapadia, Amar; Kintzel, Jessie; Anton, Bonnie B

2009-01-01

Human computer interaction (HCI) equates nurses using voice assisted technology within a clinical setting to document patient care real time, retrieve patient information from care plans, and complete routine tasks. This is a reality currently utilized by clinicians today in acute and long term care settings. Voice assisted documentation provides hands & eyes free accurate documentation while enabling effective communication and task management. The speech technology increases the accuracy of documentation, while interfacing directly into the electronic health record (EHR). Using technology consisting of a light weight headset and small fist size wireless computer, verbal responses to easy to follow cues are converted into a database systems allowing staff to obtain individualized care status reports on demand. To further assist staff in their daily process, this innovative technology allows staff to send and receive pages as needed. This paper will discuss how leading edge and award winning technology is being integrated within the United States. Collaborative efforts between clinicians and analyst will be discussed reflecting the interactive design and build functionality. Features such as the system's voice responses and directed cues will be shared and how easily data can be documented, viewed and retrieved. Outcome data will be presented on how the technology impacted organization's quality outcomes, financial reimbursement, and employee's level of satisfaction.
Enhancing nursing informatics competencies and critical thinking skills using wireless clinical simulation laboratories.

PubMed

Cholewka, Patricia A; Mohr, Bernard

2009-01-01

Nursing students at New York City College of Technology are assigned client care experiences that focus on common alterations in health status. However, due to the unpredictability of client census within any healthcare facility, it is not possible for all students to have the same opportunity to care for clients with specific medical conditions. But with the use of patient simulators in a dedicated Clinical Simulation Laboratory setting, students can be universally, consistently, and repeatedly exposed to programmed scenarios that connect theory with the clinical environment. Outcomes from using patient simulators include improved nursing knowledge base, enhanced critical thinking, reflective learning, and increased understanding of information technology for using a Personal Digital Assistant and documenting care by means of an electronic Patient Record System. An innovative nursing education model using a wireless, inter-connective data network was developed by this college in response to the need for increasing nursing informatics competencies and critical thinking skills by students in preparation for client care.
Cognitive workload changes for nurses transitioning from a legacy system with paper documentation to a commercial electronic health record.

PubMed

Colligan, Lacey; Potts, Henry W W; Finn, Chelsea T; Sinkin, Robert A

2015-07-01

Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR. Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR. Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after "go-live". These increases abated at differing rates predicted by participants' computer attitudes scores (p = 0.01). There is substantially increased cognitive workload for nurses during the early phases (1-5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to "meaningful use" EHRs. "One-size-fits-all" training strategies may not be suitable and longer periods of technical support may be necessary for some workers. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Electronic theses and dissertations: a review of this valuable resource for nurse scholars worldwide.

PubMed

Goodfellow, L M

2009-06-01

A worldwide repository of electronic theses and dissertations (ETDs) could provide worldwide access to the most up-to-date research generated by masters and doctoral students. Until that international repository is established, it is possible to access some of these valuable knowledge resources. ETDs provide a technologically advanced medium with endless multimedia capabilities that far exceed the print and bound copies of theses and dissertations housed traditionally in individual university libraries. CURRENT USE: A growing trend exists for universities worldwide to require graduate students to submit theses or dissertations as electronic documents. However, nurse scholars underutilize ETDs, as evidenced by perusing bibliographic citation lists in many of the research journals. ETDs can be searched for and retrieved through several digital resources such as the Networked Digital Library of Theses and Dissertations (http://www.ndltd.org), ProQuest Dissertations and Theses (http://www.umi.com), the Australasian Digital Theses Program (http://adt.caul.edu.au/) and through individual university web sites and online catalogues. An international repository of ETDs benefits the community of nurse scholars in many ways. The ability to access recent graduate students' research electronically from anywhere in the world is advantageous. For scholars residing in developing countries, access to these ETDs may prove to be even more valuable. In some cases, ETDs are not available for worldwide access and can only be accessed through the university library from which the student graduated. Public access to university library ETD collections is not always permitted. Nurse scholars from both developing and developed countries could benefit from ETDs.
Shared Electronic Health Record Systems: Key Legal and Security Challenges.

PubMed

Christiansen, Ellen K; Skipenes, Eva; Hausken, Marie F; Skeie, Svein; Østbye, Truls; Iversen, Marjolein M

2017-11-01

Use of shared electronic health records opens a whole range of new possibilities for flexible and fruitful cooperation among health personnel in different health institutions, to the benefit of the patients. There are, however, unsolved legal and security challenges. The overall aim of this article is to highlight legal and security challenges that should be considered before using shared electronic cooperation platforms and health record systems to avoid legal and security "surprises" subsequent to the implementation. Practical lessons learned from the use of a web-based ulcer record system involving patients, community nurses, GPs, and hospital nurses and doctors in specialist health care are used to illustrate challenges we faced. Discussion of possible legal and security challenges is critical for successful implementation of shared electronic collaboration systems. Key challenges include (1) allocation of responsibility, (2) documentation routines, (3) and integrated or federated access control. We discuss and suggest how challenges of legal and security aspects can be handled. This discussion may be useful for both current and future users, as well as policy makers.
Getting eHealth into basic nursing education: report of the RCN information in nursing project.

PubMed

Clark, June; Baker, Bernice; Baker, David

2009-01-01

This paper reports the results of a project undertaken in 2008 by the Royal College of Nursing's Information in Nursing Forum. The project, undertaken by the RCN IN Forum in association with the RCN Education Forum and the RCN Association of Nursing Students, was in two parts. The first part consisted of an on-line survey of nursing students to discover their "readiness" for working in an electronic environment. The second part consisted of a workshop for invited stakeholders - organisations responsible for commissioning and providing basic nursing education, regulators, nurse teachers, and nursing students themselves - the objective of which was to consider the results of the survey and other information, in order to develop a consensus on how best to incorporate eHealth issues into basic nursing education. The survey was undertaken during April 2008 via the RCN website. Students were asked how well they felt their nursing education had prepared them for competencies set out in a previously published model curriculum. 1,120 students responded. 565 students who had used electronic patient records during their most recent clinical placement were asked about their experience. Students rated their basic computer skills much higher than their understanding of eHealth. While they felt competent to document assessments and care plans using paper records, few felt competent to do so using electronic records. Few know anything about telehealth (remote diagnosis and delivery of healthcare) or telecare (assistive technology in people's homes). Among those who had used computers in their most recent clinical placement there were clear breaches of the protocols designed to ensure security and confidentiality. Twenty seven invited participants attended the workshop held in October 2008, plus 12 members of the participating Forums and relevant RCN staff. Following presentation and discussion of the findings of the survey, participants worked in three groups to identify and discuss issues arising from the survey, and to identify barriers using a Force Field Analysis. All participants agreed eHealth should be an integral part of nursing education and not an "add-on", and that the responsibility for "Getting eHealth into basic nursing education" had to be shared by university based educators, placement supervisors, and regulators.
[Psychometric properties of Q-DIO, an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes].

PubMed

Müller-Staub, Maria; Lunney, Margaret; Lavin, Mary Ann; Needham, Ian; Odenbreit, Matthias; van Achterberg, Theo

2010-04-01

The instrument Q-DIO was developed in the years 2005 till 2006 to measure the quality of documented nursing diagnoses, interventions, and nursing sensitive patient outcomes. Testing psychometric properties of the Q-DIO (Quality of nursing Diagnoses, Interventions and Outcomes.) was the study aim. Instrument testing included internal consistency, test-retest reliability, interrater reliability, item analyses, and an assessment of the objectivity. To render variation in scores, a random strata sample of 60 nursing documentations was drawn. The strata represented 30 nursing documentations with and 30 without application of theory based, standardised nursing language. Internal consistency of the subscale nursing diagnoses as process showed Cronbach's Alpha 0.83 [0.78, 0.88]; nursing diagnoses as product 0.98 [0.94, 0.99]; nursing interventions 0.90 [0.85, 0.94]; and nursing-sensitive patient outcomes 0.99 [0.95, 0.99]. With Cohen's Kappa of 0.95, the intrarater reliability was good. The interrater reliability showed a Kappa of 0.94 [0.90, 0.96]. Item analyses confirmed the fulfilment of criteria for degree of difficulty and discriminative validity of the items. In this study, Q-DIO has shown to be a reliable instrument. It allows measuring the documented quality of nursing diagnoses, interventions and outcomes with and without implementation of theory based, standardised nursing languages. Studies for further testing of Q-DIO in other settings are recommended. The results implicitly support the use of nursing classifications such as NANDA, NIC and NOC.
Documentation of Nursing Practice Using a Computerized Medical Information System

PubMed Central

Romano, Carol

1981-01-01

This paper discusses a definition of the content of the computerized nursing data base developed by the Nursing Department for the Clinical Center Medical Information System at the National Institutes of Health in Bethesda, Maryland. The author describes the theoretical framework for the content and presents a model to describe the organization of the nursing data components in relation to the process of nursing care delivery. Nursing documentation requirements of Nurse Practice Acts, American Nurses Association Standards of Practice and the Joint Commission on Accreditation of Hospitals are also addressed as they relate to this data base. The advantages and disadvantages of such an approach to computerized documentation are discussed.
Radiofrequency identification: exploiting an old technology for measuring nurse time and motion.

PubMed

Jones, Terry L

2012-09-01

A national campaign is underway to increase the amount of time staff nurses spend at the bedside of hospitalized patients through redesign of the work environment. This kind of work redesign requires robust data depicting what nurses do and how they spend their time. Historically, these kinds of data have been difficult, costly, and time consuming to collect. Wireless capture of data on the movement of humans within the work environment (ie, time and motion) is now possible through radiofrequency identification technology. When small tracking devices the size of a quarter are affixed to their clothing, the movement of nurses throughout a patient care unit can be monitored. The duration and frequency of patient interaction are captured along with the duration of time spent in other locations of interest to include nurses' station, supply room, medication room, doctors' station, electronic documentation stations, family waiting rooms, and the hallway. Patterns of nurse movement and time allocation can be efficiently identified, and the effects of staffing practices, workflows, and unit layout evaluated. Integration of radiofrequency identification time and motion data with other databases enables nurse leaders to link nursing time to important cost and quality outcomes. Nurse leaders should explore the usefulness of radiofrequency identification technology in addressing data needs for nurse time and motion.
Designing an Electronic Patient Management System for Multiple Sclerosis: Building a Next Generation Multiple Sclerosis Documentation System.

PubMed

Kern, Raimar; Haase, Rocco; Eisele, Judith Christina; Thomas, Katja; Ziemssen, Tjalf

2016-01-08

Technologies like electronic health records or telemedicine devices support the rapid mediation of health information and clinical data independent of time and location between patients and their physicians as well as among health care professionals. Today, every part of the treatment process from diagnosis, treatment selection, and application to patient education and long-term care may be enhanced by a quality-assured implementation of health information technology (HIT) that also takes data security standards and concerns into account. In order to increase the level of effectively realized benefits of eHealth services, a user-driven needs assessment should ensure the inclusion of health care professional perspectives into the process of technology development as we did in the development process of the Multiple Sclerosis Documentation System 3D. After analyzing the use of information technology by patients suffering from multiple sclerosis, we focused on the needs of neurological health care professionals and their handling of health information technology. Therefore, we researched the status quo of eHealth adoption in neurological practices and clinics as well as health care professional opinions about potential benefits and requirements of eHealth services in the field of multiple sclerosis. We conducted a paper-and-pencil-based mail survey in 2013 by sending our questionnaire to 600 randomly chosen neurological practices in Germany. The questionnaire consisted of 24 items covering characteristics of participating neurological practices (4 items), the current use of network technology and the Internet in such neurological practices (5 items), physicians' attitudes toward the general and MS-related usefulness of eHealth systems (8 items) and toward the clinical documentation via electronic health records (4 items), and physicians' knowledge about the Multiple Sclerosis Documentation System (3 items). From 600 mailed surveys, 74 completed surveys were returned. As much as 9 of the 10 practices were already connected to the Internet (67/74), but only 49% preferred a permanent access. The most common type of HIT infrastructure was a complete practice network with several access points. Considering data sharing with research registers, 43% opted for an online interface, whereas 58% decided on an offline method of data transmission. eHealth services were perceived as generally useful for physicians and nurses in neurological practices with highest capabilities for improvements in clinical documentation, data acquisition, diagnosis of specific MS symptoms, physician-patient communication, and patient education. Practices specialized in MS in comparison with other neurological practices presented an increased interest in online documentation. Among the participating centers, 91% welcomed the opportunity of a specific clinical documentation for MS and 87% showed great interest in an extended and more interconnected electronic documentation of MS patients. Clinical parameters (59/74) were most important in documentation, followed by symptomatic parameters like measures of fatigue or depression (53/74) and quality of life (47/74). Physicians and nurses may significantly benefit from an electronically assisted documentation and patient management. Many aspects of patient documentation and education will be enhanced by eHealth services if the most informative measures are integrated in an easy-to-use and easily connectable approach. MS-specific eHealth services were highly appreciated, but the current level of adoption is still behind the level of interest in an extended and more interconnected electronic documentation of MS patients.
Royal College of Nursing (Rcn) code of professional conduct: a discussion document.

PubMed Central

Dawson, J D; Altschul, A T; Sampson, C; Smith, A M

1977-01-01

We are printing in its entirety the discussion document which sets out a code of professional conduct for nurses published by the Royal College of Nursing in November 1976 together with commentaries by the Assistant Secretary of the British Medical Association, a professor of nursing studies, student nurses and a lawyer. The image of the nurse is still that of one of Florence Nightingale's young ladies or of a member of a religious order who is wholly dedicated to caring for the sick. Today, as this document and the comments upon it show, 'dedication' is still part of the motive which leads a man or woman to become a nurse but in addition, and this is where the public may be ignorant or choose to be ignorant, nursing offers a career where intellectual achievement and the satisfaction of a demanding job bring their proper financial reward and place in the professional community. We are grateful to the Royal College of Nursing for permission to publish this document. PMID:926130
Information-seeking behavior of health sciences faculty: the impact of new information technologies.

PubMed

Curtis, K L; Weller, A C; Hurd, J M

1997-10-01

This paper reports on an ongoing investigation into health sciences faculty's information-seeking behavior, including their use of new information technologies. A survey was administered to all faculty in medicine, nursing, and pharmacy at the University of Illinois at Chicago. It was similar to one administered to the same population in 1991. The survey asked about faculty's use of electronic resources, documented any shift from the use of print to electronic formats, and measured the utilization of library training. The response rate was 48.5% for medicine faculty, 45.0% for nursing, and 62.5% for pharmacy. The study found that use of the print Index Medicus among faculty was in transition: While 30.5% continued to use the print resources, 68.0% of faculty accessed MEDLINE through electronic means. Faculty preferred accessing electronic databases from their offices to doing so from the library. Health sciences faculty used a wide variety of databases, in addition to MEDLINE, to fill their information needs. Most faculty did not take advantage of either in-house or electronic training sessions offered by librarians. The study concluded that the training preferences of faculty need to be further explored.
The validation of AORN recommended practices in Finnish perioperative nursing documentation.

PubMed

Tiusanen, Teija Susanna; Junttila, Kristiina; Leinonen, Tuija; Salanterä, Sanna

2010-02-01

In Finland, there are no common guidelines or recommended practices for perioperative documentation. Thus, perioperative nursing documentation varies from one operating department to another. To create minimum criteria for nursing documentation in Finland, we conducted an investigation in a university hospital district in 2006. Purposive sampling was used to invite experts in perioperative nursing documentation (N = 42) to serve as a Delphi panel. The final criteria are 120 items, 71% of which are based on the AORN standards and recommended practices. These criteria may be used to educate students and new perioperative personnel and to enhance the quality of nursing practice. To ensure relevance and usability, the criteria should be tested in various perioperative settings with a variety of surgical patients. Copyright 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Psychometric Evaluation of the D-Catch, an Instrument to Measure the Accuracy of Nursing Documentation.

PubMed

D'Agostino, Fabio; Barbaranelli, Claudio; Paans, Wolter; Belsito, Romina; Juarez Vela, Raul; Alvaro, Rosaria; Vellone, Ercole

2017-07-01

To evaluate the psychometric properties of the D-Catch instrument. A cross-sectional methodological study. Validity and reliability were estimated with confirmatory factor analysis (CFA) and internal consistency and inter-rater reliability, respectively. A sample of 250 nursing documentations was selected. CFA showed the adequacy of a 1-factor model (chronologically descriptive accuracy) with an outlier item (nursing diagnosis accuracy). Internal consistency and inter-rater reliability were adequate. The D-Catch is a valid and reliable instrument for measuring the accuracy of nursing documentation. Caution is needed when measuring diagnostic accuracy since only one item measures this dimension. The D-Catch can be used as an indicator of the accuracy of nursing documentation and the quality of nursing care. © 2015 NANDA International, Inc.
What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology.

PubMed

Juvé-Udina, Maria Eulàlia

2013-12-01

The nurses' ability to document patient's status, problems and progress is an important issue in patients' safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians. This study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts. Observational, longitudinal, multicentre study. A total of 8 hospitals representing 162 acute medical-surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included. Overall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%). The main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals. Most of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients' problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25-51.65) or Acute pain (49.6%; CI: 49.49-49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking. Results for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting. Copyright © 2013 Elsevier Ltd. All rights reserved.

Electronic Clinic Journaling: The Use of Weblogs to Support Evidence-Based Practice in Doctor of Audiology Students

ERIC Educational Resources Information Center

Neldon, Gayle B.

2009-01-01

Evidence-based practice (EBP) is a strategy for the provision of high quality health care. The use of journals to document clinical experiences and reflection has been used in speech-language pathology as well as nursing and psychology. This study uses qualitative analysis to study what AuD students learn about evidence-based practice from writing…
Quality Evaluation of Nursing Observation Based on a Survey of Nursing Documents Using NursingNAVI.

PubMed

Tsuru, Satoko; Omori, Miho; Inoue, Manami; Wako, Fumiko

2016-01-01

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI^® contents collaborated with some quality centred hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI^®" developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI^® contents. It is important to identify the problem of the volatility of the patients' data, conditions and some situation. We developed a survey tool of nursing documents using NursingNAVI^® Content for quality evaluation of nursing observation. We recommended some hospitals to use this survey tool. Fifteen hospitals participated the survey using this tool. It is estimated that the volatilizing situation. A hospital which don't participate this survey, knew the result. So the hospital decided to use NursingNAVI^® contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.
Technology Implementation and Workarounds in the Nursing Home

PubMed Central

Vogelsmeier, Amy A.; Halbesleben, Jonathon R.B.; Scott-Cawiezell, Jill R.

2008-01-01

Objective This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes. Design As a part of a larger study, this qualitative evaluation was conducted to identify workarounds associated with the implementation of an electronic medication administration record. Data were collected using multimethods including direct observation, process mapping, key informant interviews, and review of field notes from medication safety team meetings. Measurements Open and axial coding techniques were used to identify and categorize types of workarounds in relation to work flow blocks. Results Workarounds presented in two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team. Conclusion This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety. PMID:17947626
Updating the definition and role of public health nursing to advance and guide the specialty.

PubMed

Bekemeier, Betty; Walker Linderman, Tessa; Kneipp, Shawn; Zahner, Susan J

2015-01-01

National changes in the context for public health services are influencing the nature of public health nursing practice. Despite this, the document that defines public health nursing as a specialty--The Definition and Role of Public Health Nursing--has remained in wide use since its publication in 1996 without a review or update. With support from the American Public Health Association (APHA) Public Health Nursing Section, a national Task Force, was formed in November 2012 to update the definition of public health nursing, using processes that reflected deliberative democratic principles. A yearlong process was employed that included a modified Delphi technique and various modes of engagement such as online discussion boards, questionnaires, and public comment to review. The resulting 2013 document consisted of a reaffirmation of the one-sentence 1996 definition, while updating supporting documentation to align with the current social, economic, political, and health care context. The 2013 document was strongly endorsed by vote of the APHA Public Health Nursing Section elected leadership. The 2013 definition and document affirm the relevance of a population-focused definition of public health nursing to complex systems addressed in current practice and articulate critical roles of public health nurses (PHN) in these settings. © 2014 Wiley Periodicals, Inc.
Assessment of oral mucositis in adult and pediatric oncology patients: an evidence-based approach.

PubMed

Farrington, Michele; Cullen, Laura; Dawson, Cindy

2010-01-01

Oral mucositis is a frequent side effect of cancer treatment and can lead to delayed treatment, reduced treatment dosage, altered nutrition, dehydration, infections, xerostomia, pain, and higher healthcare costs. Mucositis is defined as "inflammatory lesions of the oral and/or gastrointestinal tract caused by high-dose cancer therapies. Alimentary tract mucositis refers to the expression of mucosal injury across the continuum of oral and gastrointestinal mucosa, from the mouth to the anus" (Peterson, Bensadoun, & Roila, 2008, p. ii122). Evidence demonstrates that oral mucositis is quite distressing for patients. In addition, the majority of oncology nurses are unaware of available guidelines related to the care of oral mucositis. A multidisciplinary Oral Mucositis Committee was formed by the University of Iowa Hospitals and Clinics to develop evidence-based prevention and treatment strategies for adult and pediatric oncology patients experiencing oral mucositis. The first step was implementing an evidence-based nursing oral assessment. The Iowa Model was used to guide this evidence-based practice initiative. The Oral Assessment Guide (OAG) is reliable and valid, feasible, and sensitive to changing conditions. The OAG was piloted on an Adult Leukemia and Bone Marrow Transplant Unit leading to modification and adaptation. The pilot evaluation found 87% of patients had an abnormal oral assessment involving all categories in the tool. Nursing questionnaires showed that staff (8/23; 35% response) felt they were able to identify at risk patients using the OAG (3.3; 1-4 scale), and the tool accurately identifies mucosal changes (2.9; 1-4 scale). A knowledge assessment found nurses correctly identified OAG components 63% of the time. Unlike results from a national survey, most University of Iowa Hospitals and Clinics nurses (63%) were aware of national guidelines for prevention and treatment of oral mucositis. Developing an evidence-based nursing policy and updating documentation systems was done before implementation occurred. Computer-based and printed educational materials were developed for nursing staff caring for oncology patients. Team members were responsible for facilitating adoption in clinical areas. After organizational roll out, the nursing assessment was documented in all patients 87% of the time, and 99% for inpatients. The highest risk population, head and neck cancer patients receiving radiation, had documentation in 88% of audited visits. Other clinics required further work. Changing the system to the electronic medical record created an additional need for integration of the evidence-based practice with housewide documentation of oral assessment being completed 60.9% of the time. Use of an evidence-based assessment is the first step in a comprehensive program to reduce a common and highly distressing side effect of cancer treatment. Nursing documentation of oral assessment is well integrated on inpatient units. Opportunities for improvement remain in ambulatory care. Multidisciplinary team collaborations to expand evidence-based assessment and research questions generated from this work will be shared.
Social inequality, health policies and the training of physicians, nurses and dentists in Brazil and in Portugal.

PubMed

Craveiro, Isabel Maria Rodrigues; Hortale, Virginia Alonso; de Oliveira, Ana Paula Cavalcante; Dussault, Gilles

2015-10-01

This study analyzes the production of scientific knowledge on Health Inequalities (HI) and its use in policies of education of dentists, nurses and physicians in Brazil and Portugal. Documents published between January 2000 and December 2001, in Portuguese, French, English and Spanish, were identified by means of a combination of a manual and intentional electronic database survey of the grey literature. Fifty-three documents were selected from a total of 1,652. The findings revealed that there is still little knowledge available to enable an assessment of policies for human resource training in healthcare in general and for those related to physicians, nurses and dentists in particular. In Brazil, few studies have thus far been made to understand how such training can contribute towards reducing these inequalities and, in the case of Portugal, no studies were found that established a direct relationship between human resource training and the future role that these could play in combating inequality. Despite a vast increase in scientific production, many lacunae still exist in this field. Knowledge production and its relationship with decision-making still seem to be separate processes in these two countries.
A comparative study on effect of e-learning and instructor-led methods on nurses' documentation competency.

PubMed

Abbaszadeh, Abbas; Sabeghi, Hakimeh; Borhani, Fariba; Heydari, Abbas

2011-01-01

Accurate recording of the nursing care indicates the care performance and its quality, so that, any failure in documentation can be a reason for inadequate patient care. Therefore, improving nurses' skills in this field using effective educational methods is of high importance. Since traditional teaching methods are not suitable for communities with rapid knowledge expansion and constant changes, e-learning methods can be a viable alternative. To show the importance of e-learning methods on nurses' care reporting skills, this study was performed to compare the e-learning methods with the traditional instructor-led methods. This was a quasi-experimental study aimed to compare the effect of two teaching methods (e-learning and lecture) on nursing documentation and examine the differences in acquiring competency on documentation between nurses who participated in the e-learning (n = 30) and nurses in a lecture group (n = 31). The results of the present study indicated that statistically there was no significant difference between the two groups. The findings also revealed that statistically there was no significant correlation between the two groups toward demographic variables. However, we believe that due to benefits of e-learning against traditional instructor-led method, and according to their equal effect on nurses' documentation competency, it can be a qualified substitute for traditional instructor-led method. E-learning as a student-centered method as well as lecture method equally promote competency of the nurses on documentation. Therefore, e-learning can be used to facilitate the implementation of nursing educational programs.
Congruence between nursing problems in nursing care plans and NANDA nursing diagnoses.

PubMed

Varsi, Cecilie; Ruland, Cornelia M

2009-01-01

This study abstracted nursing problems documented in cancer patients' nursing care plans to analyze (1) which nursing problems were documented and (2) the degree of congruence between the abstracted problems and NANDA nursing diagnoses. 236 unique nursing problems were identified and could be mapped to 32 NANDA nursing diagnoses. However, only 4.3% had a precise match with NANDA, Thirty-eight percent were classified as similar and the rest were broader, narrower or no match. Thus NANDA only partially covered problems written by nurses in the care plans for this group of patients.
Nursing philosophy: A review of current pre registration curricula in the UK.

PubMed

Mackintosh-Franklin, Carolyn

2016-02-01

Nursing in the UK has been subject to criticism for failing to provide care and compassion in practice, with a series of reports highlighting inadequacies in care. This scrutiny provides nursing with an ideal opportunity to evaluate the underpinning philosophy of nursing practice, and for nurse educators to use this philosophy as the basis for programmes which can inculcate neophyte student nurses with a fundamental understanding of the profession, whilst providing other health care professionals and service users with a clear representation of professional nursing practice. The key word philosophy was used in a systematic stepwise descriptive content analysis of the programme specifications of 33 current undergraduate programme documents, leading to an undergraduate award and professional registration as a nurse. The word philosophy featured minimally in programme specification documents, with 12 (36%) documents including it. Its use was superficial in 3 documents and focused on educational philosophy in a further 3 documents. 2 programme specifications identified their philosophy as the NMC (2010) standards for pre-registration nurse education. 2 programme specifications articulated a philosophy specific to that programme and HEI, focusing on caring, and 2 made reference to underpinning philosophies present in nursing literature; the Relationship Centred Care Approach, and The Humanising Care Philosophy. The philosophy of nursing practice is not clearly articulated in pre-registration curricula. This failure to identify the fundamental nature of nursing is detrimental to the development of the profession, and given this lack of direction it is not surprising that some commentators feel nursing has lost its way. Nurse educators must review their current curricula to ensure that there is clear articulation of nursing's professional philosophical stance, and use this as the framework for pre-registration curricula to support the development of neophyte nursing students towards a clear and focused understanding of what nursing practice is. Copyright © 2015 Elsevier Ltd. All rights reserved.
Nurse's use of power to standardise nursing terminology in electronic health records.

PubMed

Ali, Samira; Sieloff, Christina L

2017-07-01

To describe nurses' use of power to influence the incorporation of standardised nursing terminology within electronic health records. Little is known about nurses' potential use of power to influence the incorporation of standardised nursing terminology within electronic health records. The theory of group power within organisations informed the design of the descriptive, cross-sectional study used a survey method to assess nurses' use of power to influence the incorporation of standardised nursing terminology within electronic health records. The Sieloff-King Assessment of Group Power within Organizations © and Nursing Power Scale was used. A total of 232 nurses responded to the survey. The mean power capability score was moderately high at 134.22 (SD 18.49), suggesting that nurses could use power to achieve the incorporation of standardised nursing terminology within electronic health records. The nurses' power capacity was significantly correlated with their power capability (r = 0.96, P < 0.001). Nurses may use power to achieve their goals, such as the incorporation of standardised nursing terminology within electronic health records. Nurse administrators may use their power to influence the incorporation of standardised nursing terminology within electronic health records. If nurses lack power, this could decrease nurses' ability to achieve their goals and contribute to the achievement of effective patient outcomes. © 2017 John Wiley & Sons Ltd.
Radiofrequency Identification

PubMed Central

Jones, Terry L.

2017-01-01

A national campaign is underway to increase the amount of time staff nurses spend at the bedside of hospitalized patients through redesign of the work environment. This kind of work redesign requires robust data depicting what nurses do and how they spend their time. Historically, these kinds of data have been difficult, costly, and time consuming to collect. Wireless capture of data on the movement of humans within the work environment (ie, time and motion) is now possible through radiofrequency identification technology. When small tracking devices the size of a quarter are affixed to their clothing, the movement of nurses throughout a patient care unit can be monitored. The duration and frequency of patient interaction are captured along with the duration of time spent in other locations of interest to include nurses’ station, supply room, medication room, doctors’ station, electronic documentation stations, family waiting rooms, and the hallway. Patterns of nurse movement and time allocation can be efficiently identified, and the effects of staffing practices, workflows, and unit layout evaluated. Integration of radiofrequency identification time and motion data with other databases enables nurse leaders to link nursing time to important cost and quality outcomes. Nurse leaders should explore the usefulness of radiofrequency identification technology in addressing data needs for nurse time and motion. PMID:22592451
Chemotherapy extravasations: prevention, identification, management, and documentation.

PubMed

Gonzalez, Tulia

2013-02-01

The nurses' role in safe and effective practice of chemotherapy administration is paramount. The purpose of this article is to present nurses administering chemotherapy with evidence-based information useful in eliminating or reducing the severity of an injury from a chemotherapy extravasation. Nurse education is essential to prevent, recognize, manage, and document chemotherapy extravasations. The classification of the cytotoxic drug and its mechanism of action is useful when selecting the IV access device and also will direct the nurse's intervention to manage the injury. The Oncology Nursing Society's Chemotherapy and Biotherapy Guidelines and Recommendations for Practice and the drug manufacturer are the best sources offering pharmacologic and nonpharmacologic recommendations. The nurse's best ally in the prevention, prompt recognition, and management of an extravasation is the educated patient. Documenting chemotherapy extravasation is another important step to guide the treatment plan; therefore, the document must provide complete details and the extent of the event.
The content and meaning of administrative work: a qualitative study of nursing practices.

PubMed

Michel, Lucie; Waelli, Mathias; Allen, Davina; Minvielle, Etienne

2017-09-01

To investigate the content and meaning of nurses' administrative work. Nurses often report that administrative work keeps them away from bedside care. The content and meaning of this work remains insufficiently explored. Comparative case studies. The investigation took place in 2014. It was based on 254 hours of observations and 27 interviews with nurses and staff in two contrasting units: intensive care and long-term care. A time and motion study was also performed over a period of 96 hours. Documentation and Organizational Activities is composed of six categories; documenting the patient record, coordination, management of patient flow, transmission of information, reporting quality indicators, ordering supplies- stock management Equal amounts of time were spent on these activities in each case. Nurses did not express complaints about documentation in intensive care, whereas they reported feeling frustrated by it in long-term care. These differences reflected the extent to which these activities could be integrated into nurses' clinical work and this is in turn was related to several factors: staff ratios, informatics, and relevance to nursing work. Documentation and Organizational Activities are a main component of care. The meaning nurses attribute to them is dependent on organizational context. These activities are often perceived as competing with bedside care, but this does not have to be the case. The challenge for managers is to fully integrate them into nursing practice. Results also suggest that nurses' Documentation and Organizational Activities should be incorporated into informatics strategies. © 2017 John Wiley & Sons Ltd.
Improving information technology competencies: implications for psychiatric mental health nursing.

PubMed

Fetter, Marilyn S

2009-01-01

While substantial evidence links information technology (IT) with improved patient safety, care quality, access, and efficiency, nurses must demonstrate competencies in computers, informatics, and information literacy in order to use IT for practice, education, and research. The nursing profession has established IT competencies for all nurses at beginning and experienced levels. Newly revised standards also articulate role-specific expectations for advanced practice nurses. Unfortunately, there is a concern that many nurses may not possess these capabilities and that nurse educators are not prepared to teach them. IT competency evaluations, which have focused predominately on nursing education, indicate novice skill levels for most faculty and students. In numerous studies, again conducted largely in nursing education, significant improvement in IT competencies has been achieved only with intensive interventions. Deficits in IT competencies are a significant concern, because the federal government has mandated full implementation of Electronic Health Records (EHR) by 2014. EHR will require all nurses to use IT to deliver, document, and obtain reimbursement for patient care. In response to these concerns, two recent initiatives, the "Health Information Technology Scholars (HITS)" and "Technology Informatics Guiding Education Reform (TIGER)" projects, have been launched. By enhancing IT competencies, these projects will enable nurses to use evidence-based practice and other innovations to transform clinical care, education, and research. This report updates psychiatric-mental health nurses on the IT competencies literature, recent enhancement initiatives and innovations, and their implications for the specialty.
Perceptions of the effect of information and communication technology on the quality of care delivered in emergency departments: a cross-site qualitative study.

PubMed

Callen, Joanne; Paoloni, Richard; Li, Julie; Stewart, Michael; Gibson, Kathryn; Georgiou, Andrew; Braithwaite, Jeffrey; Westbrook, Johanna

2013-02-01

We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED. A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations. Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge. Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed. Copyright © 2012. Published by Mosby, Inc.
Personal data assistants: using new technology to enhance nursing practice.

PubMed

Lewis, Judith A; Sommers, Catherine O

2003-01-01

This article explains how the new technology of personal data assistants can be used to enhance and augment comprehensive nursing care. Nurses are constantly challenged in their need for current, reliable, and accurate information at the point of patient care. Professional books and journals, by the very nature of their print format, have been prepared long before they can be actually used in practice. More current information is available from the World Wide Web, but it is often impractical for a nurse to access a computer during a patient encounter. Personal data assistants [PDAs] allow clinicians to access and document absolutely current information at the moment the patient is being seen. There are many general applications for PDAs that nurses might use such as keeping electronic calendars, address books, and reminder lists. In addition, however, there are even more actual healthcare applications, including patient tracking systems, access to pharmacologic databases, and a variety of clinical decision-making support tools. This article describes the wide variety of PDAs, along with the factors a nurse should consider in the decision of whether to purchase a PDA, and which type of device is best suited for which application.
The valuation of nursing begins with identifying value drivers.

PubMed

Rutherford, Marcella M

2010-03-01

Adequate investment in a profession links to its ability to define and document its value. This requires identifying those elements or value drivers that demonstrate its worth. To completely identify nursing's value drivers requires meshing the economic, technical, and caring aspects of its profession. Nursing's valuation includes assessing nursing's tangible and intangible assets and documenting these assets. This information communicates nursing's worth and ensures adequate economic investment in its services.
Migration: a concept analysis from a nursing perspective.

PubMed

Freeman, Michelle; Baumann, Andrea; Blythe, Jennifer; Fisher, Anita; Akhtar-Danesh, Noori

2012-05-01

This article is a report of a concept analysis of nurse migration. International migration is increasing and nurse migrants are active participants in this movement. Migration is a complex term and can be examined from a range of perspectives. Analysis of nurse migration is needed to guide policy, practice and research. A literature search was undertaken using electronic literature indexes, specific journals and websites, internet search engines and hand searches. No timeframe was placed on the search. Most literature found was published between 2001 and 2009. A sample of 80 documents met the inclusion criteria. Walker and Avant's approach guided the analysis. Nurse migration can be defined by five attributes: the motivation and decisions of individuals; external barriers and facilitators; freedom of choice to migrate; freedom to migrate as a human right, and dynamic movement. Antecedents of migration include the political, social, economic, legal, historical and educational forces that comprise the push and pull framework. The consequences of migration are positive or negative depending on the viewpoint and its affect on the individual and other stakeholders such as the source country, destination country, healthcare systems and the nursing profession. This concept analysis clarified the complexities surrounding nurse migration. A nursing-specific middle-range theory was proposed to guide the understanding and study of nurse migration. © 2011 Blackwell Publishing Ltd.
Introduction and development of NCP using ICNP in Pakistan.

PubMed

Rukanuddin, R J

2005-12-01

Traditionally, nursing care has been described as performing nursing tasks and often focused on nurses carrying out doctors' orders. In many countries of the world, including Pakistan, nurses do not document care in a standardized manner. Because of this limitation many health administrators, policy makers, and consumers make inadequate assumptions about nursing work, often regarding nurses as any other 'health care technician' who can be easily replaced by more economical health care workers. To overcome this problem, standardized documentation is being introduced into the Aga Khan University School of Nursing and hospital, Aga Khan Health Services, Public Health School in Karachi, and government colleges of nursing, using the International Classification for Nursing Practice (ICNP). The purpose of this paper is to highlight the process of introducing and developing standardized nursing care plans (NCP) using ICNP in Pakistan. The process for introducing ICNP consists of four components, including administrative planning, development, teaching and training, and testing. Subsets of the ICNP for (i) maternity: antenatal, postnatal and natal care; and (ii) cardiology were developed using standardized NCPs. The subsets were developed by nurse experts and introduced at the testing sites. The testing will be conducted as a pilot project. Findings from the pilot will be used to continue and expand standardized nursing documentation using the ICNP across Pakistan. Through this project, nurses, midwives and lady health visitors (midwives, vaccinator and health educators) will test standardization of documentation and begin to evaluate efficiency and effectiveness of clinical practice.
Model Development for EHR Interdisciplinary Information Exchange of ICU Common Goals

PubMed Central

Collins, Sarah A.; Bakken, Suzanne; Vawdrey, David K.; Coiera, Enrico; Currie, Leanne

2010-01-01

Purpose Effective interdisciplinary exchange of patient information is an essential component of safe, efficient, and patient–centered care in the intensive care unit (ICU). Frequent handoffs of patient care, high acuity of patient illness, and the increasing amount of available data complicate information exchange. Verbal communication can be affected by interruptions and time limitations. To supplement verbal communication, many ICUs rely on documentation in electronic health records (EHRs) to reduce errors of omission and information loss. The purpose of this study was to develop a model of EHR interdisciplinary information exchange of ICU common goals. Methods The theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5 hours of interdisciplinary rounds in a Neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted. Results Current documentation tools in the ICU were not sufficient to capture the nurses' and physicians' collaborative decision-making and verbal communication of goal-directed actions and interactions. Clinicians perceived the EHR to be inefficient for information retrieval, leading to a further reliance on verbal information exchange. Conclusion The model suggests that EHRs should support: 1) Information tools for the explicit documentation of goals, interventions, and assessments with synthesized and summarized information outputs of events and updates; and 2) Messaging tools that support collaborative decision-making and patient safety double checks that currently occur between nurses and physicians in the absence of EHR support. PMID:20974549

Comparing usability testing outcomes and functions of six electronic nursing record systems.

PubMed

Cho, Insook; Kim, Eunman; Choi, Woan Heui; Staggers, Nancy

2016-04-01

This study examined the usability of six differing electronic nursing record (ENR) systems on the efficiency, proficiency and available functions for documenting nursing care and subsequently compared the results to nurses' perceived satisfaction from a previous study. The six hospitals had different ENR systems, all with narrative nursing notes in use for more than three years. Stratified by type of nursing unit, 54 staff nurses were digitally recorded during on-site usability testing by employing validated patient care scenarios and think-aloud protocols. The time to complete specific tasks was also measured. Qualitative performance data were converted into scores on efficiency (relevancy), proficiency (accuracy), and a competency index using scoring schemes described by McGuire and Babbott. Six nurse managers and the researchers completed assessments of available ENR functions and examined computerized nursing process components including the linkages among them. For the usability test, participants' mean efficiency score was 94.2% (95% CI, 91.4-96.9%). The mean proficiency was 60.6% (95% CI, 54.3-66.8%), and the mean competency index was 59.5% (95% CI, 52.9-66.0). Efficiency scores were significantly different across ENRs as was the time to complete tasks, ranging from 226.3 to 457.2s (χ(2)=12.3, P=0.031; χ(2)=11.2, P=0.048). No significant differences were seen for proficiency scores. The coverage of the various ENRs' nursing process ranged from 67% to 100%, but only two systems had complete integration of nursing components. Two systems with high efficiency and proficiency scores had much lower usability test scores and perceived user satisfaction along with more complex navigation patterns. In terms of system usability and functions, different levels of sophistication of and interaction performance with ENR systems exist in practice. This suggests that ENRs may have variable impacts on clinical outcomes and care quality. Future studies are needed to explore ENR impact on nursing care quality, efficiency, and safety. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
A concept analysis of nursing overtime.

PubMed

Lobo, Vanessa M; Fisher, Anita; Ploeg, Jenny; Peachey, Gladys; Akhtar-Danesh, Noori

2013-11-01

To report a concept analysis of nursing overtime. Economic constraints have resulted in hospital restructuring with the aim of reducing costs. These processes often target nurse staffing (the largest organizational expense) by increasing usage of alternative staffing strategies including overtime hours. Overtime is a multifaceted, poorly defined, and indiscriminately used concept. Analysis of nursing overtime is an important step towards development and propagation of appropriate staffing strategies and rigorous research. Concept analysis. The search of electronic literature included indexes, grey literature, dictionaries, policy statements, contracts, glossaries and ancestry searching. Sources included were published between 1993-2012; dates were chosen in relation to increases in overtime hours used as a result of the healthcare structuring in the early 1990s. Approximately 65 documents met the inclusion criteria. Walker and Avant's methodology guided the analysis. Nursing overtime can be defined by four attributes: perception of choice or control over overtime hours worked; rewards or lack thereof; time off duty counts equally as much as time on duty; and disruption due to a lack of preparation. Antecedents of overtime arise from societal, organizational, and individual levels. The consequences of nursing overtime can be positive and negative, affecting organizations, nurses, and the patients they care for. This concept analysis clarifies the intricacies surrounding nursing overtime with recommendations to advance nursing research, practice, and policies. A nursing-specific middle-range theory was proposed to guide the understanding and study of nursing overtime. © 2013 Blackwell Publishing Ltd.
The relationship of attitude, subjective norm, and behavioral intent to the documentation behavior of nurses.

PubMed

Renfroe, D H; O'Sullivan, P S; McGee, G W

1990-01-01

Ajzen and Fishbein's theory of reasoned action was used to assess the relationship of nurses' attitude, subjective norm, and behavioral intention to their documentation behavior. Attitudes, subjective norms, and behavioral intentions toward documentation were elicited from 108 staff nurses. Documentation behavior was based on what should be documented in any hospitalized patient's chart during a shift. This exploratory model was analyzed with LISREL VI. The overall fit of the final model to the data was good, as judged by a chi-square (df = 7, p = .845). The total coefficient of determination for the structural equation was .461. Attitude toward documentation did not relate significantly to intention to document optimally. Subjective norm did have a significant effect on behavioral intent. Attitude and subjective norm accounted for 46.1% of the variance in behavioral intent. Behavioral intent had a significant effect on documentation behavior, accounting for 15.2% of the variance. It appears that subjective norm, which is the influence of others, is what directs the intention to document and thus relates to subsequent documentation. Recommendations for practice include the communication of high ideals and expectations of important others to the staff nurse in order to improve the quality of documentation.
Global Nursing Issues and Development: Analysis of World Health Organization Documents.

PubMed

Wong, Frances Kam Yuet; Liu, Huaping; Wang, Hui; Anderson, Debra; Seib, Charrlotte; Molasiotis, Alex

2015-11-01

To analyze World Health Organization (WHO) documents to identify global nursing issues and development. Qualitative content analysis. Documents published by the six WHO regions between 2007 and 2012 and with key words related to nurse/midwife or nursing/midwifery were included. Themes, categories, and subcategories were derived. The final coding reached 80% agreement among three independent coders, and the final coding for the discrepant coding was reached by consensus. Thirty-two documents from the regions of Europe (n = 19), the Americas (n = 6), the Western Pacific (n = 4), Africa (n = 1), the Eastern Mediterranean (n = 1), and Southeast Asia (n = 1) were examined. A total of 385 units of analysis dispersed in 31 subcategories under four themes were derived. The four themes derived (number of unit of analysis, %) were Management & Leadership (206, 53.5), Practice (75, 19.5), Education (70, 18.2), and Research (34, 8.8). The key nursing issues of concern at the global level are workforce, the impacts of nursing in health care, professional status, and education of nurses. International alliances can help advance nursing, but the visibility of nursing in the WHO needs to be strengthened. Organizational leadership is important in order to optimize the use of nursing competence in practice and inform policy makers regarding the value of nursing to promote people's health. © 2015 Sigma Theta Tau International.
A systematic review of clinical supervision evaluation studies in nursing.

PubMed

Cutcliffe, John R; Sloan, Graham; Bashaw, Marie

2018-02-15

According to the international, extant literature published during the last 20 years or so, clinical supervision (CS) in nursing is now a reasonably common phenomenon. Nevertheless, what appears to be noticeably 'thin on the ground' in this body of literature are empirical evaluations of CS, especially those pertaining to client outcomes. Accordingly, the authors undertook a systematic review of empirical evaluations of CS in nursing to determine the state of the science. Adopting the approach documented by Stroup et al. (JAMA, 283, 2000, 2008), the authors searched for reports of evaluation studies of CS in nursing - published during the years 1995 to 2015. Keywords for the search were 'clinical supervision', 'evaluation', 'efficacy', 'nursing', and combinations of these keywords. Electronic databases used were CINAHL, MEDLINE, PsychLIT, and the British Nursing Index. The research evidence from twenty-eight (28) studies reviewed is presented, outlining the main findings with an overview of each study presented. The following broad themes were identified and are each discussed in the study: narrative/anecdotal accounts of positive outcomes for clinical supervision, narrative/anecdotal accounts of negative outcomes for clinical supervision, empirical positive outcomes reported by supervisee, and empirical findings showing no effect by supervisee. © 2018 Australian College of Mental Health Nurses Inc.
How do nurses record pedagogical activities? Nurses' documentation in patient records in a cardiac rehabilitation unit for patients who have undergone coronary artery bypass surgery.

PubMed

Bergh, Anne-Louise; Bergh, Claes-Håkan; Friberg, Febe

2007-10-01

To describe the use of pedagogically related keywords and the content of notes connected to these keywords, as they appear in nursing records in a coronary artery bypass graft (CABG) surgery rehabilitation unit. Nursing documentation is an important component of clinical practice and is regulated by law in Sweden. Studies have been carried out in order to evaluate the educational and rehabilitative needs of patients following CABG surgery but, as yet, no study has contained an in-depth evaluation of how nurses document pedagogical activities in the records of these patients. The records of 265 patients admitted to a rehabilitation unit following CABG surgery were analysed. The records were structured in accordance with the VIPS model. Using this model, pedagogically related keywords: communication, cognition/development and information/education were selected. The analysis of the data consisted of three parts: the frequency with which pedagogically related keywords are used, the content and the structure of the notes. Apart from the term 'communication', pedagogically related keywords were seldom used. Communication appeared in all records describing limitations, although no explicit reference was made to pedagogical activities. The notes related to cognition/development were grouped into the following themes: nurses' actions, assessment of knowledge and provision of information, advice and instructions as well as patients' wishes and experiences. The themes related to information were the provision of information and advice in addition to relevant nursing actions. The structure of the documentation was simple. The documentation of pedagogical activities in nursing records was infrequent and inadequate. The patients' need for knowledge and the nurses' teaching must be documented in the patient records so as to clearly reflect the frequency and quality of pedagogical activities.
Creating history: documents and patient participation in nurse-patient interviews.

PubMed

Jones, Aled

2009-09-01

Strongly worded directives regarding the need for increased patient participation during nursing interaction with patients have recently appeared in a range of 'best-practice' documents. This paper focuses on one area of nurse-patient communication, the hospital admission interview, which has been put forward as an ideal arena for increased patient participation. It uses data from a total of 27 admission interviews, extensive periods of participant observation and analysis of nursing records to examine how hospital admission interviews are performed by nurses and patients. Analysis shows that topics discussed during admission closely follow the layout of the admission document which nurses complete during the interview. Whilst it is tempting to describe the admission document as a 'super technological power' in influencing the interaction and restricting patient participation, this analysis attempts a more rounded reading of the data. Findings demonstrate that, whilst opportunities for patient participation were rare, admission interviews are complex interactional episodes that often belie simplistic or prescriptive guidance regarding interaction between nurses and patients. In particular, issue is taken with the lack of contextual and conceptual clarity with which best-practice guidelines are written.
The Role of Certified Registered Nurse Anesthetists in Patient Education

DTIC Science & Technology

2000-10-01

As advanced practice nurses, certified registered nurse anesthetists (CRNAs) have a responsibility to engage in patient education about health...Categories and themes include; engaging in perioperative patient education , focusing on explanations about anesthesia and surgery, prior nursing...experiences make patient education easier, documenting patient education is important and uncertainty about where to document it. Common topics and themes
Introduction of Situation, Background, Assessment, Recommendation into Nursing Practice: A Prospective Study.

PubMed

Achrekar, Meera S; Murthy, Vedang; Kanan, Sadhana; Shetty, Rani; Nair, Mini; Khattry, Navin

2016-01-01

The aim of the study was to introduce and evaluate the compliance to documentation of situation, background, assessment, recommendation (SBAR) form. Twenty nurses involved in active bedside care were selected by simple random sampling. Use of SBAR was illustrated thru self-instructional module (SIM). Content validity and reliability were established. The situation, background, assessment, recommendation (SBAR) form was disseminated for use in a clinical setting during shift handover. A retrospective audit was undertaken at 1 st week (A1) and 16 th week (A2), post introduction of SIM. Nurse's opinion about the SBAR form was also captured. Majority of nurses were females (65%) in the age group 21-30 years (80%). There was a significant association ( P = 0.019) between overall audit scores and graduate nurses. Significant improvement ( P = 0.043) seen in overall scores between A1 (mean: 23.20) and A2 (mean: 24.26) and also in "Situation" domain ( P = 0.045) as compared to other domains. There was only a marginal improvement in documentation related to patient's allergies and relevant past history (7%) while identifying comorbidities decreased by 40%. Only 70% of nurses had documented plan of care. Most (76%) of nurses expressed that SBAR form was useful, but 24% nurses felt SBAR documentation was time-consuming. The assessment was easy (53%) to document while recommendation was the difficult (53%) part. SBAR technique has helped nurses to have a focused and easy communication during transition of care during handover. Importance and relevance of capturing information need to be reinforced. An audit to look for reduced number of incidents related to communication failures is essential for long-term evaluation of patient outcomes. Use of standardized SBAR in nursing practice for bedside shift handover will improve communication between nurses and thus ensure patient safety.
In search of details of patient teaching in nursing documentation--an analysis of patient records in a medical ward in Sweden.

PubMed

Friberg, Febe; Bergh, Anne-Louise; Lepp, Margret

2006-12-01

The aim of this study was to identify terms and expressions indicating patients' need for knowledge and understanding, as well as nurses' teaching interventions, as documented in nursing records. Previous international studies have shown that nursing documentation is often deficient in terms of recording patient teaching. Patient records (N = 35) were collected in a general medical ward in a hospital in Sweden. The data contain 206 days of nursing documentation. The records were analysed with regard to content and structure. Terms and expressions indicating patients' need for knowledge and understanding and terms and expressions indicating nurses' teaching activities were analysed. The results showed that patients' need for knowledge is implicitly indicated by conceptions and experiences as well as questions. Furthermore, nurses' implicit teaching interventions consist of information, motivating conversations, explanations, instructions and setting expectations. However, the content and structure of the pedagogical activities in the patient records are fragmented and vague. Efforts must be directed towards elaborating upon the above-mentioned terms and expressions as indications of patients' need for knowledge and nurses' teaching interventions. Moreover, these terms and expressions must be recognized and acknowledged.
Australia's health care reform agenda: implications for the nurses' role in chronic heart failure management.

PubMed

Betihavas, Vasiliki; Newton, Phillip J; Du, Hui Yun; Macdonald, Peter S; Frost, Steven A; Stewart, Simon; Davidson, Patricia M

2011-08-01

The importance of the nursing role in chronic heart failure (CHF) management is increasingly recognised. With the recent release of the National Health and Hospitals Reform Commission (NHHRC) report in Australia, a review of nursing roles in CHF management is timely and appropriate. This paper aims to discuss the implications of the NHHRC report and nursing roles in the context of CHF management in Australia. The electronic databases, Thomson Rheuters Web of Knowledge, Scopus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), were searched using keywords including; "heart failure", "management", "Australia" and "nursing". In addition policy documents were reviewed including statements and reports from key professional organisations and Government Departments to identify issues impacting on nursing roles in CHF management. There is a growing need for the prevention and control of chronic conditions, such as CHF. This involves an increasing emphasis on specialist cardiovascular nurses in community based settings, both in outreach and inreach health service models. This review has highlighted the need to base nursing roles on evidence based principles and identify the importance of the nursing role in coordinating and managing CHF care in both independent and collaborative practice settings. The importance of the nursing role in early chronic disease symptom recognition and implementing strategies to prevent further deterioration of individuals is crucial to improving health outcomes. Consideration should be given to ensure that evidence based principles are adopted in models of nursing care. Copyright © 2010 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
Modes of rationality in nursing documentation: biology, biography and the 'voice of nursing'.

PubMed

Hyde, Abbey; Treacy, Margaret P; Scott, P Anne; Butler, Michelle; Drennan, Jonathan; Irving, Kate; Byrne, Anne; MacNeela, Padraig; Hanrahan, Marian

2005-06-01

This article is based on a discourse analysis of the complete nursing records of 45 patients, and concerns the modes of rationality that mediated text-based accounts relating to patient care that nurses recorded. The analysis draws on the work of the critical theorist, Jurgen Habermas, who conceptualised rationality in the context of modernity according to two types: purposive rationality based on an instrumental logic, and value rationality based on ethical considerations and moral reasoning. Our analysis revealed that purposive rationality dominated the content of nursing documentation, as evidenced by a particularly bio-centric and modernist construction of the workings of the body within the texts. There was little reference in the documentation to central themes of contemporary nursing discourses, such as notions of partnership, autonomy, and self-determination, which are associated with value rationality. Drawing on Habermas, we argue that this nursing documentation depicted the colonisation of the sociocultural lifeworld by the bio-technocratic system. Where nurses recorded disagreements that patients had with medical regimes, the central struggle inherent in the project of modernity became transparent--the tension between the rational and instrumental control of people through scientific regulation and the autonomy of the subject. The article concludes by problematising communicative action within the context of nursing practice.
Nurse Continuity and Hospital-Acquired Pressure Ulcers: A Comparative Analysis Using an Electronic Health Record "Big Data" Set.

PubMed

Stifter, Janet; Yao, Yingwei; Lodhi, Muhammad Kamran; Lopez, Karen Dunn; Khokhar, Ashfaq; Wilkie, Diana J; Keenan, Gail M

2015-01-01

Little research demonstrating the association between nurse continuity and patient outcomes exists despite an intuitive belief that continuity makes a difference in care outcomes. The aim of this study was to examine the association of nurse continuity with the prevention of hospital-acquired pressure ulcers (HAPU). A secondary use of data from the Hands on Automated Nursing Data System (HANDS) was performed for this comparative study. The HANDS is a nursing plan of care data set containing 42,403 episodes documented by 787 nurses, on nine units, in four hospitals and includes nurse staffing and patient characteristics. The HANDS data set resides in a "big data" relational database consisting of 89 tables and 747 columns of data. Via data mining, we created an analytic data set of 840 care episodes, 210 with and 630 without HAPUs, matched by nursing unit, patient age, and patient characteristics. Logistic regression analysis determined the association of nurse continuity and additional nurse-staffing variables on HAPU occurrence. Poor nurse continuity (unit mean continuity index = .21-.42 [1.0 = optimal continuity]) was noted on all nine study units. Nutrition, mobility, perfusion, hydration, and skin problems on admission, as well as patient age, were associated with HAPUs (p < .001). Controlling for patient characteristics, nurse continuity, and the interactions between nurse continuity and other nurse-staffing variables were not significantly associated with HAPU development. Patient characteristics including nutrition, mobility, and perfusion were associated with HAPUs, but nurse continuity was not. We demonstrated a high level of variation in the degree of continuity between patient episodes in the HANDS data, showing that it offers rich potential for future study of nurse continuity and its effect on patient outcomes.
Using Electronic Health Record (EHR) “Big Data” to Examine the Influence of Nurse Continuity on a Hospital-Acquired Never Event

PubMed Central

STIFTER, Janet; YAO, Yingwei; LODHI, Muhammad Kamran; LOPEZ, Karen Dunn; KHOKHAR, Ashfaq; WILKIE, Diana J.; KEENAN, Gail M.

2015-01-01

Background There is little research demonstrating the influence of nurse continuity on patient outcomes despite an intuitive belief that continuity of care makes a difference in care outcomes. Objective To examine the influence of nurse continuity (the number of consecutive care days by the same/consistent RN[s]) on the prevention of hospital-acquired pressure ulcers (HAPU). Method A secondary use of data from the Hands on Automated Nursing Data System (HANDS) was performed for this comparative study. The HANDS is a nursing plan of care (POC) “big data” database containing 42,403 episodes documented by 787 nurses, on 9 units, in four hospitals and includes nurse staffing and patient characteristics. Via data mining, we created an analytic dataset of 840 care episodes, 210 with and 630 without HAPUs, matched by nursing unit, patient age, and patient characteristics. Logistic regression analysis determined the influence of nurse continuity and additional nurse-staffing variables on the presence of HAPUs. Results Poor nurse continuity (Continuity Index=.21-.42 [1.0=optimal continuity]) was noted on all nine study units. Nutrition, mobility, perfusion, hydration, and skin problems on admission as well as patient age were associated with HAPUs (p<.001). Controlling for patient characteristics, nurse continuity and the interactions between nurse continuity and other nurse-staffing variables were not significantly associated with HAPU development. Discussion Patient characteristics including nutrition, mobility, and perfusion were associated with HAPUs, but nurse continuity was not. One study implication is that to reduce the incidence of HAPUs the most effective resource utilization might be in the continued development of best practices to address patient characteristics that lead to pressure ulcer vulnerability rather than a focus on nurse staffing. PMID:26325278
Nursing documentation with NANDA and NIC in a comprehensive HIS/EPR system.

PubMed

Flø, Kåre

2006-01-01

DIPS nursing documentation system facilitates that nurses can write several types of notes into the EPR. Within these notes the nurses can register NANDA diagnoses and NIC interventions with nursing activities. To choose NANDA and NIC the nurse can use a search engine, or she can choose a relevant Care plan guideline and pick the suggested diagnoses and interventions from there. Diagnoses and interventions with nursing activities registered are presented in a Care plan. When a nurse writes a note for a patient she will always be presented the Care plan and she can easy evaluate and update the Care plan.
A Mixed-methods Study to Assess Interrater Reliability and Nurse Perception of the Braden Scale in a Tertiary Acute Care Setting.

PubMed

Ho, Chester H; Cheung, Amanda; Southern, Danielle; Ocampo, Wrechelle; Kaufman, Jaime; Hogan, David B; Baylis, Barry; Conly, John M; Stelfox, Henry T; Ghali, William A

2016-12-01

Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden Scale in clinical practice. Further study of the value of the total Braden Scale and its subscales is warranted.
Meeting the criteria of a nursing diagnosis classification: Evaluation of ICNP, ICF, NANDA and ZEFP.

PubMed

Müller-Staub, Maria; Lavin, Mary Ann; Needham, Ian; van Achterberg, Theo

2007-07-01

Few studies described nursing diagnosis classification criteria and how classifications meet these criteria. The purpose was to identify criteria for nursing diagnosis classifications and to assess how these criteria are met by different classifications. First, a literature review was conducted (N=50) to identify criteria for nursing diagnoses classifications and to evaluate how these criteria are met by the International Classification of Nursing Practice (ICNP), the International Classification of Functioning, Disability and Health (ICF), the International Nursing Diagnoses Classification (NANDA), and the Nursing Diagnostic System of the Centre for Nursing Development and Research (ZEFP). Using literature review based general and specific criteria, the principal investigator evaluated each classification, applying a matrix. Second, a convenience sample of 20 nursing experts from different Swiss care institutions answered standardized interview forms, querying current national and international classification state and use. The first general criterion is that a diagnosis classification should describe the knowledge base and subject matter for which the nursing profession is responsible. ICNP) and NANDA meet this goal. The second general criterion is that each class fits within a central concept. The ICF and NANDA are the only two classifications built on conceptually driven classes. The third general classification criterion is that each diagnosis possesses a description, diagnostic criteria, and related etiologies. Although ICF and ICNP describe diagnostic terms, only NANDA fulfils this criterion. The analysis indicated that NANDA fulfilled most of the specific classification criteria in the matrix. The nursing experts considered NANDA to be the best-researched and most widely implemented classification in Switzerland and internationally. The international literature and the opinion of Swiss expert nurses indicate that-from the perspective of classifying comprehensive nursing diagnoses-NANDA should be recommended for nursing practice and electronic nursing documentation. Study limitations and future research needs are discussed.
The Effects of Structured Health Policy Education on Connecticut Registered Nurses' Clinical Documentation

ERIC Educational Resources Information Center

Lobo, Rosale Constance

2017-01-01

Registered Nurses use clinical documentation to describe care planning processes, measure quality outcomes, support reimbursement, and defend litigation. The Connecticut Department of Health, guided by federal Conditions of Participation, defines state-level healthcare policy to include required care planning processes. Nurses are educated in care…
Discourse analysis of an 'observation levels' nursing policy.

PubMed

Horsfall, J; Cleary, M

2000-11-01

The practice of special observation (or constant observation) is widely used in inpatient psychiatric facilities for the care of people who are suicidal. In this study, the policy of special observation was examined using a discourse analysis method to discern prevailing ideas and practices highlighted within the policy. After reading, studying and analysing the special observation nursing policy, the authors briefly describe the document and outline the terms and phrases prevalent within the document. These recurrent ideas are then organized into five categories: professional responsibilities, suicidality, the patient's immediate context, the patient's observable behaviour and the nursing checklist. In discussion of the policy document, the invisibility of the authors, target audience and patients is noted. The authors attempt to elicit evidence for the therapeutic nurse-patient relationship in the document. In the analysis of patient, nurse and doctor roles and responsibilities, it is evident that the policy document reinforces the traditional medical hierarchy of power relations. Some assumptions that underpin the document are postulated. Questions regarding the nature of risk assessment and the evidence base for the medical prescription of special observation are raised. As well as ideas and themes evident in the document, the absence of some relevant issues is explored. While the need for succinctness and clarity in policy documents is acknowledged, the fact that patient rights, therapeutic processes and ethical dilemmas are absent is deemed significant.
Point of care experience with pneumococcal and influenza vaccine documentation among persons aged ≥65 years: high refusal rates and missing information.

PubMed

Brownfield, Elisha; Marsden, Justin E; Iverson, Patty J; Zhao, Yumin; Mauldin, Patrick D; Moran, William P

2012-09-01

Missed opportunities to vaccinate and refusal of vaccine by patients have hindered the achievement of national health care goals. The meaningful use of electronic medical records should improve vaccination rates, but few studies have examined the content of these records. In our vaccine intervention program using an electronic record with physician prompts, paper prompts, and nursing standing orders, we were unable to achieve national vaccine goals, due in large part to missing information and patient refusal. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Evaluating acceptance of an electronic data management system at a tertiary care institution.

PubMed

Young, Wendy; Klima, George; Isaac, Winston

2011-01-01

This research reports on satisfaction with the introduction of an electronic document management system in a tertiary hospital environment. A buffet of training and familiarization options were offered: one-on-one training, open house, drop-in, e-learning, classroom training, and self-study. It was found that professions differ in their pattern of satisfaction with training and they also differ in their satisfaction with both the usefulness and the ease of use of the system. Satisfaction among administrators was highest and that among nurses lowest. There was an association between attendance at the open house event and satisfaction with the system.
Shoulder dystocia documentation: an evaluation of a documentation training intervention.

PubMed

LeRiche, Tammy; Oppenheimer, Lawrence; Caughey, Sharon; Fell, Deshayne; Walker, Mark

2015-03-01

To evaluate the quality and content of nurse and physician shoulder dystocia delivery documentation before and after MORE training in shoulder dystocia management skills and documentation. Approximately 384 charts at the Ottawa Hospital General Campus involving a diagnosis of shoulder dystocia between the years of 2000 and 2006 excluding the training year of 2003 were identified. The charts were evaluated for 14 key components derived from a validated instrument. The delivery notes were then scored based on these components by 2 separate investigators who were blinded to delivery note author, date, and patient identification to further quantify delivery record quality. Approximately 346 charts were reviewed for physician and nurse delivery documentation. The average score for physician notes was 6 (maximum possible score of 14) both before and after the training intervention. The nurses' average score was 5 before and after the training intervention. Negligible improvement was observed in the content and quality of shoulder dystocia documentation before and after nurse and physician training.
Nursing Shortage: Strategies for Nursing Practice and Education. Report of the National Invitational Workshop (Washington, D.C., February 22-24, 1988).

ERIC Educational Resources Information Center

Circle, Inc., McLean, VA.

This document reports the proceedings of a conference held in response to concerns about the nursing shortage and its implications for health care in the United States. Following a keynote address ("Nursing and Shortage: Part of the Problem or Part of the Solution?") by Dona Diers, the document is organized in five sections, with each section…
[Analysis of literature citations in original articles published in Spanish and international nursing journals and journals in 2 closely related disciplines].

PubMed

Muñoz-Soler, Verónica; Flores-López, María José; Cabañero-Martínez, María José; Richart-Martínez, Miguel

2007-01-01

To compare Spanish nursing journals with 2 English-language standard journals, as well as Spanish journals in closely related disciplines, to identify possible quantitative and qualitative shortcomings in scientific documentation. We performed a descriptive, cross-sectional study of the references contained in 796 articles from 6 Spanish journals from 3 health disciplines (2000-2002) and 2 English-language nursing journals (2000-2001). The number of references, type of publication cited, and language of the document cited were compared in individual journals, and in journals grouped by discipline and according to language. Spanish-language nursing journals had the lowest mean number of references per article (X- = 16.20) when compared with psychology journals (X- = 31.24), medical journals (X- = 31.39) and international nursing journals (X- = 37.11). Among Spanish journals, citation of English-language publications was most frequent in medical journals (X- = 26.28) and least frequent in nursing journals (X- = 6.04). In contrast, citation of Spanish documents was most frequent in nursing journals (X- = 9.79) and least frequent in medical journals (X- = 4.43). Although scientific publication of Spanish nursing has improved, it is not comparable to publication of closely related disciplines and international nursing. The low citation of English documents clearly reveals the risk of scientific insularity.
Removal of paper-based health records from Norwegian hospitals: effects on clinical workflow.

PubMed

Lium, Jan Tore; Faxvaag, Arild

2006-01-01

Several Norwegian hospitals have, plan, or are in the process of removing the paper-based health record from clinical workflow. To assess the impact on usage and satisfaction of electronic health record (EHR) systems, we conducted a survey among physicians, nurses and medical secretaries at selected departments from six Norwegian hospitals. The main feature of the questionnaire is the description of a set of tasks commonly performed at hospitals, and respondents were asked to rate their usage and change of ease compared to previous routines for each tasks. There were 24 tasks for physicians, 19 for nurses and 23 for medical secretaries. In total, 64 physicians, 128 nurses and 57 medical secretaries responded, corresponding to a response rate of 68%, 58% and 84% respectively. Results showed a large degree of use among medical secretaries, while physicians and nurses displayed a more modest degree of use. Possibly suggesting that the EHR systems among clinicians still is considered more of an administrative system. Among the two latter groups, tasks regarding information retrieval were used more extensively than tasks regarding generating and storing information. Also, we observed large differences between hospitals and higher satisfaction with the part of the system handling regular electronic data than scanned document images. Even though the increase in use among clinicians after removing the paper based record were mainly in tasks where respondents had no choice other than use the electronic health record, the attitude towards EHR-systems were mainly positive. Thus, while removing the paper based record has yet to promote new ways of working, we see it as an important step towards the EHR system of tomorrow. Several Norwegian hospitals have shown that it is possible.
Improving the Quality of Nursing Documentation in Home Health Care Setting

ERIC Educational Resources Information Center

Obioma, Chidiadi

2017-01-01

Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the…
A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center

PubMed Central

2012-01-01

Background Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients. Methods We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting. Results A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features. Conclusions RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients. PMID:23186245
Relationships between public health nurse-delivered physical activity interventions and client physical activity behavior.

PubMed

Olsen, Jeanette M; Horning, Melissa L; Thorson, Diane; Monsen, Karen A

2018-04-01

The purpose of this study was to identify physical activity interventions delivered by public health nurses (PHNs) and examine their association with physical activity behavior change among adult clients. Physical activity is a public health priority, yet little is known about nurse-delivered physical activity interventions in day-to-day practice or their outcomes. This quantitative retrospective evaluation examined de-identified electronic-health-record data. Adult clients with at least two Omaha System Physical activity Knowledge, Behavior, and Status (KBS) ratings documented by PHNs between October 2010-June 2016 (N=419) were included. Omaha System baseline and follow-up Physical activity KBS ratings, interventions, and demographics were examined. Younger clients typically receiving maternal-child/family services were more likely to receive interventions than older clients (p<0.001). A total of 2869 Physical activity interventions were documented among 197 clients. Most were from categories of Teaching, Guidance, Counseling (n=1639) or Surveillance (n=1183). Few were Case Management (n=46). Hierarchical regression modeling explained 15.4% of the variance for change in Physical activity Behavior rating with significant influence from intervention dose (p=0.03) and change in Physical activity Knowledge (p<0.001). This study identified and described physical activity interventions delivered by PHNs. Implementation of department-wide policy requiring documentation of Physical activity assessment for all clients enabled the evaluation. A higher dose of physical activity interventions and increased Physical activity knowledge were associated with increased Physical activity Behavior. More research is needed to identify factors influencing who receives interventions and how interventions are selected. Copyright © 2017 Elsevier Inc. All rights reserved.
Usability Assessment of Secure Messaging for Clinical Document Sharing between Health Care Providers and Patients.

PubMed

Jahn, Michelle A; Porter, Brian W; Patel, Himalaya; Zillich, Alan J; Simon, Steven R; Russ, Alissa L

2018-04-01

Web-based patient portals feature secure messaging systems that enable health care providers and patients to communicate information. However, little is known about the usability of these systems for clinical document sharing. This article evaluates the usability of a secure messaging system for providers and patients in terms of its ability to support sharing of electronic clinical documents. We conducted usability testing with providers and patients in a human-computer interaction laboratory at a Midwestern U.S. hospital. Providers sent a medication list document to a fictitious patient via secure messaging. Separately, patients retrieved the clinical document from a secure message and returned it to a fictitious provider. We collected use errors, task completion, task time, and satisfaction. Twenty-nine individuals participated: 19 providers (6 physicians, 6 registered nurses, and 7 pharmacists) and 10 patients. Among providers, 11 (58%) attached and sent the clinical document via secure messaging without requiring assistance, in a median (range) of 4.5 (1.8-12.7) minutes. No patients completed tasks without moderator assistance. Patients accessed the secure messaging system within 3.6 (1.2-15.0) minutes; retrieved the clinical document within 0.8 (0.5-5.7) minutes; and sent the attached clinical document in 6.3 (1.5-18.1) minutes. Although median satisfaction ratings were high, with 5.8 for providers and 6.0 for patients (scale, 0-7), we identified 36 different use errors. Physicians and pharmacists requested additional features to support care coordination via health information technology, while nurses requested features to support efficiency for their tasks. This study examined the usability of clinical document sharing, a key feature of many secure messaging systems. Our results highlight similarities and differences between provider and patient end-user groups, which can inform secure messaging design to improve learnability and efficiency. The observations suggest recommendations for improving the technical aspects of secure messaging for clinical document sharing. Schattauer GmbH Stuttgart.
Electronic growth charts: watching our patients grow.

PubMed

Murphy, Cynthia A; Carstens, Kimberly; Villamayor, Precy

2005-01-01

Pediatric Growth Charts have been used in the pediatric community since 1977. The first growth charts were developed by the National Center for Health Statistics as a clinical tool for health care professionals. The growth charts, revised in 2000, by the Center for Disease Control consists of a series of percentile curves for selected body measurements in children [1]. Capitalizing on the benefits of our Electronic Medical Record (EMR), and as a byproduct of nursing electronic documentation of routine heights, weights, and frontal occipital circumferences, our system plots the routine measurements without additional intervention by the staff. Clinicians can view the graphs online or generate printed reports as needed during routine examination for outpatient or hospitalized care. This abstract outlines the background, design process, programming rules utilized to plot growth curves, and the evaluation of the electronic CDC growth charts in our organization.
Evaluating a Proof-of-Concept Approach of the German Health Telematics Infrastructure in the Context of Discharge Management.

PubMed

Hübner, Ursula; Schulte, Georg; Sellemann, Björn; Quade, Matthias; Rottmann, Thorsten; Fenske, Matthias; Egbert, Nicole; Kuhlisch, Raik; Rienhoff, Otto

2015-01-01

Although national eHealth strategies have existed now for more than a decade in many countries, they have been implemented with varying success. In Germany, the eHealth strategy so far has resulted in a roll out of electronic health cards for all citizens in the statutory health insurance, but in no clinically meaningful IT-applications. The aim of this study was to test the technical and organisation feasibility, usability, and utility of an eDischarge application embedded into a laboratory Health Telematics Infrastructure (TI). The tests embraced the exchange of eDischarge summaries based on the multiprofessional HL7 eNursing Summary standard between a municipal hospital and a nursing home. All in all, 36 transmissions of electronic discharge documents took place. They demonstrated the technical-organisation feasibility and resulted in moderate usability ratings. A comparison between eDischarge and paper-based summaries hinted at higher ratings of utility and information completeness for eDischarges. Despite problems with handling the electronic health card, the proof-of-concept for the first clinically meaningful IT-application in the German Health TI could be regarded as successful.
Nursing diagnosis taxonomy across the Atlantic Ocean: congruence between nurses' charting and the NANDA taxonomy.

PubMed

Thoroddsen, Asta; Thorsteinsson, Hrund Sch

2002-02-01

The purpose of this study was to analyse expressions or terms used by nurses in Iceland to describe patient problems. The classification of NANDA was used as reference. The research questions were: (a) Does NANDA terminology represent patient problems documented by Icelandic nurses? (b) If so, what kind of nursing diagnoses does it represent? (c) What kind of patient problems are not represented by NANDA terminology? (d) What are the most frequent nursing diagnoses used? A retrospective chart review was conducted in a 400 bed acute care hospital in Iceland. The sample was defined as nursing diagnosis statements in charts of patients hospitalized in two 6-month periods in two separate years. The data were analysed according to a predefined grading system based on the PES format or Problem -- (A)aetiology -- Signs and symptoms. A total of 1217 charts were used for the study, which yielded 2171 nursing diagnoses statements for analysis. Charts with at least one nursing diagnosis documented were 60.1% and the number of diagnoses per patient ranged from 0 to 10, with 65% of charts with three diagnoses or less. The number of diagnoses correlated with patients' length of stay, but not with increased age of the patients. The average number of statements per patient was 3.28. Almost 60% of the diagnoses were according to NANDA terminology, another 20% were stated as procedures, medical diagnoses or risks for complications. The 20 most frequently used nursing diagnoses accounted for 80% of all diagnoses documented. Discrepancy between nurses' documentation on emotional problems and availability of diagnosis in the NANDA taxonomy was evident. It can be concluded that the NANDA taxonomy seems to be culturally relevant for nurses in different cultures.
Education, leadership and partnerships: nursing potential for Universal Health Coverage

PubMed Central

Mendes, Isabel Amélia Costa; Ventura, Carla Aparecida Arena; Trevizan, Maria Auxiliadora; Marchi-Alves, Leila Maria; de Souza-Junior, Valtuir Duarte

2016-01-01

Objective: to discuss possibilities of nursing contribution for universal health coverage. Method: a qualitative study, performed by means of document analysis of the World Health Organization publications highlighting Nursing and Midwifery within universal health coverage. Results: documents published by nursing and midwifery leaders point to the need for coordinated and integrated actions in education, leadership and partnership development. Final Considerations: this article represents a call for nurses, in order to foster reflection and understanding of the relevance of their work on the consolidation of the principles of universal health coverage. PMID:26959333
[The registered nurse and the battle against tuberculosis in Brazil: 1961-1966].

PubMed

Montenegro, Hercília Regina do Amaral; de Almeida Filho, Antonio José; Santos, Tânia Cristina Franco; Lourenço, Lucia Helena Silva Corrêa

2009-12-01

The objective of this study was to describe the circumstances that promoted the implementation of the new Program for Action Against Tuberculosis in Brazil (Programa de Ação na Luta contra a Tuberculose no Brasil) and discuss the strategies used by registered nurses from the Santa Maria State Hospital, Guanabara State, to adjust nursing care to the new program against tuberculosis. This was performed through document research, interviews, and statements from nurses working at the time of the reorganization. Documents were analyzed based on the concepts of habitus, field, and symbolic power by Pierre Bourdieu, and included written and oral documents as well as secondary sources. The reorganization of the nursing service was performed under the leadership of a nurse whose symbolic capital assigned power and prestige to implement the necessary changes. It is concluded that the work of that nurse made it possible to implement the new program and contributed to establishing the position and importance of the registered nurse in providing care to individuals with tuberculosis, for prevention and cure.
Satisfaction of health-care providers with electronic health records and perceived barriers to its implementation in the United Arab Emirates.

PubMed

Bani-Issa, Wegdan; Al Yateem, Nabeel; Al Makhzoomy, Ibtihal Khalaf; Ibrahim, Ali

2016-08-01

The integration of electronic health records (EHRs) has shown promise in improving health-care quality. In the United Arab Emirates, EHRs have been recently adopted to improve the quality and safety of patient care. A cross-sectional survey of 680 health-care providers (HCPs) was conducted to assess the satisfaction of HCPs in the United Arab Emirates with EHRs' impact on access/viewing, documentation and medication administration and to explore the barriers encountered in their use. Data were collected over 6 months from April to September 2014. High overall satisfaction with EHRs was reported by HCPs, suggesting their acceptance. Physicians reported the greatest overall satisfaction with EHRs, although nurses showed significantly higher satisfaction with the impact on medication administration compared with other HCPs. The most significant barriers reported by nurses were lack of belief in the value of EHRs for patients and lack of adequate computer skills. Given the large investment in technology, additional research is necessary to promote the full utilization of EHRs. Nurses need to be aware of the value of EHRs for patient care and be involved in all stages of EHR implementations to maximize its meaningful use for better clinical outcomes. © 2016 John Wiley & Sons Australia, Ltd.
Wound, Ostomy, and Continence Nursing: Scope and Standards of Practice, 2nd Edition: An Executive Summary.

PubMed

2018-04-25

Wound, ostomy, and continence (WOC) nursing was recognized as a nursing specialty by the American Nurses Association in February 2010, and the Society published the original scope and standards of WOC nursing practice in May 2010. The Wound, Ostomy, and Continence Nursing: Scope and Standards of Practice, 2nd Edition is the definitive resource promoting excellence in professional practice, quality care, and improved patient outcomes in WOC specialty practice. It can be used to articulate the value of WOC nurses to administrators, legislators, payers, patients, and others. The second edition also provides an overview of the scope of WOC nursing practice including a description of the specialty, the history and evolution of WOC nursing, characteristics of WOC nursing practice, and description of the trispecialty. The document describes various WOC nurse roles, populations served, practice settings, care coordination, and collaboration. Educational preparation, levels of practice within WOC specialty nursing, certification, mandate for continuous professional development, ethics, current trends, future considerations and challenges, and standards of WOC nursing practice and professional performance with competencies for each standard are provided. The purpose of this Executive Summary is to describe the process for developing the scope and standards document, provide an overview of the scope of WOC nursing practice, and list the standards of practice and professional performance along with the competencies for each level of WOC nurse provider. The original document is available from the WOCN Society's online book store (www.wocn.org).
Problem Solving for Volatilizing Situation in Nursing: Developing Thinking Process Supporting System using NursingNAVI® Contents.

PubMed

Tsuru, Satoko; Wako, Fumiko; Omori, Miho; Sudo, Kumiko

2015-01-01

We have identified three foci of the nursing observation and nursing action respectively. Using these frameworks, we have developed the structured knowledge model for a number of diseases and medical interventions. We developed this structure based NursingNAVI® contents collaborated with some quality centered hospitals. Authors analysed the nursing care documentations of post-gastrectomy patients in light of the standardized nursing care plan in the "NursingNAVI®" developed by ourselves and revealed the "failure to observe" and "failure to document", which leaded to the volatility of the patients' data, conditions and some situation. This phenomenon should have been avoided if nurses had employed a standardized nursing care plan. So, we developed thinking process support system for planning, delivering, recording and evaluating in daily nursing using NursingNAVI® contents. A hospital decided to use NursingNAVI® contents in HIS. It was suggested that the system has availability for nursing OJT and time reduction of planning and recording without volatilizing situation.
Improving Utilization of the Family History in the Electronic Health Record.

PubMed

Hickey, Kathleen T; Katapodi, Maria C; Coleman, Bernice; Reuter-Rice, Karin; Starkweather, Angela R

2017-01-01

The purpose of this article is to provide an overview of Family History in the Electronic Health Record and to identify opportunities to advance the contributions of nurses in obtaining, updating and assessing family history in order to improve the health of all individuals and populations. The article presents an overview of the obstacles to charting Family History within the Electronic Health Record and recommendations for using specific Family History tools and core Family History data sets. Opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. These opportunities are focused within the area of promoting the importance of communication within families and between healthcare providers to obtain, document, and update family histories. Nurses can increase awareness of existing resources that can guide collection of a comprehensive and accurate family history and facilitate family discussions. In this paper, opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. Aligned with the clinical preparation of nurses, family health should be used routinely by nurses for risk assessment and to help inform patient and family members on screening, health promotion, and disease prevention. The quality of family health information is critical in order to leverage the use of genomic healthcare information and derive new knowledge about disease biology, treatment efficacy, and drug safety. These actionable steps need to be performed in the context of promoting evidence-based applications of family history that will be essential for implementing personalized genomic healthcare approaches and disease prevention efforts. Family health history is one of the most important tools for identifying the risk of developing rare and chronic conditions, including cardiovascular disease, cancer, and diabetes, and represents an integration of disease risk from genetic, environmental, and behavioral/lifestyle factors. In fact, family history has long been recognized as a strong independent risk factor for disease and is the current best practice used in clinical practice to guide risk assessment. © 2016 Sigma Theta Tau International.
Leadership in nursing education: voices from the past.

PubMed

Gosline, Mary Beth

2004-01-01

When education for nurses became a reality, leaders in the emerging profession spoke out early and often for educational improvements to prepare those who would nurse. The writings and speeches of Isabel Hampton Robb, Mary Adelaide Nutting, Lavinia Lloyd Dock, Lillian Wald, and Isabel Maitland Stewart formed the basis for a qualitative study that documents the voices of early nursing leaders who contributed to the development of nursing education as it moved from "training" toward professional education in a university setting. What is documented in the literature is the desire of these women to enhance the professional status of nursing through improvements in its educational system.
Electronic access to scientific nursing knowledge: the Virginia Henderson International Nursing Library.

PubMed

Graves, J R

2001-02-01

To inform oncology nurses about the electronic knowledge resources offered by the Sigma Theta Tau International Virginia Henderson International Nursing Library. Published articles and research studies. Clinical nursing research dissemination has been seriously affected by publication bias. The Virginia Henderson International Nursing Library has introduced both a new publishing paradigm for research and a new knowledge indexing strategy for improving electronic access to research knowledge (findings). The ability of oncology nursing to evolve, as an evidence-based practice, is largely dependent on access to research findings.

The dilemma of "to be or not to be": developing electronically e-health & cloud computing documents for overseas transplant patients from Taiwan organ transplant health professionals' perspective.

PubMed

Shih, F-J; Fan, Y-W; Chiu, C-M; Shih, F-Ji; Wang, S-S

2012-05-01

The development of mutually accessible e-health documents (ehD) and cloud computing (CC) for overseas organ transplant health professionals (OTHP) in two medical parties (domestic and overseas) would ensure better quality of care. This project attempted to compare pro and con arguments from the perspective of Taiwan's OTHP. A sample was obtained from three leading medical centers in Taiwan. Eighty subjects including transplant surgeons (n = 20), registered nurses (RN; n = 30), coordinating nurses (OTCN; n = 15), and e-health information and communication technologies experts (ehICTs; n = 15) participated in this research. The pros of developing ehD were: (1) better and continuous care through communication and cooperation in two parties (78%); (2) better collaborative efforts between health professionals, information technology experts in two medical parties is (74%); (3) easier retrieval and communication of personal health documents with the trustworthy OTHP in the different countries (71%); and (4) CC may help develop transplant patients medical cloud based on the collaboration between medical systems in political parties of Taiwan and mainland China (69%). The cons of developing ehD and CC included: (1) inadequate knowledge of benefits and manuals of developing ehD and CC (75%); (2) no reliable communication avenues in developing ehD and CC (73%); (3) increased workload in direct care and documentation in developing new ehD and CC (70%); (4) lack of coaching and accreditation systems in medical, electronic, and law aspects to settle discrepancies in medical diagnosis and treatment protocols between two parties (68%); and (5) lacking systematic ehD and CC plans developed by interdisciplinary teams in two parties (60%). In this initial phase, the establishment of an interdisciplinary team including transplant leaders, transplant surgeon, RN, OTCN, ehICTs, and law experts from two parties might be helpful in working out developing plans with careful monitoring mechanisms. Copyright © 2012 Elsevier Inc. All rights reserved.
Medical Documentation: An English Composition Professor's Perspective.

ERIC Educational Resources Information Center

Freeman, Mary G.

Nursing textbooks which address the subject of medical documentation tend to equate good documentation of a patient's behavior and state with strong interpersonal skills on the part of the nurse. Rarely do they point out the importance of developing a deep concentrated attention to the sensory world around oneself in order to be a good medical…
Documentation of Sexual Partner Gender Is Low in Electronic Health Records: Observations, Predictors, and Recommendations to Improve Population Health Management in Primary Care

PubMed Central

Yehia, Baligh R.

2015-01-01

Abstract The 2011 Institute of Medicine report on LGBT health recommended that sexual orientation and gender identity (SO/GI) be documented in electronic health records (EHRs). Most EHRs cannot document all aspects of SO/GI, but some can record gender of sexual partners. This study sought to determine the proportion of patients who have the gender of sexual partners recorded in the EHR and to identify factors associated with documentation. A retrospective analysis was done of EHR data for 40 family medicine (FM) and general internal medicine (IM) practices, comprising 170,570 adult patients seen in 2012. The primary outcome was EHR documentation of sexual partner gender. Multivariate logistic regression assessed the impact of patient, provider, and practice factors on documentation. In all, 76,767 patients (45%) had the gender of sexual partners recorded, 4.3% of whom had same-gender partners (3.5% of females, 5.6% of males). Likelihood of documentation was independently higher for women; blacks; those with a preventive visit; those with a physician assistant, nurse practitioner, or resident primary care provider (vs. attending); those at urban practices; those at smaller practices; and those at a residency FM practice. Older age and Medicare insurance were associated with lower documentation. Sexual partner gender documentation is important to identify patients for targeted prevention and support, and holds great potential for population health management, yet documentation in the EHR currently is low. Primary care practices should routinely record the gender of sexual partners, and additional work is needed to identify best practices for collecting and using SO/GI data in this setting. (Population Health Management 2015;18:217–222). PMID:25290634
Determinants of primary care nurses' intention to adopt an electronic health record in their clinical practice.

PubMed

Leblanc, Genevieve; Gagnon, Marie-Pierre; Sanderson, Duncan

2012-09-01

A provincial electronic health record is being developed in the Province of Quebec (and in all other provinces in Canada), and authorities hope that it will enable a safer and more efficient healthcare system for citizens. However, the expected benefits can occur only if healthcare professionals, including nurses, adopt this technology. Although attention to the use of the electronic health record by nurses is growing, better understanding of nurses' intention to use an electronic health record is needed and could help managers to better plan its implementation. This study examined the factors that influence primary care nurses' intention to adopt the provincial electronic health record, since intention influences electronic health record use and implementation success. Using a modified version of Ajzen's Theory of Planned Theory of Planned Behavior, a questionnaire was developed and pretested. Questionnaires were distributed to 199 primary care nurses. Multiple hierarchical regression indicated that the Theory of Planned Behavior variables explained 58% of the variance in nurses' intention to adopt an electronic health record. The strong intention to adopt the electronic health record is mainly determined by perceived behavioral control, normative beliefs, and attitudes. The implications of the study are that healthcare managers could facilitate adoption of an electronic health record by strengthening nurses' intention to adopt the electronic health record, which in turn can be influenced through interventions oriented toward the belief that using an electronic health record will improve the quality of patient care.
Pedagogical principles underpinning undergraduate Nurse Education in the UK: A review.

PubMed

Mackintosh-Franklin, Carolyn

2016-05-01

This review provides a contextual report of the current use of pedagogy in undergraduate nursing programmes run by Higher Education Institutes (HEIs) in the United Kingdom (UK). Pedagogy provides the framework for educators to add shape and structure to the educational process, and to support student learning and programme development. Traditionally nurse education has used a behaviourist approach focusing on learning outcomes and competency based education, although there is also increasing support for the cognitive/student learning focused pedagogic approach. The keywords andragogy, pedagogy and student centred learning were used in a systematic stepwise descriptive content analysis of the programme specifications and programme handbooks of 40 current undergraduate programme documents, leading to an undergraduate award and professional registration as a nurse. 42% (17) of documents contained reference to the words, pedagogy and student centred learning, whilst no documents used the word andragogy. Where identified, pedagogy was used in a superficial manner, with only three documents identifying a specific pedagogical philosophy: one HEI citing a value based curriculum and two HEIs referencing social constructionism. Nine HEIs made reference to student centred learning but with no additional pedagogic information. A review of teaching, learning and assessment strategies indicated no difference between the documented strategies used by HEIs when comparing those with an espoused pedagogy and those without. Although educational literature supports the use of pedagogic principles in curriculum design, this is not explicit in undergraduate nursing programme documentation, and suggests that nurse educators do not view pedagogy as important to their programmes. Instead programmes appear to be developed based on operational and functional requirements with a focus on acquisition of knowledge and skills, and the fitness to practice of graduates entering the nursing workforce. Copyright © 2016 Elsevier Ltd. All rights reserved.
Medication communication through documentation in medical wards: knowledge and power relations.

PubMed

Liu, Wei; Manias, Elizabeth; Gerdtz, Marie

2014-09-01

Health professionals communicate with each other about medication information using different forms of documentation. This article explores knowledge and power relations surrounding medication information exchanged through documentation among nurses, doctors and pharmacists. Ethnographic fieldwork was conducted in 2010 in two medical wards of a metropolitan hospital in Australia. Data collection methods included participant observations, field interviews, video-recordings, document retrieval and video reflexive focus groups. A critical discourse analytic framework was used to guide data analysis. The written medication chart was the main means of communicating medication decisions from doctors to nurses as compared to verbal communication. Nurses positioned themselves as auditors of the medication chart and scrutinised medical prescribing to maintain the discourse of patient safety. Pharmacists utilised the discourse of scientific judgement to guide their decision-making on the necessity of verbal communication with nurses and doctors. Targeted interdisciplinary meetings involving nurses, doctors and pharmacists should be organised in ward settings to discuss the importance of having documented medication information conveyed verbally across different disciplines. Health professionals should be encouraged to proactively seek out each other to relay changes in medication regimens and treatment goals. © 2013 John Wiley & Sons Ltd.
Quality Improvement Initiative on Pain Knowledge, Assessment, and Documentation Skills of Pediatric Nurses.

PubMed

Margonary, Heather; Hannan, Margaret S; Schlenk, Elizabeth A

2017-01-01

Pain treatment begins with a nurse’s assessment, which relies on effective assessment skills. Hospital settings have implemented pain assessment education, but there is limited evidence in pediatric transitional care settings. The purpose of this quality improvement (QI) initiative was to develop, implement, and evaluate an evidence-based pain education session with 20 nurses in a pediatric specialty hospital that provides transitional care. Specific aims were to assess nurses’ knowledge and attitudes of pain, and evaluate assessment skills based on nurses’ documentation. A prospective pre-post design with three assessments (baseline, post-intervention, and one-month follow-up) was used. The Shriner’s Pediatric Nurses’ Knowledge and Attitudes Regarding Pain questionnaire and an electronic health record review were completed at each assessment. There was significant improvement in nurses’ knowledge and attitudes of pain after the education session (F[2,6] = 50.281, p < 0.0001) from baseline to post-intervention (p < 0.0001), which was maintained at follow-up (p = 0.009). Pain assessment frequency by nurses significantly increased from 43.1% at baseline to 64.8% at post-intervention, and 67.7% at follow-up (χ²[2] = 20.55, p < 0.0001). Developmentally appropriate pain scale usage increased significantly, from 13.1% at baseline to 77.4% at post-intervention, and 81.8% at follow-up (χ²[2] = 169.19, p < 0.0001). Nursing interventions for pain increased significantly, from 33.3% at baseline to 84.0% at post-intervention, and stabilized at 80.0% at follow-up (χ²[2] = 8.91, p = 0.012). Frequency of pain reassessments did not show a statistically significant change, decreasing from 77.8% at baseline to 44.0% at post-intervention and 40.0% at follow-up (χ²[2]= 3.538, p = 0.171). Nurses’ pain knowledge and documentation of assessment skills were improved in this QI initiative.
[Nursing in the movies: its image during the Spanish Civil War].

PubMed

Siles González, J; García Hernández, E; Cibanal Juan, L; Gallardo Frías, Y; Lillo Crespo, M

1998-12-01

The cinema had carried out a determining role in the development of stereotypes and in a wide gamut of models related to real life situations. The objective of this analysis is to determine the influence cinema had on the image of nurses during the Spanish Civil War from 1936-1939. These are the initial hypotheses: the role of Spanish nurses during the civil war was reflected by both sides in their respective movie productions; and the image of nurses shown in these films, on both sides, presents a conflicting role concept for women in society. Following strategies developed by specialists in film analysis (Bondwell 1995, Uneso 1995, Carmona 1991) a total of 453 movie productions, 360 on the republican side and 93 on the national side, were reviewed. These films were listed in the Spanish National Films Library records. After analyzing the Spanish cinema productions during the Spanish Civil War, data relating to 453 films were identified. The genre included documents, news programs and fiction movies. 77 were produced in 1936, 235 in 1937, 102 in 1938 and 39 in 1939. A tremendous difference exists between the republican productions, 79% of the total, and the national productions. By genres, the types produced on the republican side were: in 1936, 53 documentals, 4 news programs and 9 fiction films; in 1937, 186 documentals, 5 news programs and 19 fiction films; in 1938, 72 documentals, 1 news programs and 2 fiction films; in 1939, 2 documentals and 2 fiction films. On the national side, their productions were: in 1936, 10 documentals and 1 fiction film; in 1937, 22 documentals, 2 news programs and 1 fiction film; in 1938, 19 documentals and 3 news programs; in 1939, 29 documentals and 6 fiction films. During the Spanish Civil War, movies produced by both sides made an effort to reflect their ideal woman as a stereotypical ideal nurse. This ideal nurse showed the values, ideas, aesthetics and prejudices each side held in the war.
Using Quality Improvement to Introduce and Standardize the National Early Warning Score (NEWS) for Adult Inpatients at a Children's Hospital.

PubMed

Conway-Habes, Erin E; Herbst, Brian F; Herbst, Lori A; Kinnear, Benjamin; Timmons, Kristen; Horewitz, Deborah; Falgout, Rachel; O'Toole, Jennifer K; Vossmeyer, Michael

2017-03-01

The population of adults with childhood-onset chronic illness is growing across children's hospitals and constitutes a high risk population. National Early Warning Score (NEWS) is among the most recently validated adult early warning scores (EWSs) for early recognition of and response to clinical deterioration. Our aim was to implement and standardize NEWS scoring in 80% of patients age 21 and older admitted to a children's hospital. Our intervention was tested on a single unit of our children's hospital. The primary process measure was the percentage of NEWS documented within 1 hour of routine nursing assessments, and was tracked using a run chart. Improvement activities focused on effective training, key stakeholder buy-in, increased awareness, real-time mitigation of failures, accountability for adherence, and action-oriented response. We also tracked the distribution of NEWS values and medical emergency team calls. The percentage of NEWS documented with routine nursing assessments for patients age 21 and over increased from 0% to 90% within 15 weeks and remained at 77% or greater for 17 weeks. Our distribution of NEWS values was similar to previously reported NEWS distribution. A nurse-driven adult early warning system for inpatients age 21 and older at a children's hospital can be achieved through a standardized EWS assessment process, incorporation into the electronic health record, and charge nurse and key stakeholder oversight. Furthermore, implementation of an adult EWS being used at a pediatric institution and our distribution of NEWS values were comparable to distribution published from adult hospitals. Copyright © 2017 by the American Academy of Pediatrics.
[Development of a computerized system using standard nursing language for creation of a nursing minimum data set].

PubMed

D'Agostino, Fabio; Vellone, Ercole; Tontini, Francesco; Zega, Maurizio; Alvaro, Rosaria

2012-01-01

The aim of a nursing data set is to provide useful information for assessing the level of care and the state of health of the population. Currently, both in Italy and in other countries, this data is incomplete due to the lack of a structured nursing documentation , making it indispensible to develop a Nursing Minimum Data Set (NMDS) using standard nursing language to evaluate care, costs and health requirements. The aim of the project described , is to create a computer system using standard nursing terms with a dedicated software which will aid the decision-making process and provide the relative documentation. This will make it possible to monitor nursing activity and costs and their impact on patients' health : adequate training and involvement of nursing staff will play a fundamental role.
Neonatal Nurses Experience Unintended Consequences and Risks to Patient Safety With Electronic Health Records.

PubMed

Dudding, Katherine M; Gephart, Sheila M; Carrington, Jane M

2018-04-01

In this article, we examine the unintended consequences of nurses' use of electronic health records. We define these as unforeseen events, change in workflow, or an unanticipated result of implementation and use of electronic health records. Unintended consequences experienced by nurses while using electronic health records have been well researched. However, few studies have focused on neonatal nurses, and it is unclear to what extent unintended consequences threaten patient safety. A new instrument called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire has been validated, and secondary analysis using the tool explored the phenomena among neonatal nurses (N = 40). The purposes of this study were to describe unintended consequences of use of electronic health records for neonatal nurses and to explore relationships between the phenomena and characteristics of the nurse and the electronic health record. The most frequent unintended consequences of electronic health record use were due to interruptions, followed by a heavier workload due to the electronic health record, changes to the workflow, and altered communication patterns. Neonatal nurses used workarounds most often with motivation to better assist patients. Teamwork was moderately related to higher unintended consequences including patient safety risks (r = 0.427, P = .007), system design (r = 0.419, P = .009), and technology barriers (r = 0.431, P = .007). Communication about patients was reduced when patient safety risks were high (r = -0.437, P = .003). By determining the frequency with which neonatal nurses experience unintended consequences of electronic health record use, future research can be targeted to improve electronic health record design through customization, integration, and refinement to support patient safety and better outcomes.
Designing the Information Literacy Competency Standards for nursing.

PubMed

Phelps, Sue F

2013-01-01

This column documents the rationale for creating information literacy competency standards for nursing based on the Association of College and Research Libraries (ACRL) "Information Literacy Competency Standards for Higher Education" and the three documents from the American Association of Colleges of Nursing (AACN) on essential skills for nurses in baccalaureate, masters, and doctoral level education and practice. It chronicles the process of the task force which is designing the discipline specific skills and predicts the value of their use, once they are published.
Concordance Between Veterans' Self-Report and Documentation of Surrogate Decision Makers: Implications for Quality Measurement.

PubMed

Garner, Kimberly K; Dubbert, Patricia; Lensing, Shelly; Sullivan, Dennis H

2017-01-01

The Measuring What Matters initiative of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association identified documentation of a surrogate decision maker as one of the top 10 quality indicators in the acute hospital and hospice settings. To better understand the potential implementation of this Measuring What Matters quality measure #8, Documentation of Surrogate in outpatient primary care settings by describing primary care patients' self-reported identification and documentation of a surrogate decision maker. Examination of patient responses to self-assessment questions from advance health care planning educational groups conducted in one medical center primary care clinic and seven community-based outpatient primary care clinics. We assessed the concordance between patient reports of identifying and naming a surrogate decision maker and having completed an advance directive (AD) with presence of an AD in the electronic medical record. Of veterans without a documented AD on file, more than half (66%) reported that they had talked with someone they trusted and nearly half (52%) reported that they had named someone to communicate their preferences. Our clinical project data suggest that many more veterans may have initiated communications with surrogate decision makers than is evident in the electronic medical record. System changes are needed to close the gap between veterans' plans for a surrogate decision maker and the documentation available to acute care health care providers. Published by Elsevier Inc.
Home health nursing care services in Greece during an economic crisis.

PubMed

Adamakidou, T; Kalokerinou-Anagnostopoulou, A

2017-03-01

The purpose of this review was to describe public home healthcare nursing services in Greece. The effectiveness and the efficiency of home healthcare nursing are well documented in the international literature. In Greece, during the current financial crisis, the development of home healthcare nursing services is the focus and interest of policymakers and academics because of its contribution to the viability of the healthcare system. A review was conducted of the existing legislation, the printed and electronic bibliography related to the legal framework, the structures that provide home health care, the funding of the services, the human resources and the services provided. The review of the literature revealed the strengths and weaknesses of the existing system of home health care and its opportunities and threats, which are summarized in a SWOT analysis. There is no Greek nursing literature on this topic. The development of home health nursing care requires multidimensional concurrent and combined changes and adjustments that would support and strengthen healthcare professionals in their practices. Academic and nursing professionals should provide guidelines and regulations and develop special competencies for the best nursing practice in home health care. At present, in Greece, which is in an economic crisis and undergoing reforms in public administration, there is an undeniable effort being made to give primary health care the position it deserves within the health system. There is an urgent need at central and academic levels to develop home healthcare services to improve the quality and efficiency of the services provided. © 2016 International Council of Nurses.
A comparative study on effect of e-learning and instructor-led methods on nurses’ documentation competency

PubMed Central

Abbaszadeh, Abbas; Sabeghi, Hakimeh; Borhani, Fariba; Heydari, Abbas

2011-01-01

BACKGROUND: Accurate recording of the nursing care indicates the care performance and its quality, so that, any failure in documentation can be a reason for inadequate patient care. Therefore, improving nurses’ skills in this field using effective educational methods is of high importance. Since traditional teaching methods are not suitable for communities with rapid knowledge expansion and constant changes, e-learning methods can be a viable alternative. To show the importance of e-learning methods on nurses’ care reporting skills, this study was performed to compare the e-learning methods with the traditional instructor-led methods. METHODS: This was a quasi-experimental study aimed to compare the effect of two teaching methods (e-learning and lecture) on nursing documentation and examine the differences in acquiring competency on documentation between nurses who participated in the e-learning (n = 30) and nurses in a lecture group (n = 31). RESULTS: The results of the present study indicated that statistically there was no significant difference between the two groups. The findings also revealed that statistically there was no significant correlation between the two groups toward demographic variables. However, we believe that due to benefits of e-learning against traditional instructor-led method, and according to their equal effect on nurses’ documentation competency, it can be a qualified substitute for traditional instructor-led method. CONCLUSIONS: E-learning as a student-centered method as well as lecture method equally promote competency of the nurses on documentation. Therefore, e-learning can be used to facilitate the implementation of nursing educational programs. PMID:22224113
Identification of Hypertension Management-related Errors in a Personal Digital Assistant-based Clinical Log for Nurses in Advanced Practice Nurse Training.

PubMed

Lee, Nam-Ju; Cho, Eunhee; Bakken, Suzanne

2010-03-01

The purposes of this study were to develop a taxonomy for detection of errors related to hypertension management and to apply the taxonomy to retrospectively analyze the documentation of nurses in Advanced Practice Nurse (APN) training. We developed the Hypertension Diagnosis and Management Error Taxonomy and applied it in a sample of adult patient encounters (N = 15,862) that were documented in a personal digital assistant-based clinical log by registered nurses in APN training. We used Standard Query Language queries to retrieve hypertension-related data from the central database. The data were summarized using descriptive statistics. Blood pressure was documented in 77.5% (n = 12,297) of encounters; 21% had high blood pressure values. Missed diagnosis, incomplete diagnosis and misdiagnosis rates were 63.7%, 6.8% and 7.5% respectively. In terms of treatment, the omission rates were 17.9% for essential medications and 69.9% for essential patient teaching. Contraindicated anti-hypertensive medications were documented in 12% of encounters with co-occurring diagnoses of hypertension and asthma. The Hypertension Diagnosis and Management Error Taxonomy was useful for identifying errors based on documentation in a clinical log. The results provide an initial understanding of the nature of errors associated with hypertension diagnosis and management of nurses in APN training. The information gained from this study can contribute to educational interventions that promote APN competencies in identification and management of hypertension as well as overall patient safety and informatics competencies. Copyright © 2010 Korean Society of Nursing Science. Published by . All rights reserved.
Standardized Nursing Languages. Position Statement. Revised

ERIC Educational Resources Information Center

Duff, Carolyn; Endsley, Patricia; Chau, Elizabeth; Morgitan, Judith

2012-01-01

It is the position of the National Association of School Nurses (NASN) that standardized nursing languages (SNL) are essential communication tools for registered professional school nurses (hereinafter, school nurses) to assist in planning, delivery, and evaluation of quality nursing care. SNL help identify, clarify and document the nature and…
75 FR 27797 - Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-18

... Offering and Documenting Influenza Vaccination for Nursing Home Residents, Funding Opportunity Announcement... State Law Requiring Mandatory Influenza Vaccination of Hospital Employees, FOA IP10-003; and Improving... Offering and Documenting Influenza Vaccination for Nursing Home Residents, FOA IP10-001; Development...
Making Patient Risk Visible: Implementation of a Nursing Document Information System to Improve Patient Safety.

PubMed

Wang, Panfeng; Zhang, Hongjun; Li, Baohua; Lin, Keke

2016-01-01

The aims of this study were to develop a nursing information system (NIS), enhance the visibility of patient risk, and identify challenges and facilitators to adoption of the NIS risk assessment system for nurse leaders. This article describes the function of a nursing risk assessment information system, and the results of a survey on the risk assessment system. The results suggested that quality of information processing in nursing significantly improved patient safety. Nurses surveyed demonstrated a high degree of satisfaction, with saving time and improving safety. The nursing document information system described was introduced to improve patient safety and decrease risk. The application of the system has greatly enhanced the efficiency of nursing work, and guides the nurses to make an accurate, comprehensive and objective assessment of patient information, contributing significantly to further improvement in care standards and care decisions.
[(Re)configuration of the nursing field in the new state (1937-1945)].

PubMed

Barreira, Ieda de Alencar; Baptista, Suely de Souza

2002-01-01

The subject of this study is the changes the nursing field went through during the period called Novo Estado. Analyze the nursing environment in the Federal Capital during the period mentioned; discuss the effects of the influence of the Catholic Church and nurses of the American government in the Brazilian nursing environment. Documents obtained from the Documentation Center in Anna Nery/UFRJ School of Nursing and from literature on the topic. The interpretation of the findings was based on the Theory of the Social World by Pierre Bourdieu. Results showed deep changes in terms of professional education, labor market and institutionalization of the nursing assistance in a period (after the World War II) in which the Catholic Church and the United States had increased their power and influence. This new context determined the reconfiguration of the identity of Brazilian nurses and of the nursing field.

[Participation of the Anna Nery School in the Constitutionalist Revolution of 1932].

PubMed

de Almeida Filho, Antonio José; Santos, Tânia Cristina Franco

2003-01-01

This is a historical-social research project. The main objective is to present the participation of the Anna Nery Nursing School in the medical assistance positions in the state of Sao Paulo during the Constitutionalist Revolution of 1932. The objective of the present investigation is to describe how the teachers and students of the Anna Nery Nursing School participated in the different operation fronts during this war and to analyse the implications of the performance of nurses and students of this School. Our main documental resource were written and photographical documents that belong to the Centre of Documentation of the EEA/UFRJ. The secondary source were articles and books that about the history of Brazil and Brazilian nursing. This investigation evidenced the importance of the nurse's work during times of crisis and it also made possible for the EEAN to earn symbolic profits.
Is Spending More Time Associated With Less Missed Care?: A Comparison of Time Use and Missed Care Across 15 Nursing Units at 2 Hospitals.

PubMed

McNair, Norma; Baird, Jennifer; Grogan, Tristan R; Walsh, Catherine M; Liang, Li-Jung; Worobel-Luk, Pamela; Needleman, Jack; Nuckols, Teryl K

2016-09-01

The aim of this study is to examine the relationship between nursing time use and perceptions of missed care. Recent literature has highlighted the problem of missed nursing care, but little is known about how nurses' time use patterns are associated with reports of missed care. In 15 nursing units at 2 hospitals, we assessed registered nurse (RN) perceptions of missed care, observed time use by RNs, and examined the relationship between time spent and degree of missed care at the nursing unit level. Patterns of time use were similar across hospitals, with 25% of time spent on documentation. For 6 different categories of nursing tasks, no association was detected between time use, including time spent on documentation, and the degree of missed care at the nursing unit level. Nursing time use cannot fully explain variation in missed care across nursing units. Further work is needed to account for patterns of missed care.
Nursing staff work patterns in a residential aged care home: a time-motion study.

PubMed

Qian, Siyu; Yu, Ping; Hailey, David

2016-11-01

Objective Residential aged care services are challenged by an increasing number of residents and a shortage of nursing staff. Developing strategies to overcome this challenge requires an understanding of nursing staff work patterns. The aim of the present study was to investigate the work processes followed by nursing staff and how nursing time is allocated in a residential aged care home. Methods An observational time-motion study was conducted at two aged care units for 12 morning shifts. Seven nurses were observed, one per shift. Results In all, there were 91h of observation. The results showed that there was a common work process followed by all nurse participants. Medication administration, documentation and verbal communication were the most time-consuming activities and were conducted most frequently. No significant difference between the two units was found in any category of activities. The average duration of most activities was less than 1min. There was no difference in time utilisation between the endorsed enrolled nurses and the personal carers in providing nursing care. Conclusion Medication administration, documentation and verbal communication were the major tasks in morning shifts in a residential aged care home. Future research can investigate how verbal communication supports nursing care. What is known about the topic? The aging population will substantially increase the demand for residential aged care services. There is a lack of research on nurses' work patterns in residential aged care homes. What does this paper add? The present study provides a comprehensive understanding of nurses' work patterns in a residential aged care home. There is a common work process followed by nurses in providing nursing care. Medication administration, verbal communication and documentation are the most time-consuming activities and they are frequently conducted in the same period of time. Wound care, physical review and documentation on desktop computers are arranged flexibly by the nurses. What are the implications for practitioners? When developing a task reallocation strategy to improve work efficiency, effort can be put into tasks that can be arranged more flexibly.
Situation awareness and documentation of changes that affect patient outcomes in progress notes.

PubMed

Tower, Marion; Chaboyer, Wendy

2014-05-01

To report on registered nurses' situation awareness as a precursor to decision-making when recording changes in patients' conditions. Progress notes are important to communicate patients' progress and detail changes in patients' conditions. However, documentation is often poorly completed. There is little work that examines nurses' decision-making during documentation. This study focused on describing situation awareness as a precursor to decision-making during documentation. This study used Endsley's (Situation Awareness Analysis and Measurement, 2000, Lawrence Erlbaum Associates, NJ) work on situation awareness to guide and conceptualise information. The study was situated in a naturalistic paradigm to provide an interpretation of nurses' decision-making. Think-aloud research methods and semi-structured interviews were employed to illuminate decision-making processes. Audio recordings and interview texts were individually examined for evidence of cues, informed by Endsley's (Situation Awareness Analysis and Measurement, 2000, Lawrence Erlbaum Associates, NJ) descriptions of situation awareness. As patients' conditions changed, nurses used complex mental models and pattern-matching of information, drawing on all 3 levels of situation awareness during documentation. Level 1 situation awareness provided context, level 2 situation awareness signified a change in condition and its significance for the patient, and level 3 situation awareness was evident when nurses thought aloud about what this information indicated. Three themes associated with changes in patients' conditions emerged: deterioration in condition, not responding to prescribed treatments as expected and issues related to professional practice that impacted on patients' conditions. Nurses used a complex mental model for decision-making, drawing on 3 levels of situation awareness. Hamm's cognitive continuum theory, when related to situation awareness, is a useful decision-making theory to provide a platform on which to draw together components of situation awareness and provide a framework on which to base decision-making regarding documentation. Understanding how RNs employ situation awareness and providing a framework for decision-making during documentation may assist effective documentation about changes in patients' conditions. © 2013 John Wiley & Sons Ltd.
Integrating an Academic Electronic Health Record: Challenges and Success Strategies.

PubMed

Herbert, Valerie M; Connors, Helen

2016-08-01

Technology is increasing the complexity in the role of today's nurse. Healthcare organizations are integrating more health information technologies and relying on the electronic health record for data collection, communication, and decision making. Nursing faculty need to prepare graduates for this environment and incorporate an academic electronic health record into a nursing curriculum to meet student-program outcomes. Although the need exists for student preparation, some nursing programs are struggling with implementation, whereas others have been successful. To better understand these complexities, this project was intended to identify current challenges and success strategies of effective academic electronic health record integration into nursing curricula. Using Rogers' 1962 Diffusion of Innovation theory as a framework for technology adoption, a descriptive survey design was used to gain insights from deans and program directors of nursing schools involved with the national Health Informatics & Technology Scholars faculty development program or Cerner's Academic Education Solution Consortium, working to integrate an academic electronic health record in their respective nursing schools. The participants' experiences highlighted approaches used by these schools to integrate these technologies. Data from this project provide nursing education with effective strategies and potential challenges that should be addressed for successful academic electronic health record integration.
Invisible inventors. A historical overview of creative midwives and nurses.

PubMed

Hiestand, W C

1999-01-01

This historical overview documents women's inventions for providing nursing care dating from 1608 to 1928. The word invention is broadly defined and includes ideas that created therapeutic activities, caregiving environments, and specific devices for care. It focuses on the creative contributions of early outstanding midwives and other practicing nurses around the late 19th and early 20th centuries. Sources include illustrations of patented items, practical hints published in early issues of the American Journal of Nursing (AJN), published translations of original documents from Europe, original historical research on women in Europe and America, and records from the U.S. Government Patent Office. The role of nurses in creating and developing tools and methods for providing nursing care has gone unrecognized. It is important to clarify the record of women's and nurses' inventiveness.
School Nursing Practice: Roles and Standards.

ERIC Educational Resources Information Center

Proctor, Susan Tonskemper; And Others

This document is an application of the American Nurses' Association's (ANA's) "Standards of Clinical Nursing Practice" (1991) to the specialty of school nursing. It identifies specialty standards of practice for the school nurse subsumed under the standards of clinical practice which apply to all nurses. Chapter One focuses on the ANA standards…
Nurse Reinvestment Act. Public Law.

ERIC Educational Resources Information Center

Congress of the U.S., Washington, DC.

This document contains the text of the Nurse Reinvestment Act, which amends the Public Health Service Act to address the increasing shortage of registered nurses by instituting a series of policies to improve nurse recruitment and nurse retention. Title I details two initiatives to boost recruitment of nurses. The first initiative includes the…
Academic Incivility in Nursing Education

ERIC Educational Resources Information Center

Marlow, Sherri

2013-01-01

A well-documented and growing problem impacting the nursing shortage in the United States is the increasing shortage of qualified nursing faculty. Many factors contribute to the nursing faculty shortage such as retirement, dissatisfaction with the nursing faculty role and low salary compensation (American Association of Colleges of Nursing (AACN),…
Competence in advanced older people nursing: development of 'nursing older people--competence evaluation tool'.

PubMed

Bing-Jonsson, Pia Cecilie; Bjørk, Ida Torunn; Hofoss, Dag; Kirkevold, Marit; Foss, Christina

2015-03-01

Community care is characterised by a move from institutionalised to home-based care, a large patient population with comorbidities including cognitive failure, and nurses who struggle to keep up with their many competence demands. No study has examined the competence of nurses based on present demands, and an instrument for this purpose is lacking. We conducted a Delphi study based in Norway to develop the substantial content of a new competence measurement instrument. We sought to reach consensus regarding which nursing staff competence is most relevant to meet the current needs of older patients. A total of 42 experts participated in three consecutive panel investigations. Snowball sampling was used. The experts were clinicians, leaders, teachers, researchers and relatives of older people who required nursing. In Round 1, all experts were interviewed individually. These data were analysed using meaning coding and categorisation. In Rounds 2 and 3, the data were collected using electronic questionnaires and analysed quantitatively with SPSS. The experts agreed that health promotion as well as disease prevention, treatment, palliative care, ethics and regulation, assessment and taking action, covering basic needs, communication and documentation, responsibility and activeness, cooperation, and attitudes towards older people were the most relevant categories of competence. The experts showed clear consensus regarding the most relevant and current competence for nurses of older people. Assuming that older people in need of health care have the same requirements across cultures, this study's findings could be used as a basis for international studies. Those who nurse older people require competence that is complex and comprehensive. One way to evaluate nursing competence is through evaluation tools such as the Nursing Older People--Competence Evaluation tool. © 2014 John Wiley & Sons Ltd.
The effect of a nurse team leader on communication and leadership in major trauma resuscitations.

PubMed

Clements, Alana; Curtis, Kate; Horvat, Leanne; Shaban, Ramon Z

2015-01-01

Effective assessment and resuscitation of trauma patients requires an organised, multidisciplinary team. Literature evaluating leadership roles of nurses in trauma resuscitation and their effect on team performance is scarce. To assess the effect of allocating the most senior nurse as team leader of trauma patient assessment and resuscitation on communication, documentation and perceptions of leadership within an Australian emergency department. The study design was a pre-post-test survey of emergency nursing staff (working at resuscitation room level) perceptions of leadership, communication, and documentation before and after the implementation of a nurse leader role. Patient records were audited focussing on initial resuscitation assessment, treatment, and nursing clinical entry. Descriptive statistical analyses were performed. Communication trended towards improvement. All (100%) respondents post-test stated they had a good to excellent understanding of their role, compared to 93.2% pre-study. A decrease (58.1-12.5%) in 'intimidating personality' as a negative aspect of communication. Nursing leadership had a 6.7% increase in the proportion of those who reported nursing leadership to be good to excellent. Accuracy of clinical documentation improved (P = 0.025). Trauma nurse team leaders improve some aspects of communication and leadership. Development of trauma nurse leaders should be encouraged within trauma team training programmes. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.
The effect of nursing participation in the design of a critical care information system: a case study in a Chinese hospital.

PubMed

Qin, Yanhong; Zhou, Ranyun; Wu, Qiong; Huang, Xiaodi; Chen, Xinli; Wang, Weiwei; Wang, Xun; Xu, Hua; Zheng, Jing; Qian, Siyu; Bai, Changqing; Yu, Ping

2017-12-06

Intensive care information systems (ICIS) are continuously evolving to meet the ever changing information needs of intensive care units (ICUs), providing the backbone for a safe, intelligent and efficient patient care environment. Although beneficial for the international advancement in building smart environments to transform ICU services, knowledge about the contemporary development of ICIS worldwide, their usage and impacts is limited. This study aimed to fill this knowledge gap by researching the development and implementation of an ICIS in a Chinese hospital, nurses' use of the system, and the impact of system use on critical care nursing processes and outcomes. This descriptive case study was conducted in a 14-bed Respiratory ICU in a tertiary hospital in Beijing. Participative design was the method used for ICU nurses, hospital IT department and a software company to collaboratively research and develop the ICIS. Focus group discussions were conducted to understand the subjective perceptions of the nurses toward the ICIS. Nursing documentation time and quality were compared before and after system implementation. ICU nursing performance was extracted from the annual nursing performance data collected by the hospital. A participative design process was followed by the nurses in the ICU, the hospital IT staff and the software engineers in the company to develop and implement a highly useful ICIS. Nursing documentation was fully digitized and was significantly improved in quality and efficiency. The wrong data, missing data items and calculation errors were significantly reduced. Nurses spent more time on direct patient care after the introduction of the ICIS. The accuracy and efficiency of medication administration was also improved. The outcome was improvement in ward nursing performance as measured by ward management, routine nursing practices, disinfection and isolation, infection rate and mortality rate. Nurses in this ICU unit in China actively participated in the ICIS development and fully used the system to document care. Introduction of the ICIS led to significant improvement in quality and efficiency in nursing documentation, medication order transcription and administration. It allowed nurses to spend more time with patients to improve quality of care. These led to improvement in overall nursing performance. Further study should investigate how the ICIS system contributes to the improvement in decision making of ICU nurses and intensivists.
Predictive power of individual factors and clinical learning experience on academic success: findings from a longitudinal study.

PubMed

Dante, Angelo; Fabris, Stefano; Palese, Alvisa

2015-01-01

Academic failure is the inability of a nursing student to graduate or to complete the nursing degree on time. This longitudinal cohort study, involving 2 Italian universities, documents the effects of selected individual variables and the quality of the clinical learning experience as perceived by students on academic success. Factors related to the clinical learning experience were the quality of the supervisory relationship, pedagogical atmosphere, and commitment of the ward related to the level of personalized nursing care delivered and clarity of nursing documentation.
Competency frameworks for advanced practice nursing: a literature review.

PubMed

Sastre-Fullana, P; De Pedro-Gómez, J E; Bennasar-Veny, M; Serrano-Gallardo, P; Morales-Asencio, J M

2014-12-01

This paper describes a literature review that identified common traits in advanced practice nursing that are specific to competency development worldwide. There is a lack of international agreement on the definition of advanced practice nursing and its core competencies. Despite the lack of consensus, there is an ongoing process worldwide to establish and outline the standards and competencies for advanced practice nursing roles. International agencies, such as the International Council of Nurses, have provided general definitions for advanced practice nursing. Additionally, a set of competency standards for this aim has been developed. A literature review and a directed search of institutional websites were performed to identify specific developments in advanced practice nursing competencies and standards of practice. To determine a competency map specific to international advanced practice nursing, key documents were analysed using a qualitative approach based on content analysis to identify common traits among documents and countries. The review process identified 119 relevant journal articles related to advanced practice nursing competencies. Additionally, 97 documents from grey literature that were related to advanced practice nursing competency mapping were identified. From the text analysis, 17 worldwide transversal competency domains emerged. Despite the variety of patterns in international advanced practice nursing development, essential competency domains can be found in most national frameworks for the role development of international advanced practice nursing. These 17 core competencies can be used to further develop instruments that assess the perceived competency of advanced practice nurses. The results of this review can help policy developers and researchers develop instruments to compare advanced practice nursing services in various contexts and to examine their association with related outcomes. © 2014 International Council of Nurses.
Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: the on-time quality improvement program to prevent pressure ulcers.

PubMed

Sharkey, Siobhan; Hudak, Sandra; Horn, Susan D; Spector, William

2011-04-01

The goal of this article was to enhance understanding of the On-Time Quality Improvement for Long-term Care Program, a practical approach to embed health information technology into quality improvement in nursing homes that leverages certified nursing assistant documentation and knowledge, supports frontline clinical decision making, and establishes proactive intervention for pressure ulcer prevention.
Modeling the Distribution of Nursing Effort Using Structured Labor and Delivery Documentation

PubMed Central

Hall, Eric S.; Poynton, Mollie R.; Narus, Scott P.; Thornton, Sidney N.

2008-01-01

Our study objectives included the development and evaluation of models for representing the distribution of shared unit-wide nursing care resources among individual Labor and Delivery patients using quantified measurements of nursing care, referred to as Nursing Effort. The models were intended to enable discrimination between the amounts of care delivered to patient subsets defined by attributes such as patient acuity. For each of five proposed models, scores were generated using an analysis set of 686,402 computerized nurse-documented events associated with 1,093 patients at three hospitals during January and February 2006. Significant differences were detected in Nursing Effort scores according to patient acuity, care facility, and in scores generated during shift-change versus non shift-change hours. The development of nursing care quantification strategies proposed in this study supports outcomes analysis by establishing a foundation for measuring the effect of patient-level nursing care on individual patient outcomes. PMID:18495549
Capability of Using Clinical Care Classification System to Represent Nursing Practice in Acute Setting in Taiwan

PubMed Central

Feng, Rung-Chuang; Tseng, Kuan-Jui; Yan, Hsiu-Fang; Huang, Hsiu-Ya; Chang, Polun

2012-01-01

This study examines the capability of the Clinical Care Classification (CCC) system to represent nursing record data in a medical center in Taiwan. Nursing care records were analyzed using the process of knowledge discovery in data sets. The study data set included all the nursing care plan records from December 1998 to October 2008, totaling 2,060,214 care plan documentation entries. Results show that 75.42% of the documented diagnosis terms could be mapped using the CCC system. A total of 21 established nursing diagnoses were recommended to be added into the CCC system. Results show that one-third of the assessment and care tasks were provided by nursing professionals. This study shows that the CCC system is useful for identifying patterns in nursing practices and can be used to construct a nursing database in the acute setting. PMID:24199066
A systematic review of nursing research priorities on health system and services in the Americas.

PubMed

Garcia, Alessandra Bassalobre; Cassiani, Silvia Helena De Bortoli; Reveiz, Ludovic

2015-03-01

To systematically review literature on priorities in nursing research on health systems and services in the Region of the Americas as a step toward developing a nursing research agenda that will advance the Regional Strategy for Universal Access to Health and Universal Health Coverage. This was a systematic review of the literature available from the following databases: Web of Science, PubMed, LILACS, and Google. Documents considered were published in 2008-2014; in English, Spanish, or Portuguese; and addressed the topic in the Region of the Americas. The documents selected had their priority-setting process evaluated according to the "nine common themes for good practice in health research priorities." A content analysis collected all study questions and topics, and sorted them by category and subcategory. Of 185 full-text articles/documents that were assessed for eligibility, 23 were selected: 12 were from peer-reviewed journals; 6 from nursing publications; 4 from Ministries of Health; and 1 from an international organization. Journal publications had stronger methodological rigor; the majority did not present a clear implementation or evaluation plan. After compiling the 444 documents' study questions and topics, the content analysis resulted in a document with 5 categories and 16 subcategories regarding nursing research priorities on health systems and services. Research priority-setting is a highly important process for health services improvement and resources optimization, but implementation and evaluation plans are rarely included. The resulting document will serve as basis for the development of a new nursing research agenda focused on health systems and services, and shaped to advance universal health coverage and universal access to health.
Perceptions of Novice Clinical Adjunct Nursing Faculty

ERIC Educational Resources Information Center

Himmelberg, Layna

2011-01-01

The anticipated nursing shortage in the United States is well documented and continues to be a topic of discussion. A nationwide solution has been for nursing programs to increase their enrollment of nursing students. This could be difficult for many nursing schools; as many have a shortage of qualified nursing faculty with which to instruct…
Information sources for developing the nursing literature.

PubMed

Oermann, Marilyn H; Nordstrom, Cheryl K; Wilmes, Nancy A; Denison, Doris; Webb, Sue A; Featherston, Diane E; Bednarz, Hedi; Striz, Penelope

2008-04-01

Journals are an important method for disseminating research findings and other evidence for practice to nurses. Bibliometric analyses of nursing journals can reveal information about authorship, types of documents cited, and how information is communicated in nursing, among other characteristics. The purposes of our study were to describe the types of documents used to develop the clinical and research literature in nursing, and extent of gray literature cited in those publications. This was a descriptive study of 18,901 citations of articles in clinical specialty and research journals in nursing published between January 2004 and June 2005. The research team reviewed each citation to assess if the cited document was a journal article, book chapter or book, or document falling into the category of gray literature. Frequency counts for each type of cited document were recorded. Most of the citations were to journal articles (n=14,392, 76.1%) and among those, to articles in medical journals (n=7719, 40.8% of all the citations). This was true for the literature as a whole and for the clinical specialty and research literature separately. Although citations to medical journals were most common, in the clinical nursing literature there was a significantly higher proportion of citations to medical journal articles (n=6332, 44.5%) than in the nursing research literature (n=1387, 29.7%) (LR(X)(2)=326.7, p<0.0001). Nearly 10% of the citations were to gray literature. There was an increase in citations to websites (5.7%) compared to a study done only a few years earlier. Our study documented that journal literature was the primary source of information for communication within nursing. This is consistent with other biomedical and hard sciences where the transfer, assimilation, and use of information occur mainly within the scientific community. With a reliance on journal articles for dissemination of research and evidence for clinical practice, improved methods will be needed for integrating this knowledge and presenting it in a usable form to clinicians. As journals proliferate, it will become increasingly difficult for clinicians to keep current with research findings to guide their practice. The development and testing of new methods for integrating and disseminating research evidence to busy clinicians will be increasingly important in nursing. Gray literature was nearly 10% of the citations. The study also revealed an increase in citations to websites, which is anticipated to continue in the future. Further study is needed on the indexing of gray literature relevant to research use and evidence-based practice in nursing and on how to make this literature easily available to clinicians.

Community mental health nurses' perspectives of recovery-oriented practice.

PubMed

Gale, J; Marshall-Lucette, S

2012-05-01

Recovery-oriented practice, an approach aligned towards the service user perspective, has dominated the mental health care arena. Numerous studies have explored service users' accounts of the purpose, meaning and importance of 'recovery'; however, far less is known about healthcare staff confidence in its application to care delivery. A self-efficacy questionnaire and content analysis of nursing course documents were used to investigate a cohort of community mental health nurses' recovery-oriented practice and to determine the extent to which the current continuing professional development curriculum met their educational needs in this regard. Twenty-three community mental health nurses completed a self-efficacy questionnaire and 28 course documents were analysed. The findings revealed high levels of nurses' confidence in their understanding and ability to apply the recovery model and low levels of confidence were found in areas of social inclusion. The content analysis found only one course document that used the whole term 'recovery model'. The findings suggest a gap in the nurses' perceived ability and confidence in recovery-oriented practice with what is taught academically. Hence, nursing education needs to be more explicitly focused on the recovery model and its application to care delivery. © 2011 Blackwell Publishing.
Electronic Personal Health Record Use Among Nurses in the Nursing Informatics Community.

PubMed

Gartrell, Kyungsook; Trinkoff, Alison M; Storr, Carla L; Wilson, Marisa L

2015-07-01

An electronic personal health record is a patient-centric tool that enables patients to securely access, manage, and share their health information with healthcare providers. It is presumed the nursing informatics community would be early adopters of electronic personal health record, yet no studies have been identified that examine the personal adoption of electronic personal health record's for their own healthcare. For this study, we sampled nurse members of the American Medical Informatics Association and the Healthcare Information and Management Systems Society with 183 responding. Multiple logistic regression analysis was used to identify those factors associated with electronic personal health record use. Overall, 72% were electronic personal health record users. Users tended to be older (aged >50 years), be more highly educated (72% master's or doctoral degrees), and hold positions as clinical informatics specialists or chief nursing informatics officers. Those whose healthcare providers used electronic health records were significantly more likely to use electronic personal health records (odds ratio, 5.99; 95% confidence interval, 1.40-25.61). Electronic personal health record users were significantly less concerned about privacy of health information online than nonusers (odds ratio, 0.32; 95% confidence interval, 0.14-0.70) adjusted for ethnicity, race, and practice region. Informatics nurses, with their patient-centered view of technology, are in prime position to influence development of electronic personal health records. Our findings can inform policy efforts to encourage informatics and other professional nursing groups to become leaders and users of electronic personal health record; such use could help them endorse and engage patients to use electronic personal health records. Having champions with expertise in and enthusiasm for the new technology can promote the adoptionof electronic personal health records among healthcare providers as well as their patients.
Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals.

PubMed

Fink, Regina; Gilmartin, Heather; Richard, Angela; Capezuti, Elizabeth; Boltz, Marie; Wald, Heidi

2012-10-01

Indwelling urinary catheters (IUCs) are commonly used in hospitalized patients, especially elders. Catheter-associated urinary tract infections (CAUTIs) account for 34% of all health care associated infections in the United States, associated with excess morbidity and health care costs. Adherence to CAUTI prevention practices has not been well described. This study used an electronic survey to examine IUC care practices for CAUTI prevention in 3 areas-(1) equipment and alternatives and insertion and maintenance techniques; (2) personnel, policies, training, and education; and (3) documentation, surveillance, and removal reminders-at 75 acute care hospitals in the Nurses Improving the Care of Healthsystem Elders (NICHE) system. CAUTI prevention practices commonly followed included wearing gloves (97%), handwashing (89%), maintaining a sterile barrier (81%), and using a no-touch insertion technique (73%). Silver-coated catheters were used to varying degrees in 59% of the hospitals; 4% reported never using a catheter-securing device. Urethral meatal care was provided daily by 43% of hospitals and more frequently that that by 41% of hospitals. Nurses were the most frequently reported IUC inserters. Training in aseptic technique and CAUTI prevention at the time of initial nursing hire was provided by 64% of hospitals; however, only 47% annually validated competency in IUC insertion. Systems for IUC removal were implemented in 56% of hospitals. IUC documentation and routine CAUTI surveillance practices varied widely. Although many CAUTI prevention practices at NICHE hospitals are in alignment with evidence-based guidelines, there is room for improvement. Further research is needed to identify the effect of enhanced compliance with CAUTI prevention practices on the prevalence of CAUTI in NICHE hospitals. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.
The impact of an oral hygiene education module on patient practices and nursing documentation.

PubMed

Coke, Lola; Otten, Karine; Staffileno, Beth; Minarich, Laura; Nowiszewski, Candice

2015-02-01

Oral hygiene is inconsistent among patients with cancer and is a national patient care issue. To promote comfort and nutritional status, oral hygiene for patients with cancer is important. The purpose of this study was to develop an evidence-based oral hygiene educational module (EM) for nursing and patient care technician (PCT) staff to promote consistent oral hygiene patient education; evaluate patient understanding of oral hygiene practices post-EM; and determine staff documentation frequency of oral hygiene care. Pre- and post-EM data were collected using a developed oral hygiene assessment tool; nursing documentation data were collected by chart review. Post-EM data were collected eight weeks post-EM. Data were analyzed using frequencies and the Mann-Whitney U test. Twenty-two patient documentation pairs were collected. Compared to pre-EM, admission teaching, patient education, and patient oral hygiene practices improved post-EM. Post-EM oral hygiene documentation and PCT teaching increased.
Addressing incontinence for people with dementia living at home: a documentary analysis of local English community nursing service continence policies and clinical guidance.

PubMed

Drennan, Vari M; Norrie, Caroline; Cole, Laura; Donovan, Sheila

2013-02-01

To establish whether the problems and issues experienced by people with dementia living at home and their carers were addressed in the clinical guidance for continence management for community nursing services in England. Internationally, the numbers of people with dementia are rising. Managing incontinence is a significant issue as the presence of incontinence is one of the triggers for people with dementia to move their residence to a care home. People with dementia living at home and their family carers report difficulties in accessing knowledgeable professionals and acceptable continence products. A review by documentary analysis of clinical policies and guidance from a sample of community nursing services in all Strategic Health Authority regions of England. A sample of clinical policy and guidance documents for continence assessment and management from up to four community nursing services in each of the ten Strategic Health Authority regions in England was sought. Documentary analysis was undertaken on the relevance of the documents identified for people with dementia living at home. Ninety-eight documents from 38 local community nursing services spread across ten Strategic Health Authority areas were obtained and analysed. Only in the documents of three services were nurses offered detailed guidance about the management of incontinence for people with dementia at home. In the documentation of only one service were people with dementia identified as a special case which warranted the provision of additional continence products. Clinical guidance on continence assessment and management for community nurses in many parts of England does not address the specific needs of people with dementia living at home or their carers. Nurses working in community settings and those providing clinical leadership in continence care should review their clinical guidance and policies to ensure relevance for people with dementia living at home and their family carers. © 2012 Blackwell Publishing Ltd.
A project to establish a skills competency matrix for EU nurses.

PubMed

Cowan, David T; Norman, Ian J; Coopamah, Vinoda P

Enhanced nurse workforce mobility in the European Union (EU) is seen as a remedy to shortages of nurses in some EU countries and a surplus in others. However, knowledge of differences in competence, culture, skill levels and working practices of nursing staff throughout EU countries is not fully documented because currently no tangible method exists to enable comparison. The European Healthcare Training and Accreditation Network (EHTAN) project intends to address this problem by establishing an assessment and evaluation methodology through the compilation of a skills competency matrix. To this end, subsequent to a review of documentation and literature on nursing competence definition and assessment, two versions of a nursing competence self-assessment questionnaire tool have been developed. The final competence matrix will be translated and disseminated for transnational use and it is hoped that this will inform EU and national policies on the training requirements of nurses and nursing mobility and facilitate the promotion of EU-wide recognition of nursing qualifications.
The Italian economic crisis and its impact on nursing services and education: hard and challenging times.

PubMed

Bortoluzzi, Guido; Palese, Alvisa

2010-07-01

Three levels of impact are reported and discussed in this commentary: the 'macro' level, which corresponds to policy(ies); the 'meso' level, which corresponds to nursing services and nursing education; and the 'micro' level, which deals with clinical practice and education, where interactions between patients and nurses and/or students take place. The Italian economy is showing some signs of recovery after the worst economic crisis of past decades. However, these signs are still quite weak and insufficient to declare that the country is finally coming out of it. Several negative impacts of the economic crisis on nursing services and nursing education are documented. Reports have started to document initial signs of the economical crisis impact on patients too. Present and future issues related to nursing services, education and clinical practice are commented both from national data and from nurses' daily perceptions. The Italian economic crisis will leave a heavy burden on the shoulders of future generations. Nurses' leaders are coping with these challenges, innovating the nursing system and preparing a sustainable future for generations of patients and nurses.
Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds.

PubMed

Miller, Daniel F; Fortier, Christopher R; Garrison, Kelli L

2011-02-01

Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield unsatisfactory error prevention and introduction of new potential medication errors. To evaluate the incidence of high-alert medication BCMA triggers and alert types and discuss the type of nursing and pharmacy workarounds occurring with the use of BCMA technology and the electronic medication administration record (eMAR). Medication scanning and override reports from January 1, 2008, through November 30, 2008, for all adult medical/surgical units were retrospectively evaluated for high-alert medication system triggers, alert types, and override reason documentation. An observational study of nursing workarounds on an adult medicine step-down unit was performed and an analysis of potential pharmacy workarounds affecting BCMA and the eMAR was also conducted. Seventeen percent of scanned medications triggered an error alert of which 55% were for high-alert medications. Insulin aspart, NPH insulin, hydromorphone, potassium chloride, and morphine were the top 5 high-alert medications that generated alert messages. Clinician override reasons for alerts were documented in only 23% of administrations. Observational studies assessing for nursing workarounds revealed a median of 3 clinician workarounds per administration. Specific nursing workarounds included a failure to scan medications/patient armband and scanning the bar code once the dosage has been removed from the unit-dose packaging. Analysis of pharmacy order entry process workarounds revealed the potential for missed doses, duplicate doses, and doses being scheduled at the wrong time. BCMA has the potential to prevent high-alert medication errors by alerting clinicians through alert messages. Nursing and pharmacy workarounds can limit the recognition of optimal safety outcomes and therefore workflow processes must be continually analyzed and restructured to yield the intended full benefits of BCMA technology. © 2011 SAGE Publications.
Computer conferencing: the "nurse" in the "Electronic School District".

PubMed

Billings, D M; Phillips, A

1991-01-01

As computer-based instructional technologies become increasingly available, they offer new mechanisms for health educators to provide health instruction. This article describes a pilot project in which nurses established a computer conference to provide health instruction to high school students participating in an electronic link of high schools. The article discusses computer conferencing, the "Electronic School District," the design of the nursing conference, and the role of the nurse in distributed health education.
Taming Big Data: An Information Extraction Strategy for Large Clinical Text Corpora.

PubMed

Gundlapalli, Adi V; Divita, Guy; Carter, Marjorie E; Redd, Andrew; Samore, Matthew H; Gupta, Kalpana; Trautner, Barbara

2015-01-01

Concepts of interest for clinical and research purposes are not uniformly distributed in clinical text available in electronic medical records. The purpose of our study was to identify filtering techniques to select 'high yield' documents for increased efficacy and throughput. Using two large corpora of clinical text, we demonstrate the identification of 'high yield' document sets in two unrelated domains: homelessness and indwelling urinary catheters. For homelessness, the high yield set includes homeless program and social work notes. For urinary catheters, concepts were more prevalent in notes from hospitalized patients; nursing notes accounted for a majority of the high yield set. This filtering will enable customization and refining of information extraction pipelines to facilitate extraction of relevant concepts for clinical decision support and other uses.
Implementation of Free Text Format Nursing Diagnoses at a University Hospital's Medical Department. Exploring Nurses' and Nursing Students' Experiences on Use and Usefulness. A Qualitative Study

PubMed Central

Frigstad, Sigrun Aasen; Nøst, Torunn Hatlen; André, Beate

2015-01-01

Background. Nursing documentation has long traditions and represents core element of nursing, but the documentation is often criticized of being incomplete. Nursing diagnoses are an important research topic in nursing in terms of quality of nursing assessment, interventions, and outcome in addition to facilitating communication and continuity. Aim. The aim of this study was to explore the nurses' and nursing students' experiences after implementing free text format nursing diagnoses in a medical department. Method. The study design included educational intervention of free text nursing diagnoses. Data was collected through five focus group interviews with 18 nurses and 6 students as informants. The data was analyzed using qualitative content analysis. Results. The informants describe positive experiences concerning free text format nursing diagnoses' use and usefulness; it promotes reflection and discussion and is described as a useful tool in the diagnostic process, though it was challenging to find the diagnosis' appropriate formulation. Conclusion. Our findings indicate a valid usability of free text format nursing diagnoses as it promotes the diagnostic process. The use seems to enhance critical thinking and may serve as valuable preparation towards an implementation of standardized nursing diagnoses. Use and support of key personnel seem valuable in an implementation process. PMID:26075091
Physician nurse care: A new use of UMLS to measure professional contribution: Are we talking about the same patient a new graph matching algorithm?

PubMed

Boyd, Andrew D; Dunn Lopez, Karen; Lugaresi, Camillo; Macieira, Tamara; Sousa, Vanessa; Acharya, Sabita; Balasubramanian, Abhinaya; Roussi, Khawllah; Keenan, Gail M; Lussier, Yves A; Li, Jianrong 'John'; Burton, Michel; Di Eugenio, Barbara

2018-05-01

Physician and nurses have worked together for generations; however, their language and training are vastly different; comparing and contrasting their work and their joint impact on patient outcomes is difficult in light of this difference. At the same time, the EHR only includes the physician perspective via the physician-authored discharge summary, but not nurse documentation. Prior research in this area has focused on collaboration and the usage of similar terminology. The objective of the study is to gain insight into interprofessional care by developing a computational metric to identify similarities, related concepts and differences in physician and nurse work. 58 physician discharge summaries and the corresponding nurse plans of care were transformed into Unified Medical Language System (UMLS) Concept Unique Identifiers (CUIs). MedLEE, a Natural Language Processing (NLP) program, extracted "physician terms" from free-text physician summaries. The nursing plans of care were constructed using the HANDS © nursing documentation software. HANDS © utilizes structured terminologies: nursing diagnosis (NANDA-I), outcomes (NOC), and interventions (NIC) to create "nursing terms". The physician's and nurse's terms were compared using the UMLS network for relatedness, overlaying the physician and nurse terms for comparison. Our overarching goal is to provide insight into the care, by innovatively applying graph algorithms to the UMLS network. We reveal the relationships between the care provided by each professional that is specific to the patient level. We found that only 26% of patients had synonyms (identical UMLS CUIs) between the two professions' documentation. On average, physicians' discharge summaries contain 27 terms and nurses' documentation, 18. Traversing the UMLS network, we found an average of 4 terms related (distance less than 2) between the professions, leaving most concepts as unrelated between nurse and physician care. Our hypothesis that physician's and nurse's practice domains are markedly different is supported by the preliminary, quantitative evidence we found. Leveraging the UMLS network and graph traversal algorithms, allows us to compare and contrast nursing and physician care on a single patient, enabling a more complete picture of patient care. We can differentiate professional contributions to patient outcomes and related and divergent concepts by each profession. Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.
Development of an Electronic Role-Play Assessment Initiative in Bioscience for Nursing Students

ERIC Educational Resources Information Center

Craft, Judy; Ainscough, Louise

2015-01-01

Devising authentic assessments for subjects with large enrolments is a challenge. This study describes an electronic role-play assessment for approximately 600 first-year nursing students to learn and apply pathophysiology (bioscience) concepts to nursing practice. Students used Microsoft Office PowerPoint[R] to prepare electronic role-plays both…
A proto-code of ethics and conduct for European nurse directors.

PubMed

Stievano, Alessandro; De Marinis, Maria Grazia; Kelly, Denise; Filkins, Jacqueline; Meyenburg-Altwarg, Iris; Petrangeli, Mauro; Tschudin, Verena

2012-03-01

The proto-code of ethics and conduct for European nurse directors was developed as a strategic and dynamic document for nurse managers in Europe. It invites critical dialogue, reflective thinking about different situations, and the development of specific codes of ethics and conduct by nursing associations in different countries. The term proto-code is used for this document so that specifically country-orientated or organization-based and practical codes can be developed from it to guide professionals in more particular or situation-explicit reflection and values. The proto-code of ethics and conduct for European nurse directors was designed and developed by the European Nurse Directors Association's (ENDA) advisory team. This article gives short explanations of the code' s preamble and two main parts: Nurse directors' ethical basis, and Principles of professional practice, which is divided into six specific points: competence, care, safety, staff, life-long learning and multi-sectorial working.
The frequency of and reasons for acute hospital transfers of older nursing home residents.

PubMed

Kirsebom, Marie; Hedström, Mariann; Wadensten, Barbro; Pöder, Ulrika

2014-01-01

The purpose of the study was to examine the frequency of and reason for transfer from nursing homes to the emergency department (ED), whether these transfers led to admission to a hospital ward, and whether the transfer rate differs as a function of type of nursing home provider and to identify the frequency of avoidable hospitalizations as defined by the Swedish Association of Local Authorities and Regions (SALAR). The design was retrospective, descriptive. Data were collected in a Swedish municipality where 30,000 inhabitants are 65 years or older. Structured reviews of the electronic healthcare records were performed. Included were residents living in a nursing home age 65+, with healthcare records including documented transfers to the ED during a 9-month period in 2010. The transfer rate to the ED was 594 among a total of 431 residents (M=1.37 each). 63% resulted in hospitalization (M=7.12 days). Nursing home's transfer rate differed between 0.00 and 1.03 transfers/bed and was higher for the private for-profit providers than for public/private non-profit providers. One-fourth of the transfers were caused by falls and/or injuries, including fractures. The frequency of avoidable hospitalizations was 16% among the 375 hospitalizations. The proportion of transfers to the ED ranged widely between nursing homes. The reasons for this finding ought to be explored. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
Articulation Matrix for Home Health Aide, Nursing Assistant, Patient Care Assistant, Practical Nursing.

ERIC Educational Resources Information Center

Florida State Univ., Tallahassee. Center for Instructional Development and Services.

This document demonstrates the relationships among four Florida nursing education programs (home health aide, nursing assistant, patient care assistant, and practical nursing) by listing student performance standards and indicating which ones are required in each program. The 268 student performance standards are arranged in 23 areas of…
On the Agenda: Changing Nurses' Careers in 1999. IES Report 360.

ERIC Educational Resources Information Center

Robinson, Dilys; Buchan, James; Hayday, Sue

A survey of a random sample of 6,000 registered nurses who were members of the Royal College of Nursing explored views on issues related to working as a nurse and having a career in nursing. Recent policy documents highlighted the high value the government placed on the role of nurses. Results indicated there were clear gender differences with…
Patients' Care Needs: Documentation Analysis in General Hospitals.

PubMed

Paans, Wolter; Müller-Staub, Maria

2015-10-01

The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs. A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards. The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity. Most care needs were determined in physiological health patterns and few in psychosocial patterns. To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns. © 2014 NANDA International, Inc.
Transition to intensive care nursing: establishing a starting point.

PubMed

Boyle, Martin; Butcher, Rand; Conyers, Vicki; Kendrick, Tina; MacNamara, Mary; Lang, Susie

2008-11-01

There is a shortage of intensive care (IC) nurses. A supported transition to IC nursing has been identified as a key strategy for recruitment and retention. In 2004 a discussion document relating to transition of IC nurses was presented to the New South Wales (NSW) Chief Nursing Officer (CNO). A workshop was held with key stakeholders and a Steering Group was established to develop a state-wide transition to IC nursing program. To survey orientation programs and educational resources and develop definitions, goals, learning objectives and clinical competencies relating to transition to IC nursing practice. A questionnaire and a draft document of definitions, target group, goals, learning objectives and clinical competencies for IC transition was distributed to 43 NSW IC units (ICUs). An iterative process of anonymous feedback and modification was undertaken to establish agreement on content. Responses were received from 29 units (return rate of 67%). The survey of educational resources indicated ICUs had access to educational support and there was evidence of a lack of a common standard or definition for "orientation" or "transition". The definitions, target group, goals and competency statements from the draft document were accepted with minor editorial change. Seventeen learning objectives or psychomotor skills were modified and an additional 19 were added to the draft as a result of the process. This work has established valid definitions, goals, learning objectives and clinical competencies that describe transition to intensive care nursing.
Nurses' reported thinking during medication administration.

PubMed

Eisenhauer, Laurel A; Hurley, Ann C; Dolan, Nancy

2007-01-01

To document nurses' reported thinking processes during medication administration before and after implementation of point-of-care technology. Semistructured interviews and real-time tape recordings were used to document the thinking processes of 40 nurses practicing in inpatient care units in a large tertiary care teaching hospital in the northeastern US. Content analysis resulted in identification of 10 descriptive categories of nurses' thinking: communication, dose-time, checking, assessment, evaluation, teaching, side effects, work arounds, anticipating problem solving, and drug administration. Situations requiring judgment in dosage, timing, or selection of specific medications (e.g., pain management, titration of antihypertensives) provided the most explicit data about nurses' use of critical thinking and clinical judgment. A key element was nurses' constant professional vigilance to ensure that patients received their appropriate medications. Nurses' thinking processes extended beyond rules and procedures and were based on patient data and interdisciplinary professional knowledge to provide safe and effective care. Identification of thinking processes can help nurses to explain the professional expertise inherent in medication administration beyond the technical application of the "5 rights."

Patients in transition--improving hospital-home care collaboration through electronic messaging: providers' perspectives.

PubMed

Melby, Line; Brattheim, Berit J; Hellesø, Ragnhild

2015-12-01

To explore how the use of electronic messages support hospital and community care nurses' collaboration and communication concerning patients' admittance to and discharges from hospitals. Nurses in hospitals and in community care play a crucial role in the transfer of patients between the home and the hospital. Several studies have shown that transition situations are challenging due to a lack of communication and information exchange. Information and communication technologies may support nurses' work in these transition situations. An electronic message system was introduced in Norway to support patient transitions across the health care sector. A descriptive, qualitative interview study was conducted. One hospital and three adjacent communities were included in the study. We conducted semi-structured interviews with hospital nurses and community care nurses. In total, 41 persons were included in the study. The analysis stemmed from three main topics related to the aims of e-messaging: efficiency, quality and safety. These were further divided into sub-themes. All informants agreed that electronic messaging is more efficient, i.e. less time-consuming than previous means of communication. The shift from predominantly oral communication to writing electronic messages has brought attention to the content of the information exchanged, thereby leading to more conscious communication. Electronic messaging enables improved information security, thereby enhancing patient safety, but this depends on nurses using the system as intended. Nurses consider electronic messaging to be a useful tool for communication and collaboration in patient transitions. Patient transitions are demanding situations both for patients and for the nurses who facilitate the transitions. The introduction of information and communication technologies can support nurses' work in the transition situations, and this is likely to benefit the patients. © 2015 John Wiley & Sons Ltd.
[The life and work of Zaíra Cintra Vidal].

PubMed

Lopes, G T; Caldas, N P; Lima, T C; Martingil, I C

2001-01-01

This is a social-historical study that aims at describing the trajectory of Zaíra Cintra Vidal, her participation in the Nursing School Rachel Haddock Lobo and in the Brazilian Association of Nursing (ABEn). The study is based on the concepts of symbolic power, habitus and symbolic struggle of Pierre Bourdieu. The primary sources are documents which were collected in the Documentation Center of Escola de Enfermagem Ana Neri (EEAN--Ana Neri School of Nursing) in the Federeal University of Rio de Janeiro (UFRJ) and at the Memory Center of the Faculty of Nursing (FENF) in the State University of Rio de Janeiro (UERJ). The data was collected between August 2000 and April 2001 by means of document analysis script. The outcomes showed that Zaíra Cintra Vidal was born on 5 May 1903; graduated from the Nursing School of the National Public Health Department in 1926; studied and post-graduated in the United States from 1927 until 1929 and returned to Brazil in 1943. Zaíra Cintra Vidal was the founder of the Nursing School Rachel Haddock Lobo and was its first director for nine years. She also and took part in ABEn's Direction Board and in the Revista Anais de Enfermagem (Nursing Magazine).
From a paper-based to an electronic registry in physiotherapy.

PubMed

Buyl, Ronald; Nyssen, Marc

2008-01-01

During the past decade the healthcare industry has evolved from paper-based storage of clinical data into the digital era. Electronic healthcare records play a crucial role to meet the growing need for integrated data-storage and data communication. In this context a new law was issued in Belgium on December 7th, 2005, which requires physiotherapists (but also nurses and speech therapists) to keep an electronic version of the registry. This (electronic) registry contains all physiotherapeutic acts, starting from January 1, 2007. Up until that day, a paper version of the registry had to be created every month.This article describes the development of an electronic version of the registry that not only meets all legal constraints, but also enables to verify the traceability and inalterability of the generated documents, by means of SHA-256 codes. One of the major concerns of the process was that the rationale behind the electronic registry would conform well to the common practice of the physiotherapist. Therefore we opted for a periodic recording of a standardized "image" of the controllable data, in the patient database of the software-system, into the XML registry messages. The proposed XSLT schema can also form a basis for the development of tools that can be used by the controlling authorities. Hopefully the electronic registry for physiotherapists will be a first step towards the future development of a fully integrated electronic physiotherapy record.By means of a certification procedure for the software systems, we succeeded in developing a user friendly system that enables end-users that use a quality labeled software package, to automatically produce all the legally necessary documents concerning the registry. Moreover, we hope that this development will be an incentive for non-users to start working in an electronic way.
E-Nursing: electronic nursing resources on your desktop.

PubMed

Kendall, Sandra; Massaralla, Susan; Hynes-Gay, Patricia; Vincent, Leslie

2003-01-01

E-Nursing represents an innovative approach to nursing education that has the potential to support professional practice throughout the institution. This paper details the benefits, design and promotion of an electronic nursing resource collection. How to divide responsibility, cost and expertise in such a project is also discussed. Preliminary usage statistics validate E-Nursing as a point-of-care education tool for nurses at Mount Sinai Hospital. A planned approach to implementation has been an effective means of introducing E-Nursing in an institution that previously relied on traditional hard-copy resources housed in the hospital's library.
Accuracy of outpatient service data for activity-based funding in New South Wales, Australia.

PubMed

Munyisia, Esther N; Reid, David; Yu, Ping

2017-05-01

Despite increasing research on activity-based funding (ABF), there is no empirical evidence on the accuracy of outpatient service data for payment. This study aimed to identify data entry errors affecting ABF in two drug and alcohol outpatient clinic services in Australia. An audit was carried out on healthcare workers' (doctors, nurses, psychologists, social workers, counsellors, and aboriginal health education officers) data entry errors in an outpatient electronic documentation system. Of the 6919 data entries in the electronic documentation system, 7.5% (518) had errors, 68.7% of the errors were related to a wrong primary activity, 14.5% were due to a wrong activity category, 14.5% were as a result of a wrong combination of primary activity and modality of care, 1.9% were due to inaccurate information on a client's presence during service delivery and 0.4% were related to a wrong modality of care. Data entry errors may affect the amount of funding received by a healthcare organisation, which in turn may affect the quality of treatment provided to clients due to the possibility of underfunding the organisation. To reduce errors or achieve an error-free environment, there is a need to improve the naming convention of data elements, their descriptions and alignment with the national standard classification of outpatient services. It is also important to support healthcare workers in their data entry by embedding safeguards in the electronic documentation system such as flags for inaccurate data elements.
Use of electronic information systems in nursing management.

PubMed

Lammintakanen, Johanna; Saranto, Kaija; Kivinen, Tuula

2010-05-01

The purpose of this study is to describe nurse managers' perceptions of the use of electronic information systems in their daily work. Several kinds of software are used for administrative and information management purposes in health care organizations, but the issue has been studied less from nurse managers' perspective. The material for this qualitative study was acquired according to the principles of focus group interview. Altogether eight focus groups were held with 48 nurse managers from both primary and specialized health care organizations. The nurse managers were asked in focus groups to describe the use of information systems in their daily work in addition to some other themes. The material was analyzed by inductive content analysis using ATLAS.ti computer program. The main category "pros and cons of using information systems in nursing management" summarized the nurse managers' perceptions of using electronic information systems. The main category consisted of three sub-categories: (1) nurse managers' perceptions of the use of information technology; (2) usability of management information systems; (3) development of personnel competencies and work processes. The nurse managers made several comments on the implementation of immature electronic information systems which caused inefficiencies in working processes. However, they considered electronic information systems to be essential elements of their daily work. Furthermore, the nurse managers' descriptions of the pros and cons of using information systems reflected partly the shortcomings of strategic management and lack of coordination in health care organizations. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.
Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review.

PubMed

Cummings, Greta G; MacGregor, Tara; Davey, Mandy; Lee, How; Wong, Carol A; Lo, Eliza; Muise, Melanie; Stafford, Erin

2010-03-01

Numerous policy and research reports call for leadership to build quality work environments, implement new models of care, and bring health and wellbeing to an exhausted and stretched nursing workforce. Rarely do they indicate how leadership should be enacted, or examine whether some forms of leadership may lead to negative outcomes. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments. The search strategy of this multidisciplinary systematic review included 10 electronic databases. Published, quantitative studies that examined leadership behaviours and outcomes for nurses and organizations were included. Quality assessments, data extractions and analysis were completed on all included studies. 34,664 titles and abstracts were screened resulting in 53 included studies. Using content analysis, 64 outcomes were grouped into five categories: staffsatisfaction with work, role and pay, staff relationships with work, staff health and wellbeing, work environment factors, and productivity and effectiveness. Distinctive patterns between relational and task focused leadership styles and their outcomes for nurses and their work environments emerged from our analysis. For example, 24 studies reported that leadership styles focused on people and relationships (transformational, resonant, supportive, and consideration) were associated with higher nurse job satisfaction, whereas 10 studies found that leadership styles focused on tasks (dissonant, instrumental and management by exception) were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes. Our results document evidence of various forms of leadership and their differential effects on the nursing workforce and work environments. Leadership focused on task completion alone is not sufficient to achieve optimum outcomes for the nursing workforce. Efforts by organizations and individuals to encourage and develop transformational and relational leadership are needed to enhance nurse satisfaction, recruitment, retention, and healthy work environments, particularly in this current and worsening nursing shortage. Copyright 2009 Elsevier Ltd. All rights reserved.
A survey-based study of factors that motivate nurses to protect the privacy of electronic medical records.

PubMed

Ma, Chen-Chung; Kuo, Kuang-Ming; Alexander, Judith W

2016-02-02

The purpose of this study is to investigate factors that motivate nurses to protect privacy in electronic medical records, based on the Decomposed Theory of Planned Behavior. This cross-sectional study used questionnaires to collect data from nurses in a large tertiary care military hospital in Taiwan. The three hundred two (302) valid questionnaires returned resulted in a response rate of 63.7 %. Structural equation modeling identified that the factors of attitude, subjective norm, and perceived behavioral control of the nurses significantly predicted the nurses' intention to protect the privacy of electronic medical records. Further, perceived usefulness and compatibility, peer and superior influence, self-efficacy and facilitating conditions, respectively predicted these three factors. The results of our study may provide valuable information for education and practice in predicting nurses' intention to protect privacy of electronic medical records.
Enhancing Key Competencies of Health Professionals in the Assessment and Care of Adults at Risk of Suicide Through Education and Technology.

PubMed

Ryan, Kathryn; Tindall, Claudia; Strudwick, Gillian

This article describes efforts undertaken to improve the clinical competencies of health professionals in the area of suicide risk assessment, documentation, and care planning. Best practices that fit the mental health and addictions setting were identified from the Registered Nurses' Association of Ontario Best Practice Guideline on Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour. A variety of methods were used to implement the guidelines at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. These included 3 in-person educational modules, an e-learning module, and the creation of an electronic health record suicide risk assessment documentation form. Results showed that interprofessional team members improved their suicide awareness and increased their confidence and knowledge in suicide risk assessment and the identification of interventions for clients at risk. Organizational level performance and quality improvement activities after implementation of the education and the electronic suicide risk assessment documentation form are being implemented through a collaboration between performance improvement, clinical education and informatics, and professional practice. The success of an interprofessional educational program of this nature is dependent on the collaboration of a number of stakeholders from a variety of areas of the organization.
Implementation of a multi-professional standardized care plan in electronic health records for the care of stroke patients.

PubMed

Pöder, Ulrika; Fogelberg-Dahm, Marie; Wadensten, Barbro

2011-09-01

To compare staff opinions about standardized care plans and self-reported habits with regard to documentation, and their perceived knowledge about the evidence-based guidelines in stroke care before and after implementation of an evidence-based-standardized care plan (EB-SCP) and quality standard for stroke care. The aim was also to describe staff opinions about, and their use of, the implemented EB-SCP. To facilitate evidence-based practice (EBP), a multi-professional EB-SCP and quality standard for stroke care was implemented in the electronic health record (EHR). Quantitative, descriptive and comparative, based on questionnaires completed before and after implementation. Perceived knowledge about evidence-based guidelines in stroke care increased after implementation of the EB-SCP. The majority agreed that the EB-SCP is useful and facilitates their work. There was no change between before and after implementation with regard to opinions about standardized care plans, self-reported documentation habits or time spent on documentation. An evidence-based SCP seems to be useful in patient care and improves perceived knowledge about evidence-based guidelines in stroke care. For nursing managers, introduction of evidence-based SCP in the EHR may improve the prerequisites for promoting high-quality EBP in multi-professional care. 2011 Blackwell Publishing Ltd.
Planning documents: a business planning strategy.

PubMed

Kaehrle, P A

2000-06-01

Strategic planning and business plan development are essential nursing management skills in today's competitive, fast paced, continually changing health care environment. Even in times of great uncertainty, nurse managers need to plan and forecast for the future. A well-written business plan allows nurse managers to communicate their expertise and proactively contribute to the programmatic decisions and changes occurring within their patient population or service area. This article presents the use of planning documents as a practical, strategic business planning strategy. Although the model addresses orthopedic services specifically, nurse managers can gain an understanding and working knowledge of planning concepts that can be applied to all patient populations.
Campus Partnerships Improve Impact Documentation of Nutrition Programs

ERIC Educational Resources Information Center

Brinkman, Patricia

2015-01-01

Partnerships with other campus college units can provide ways of improving Extension's impact documentation. Nutrition programs have relied upon knowledge gained and people's self report of behavior change. Partnering with the College of Nursing, student nurses provided blood screenings during the pre and 6 month follow-up of a pilot heart risk…
The Relationships among Job Satisfaction, Length of Employment, and Mentoring of Nursing Faculty

ERIC Educational Resources Information Center

Suzan, Zelda

2016-01-01

The shortage of faculty in nursing education programs has been well documented by the National League for Nursing. Job satisfaction is important in retaining nurse educators, and one New York nursing program was interested in examining the potential impact of mentoring on satisfaction. The purpose of this quantitative study was to examine job…
Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines.

PubMed

Ahlqvist, Margary; Bogren, Agneta; Hagman, Sari; Nazar, Isabel; Nilsson, Katarina; Nordin, Karin; Valfridsson, Berit Sunde; Söderlund, Mona; Nordström, Gun

2006-11-01

This study aimed at evaluating the outcome of implemented evidence-based clinical guidelines by means of surveying the frequency of thrombophlebitis, nurses' care, handling and documentation of peripheral intravenous cannulae. Peripheral intravenous cannulae are frequently used for vascular access and, thereby, the patients will be exposed to local and systemic infectious complications. Evidence-based knowledge of how to prevent these complications and how to care for patients with peripheral intravenous cannula is therefore of great importance. Deficient care, handling and documentation of peripheral intravenous cannulae have previously been reported. A cross-sectional survey was conducted by a group of nurses at three wards at a university hospital before and after the implementation of the evidence-based guidelines. A structured observation protocol was used to review the frequency of thrombophlebitis, the nurses' care, handling and the documentation of peripheral intravenous cannulae in the patient's record. A total of 107 and 99 cannulae respectively were observed before and after the implementation of the guidelines. The frequency of peripheral intravenous cannulae without signs of thrombophlebitis increased by 21% (P < 0.01) and the use of cannula size 0.8 mm increased by 22% (P < 0.001). Nurses' documentation of peripheral intravenous cannula improved significantly (P < 0.001). We conclude that implementation of the guidelines resulted in significant improvements by means of decreased frequency of signs of thrombophlebitis, increased application of smaller cannula size (0.8 mm), as well as of the nurses' documentation in the patient's record. Further efforts to ameliorate care and handling of peripheral intravenous cannulae are needed. This can be done by means of increasing nurses' knowledge and recurrent quality reviews. Well-informed patients can also be more involved in the care than is common today.
Community nurse's knowledge, confidence and experience of the Mental Capacity Act in practice.

PubMed

Marshall, Helen; Sprung, Sally

2016-12-02

The Mental Capacity Act (MCA) is statutory legislation introduced in 2007 to protect and empower people to make decisions for themselves and those who were deemed as unable to make choices would have decisions made on their behalf, often by health professionals. All health professionals must follow the guiding principles of this legislation. Yet a scrutiny report by the House of Lords concluded this legislation was under-used with a lack of knowledge among professionals regarding applying the legislation in practice. A review of the literature also supports these findings. A mixed method study was carried out among adult community nurses to explore if these findings were applicable within a health trust in the North West region. An electronic questionnaire (n=60), focus group (n=7) and a paired interview (n=2) were utilised to collect data regarding community nurse's experience and confidence of using the MCA in practice. Analysis identified key themes: training, knowledge and confidence among staff, working together with the wider multidisciplinary team, empowerment and improving documentation. While findings suggest clear examples of self-appraised confidence and excewllent patient care, there is also scope for development regarding the knowledge and utilisation of the MCA in the clinical practice of community nurses.
School Nurse Role in Electronic School Health Records. Position Statement

ERIC Educational Resources Information Center

Hiltz, Cynthia; Johnson, Katie; Lechtenberg, Julia Rae; Maughan, Erin; Trefry, Sharonlee

2014-01-01

It is the position of the National Association of School Nurses (NASN) that Electronic Health Records (EHRs) are essential for the registered professional school nurse (hereinafter referred to as school nurse) to provide efficient and effective care in the school and monitor the health of the entire student population. It is also the position of…
A Quantitative Analysis of Evidence-Based Testing Practices in Nursing Education

ERIC Educational Resources Information Center

Moore, Wendy

2017-01-01

The focus of this dissertation is evidence-based testing practices in nursing education. Specifically, this research study explored the implementation of evidence-based testing practices between nursing faculty of various experience levels. While the significance of evidence-based testing in nursing education is well documented, little is known…
Cancer Nursing Education: Literature Review and Documentary Analysis.

ERIC Educational Resources Information Center

Langton, Helen; Blunden, Gillian; Hek, Gill

The knowledge and skills needed by cancer nurses and the content and strategies of England's existing cancer nursing education programs were examined. The study included a comprehensive literature review and an analysis of course documents from selected English National Board-approved post-qualifying cancer nursing and palliative care courses…
[Implementation of a form for adverse effect notification: results for the 1st year].

PubMed

Pérez Blanco, Verónica; Rubio Gómez, Isabel; Alarcón Gascueña, Piedad; Mateos Rubio, José; Herradón Cano, Matilde; Delgado García, Amadeo

2009-02-01

To describe the introduction of an incident monitoring system by electronic reporting in the Complejo Hospitalario de Toledo (CHT) and to analyse the initial results. CHT is a public hospital with 750 beds, 59 for critical patients, an ambulatory surgery unit and three outpatient clinics. Access to the electronic reporting system is on the main screen of the hospital intranet. The reporting system is voluntary and confidential. It was introduced at the same time as setting up website on clinical safety and the provision of specific training on the subject. A total of 62 reports were received on the electronic system over a period of 12 months (December 2006 to December 2007), of which 74.5% were reported by nursing staff. The service from where it was reported most often was Geriatrics (43.1%). Most of the incidents were classified by the notifiers themselves as "no injury" (64.7%) and as "avoidable" 92.2%. A total of 56.9% were related to care. Some reports led to the issuing of three documents of recommendations by the Quality Unit and the Pharmacy Department. Most of the notifications were incidents related to care and were reported by nurses. The reporting system can complement other tools in promoting a clinical safety culture and defining the risk profile of a health organisation.
Outcomes of Computerized Physician Order Entry in an Electronic Health Record After Implementation in an Outpatient Oncology Setting

PubMed Central

Harshberger, Cara A.; Harper, Abigail J.; Carro, George W.; Spath, Wayne E.; Hui, Wendy C.; Lawton, Jessica M.; Brockstein, Bruce E.

2011-01-01

Purpose: Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites. Methods: This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems. Results: The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system. Conclusion: Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety. PMID:22043187

An Integrated Curriculum of Nursing, Nutrition, Exercise, and Drugs for Health Care Providers of the Elderly (Project NNED).

ERIC Educational Resources Information Center

Summit-Portage Area Health Education Network, Akron, OH.

This document is intended to give health care providers interdisciplinary information concerning drugs, nutrition, and exercise to help them enhance health maintenance of the elderly. Prepared as part of Project NNED, (Nursing, Nutrition, Exercise, and Drugs), an integrated curriculum for health care providers of the elderly, the document includes…
Electronic Assessment and Feedback Tool in Supervision of Nursing Students during Clinical Training

ERIC Educational Resources Information Center

Mettiäinen, Sari

2015-01-01

The aim of this study was to determine nursing teachers' and students' attitudes to and experiences of using an electronic assessment and feedback tool in supervision of clinical training. The tool was called eTaitava, and it was developed in Finland. During the pilot project, the software was used by 12 nursing teachers and 430 nursing students.…
Improving program documentation quality through the application of continuous improvement processes.

PubMed

Lovlien, Cheryl A; Johansen, Martha; Timm, Sandra; Eversman, Shari; Gusa, Dorothy; Twedell, Diane

2007-01-01

Maintaining the integrity of record keeping and retrievable information related to the provision of continuing education credit creates challenges for a large organization. Accurate educational program documentation is vital to support the knowledge and professional development of nursing staff. Quality review and accurate documentation of programs for nursing staff development occurred at one institution through the use of continuous improvement principles. Integration of the new process into the current system maintains the process of providing quality record keeping.
The nurse response to abnormal vital sign recording in the emergency department.

PubMed

Johnson, Kimberly D; Mueller, Lindsey; Winkelman, Chris

2017-01-01

To examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow-up for abnormal vital signs. Monitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses' roles. Abnormal vital signs have been associated with poor patient outcomes and require follow-up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care. Observational, retrospective chart review. Modified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score. About 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation. It is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow-up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow-up is not being documented. To ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required. © 2016 John Wiley & Sons Ltd.
Electronic health record tools' support of nurses' clinical judgment and team communication.

PubMed

Kossman, Susan P; Bonney, Leigh Ann; Kim, Myoung Jin

2013-11-01

Nurses need to quickly process information to form clinical judgments, communicate with the healthcare team, and guide optimal patient care. Electronic health records not only offer potential for enhanced care but also introduce unintended consequences through changes in workflow, clinical judgment, and communication. We investigated nurses' use of improvised (self-made) and electronic health record-generated cognitive artifacts on clinical judgment and team communication. Tanner's Clinical Judgment Model provided a framework and basis for questions in an online survey and focus group interviews. Findings indicated that (1) nurses rated self-made work lists and medication administration records highest for both clinical judgment and communication, (2) tools aided different dimensions of clinical judgment, and (3) interdisciplinary tools enhance team communication. Implications are that electronic health record tool redesign could better support nursing work.
Improving care transitions through meaningful use stage 2: continuity of care document.

PubMed

Murphy, Lyn Stankiewicz; Wilson, Marisa L; Newhouse, Robin P

2013-02-01

In this department, Drs Murphy, Wilson, and Newhouse highlight hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss the practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demon strate innovative approaches to organizational problems. In this article, the authors describe the elements of continuity of care documentation, how sharing information can improve the quality and safety of care transitions and the implications for nurse executives.
Physician nurse care: A new use of UMLS to measure professional contribution

PubMed Central

Boyd, Andrew D.; Lopez, Karen Dunn; Lugaresi, Camillo; Macieira, Tamara; Sousa, Vanessa; Acharya, Sabita; Balasubramanian, Abhinaya; Roussi, Khawllah; Keenan, Gail M.; Lussier, Yves A.; ‘John’ Li, Jianrong; Burton, Michel; Di Eugenio, Barbara

2018-01-01

Background Physician and nurses have worked together for generations; however, their language and training are vastly different; comparing and contrasting their work and their joint impact on patient outcomes is difficult in light of this difference. At the same time, the EHR only includes the physician perspective via the physician-authored discharge summary, but not nurse documentation. Prior research in this area has focused on collaboration and the usage of similar terminology. Objective The objective of the study is to gain insight into interprofessional care by developing a computational metric to identify similarities, related concepts and differences in physician and nurse work. Methods 58 physician discharge summaries and the corresponding nurse plans of care were transformed into Unified Medical Language System (UMLS) Concept Unique Identifiers (CUIs). MedLEE, a Natural Language Processing (NLP) program, extracted “physician terms” from free-text physician summaries. The nursing plans of care were constructed using the HANDS© nursing documentation software. HANDS© utilizes structured terminologies: nursing diagnosis (NANDA-I), outcomes (NOC), and interventions (NIC) to create “nursing terms”. The physician’s and nurse’s terms were compared using the UMLS network for relatedness, overlaying the physician and nurse terms for comparison. Our overarching goal is to provide insight into the care, by innovatively applying graph algorithms to the UMLS network. We reveal the relationships between the care provided by each professional that is specific to the patient level. Results We found that only 26% of patients had synonyms (identical UMLS CUIs) between the two professions’ documentation. On average, physicians’ discharge summaries contain 27 terms and nurses’ documentation, 18. Traversing the UMLS network, we found an average of 4 terms related (distance less than 2) between the professions, leaving most concepts as unrelated between nurse and physician care. Conclusion Our hypothesis that physician’s and nurse’s practice domains are markedly different is supported by the preliminary, quantitative evidence we found. Leveraging the UMLS network and graph traversal algorithms, allows us to compare and contrast nursing and physician care on a single patient, enabling a more complete picture of patient care. We can differentiate professional contributions to patient outcomes and related and divergent concepts by each profession. PMID:29602435
Pain: A content review of undergraduate pre-registration nurse education in the United Kingdom.

PubMed

Mackintosh-Franklin, Carolyn

2017-01-01

Pain is a global health issue with poor assessment and management of pain associated with serious disability and detrimental socio economic consequences. Pain is also a closely associated symptom of the three major causes of death in the developed world; Coronary Heart Disease, Stroke and Cancer. There is a significant body of work which indicates that current nursing practice has failed to address pain as a priority, resulting in poor practice and unnecessary patient suffering. Additionally nurse education appears to lack focus or emphasis on the importance of pain assessment and its management. A three step online search process was carried out across 71 Higher Education Institutes (HEIs) in the United Kingdom (UK) which deliver approved undergraduate nurse education programmes. Step one to find detailed programme documentation, step 2 to find reference to pain in the detailed documents and step 3 to find reference to pain in nursing curricula across all UK HEI websites, using Google and each HEIs site specific search tool. The word pain featured minimally in programme documents with 9 (13%) documents making reference to it, this includes 3 occurrences which were not relevant to the programme content. The word pain also featured minimally in the content of programmes/modules on the website search, with no references at all to pain in undergraduate pre-registration nursing programmes. Those references found during the website search were for continuing professional development (CPD) or Masters level programmes. In spite of the global importance of pain as a major health issue both in its own right, and as a significant symptom of leading causes of death and illness, pain appears to be a neglected area within the undergraduate nursing curriculum. Evidence suggests that improving nurse education in this area can have positive impacts on clinical practice, however without educational input the current levels of poor practice are unlikely to improve and unnecessary patient suffering will continue. Undergraduate nurse education in the UK needs to review its current approach to content and ensure that pain is appropriately and prominently featured within pre-registration nurse education. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Development of an audit instrument for nursing care plans in the patient record

PubMed Central

Bjorvell, C; Thorell-Ekstrand, I; Wredling, R

2000-01-01

Objectives—To develop, validate, and test the reliability of an audit instrument that measures the extent to which patient records describe important aspects of nursing care. Material—Twenty records from each of three hospital wards were collected and audited. The auditors were registered nurses with a knowledge of nursing documentation in accordance with the VIPS model—a model designed to structure nursing documentation. (VIPS is an acronym formed from the Swedish words for wellbeing, integrity, prevention, and security.) Methods—An audit instrument was developed by determining specific criteria to be met. The audit questions were aimed at revealing the content of the patient for nursing assessment, nursing diagnosis, planned interventions, and outcome. Each of the 60 records was reviewed by the three auditors independently and the reliability of the instrument was tested by calculating the inter-rater reliability coefficient. Content validity was tested by using an expert panel and calculating the content validity ratio. The criterion related validity was estimated by the correlation between the score of the Cat-ch-Ing instrument and the score of an earlier developed and used audit instrument. The results were then tested by using Pearson's correlation coefficient. Results—The new audit instrument, named Cat-ch-Ing, consists of 17 questions designed to judge the nursing documentation. Both quantity and quality variables are judged on a rating scale from zero to three, with a maximum score of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.92, respectively for each group of 20 records, the content validity ratio ranged between 0.20 and 1.0 and the criterion related validity showed a significant correlation of r = 0.68 (p< 0.0001, 95% CI 0.57 to 0.76) between the two audit instruments. Conclusion—The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation. (Quality in Health Care 2000;9:6–13) Key Words: audit instrument; nursing care plans; quality assurance PMID:10848373
Nursing practice in a post-Soviet country from the perspectives of Armenian nurses: a qualitative exploratory study.

PubMed

Poghosyan, Lusine; Poghosyan, Hermine; Berlin, Kristen; Truzyan, Nune; Danielyan, Lusine; Khourshudyan, Kristine

2012-09-01

The purpose of this qualitative descriptive study was to explore the views of head and staff nurses about nursing practice in the hospitals of Armenia. Armenia inherited its nursing frameworks from the Soviet Union. After the Soviet collapse, many changes took place to reform nursing. However, to date little has been systematically documented about nursing practice in Armenia. Qualitative descriptive design was implemented. Three major hospitals in Yerevan, the capital city of Armenia, participated in the study. Purposeful sampling was used. Forty-three nurses participated, 29 staff and fourteen head nurses. Data were collected through five focus groups comprised of seven to ten participants. A focus group guide was developed. The researcher facilitated the discussions in Armenian, which were audio taped. The research assistant took notes. Data were transcribed and translated into English, imported into atlas.ti 6.1 qualitative software, and analysed by three authors. Five themes were extracted. Lack of role clarity theme was identified from the head nurse data. The practice environment theme was identified from the staff nurse data. Nursing education, value, respect and appreciation of nursing, and becoming a nurse were common themes identified from both head and staff nurse data. Head nurses lack autonomy, do not have clear roles and are burdened with documentation. Staff nurses practice in challenging work environments with inadequate staffing and demanding workloads. All nurses reported the need to improve nursing education. This is the first study conducted in Armenia exploring nursing practice in the hospitals from the nurses' perspectives. Nurses face challenges that may impact their wellbeing and patient care. Understanding challenges nursing practice faces in the hospitals in Armenia will help administrators and care providers to take actions to improve nursing practice and subsequently patient care. © 2012 Blackwell Publishing Ltd.
The development and piloting of electronic standardized measures on nursing work: combining engineering and nursing knowledge.

PubMed

Bragadóttir, Helga; Gunnarsdóttir, Sigrún; Ingason, Helgi T

2013-05-01

This paper describes the development and piloting of electronic standardized measures on nursing work (e-SMNW) for rich data gathering on the work and work environment of registered nurses (RNs) and practical nurses (PNs). Efficient and valid methods are needed to measure nursing work to enhance the optimal use of the nursing workforce for safe patient care. The study combined human factors engineering (HFE) and nursing knowledge to develop electronic standardized measures for observational studies on nursing work in acute care. The work and work environment of RNs and PNs in acute care medical and surgical inpatient units was successfully measured using e-SMNW. With predetermined items of work activities and influencing factors in the work of nurses, and full use of computer technology, multi-layered rich standardized data were gathered, analysed and displayed. The combination of nursing knowledge, HFE and computer technology enables observational data collection for a rich picture of the complex work of nursing. Information collected by standardized and multi-layered measures makes it easier to identify potential improvements, with regard to influencing factors and management of the work and work environment of nurses. Further use of computer technology in health services research is encouraged. © 2012 Blackwell Publishing Ltd.
Eleven Years of Primary Health Care Delivery in an Academic Nursing Center.

ERIC Educational Resources Information Center

Hildebrandt, Eugenie; Baisch, Mary Jo; Lundeen, Sally P.; Bell-Calvin, Jean; Kelber, Sheryl

2003-01-01

Client visits to an academic community nursing center (n=25,495) were coded and analyzed. Results show expansion of nursing practice and services, strong case management, and management of illness care. The usefulness of computerized clinical documentation system and of the Lundeen conceptional model of community nursing care was demonstrated.…
Investigating the Educational Needs of Nurses in Telepractice: A Descriptive Exploratory Study

ERIC Educational Resources Information Center

Carter, Lorraine; Hudyma, Shirlene; Horrigan, Judith

2010-01-01

Although some nursing bodies have recognized nursing telepractice as a specialty, with its own knowledge, skills, and attitudes, there is little documented evidence of the educational needs of Canadian nurses working in telehealth. However, now that telehealth has been recognized as a partial solution to Canada's health-care challenges, the area…
A review of the nursing role in central venous cannulation: implications for practice policy and research.

PubMed

Alexandrou, Evan; Spencer, Timothy R; Frost, Steve A; Parr, Michael J A; Davidson, Patricia M; Hillman, Kenneth M

2010-06-01

The aim of this article is to review published studies about central vein cannulation to identify implications for policy, practice and research in an advanced practice nursing role. Modified integrative literature review. Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Medline, Embase, and the World Wide Web were undertaken using MeSH key words. Hand searching for relevant articles was also undertaken. All studies relating to the nurses role inserting central venous cannulae in adult populations met the search criteria and were reviewed by three authors using a critical appraisal tool. Ten studies met the inclusion criteria for the review, all reported data were from the UK. There were disparate models of service delivery and study populations and the studies were predominantly non experimental in design. The results of this review need to be considered within the methodological caveats associated with this approach. The studies identified did not demonstrate differences in rates of adverse events between a specialist nurse and a medical officer. There were only a small number of studies found in the literature review and the limited availability of clinical outcome data precluded formal analysis from being generated. Central vein cannulation is potentially an emerging practice area with important considerations for policy practice and research. Training specialist nurses to provide such a service may facilitate standardising of practice and improving surveillance of lines, and possibly improve the training and accreditation process for CVC insertions for junior medical officers. For this to occur, there is a need to undertake well-conducted clinical studies to clearly document the value and efficacy of this advanced practice nursing role.
Wired to the Workplace: The Relationship Between Electronic Connectedness to Work and Nurse Manager Satisfaction.

PubMed

Gardner, Candace; Hailey, Amy; Nguyen, Christi; Prichard, Charlsea; Newcomb, Patricia

2017-01-01

The aim of this study is to describe the beliefs and behaviors of nurse leaders regarding electronic connectedness with their workplace and workplace support. Electronic communication enables leaders' continuous availability to the workplace. This may blur home-work boundaries and contribute to burnout. This mixed-methods study surveyed nurses in 6 acute care hospitals in north Texas. A qualitative phase employed focus groups composed of nurses from participating hospitals to validate and enrich data collected in the quantitative phase. Data showed that leader support directly influenced work-related electronic communication by influencing expectations regarding connectedness. Furthermore, leaders who frequently thought of leaving employment reported significantly lower levels of supervisor support and stronger beliefs that work interfered with home life than other respondents did. Focus group data supported survey findings. Electronic availability of nurse leaders did not directly affect satisfaction, but supervisor support and perception that work interferes with home life strongly and directly affected satisfaction.
Computerized clinical documentation system in the pediatric intensive care unit

PubMed Central

2001-01-01

Background To determine whether a computerized clinical documentation system (CDS): 1) decreased time spent charting and increased time spent in patient care; 2) decreased medication errors; 3) improved clinical decision making; 4) improved quality of documentation; and/or 5) improved shift to shift nursing continuity. Methods Before and after implementation of CDS, a time study involving nursing care, medication delivery, and normalization of serum calcium and potassium values was performed. In addition, an evaluation of completeness of documentation and a clinician survey of shift to shift reporting were also completed. This was a modified one group, pretest-posttest design. Results With the CDS there was: improved legibility and completeness of documentation, data with better accessibility and accuracy, no change in time spent in direct patient care or charting by nursing staff. Incidental observations from the study included improved management functions of our nurse manager; improved JCAHO documentation compliance; timely access to clinical data (labs, vitals, etc); a decrease in time and resource use for audits; improved reimbursement because of the ability to reconstruct lost charts; limited human data entry by automatic data logging; eliminated costs of printing forms. CDS cost was reasonable. Conclusions When compared to a paper chart, the CDS provided a more legible, compete, and accessible patient record without affecting time spent in direct patient care. The availability of the CDS improved shift to shift reporting. Other observations showed that the CDS improved management capabilities; helped physicians deliver care; improved reimbursement; limited data entry errors; and reduced costs. PMID:11604105
Applying the Model of the Interrelationship of Leadership Environments and Outcomes for Nurse Executives: a community hospital's exemplar in developing staff nurse engagement through documentation improvement initiatives.

PubMed

Adams, Jeffrey M; Denham, Debra; Neumeister, Irene Ramirez

2010-01-01

The Model of the Interrelationship of Leadership, Environments & Outcomes for Nurse Executives (MILE ONE) was developed on the basis of existing literature related to identifying strategies for simultaneous improvement of leadership, professional practice/work environments (PPWE), and outcomes. Through existing evidence, the MILE ONE identifies the continuous and dependent interrelationship of 3 distinct concept areas: (1) nurse executives influence PPWE, (2) PPWE influence patient and organizational outcomes, and (3) patient and organizational outcomes influence nurse executives. This article highlights the application of the MILE ONE framework to a community district hospital's clinical documentation performance improvement projects. Results suggest that the MILE ONE is a valid and useful framework yielding both anticipated and unexpected enhancements to leaders, environments, and outcomes.
Evaluation of a patient centered e-nursing and caring system.

PubMed

Tsai, Lai-Yin; Shan, Huang; Mei-Bei, Lin

2006-01-01

This study aims to develop an electronic nursing and caring system to manage patients' information and provide patients with safe and efficient services. By transmitting data among wireless cards, optical network, and mainframe computer, nursing care will be delivered more systematically and patients' safety centered caring will be delivered more efficiently and effectively. With this system, manual record keeping time was cut down, and relevant nursing and caring information was linked up. With the development of an electronic nursing system, nurses were able to make the best use of the Internet resources, integrate information management systematically and improve quality of nursing and caring service.
Evaluating a Serious Gaming Electronic Medication Administration Record System Among Nursing Students: Protocol for a Pragmatic Randomized Controlled Trial.

PubMed

Booth, Richard; Sinclair, Barbara; McMurray, Josephine; Strudwick, Gillian; Watson, Gavan; Ladak, Hanif; Zwarenstein, Merrick; McBride, Susan; Chan, Ryan; Brennan, Laura

2018-05-28

Although electronic medication administration record systems have been implemented in settings where nurses work, nursing students commonly lack robust learning opportunities to practice the skills and workflow of digitalized medication administration during their formative education. As a result, nursing students' performance in administering medication facilitated by technology is often poor. Serious gaming has been recommended as a possible intervention to improve nursing students' performance with electronic medication administration in nursing education. The objectives of this study are to examine whether the use of a gamified electronic medication administration simulator (1) improves nursing students' attention to medication administration safety within simulated practice, (2) increases student self-efficacy and knowledge of the medication administration process, and (3) improves motivational and cognitive processing attributes related to student learning in a technology-enabled environment. This study comprised the development of a gamified electronic medication administration record simulator and its evaluation in 2 phases. Phase 1 consists of a prospective, pragmatic randomized controlled trial with second-year baccalaureate nursing students at a Canadian university. Phase 2 consists of qualitative focus group interviews with a cross-section of nursing student participants. The gamified medication administration simulator has been developed, and data collection is currently under way. If the gamified electronic medication administration simulator is found to be effective, it could be used to support other health professional simulated education and scaled more widely in nursing education programs. ClinicalTrials.gov NCT03219151; https://clinicaltrials.gov/show/NCT03219151 (Archived by WebCite at http://www.webcitation.org/6yjBROoDt). RR1-10.2196/9601. ©Richard Booth, Barbara Sinclair, Josephine McMurray, Gillian Strudwick, Gavan Watson, Hanif Ladak, Merrick Zwarenstein, Susan McBride, Ryan Chan, Laura Brennan. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 28.05.2018.
Electronic Nursing Notes: A Case Study on Interdisciplinary Collaboration

ERIC Educational Resources Information Center

Howard, Elizabeth V.; Teets, Janet

2006-01-01

In an interdisciplinary collaboration between the Computer & Information Technology (CIT) and Nursing (NSG) Departments at the Middletown and Hamilton regional campuses of Miami University (of Ohio), student team members created a Web-based application to create Electronic Nursing Notes. Students from the two departments worked together to…

42 CFR 130.20 - Form of medical documentation.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., records maintained by a physician, nurse, or other licensed health care provider, test results... under penalty of perjury, by a physician, nurse practitioner or physician assistant, verifying that the... an affidavit must include the physician's, nurse practitioner's or physician assistant's State of...
42 CFR 130.20 - Form of medical documentation.

Code of Federal Regulations, 2014 CFR

2014-10-01

... under penalty of perjury, by a physician, nurse practitioner or physician assistant, verifying that the... an affidavit must include the physician's, nurse practitioner's or physician assistant's State of..., records maintained by a physician, nurse, or other licensed health care provider, test results...
42 CFR 130.20 - Form of medical documentation.

Code of Federal Regulations, 2013 CFR

2013-10-01

... under penalty of perjury, by a physician, nurse practitioner or physician assistant, verifying that the... an affidavit must include the physician's, nurse practitioner's or physician assistant's State of..., records maintained by a physician, nurse, or other licensed health care provider, test results...
42 CFR 130.20 - Form of medical documentation.

Code of Federal Regulations, 2012 CFR

2012-10-01

... under penalty of perjury, by a physician, nurse practitioner or physician assistant, verifying that the... an affidavit must include the physician's, nurse practitioner's or physician assistant's State of..., records maintained by a physician, nurse, or other licensed health care provider, test results...
42 CFR 130.20 - Form of medical documentation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... under penalty of perjury, by a physician, nurse practitioner or physician assistant, verifying that the... an affidavit must include the physician's, nurse practitioner's or physician assistant's State of..., records maintained by a physician, nurse, or other licensed health care provider, test results...
Critical Behaviors in Psychiatric-Mental Health Nursing. Volume 2: Behavior of Nurses.

ERIC Educational Resources Information Center

Jacobs, Angeline Marchese; And Others

Part of a three-volume document, this volume is concerned with providing source data about the activities of mental health nursing personnel as these activities relate to patient care, and contains abstracts of more than 4,000 critical behaviors of psychiatric nurses in 50 psychiatric hospitals, general hospitals with psychiatric units, and…
Task Analysis for Health Occupations. Cluster: Nursing. Occupation: Professional Nurse (Associate Degree). Education for Employment Task Lists.

ERIC Educational Resources Information Center

Lake County Area Vocational Center, Grayslake, IL.

This document contains a task analysis for health occupations (professional nurse) in the nursing cluster. For each task listed, occupation, duty area, performance standard, steps, knowledge, attitudes, safety, equipment/supplies, source of analysis, and Illinois state goals for learning are listed. For the duty area of "providing therapeutic…
Connecting Professional Practice and Technology at the Bedside

PubMed Central

Gomes, Melissa; Hash, Pamela; Orsolini, Liana; Watkins, Aimee; Mazzoccoli, Andrea

2016-01-01

The purpose of this research is to determine the effects of implementing an electronic health record on medical-surgical registered nurses' time spent in direct professional patient-centered nursing activities, attitudes and beliefs related to implementation, and changes in level of nursing engagement after deployment of the electronic health record. Patient-centered activities were categorized using Watson's Caritas Processes and the Relationship-Based Care Delivery System. Methods included use of an Attitudes and Beliefs Assessment Questionnaire, Nursing Engagement Questionnaire, and Rapid Modeling Corporation's personal digital assistants for time and motion data collection. There was a significant difference in normative belief between nurses with less than 15 years' experience and nurses with more than 15 years' experience (t21 = 2.7, P = .01). While nurses spent less time at the nurses' station, less time charting, significantly more time in patients' rooms and in purposeful interactions, time spent in relationship-based caring behavior categories actually decreased in most categories. Nurses' engagement scores did not significantly increase. These results serve to inform healthcare organizations about potential factors related to electronic health record deployment which create shifts in nursing time spent across care categories and can be used to explore further patient centered care practices. PMID:27496045
Automated measurement of pressure injury through image processing.

PubMed

Li, Dan; Mathews, Carol

2017-11-01

To develop an image processing algorithm to automatically measure pressure injuries using electronic pressure injury images stored in nursing documentation. Photographing pressure injuries and storing the images in the electronic health record is standard practice in many hospitals. However, the manual measurement of pressure injury is time-consuming, challenging and subject to intra/inter-reader variability with complexities of the pressure injury and the clinical environment. A cross-sectional algorithm development study. A set of 32 pressure injury images were obtained from a western Pennsylvania hospital. First, we transformed the images from an RGB (i.e. red, green and blue) colour space to a YC b C r colour space to eliminate inferences from varying light conditions and skin colours. Second, a probability map, generated by a skin colour Gaussian model, guided the pressure injury segmentation process using the Support Vector Machine classifier. Third, after segmentation, the reference ruler - included in each of the images - enabled perspective transformation and determination of pressure injury size. Finally, two nurses independently measured those 32 pressure injury images, and intraclass correlation coefficient was calculated. An image processing algorithm was developed to automatically measure the size of pressure injuries. Both inter- and intra-rater analysis achieved good level reliability. Validation of the size measurement of the pressure injury (1) demonstrates that our image processing algorithm is a reliable approach to monitoring pressure injury progress through clinical pressure injury images and (2) offers new insight to pressure injury evaluation and documentation. Once our algorithm is further developed, clinicians can be provided with an objective, reliable and efficient computational tool for segmentation and measurement of pressure injuries. With this, clinicians will be able to more effectively monitor the healing process of pressure injuries. © 2017 John Wiley & Sons Ltd.
Nursing Minimum Data Sets for documenting nutritional care for adults in primary healthcare: a scoping review.

PubMed

Håkonsen, Sasja Jul; Pedersen, Preben Ulrich; Bjerrum, Merete; Bygholm, Ann; Peters, Micah D J

2018-01-01

To identify all published nutritional screening instruments that have been validated in the adult population in primary healthcare settings and to report on their psychometric validity. Within health care, there is an urgent need for the systematic collection of nursing care data in order to make visible what nurses do and to facilitate comparison, quality assurance, management, research and funding of nursing care. To be effective, nursing records should accurately and comprehensively document all required information to support safe and high quality care of patients. However, this process of documentation has been criticized from many perspectives as being highly inadequate. A Nursing Minimum Data Set within the nutritional area in primary health care could therefore be beneficial in order to support nurses in their daily documentation and observation of patients. The review considered studies that included adults aged over 18 years of any gender, culture, diagnosis and ethnicity, as well as nutritional experts, patients and their relatives. The concepts of interest were: the nature and content of any nutritional screening tools validated (regardless of the type of validation) in the adult population in primary healthcare; and the views and opinions of eligible participants regarding the appropriateness of nutritional assessment were the concept of interest. Studies included must have been conducted in primary healthcare settings, both within home care and nursing home facilities. This scoping review used a two-step approach as a preliminary step to the subsequent development of a Nursing Minimum Data Set within the nutritional area in primary healthcare: i) a systematic literature search of existing nutritional screening tools validated in primary health care; and ii) a systematic literature search on nutritional experts opinions on the assessment of nutritional nursing care of adults in primary healthcare as well as the views of patients and their relatives. Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemed+, MedNar, CDC, MEDION, Health Technology Assessment Database, TRIP database, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents) were searched from their inception to September 2016. The results from the studies were extracted using pre-developed extraction tools to all three questions, and have been presented narratively and by using figures to support the text. Twenty-nine nutritional screening tools that were validated within a primary care setting, and two documents on consensus statements regarding expert opinion were identified. No studies on the patients or relatives views were identified. The nutritional screening instruments have solely been validated in an over-55 population. Construct validity was the type of validation most frequently used in the validation process covering a total of 25 of the 29 tools. Two studies were identified in relation to the third review question. These two documents are both consensus statement documents developed by experts within the geriatric and nutritional care field. Overall, experts find it appropriate to: i) conduct a comprehensive geriatric assessment, ii) use a validated nutritional screening instrument, and iii) conduct a history and clinical diagnosis, physical examination and dietary assessment when assessing primarily the elderly's nutritional status in primary health care.
Improving the quality of care of patients with rheumatic disease using patient-centric electronic redesign software.

PubMed

Newman, Eric D; Lerch, Virginia; Billet, Jon; Berger, Andrea; Kirchner, H Lester

2015-04-01

Electronic health records (EHRs) are not optimized for chronic disease management. To improve the quality of care for patients with rheumatic disease, we developed electronic data capture, aggregation, display, and documentation software. The software integrated and reassembled information from the patient (via a touchscreen questionnaire), nurse, physician, and EHR into a series of actionable views. Core functions included trends over time, rheumatology-related demographics, and documentation for patient and provider. Quality measures collected included patient-reported outcomes, disease activity, and function. The software was tested and implemented in 3 rheumatology departments, and integrated into routine care delivery. Post-implementation evaluation measured adoption, efficiency, productivity, and patient perception. Over 2 years, 6,725 patients completed 19,786 touchscreen questionnaires. The software was adopted for use by 86% of patients and rheumatologists. Chart review and documentation time trended downward, and productivity increased by 26%. Patient satisfaction, activation, and adherence remained unchanged, although pre-implementation values were high. A strong correlation was seen between use of the software and disease control (weighted Pearson's correlation coefficient 0.5927, P = 0.0095), and a relative increase in patients with low disease activity of 3% per quarter was noted. We describe innovative software that aggregates, stores, and displays information vital to improving the quality of care for patients with chronic rheumatic disease. The software was well-adopted by patients and providers. Post-implementation, significant improvements in quality of care, efficiency of care, and productivity were demonstrated. Copyright © 2015 by the American College of Rheumatology.
International perspectives on social media guidance for nurses: a content analysis.

PubMed

Ryan, Gemma

2016-12-01

Aim This article reports the results of an analysis of the content of national and international professional guidance on social media for the nursing profession. The aim was to consolidate good practice examples of social media guidelines, and inform the development of comprehensive guidance. Method A scoping search of professional nursing bodies' and organisations' social media guidance documents was undertaken using google search. Results 34 guidance documents were located, and a content analysis of these was conducted. Conclusion The results, combined with a review of competency hearings and literature, indicate that guidance should cover the context of social media, and support nurses to navigate and negotiate the differences between the real and online domains to help them translate awareness into actions.
Enhancing diabetes management while teaching quality improvement methods.

PubMed

Sievers, Beth A; Negley, Kristin D F; Carlson, Marny L; Nelson, Joyce L; Pearson, Kristina K

2014-01-01

Six medical units realized that they were having issues with accurate timing of bedtime blood glucose measurement for their patients with diabetes. They decided to investigate the issues by using their current staff nurse committee structure. The clinical nurse specialists and nurse education specialists decided to address the issue by educating and engaging the staff in the define, measure, analyze, improve, control (DMAIC) framework process. They found that two issues needed to be improved, including timing of bedtime blood glucose measurement and snack administration and documentation. Several educational interventions were completed and resulted in improved timing of bedtime glucose measurement and bedtime snack documentation. The nurses understood the DMAIC process, and collaboration and cohesion among the medical units was enhanced. Copyright 2014, SLACK Incorporated.
Interpersonal relationships and safety culture in Brazilian health care organisations.

PubMed

Migowski, Eliana R; Oliveira Júnior, Nery; Riegel, Fernando; Migowski, Sérgio A

2018-06-20

To examine the association between interpersonal relationships, nursing leadership and patient safety culture and the impact on the efficiency of hospitals. Hospitals are still affected by the increased complexity of the treatments offered and by the diverse knowledge of professionals involved, which has made this assistance model ineffective, expensive and unsustainable over time. A qualitative study of 32 professionals from three large hospitals in Southern Brazil was made. Semi-structured interviews, document analysis and analysis of electronic records were used. All the hospitals had infection rates and an average stay higher than their goal. Lack of interpersonal relationships and physicians failing to commit to organisational objectives were demonstrated. Nursing leadership styles are not definitive factors to improving patient safety and efficiency. The flaws in consolidating interpersonal relationships seem to be related to difficulties in consolidating patient safety culture, which prevented hospitals reaching their efficiency indicators. Professionals who work at the patients' bedside should be involved in the development of strategies, in order to commit them to the organisational objectives. The consolidation of interpersonal relationships of nursing professionals can lead to improvements with medical professionals, with positive impacts on patient safety and efficiency. © 2018 John Wiley & Sons Ltd.
[Modification of nursing practice through reflection: participatory action research].

PubMed

Delgado Hito, P; Sola Prado, A; Mirabete Rodríguez, I; Torrents Ros, R; Blasco Afonso, M; Barrero Pedraza, R; Catalá Gil, N; Mateos Dávila, A; Quinteiro Canedo, M

2001-01-01

Technology and complex techniques are inevitably playing an increasing role in intensive care units. They continue to characterize nursing care and in some cases dehumanize it. The general aim of this study was to stimulate reflection on nursing care. The study was based on the participation of the investigators with the goal of producing changes in nursing practice. Qualitative methodology in the form of participatory action research and the Kemmis and McTaggart method were used. Data were collected through systematic observation, seven group meetings and document analysis. Eight nurses took part in the study. The meetings were recorded and transcribed verbatim into a computer. This process and the meaning of the verbatim transcription (codification/categorization process and document synthesis cards) were analyzed. The results of this study enabled exploration of the change in nursing practice and showed that the reflection in action method stimulates changes in practice. The new way of conceiving nursing action has increased nursing care quality and its humanization since it shows greater respect for the patient, provides families with closer contact and greater support, improves coordination of nursing care acts and increases collaboration among professionals.In conclusion, participatory action research is a valid and appropriate method that nurses can use to modify their daily practice.
The Omaha System as a Structured Instrument for Bridging Nursing Informatics With Public Health Nursing Education: A Feasibility Study.

PubMed

Eardley, Debra L; Krumwiede, Kelly A; Secginli, Selda; Garner, Linda; DeBlieck, Conni; Cosansu, Gulhan; Nahcivan, Nursen O

2018-06-01

Advancements in healthcare systems include adoption of health information technology to ensure healthcare quality. Educators are challenged to determine strategies to integrate health information technology into nursing curricula for building a nursing workforce competent with electronic health records, standardized terminology, evidence-based practice, and evaluation. Nursing informatics, a growing specialty field, comprises health information technology relative to the profession of nursing. It is essential to integrate nursing informatics across nursing curricula to effectively position competent graduates in technology-laden healthcare environments. Nurse scholars developed and evaluated a nursing informatics case study assignment used in undergraduate level public health nursing courses. The assignment included an unfolding scenario followed by electronic health record charting using standardized terminology to guide the nursing process. The assignment was delivered either online or in class. Seventy-two undergraduate students completed the assignment and a posttest. Fifty-one students completed a satisfaction survey. Results indicated that students who completed the assignment online demonstrated a higher level of content mastery than those who completed the assignment in class. Content mastery was based on posttest results, which evaluated students' electronic health record charting for the nursing assessment, evidence-based interventions, and evaluations. This innovative approach may be valuable to educators in response to the National Academy of Sciences recommendations for healthcare education reform.
Impact of Homecare Electronic Health Record on Timeliness of Clinical Documentation, Reimbursement, and Patient Outcomes

PubMed Central

Bowles, K. H.; Adelsberger, M. C.; Chittams, J. L.; Liao, C.

2014-01-01

Summary Background Homecare is an important and effective way of managing chronic illnesses using skilled nursing care in the home. Unlike hospitals and ambulatory settings, clinicians visit patients at home at different times, independent of each other. Twenty-nine percent of 10,000 homecare agencies in the United States have adopted point-of-care EHRs. Yet, relatively little is known about the growing use of homecare EHRs. Objective Researchers compared workflow, financial billing, and patient outcomes before and after implementation to evaluate the impact of a homecare point-of-care EHR. Methods The design was a pre/post observational study embedded in a mixed methods study. The setting was a Philadelphia-based homecare agency with 137 clinicians. Data sources included: (1) clinician EHR documentation completion; (2) EHR usage data; (3) Medicare billing data; (4) an EHR Nurse Satisfaction survey; (5) clinician observations; (6) clinician interviews; and (7) patient outcomes. Results Clinicians were satisfied with documentation timeliness and team communication. Following EHR implementation, 90% of notes were completed within the 1-day compliance interval (n = 56,702) compared with 30% of notes completed within the 7-day compliance interval in the pre-implementation period (n = 14,563; OR 19, p <. 001). Productivity in the number of clinical notes documented post-implementation increased almost 10-fold compared to pre-implementation. Days to Medicare claims fell from 100 days pre-implementation to 30 days post-implementation, while the census rose. EHR implementation impact on patient outcomes was limited to some behavioral outcomes. Discussion Findings from this homecare EHR study indicated clinician EHR use enabled a sustained increase in productivity of note completion, as well as timeliness of documentation and billing for reimbursement with limited impact on improving patient outcomes. As EHR adoption increases to better meet the needs of the growing population of older people with chronic health conditions, these results can inform homecare EHR development and implementation. PMID:25024760
Exploring faculty perceptions towards electronic health records for nursing education.

PubMed

Kowitlawakul, Y; Chan, S W C; Wang, L; Wang, W

2014-12-01

The use of electronic health records in nursing education is rapidly increasing worldwide. The successful implementation of electronic health records for nursing education software program relies on students as well as nursing faculty members. This study aimed to explore the experiences and perceptions of nursing faculty members using electronic health records for nursing education software program, and to identify the influential factors for successful implementation of this technology. This exploratory qualitative study was conducted using in-depth individual interviews at a university in Singapore. Seven faculty members participated in the study. The data were gathered and analysed at the end of the semester in the 2012/2013 academic year. The participants' perceptions of the software program were organized into three main categories: innovation, transition and integration. The participants perceived this technology as innovative, with both values and challenges for the users. In addition, using the new software program was perceived as transitional process. The integration of this technology required time from faculty members and students, as well as support from administrators. The software program had only been implemented for 2-3 months at the time of the interviews. Consequently, the participants might have lacked the necessary skill and competence and confidence to implement it successfully. In addition, the unequal exposure to the software program might have had an impact on participants' perceptions. The findings show that the integration of electronic health records into nursing education curricula is dependent on the faculty members' experiences with the new technology, as well as their perceptions of it. Hence, cultivating a positive attitude towards the use of new technologies is important. Electronic health records are significant applications of health information technology. Health informatics competency should be included as a required competency component in faculty professional development policy and programmes. © 2014 International Council of Nurses.
Audit of pressure area care and documentation.

PubMed

Cockbill-Black, S; Bond, J; Bersée-Mills, A; Warren, K; Hammerton, S; Found, D; Daley, L

1999-12-01

Intensive care patients are at particular risk of pressure damage. Documentation does not always fully reflect practice. Pressure sore identification remains a subjective issue. Nurses do not always complete patient documentation.
Privacy Questions from Practicing School Nurses

ERIC Educational Resources Information Center

Bergren, Martha Dewey

2004-01-01

This Question and Answer (Q&A) article addresses practice issues related to school health records and school nursing documentation that were posed by school nurses in the field. Specifically, the questions addressed concern the following: education records, medication privacy issues, sharing of sensitive health information, privacy of…

CINAHL: an exploratory analysis of the current status of nursing theory construction as reflected by the electronic domain.

PubMed

Riddlesperger, K L; Beard, M; Flowers, D L; Hisley, S M; Pfeifer, K A; Stiller, J J

1996-09-01

Since the 1980s the electronic domain has become the primary method for academic and professional communication of research and information. Papers relating to theory construction in nursing are a frequently occurring phenomenon within the electronic domain. Theory construction provides the underpinning for the advancement of professional nursing, facilitating the conceptualization of nursing actions leading to theory-based practice and research. The purpose of this study was to address the research question, 'What are the similarities and differences among theory construction papers that are accessible electronically in nursing literature today?' The Cumulative Index to Nursing and Allied Health Literature (CINAHL) was accessed to obtain a listing of papers from which an overall description of the type of theory construction papers being published in the nursing literature today could be determined. A literature search was conducted using the description 'theory construction'. Papers were limited to publication years from 1990 onwards. A total of 125 papers were obtained and read by one of the six authors. Using grounded theory, categories emerged by identification of similarities and differences among the papers. The findings are discussed here along with suggestions for further study. A second purpose of this paper was to present both traditional and non-traditional methods of tapping into the electronic domain when searching for assistance with theory construction.
[New model of doctor-nurse communication based on electronic medical advice platform].

PubMed

Cao, Yang; Ding, Aimin; Wang, Yan

2012-01-01

This article introduces a new model of the communication between doctors and nurses, with the aid of the electronic medical advice platform. This model has achieved good results in improving doctor and nurse's co-working efficiency, treating patients safely, preventing medical accidents, reducing medical errors and so on.
Patient Health Goals Elicited During Home Care Admission: A Categorization.

PubMed

Sockolow, Paulina; Radhakrishnan, Kavita; Chou, Edgar Y; Wojciechowicz, Christine

2017-11-01

Home care agencies are initiating "patient health goal elicitation" activities as part of home care admission planning. We categorized elicited goals and identified "clinically informative" goals at a home care agency. We examined patient goals that admitting clinicians documented in the point-of-care electronic health record; conducted content analysis on patient goal data to develop a coding scheme; grouped goal themes into codes; assigned codes to each goal; and identified goals that were in the patient voice. Of the 1,763 patient records, 16% lacked a goal; only 15 goals were in a patient's voice. Nurse and physician experts identified 12 of the 20 codes as clinically important accounting for 82% of goal occurrences. The most frequent goal documented was safety/falls (23%). Training and consistent communication of the intent and operationalization of patient goal elicitation may address the absence of patient voice and the less than universal recording of home care patients' goals.
The transforming effect of handheld computers on nursing practice.

PubMed

Thompson, Brent W

2005-01-01

Handheld computers have the power to transform nursing care. The roots of this power are the shift to decentralization of communication, electronic health records, and nurses' greater need for information at the point of care. This article discusses the effects of handheld resources, calculators, databases, electronic health records, and communication devices on nursing practice. The US government has articulated the necessity of implementing the use of handheld computers in healthcare. Nurse administrators need to encourage and promote the diffusion of this technology, which can reduce costs and improve care.
Design of an Electronic Reminder System for Supporting the Integerity of Nursing Records.

PubMed

Chen, Chien-Min; Hou, I-Ching; Chen, Hsiao-Ping; Weng, Yung-Ching

2016-01-01

The integrity of electronic nursing records (ENRs) stands for the quality of medical records. But patients' conditions are varied (e.g. not every patient had wound or need fall prevention), to achieve the integrity of ENRs depends much on clinical nurses' attention. Our study site, an one 2,300-bed hospital in northern Taiwan, there are a total of 20 ENRs including nursing assessments, nursing care plan, discharge planning etc. implemented in the whole hospital before 2014. It become important to help clinical nurses to decrease their human recall burden to complete these records. Thus, the purpose of this study was to design an ENRs reminder system (NRS) to facilitate nursing recording process. The research team consisted of an ENR engineer, a clinical head nurse and a nursing informatics specialist began to investigate NRS through three phases (e.g. information requirements; design and implementation). In early 2014, a qualitative research method was used to identify NRS information requirements through both groups (e.g. clinical nurses and their head nurses) focus interviews. According to the their requirements, one prototype was created by the nursing informatics specialist. Then the engineer used Microsoft Visual Studio 2012, C#, and Oracle to designed a web-based NRS (Figure 1). Then the integrity reminder system which including a total of twelve electronic nursing records was designed and the preliminary accuracy validation of the system was 100%. NRS could be used to support nursing recording process and prepared for implementing in the following phase.
Adult cardiothoracic transplant nursing: an ISHLT consensus document on the current adult nursing practice in heart and lung transplantation.

PubMed

Coleman, Bernice; Blumenthal, Nancy; Currey, Judy; Dobbels, Fabienne; Velleca, Angela; Grady, Kathleen L; Kugler, Christiane; Murks, Catherine; Ohler, Linda; Sumbi, Christine; Luu, Minh; Dark, John; Kobashigawa, Jon; White-Williams, Connie

2015-02-01

The role of nurses in cardiothoracic transplantation has evolved over the last 25 years. Transplant nurses work in a variety of roles in collaboration with multidisciplinary teams to manage complex pre- and post-transplantation issues. There is lack of clarity and consistency regarding required qualifications to practice transplant nursing, delineation of roles and adequate levels of staffing. A consensus conference with workgroup sessions, consisting of 77 nurse participants with clinical experience in cardiothoracic transplantation, was arranged. This was followed by subsequent discussion with the ISHLT Nursing, Health Science and Allied Health Council. Evidence and expert opinions regarding key issues were reviewed. A modified nominal group technique was used to reach consensus. Consensus reached included: (1) a minimum of 2 years nursing experience is required for transplant coordinators, nurse managers or advanced practice nurses; (2) a baccalaureate in nursing is the minimum education level required for a transplant coordinator; (3) transplant coordinator-specific certification is recommended; (4) nurse practitioners, clinical nurse specialists and nurse managers should hold at least a master's degree; and (5) strategies to retain transplant nurses include engaging donor call teams, mentoring programs, having flexible hours and offering career advancement support. Future research should focus on the relationships between staffing levels, nurse education and patient outcomes. Delineation of roles and guidelines for education, certification, licensure and staffing levels of transplant nurses are needed to support all nurses working at the fullest extent of their education and licensure. This consensus document provides such recommendations and draws attention to areas for future research. Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.
School nurses in New Jersey: a quantitative inquiry on roles and responsibilities.

PubMed

Krause-Parello, Cheryl A; Samms, Kimika

2010-07-01

This study examined types of chronic diseases present and nursing procedures administered in school, health promotion and disease prevention efforts, collaborative efforts, perception of school nursing activities, documentation media of school nursing activities, and student academic outcomes. A nonexperimental research design was employed. The sample (N= 63) was practicing school nurses in New Jersey public schools. The increased numbers of students with chronic illnesses in mainstream classrooms have increased the roles and responsibilities of school nurses. School nurses can use the findings as a framework to articulate their roles and responsibilities.
Practice versus knowledge when it comes to pressure ulcer prevention.

PubMed

Provo, B; Piacentine, L; Dean-Baar, S

1997-09-01

This study was completed to determine the current knowledge and documentation patterns of nursing staff in the prevention of pressure ulcers and to identify the prevalence of pressure ulcers. This pre-post intervention study was carried out in three phases. In phase 1, 67 nursing staff members completed a modified version of Bostrom's Patient Skin Integrity Survey. A Braden Scale score, the presence of actual skin breakdown, and the presence of nursing documentation were collected for each patient (n = 43). Phase II consisted of a 20-minute educational session to all staff. In phase III, 51 nursing staff completed a second questionnaire similar to that completed in phase I. Patient data (n = 49) were again collected using the same procedure as phase I. Twenty-seven staff members completed questionnaires in both phase I and phase III of the study. No statistically significant differences were found in the knowledge of the staff before or after the educational session. The number of patients with a documented plan of care showed a statistically significant difference from phase I to phase III. The number of patients with pressure ulcers or at risk for pressure ulcer development (determined by a Braden Scale score of 16 or less) did not differ statistically from phase I to phase III. Knowledge about pressure ulcers in this sample of staff nurses was for the most part current and consistent with the recommendations in the Agency for Health Care Policy and Research guideline. Documentation of pressure ulcer prevention and treatment improved after the educational session. Although a significant change was noted in documentation, it is unclear whether it reflected an actual change in practice.
Horizontal violence in nursing: the continuing silence.

PubMed

McCall, E

1996-04-01

Horizontal violence continues to affect the lives of many nurses today. This paper will present the findings of research which utilised a feminist methodology to document the stories of nurses illustrating their experiences of horizontal violence in their workplaces, and their perceptions of the reasons for the continued oppression of nurses, despite almost fifteen years of academic writing on the subject.
Critical discourse analysis of social justice in nursing's foundational documents.

PubMed

Valderama-Wallace, Claire P

2017-07-01

Social inequities threaten the health of the global population. A superficial acknowledgement of social justice by nursing's foundational documents may limit the degree to which nurses view injustice as relevant to nursing practice and education. The purpose was to examine conceptualizations of social justice and connections to broader contexts in the most recent editions. Critical discourse analysis examines and uncovers dynamics related to power, language, and inequality within the American Nurses Association's Code of Ethics, Scope and Standards of Practice, and Social Policy Statement. This analysis found ongoing inconsistencies in conceptualizations of social justice. Although the Code of Ethics integrates concepts related to social justice far more than the other two, tension between professionalism and social change emerges. The discourse of professionalism renders interrelated cultural, social, economic, historical, and political contexts nearly invisible. Greater consistency would provide a clearer path for nurses to mobilize and engage in the courageous work necessary to address social injustice. These findings also call for an examination of how nurses can critique and use the power and privilege of professionalism to amplify the connection between social institutions and health equity in nursing education, practice, and policy development. © 2017 Wiley Periodicals, Inc.
Certified Nurses' Aide Job-Related Curriculum.

ERIC Educational Resources Information Center

Massachusetts Career Development Inst., Springfield.

This document, which is designed for students preparing to become a certified nurses' aide, contains instructional text and learning activities organized in nine sections. The following topics are covered: the role of the certified nurse's aide (job duties, personal health, professionalism, code of ethics); infection control (the infection…
Using the Electronic Health Record in Nursing Research: Challenges and Opportunities.

PubMed

Samuels, Joanne G; McGrath, Robert J; Fetzer, Susan J; Mittal, Prashant; Bourgoine, Derek

2015-10-01

Changes in the patient record from the paper to the electronic health record format present challenges and opportunities for the nurse researcher. Current use of data from the electronic health record is in a state of flux. Novel data analytic techniques and massive data sets provide new opportunities for nursing science. Realization of a strong electronic data output future relies on meeting challenges of system use and operability, data presentation, and privacy. Nurse researchers need to rethink aspects of proposal development. Joining ongoing national efforts aimed at creating usable data output is encouraged as a means to affect system design. Working to address challenges and embrace opportunities will help grow the science in a way that answers important patient care questions. © The Author(s) 2015.
Examining the Relationship Between Nursing Informatics Competency and the Quality of Information Processing.

PubMed

Al-Hawamdih, Sajidah; Ahmad, Muayyad M

2018-03-01

The purpose of this study was to examine nursing informatics competency and the quality of information processing among nurses in Jordan. The study was conducted in a large hospital with 380 registered nurses. The hospital introduced the electronic health record in 2010. The measures used in this study were personal and job characteristics, self-efficacy, Self-Assessment Nursing Informatics Competencies, and Health Information System Monitoring Questionnaire. The convenience sample consisted of 99 nurses who used the electronic health record for at least 3 months. The analysis showed that nine predictors explained 22% of the variance in the quality of information processing, whereas the statistically significant predictors were nursing informatics competency, clinical specialty, and years of nursing experience. There is a need for policies that advocate for every nurse to be educated in nursing informatics and the quality of information processing.
Mapping the literature of pediatric nursing: update and implications for library services

PubMed Central

Watwood, Carol L.

2016-01-01

Objective The purpose of this study was to identify core journals and other types of literature cited in four major pediatric nursing journals and to characterize coverage of these resources in major bibliographic databases. The study was part of the “Mapping the Literature of Nursing Project” of the Medical Library Association's Nursing and Allied Health Resource Section. It updates a similar analysis published in 2006 and determines whether citation patterns have changed over time. Methods Cited references from articles published in 4 pediatric nursing journals between 2011 and 2013 were collected. Cited journal titles were ranked according to number of times cited and analyzed according to Bradford's Law of Scattering and the 80/20 rule to identify the most frequently cited journals. Five databases were surveyed to assess the coverage of the most-often-cited journals. The most frequently cited non-journal sources were also identified. Results Journals were the most frequently cited sources, followed by books, government documents, Internet resources, and miscellaneous resources. Most cited sources were cited within ten years of their publication, which was particularly true for government documents and Internet resources. Scopus had complete coverage of the most frequently cited journals, whereas PubMed had nearly complete coverage. Conclusions Compared with the 2006 study, the list of top-cited journals referenced by pediatric nursing researchers has remained relatively stable, but the number of cited journal titles has increased. Book citations have declined, and Internet and government document references have increased. These findings suggest that librarians should retain subscriptions to frequently cited journal titles, provide efficient document delivery of articles from infrequently used journals, de-emphasize but not eliminate books, and connect patrons with useful open-access Internet resources. PMID:27822148
The adverse drug reaction reporting assignment for specialist oncology nurses: a preliminary evaluation of quality, relevance and educational value in a prospective cohort study.

PubMed

Schutte, Tim; van Eekeren, Rike; Richir, Milan; van Staveren, Jojanneke; van Puijenbroek, Eugène; Tichelaar, Jelle; van Agtmael, Michiel

2018-01-01

In a new prescribing qualification course for specialist oncology nurses, we thought that it is important to emphasize pharmacovigilance and adverse drug reaction (ADR) reporting. We aimed to develop and evaluate an ADR reporting assignment for specialist oncology nurses. The quality of report documentation was assessed with the "Clinical Documentation tool to assess Individual Case Safety Reports" (ClinDoc). The relevance of the reports was evaluated in terms of ADR seriousness, the listing for additional monitoring of the drug by European Medicines Agency (EMA), and lack of labelling information about the ADR. Nurses' opinions of the assignment were evaluated using an E-survey. Thirty-three ADRs were reported, 32 (97%) of which were well documented according to ClinDoc. Thirteen ADRs (39%) were "serious" according to CIOMS criteria. In five cases (15%), the suspect drugs were listed for additional monitoring by EMA and in seven cases (21%), the ADR was not mentioned in the Summary of Product Characteristics. Twenty-five (78.1%) of the 32 enrolled nurses completed the E-survey. Most were > 45 years of age (68%), female (92%) and had extensive clinical experience (6-33 years). All agreed or completely agreed that the reporting assignment was useful, that it fitted in daily practice and that it increased their attention for medication/patient safety. A large majority (84.0%) agreed the assignment changed how they dealt with ADRs. Specialist oncology nurses are capable of reporting ADRs, and they considered the assignment useful. The assignment yielded valuable, relevant, and well-documented ADR reports for pharmacovigilance practice.
Mapping the literature of pediatric nursing: update and implications for library services.

PubMed

Watwood, Carol L

2016-10-01

The purpose of this study was to identify core journals and other types of literature cited in four major pediatric nursing journals and to characterize coverage of these resources in major bibliographic databases. The study was part of the "Mapping the Literature of Nursing Project" of the Medical Library Association's Nursing and Allied Health Resource Section. It updates a similar analysis published in 2006 and determines whether citation patterns have changed over time. Cited references from articles published in 4 pediatric nursing journals between 2011 and 2013 were collected. Cited journal titles were ranked according to number of times cited and analyzed according to Bradford's Law of Scattering and the 80/20 rule to identify the most frequently cited journals. Five databases were surveyed to assess the coverage of the most-often-cited journals. The most frequently cited non-journal sources were also identified. Journals were the most frequently cited sources, followed by books, government documents, Internet resources, and miscellaneous resources. Most cited sources were cited within ten years of their publication, which was particularly true for government documents and Internet resources. Scopus had complete coverage of the most frequently cited journals, whereas PubMed had nearly complete coverage. Compared with the 2006 study, the list of top-cited journals referenced by pediatric nursing researchers has remained relatively stable, but the number of cited journal titles has increased. Book citations have declined, and Internet and government document references have increased. These findings suggest that librarians should retain subscriptions to frequently cited journal titles, provide efficient document delivery of articles from infrequently used journals, de-emphasize but not eliminate books, and connect patrons with useful open-access Internet resources.
Differing perspectives on parent access to their child's electronic medical record during neonatal intensive care hospitalization: a pilot study.

PubMed

Chung, Rebecca K; Kim, Una Olivia; Basir, Mir Abdul

2018-04-01

To improve informed medical decision-making, principles for family-centered neonatal care recommend that parents have access to their child's medical record on an ongoing basis during neonatal intensive unit care (NICU) hospitalization. Currently, many NICUs do not allow independent parent access to their child's electronic medical record (EMR) during hospitalization. We undertook a cross-sectional survey pilot study of medical professionals and parents to explore opinions regarding this practice. Inclusion criteria: 18-years old, English-literate, legal guardian of patients admitted to the NICU for 14 days. NICU medical professionals included physicians, nurse practitioners, nurses, and respiratory therapists. Medical professionals believed parent access would make their work more difficult, increase time documenting and updating families, making them more liable to litigation and hesitant to chart sensitive information. However, parents felt that they lacked control over their child's care and desired direct access to the EMR. Parents believed this would improve accuracy of their child's medical chart, and increase advocacy and understanding of their child's illness. NICU parents and medical professionals have differing perspectives on independent parental access to their child's EMR. More research is needed to explore the potential of independent parental EMR access to further improve family-centered neonatal care.
Measuring Nursing Value from the Electronic Health Record.

PubMed

Welton, John M; Harper, Ellen M

2016-01-01

We report the findings of a big data nursing value expert group made up of 14 members of the nursing informatics, leadership, academic and research communities within the United States tasked with 1. Defining nursing value, 2. Developing a common data model and metrics for nursing care value, and 3. Developing nursing business intelligence tools using the nursing value data set. This work is a component of the Big Data and Nursing Knowledge Development conference series sponsored by the University Of Minnesota School Of Nursing. The panel met by conference calls for fourteen 1.5 hour sessions for a total of 21 total hours of interaction from August 2014 through May 2015. Primary deliverables from the bit data expert group were: development and publication of definitions and metrics for nursing value; construction of a common data model to extract key data from electronic health records; and measures of nursing costs and finance to provide a basis for developing nursing business intelligence and analysis systems.
Critical care providers refer to information tools less during communication tasks after a critical care clinical information system introduction.

PubMed

Ballermann, Mark; Shaw, Nicola T; Mayes, Damon C; Gibney, R T Noel

2011-01-01

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.
Electronic evaluation for freshmen nursing students: Advantages and disadvantages.

PubMed

González, Fidelina; Ramírez, Julia

2006-01-01

An electronic evaluation was applied to freshmen nursing students who are taking Biology and Nursing Introduction. Questions and alternatives were randomly ordered. Evaluation took place simultaneously for all the students. Students preferred multiple choice questions with no more than two lines of headings and requested about three minutes for test timing. Test scores from electronic evaluation were higher than the ones obtained with written evaluation. This result implies that information technology can be used for evaluating large group of students.

[Development and integration of the Oncological Documentation System ODS].

PubMed

Raab, G; van Den Bergh, M

2001-08-01

To simplify clinical routine and to improve medical quality without exceeding the existing resources. Intensifying communication and cooperation between all institutions of patients' health care. The huge amount of documentation work of physicians can no longer be done without modern tools of paperless data processing. The development of ODS was a tight cooperation between physician and technician which resulted in a mutual understanding and led to a high level of user convenience. - At present all cases of gynecology, especially gynecologic oncology can be documented and processed by ODS. Users easily will adopt the system as data entry within different program areas follows the same rules. In addition users can choose between an individual input of data and assistants guiding them through highly specific areas of documentation. ODS is a modern, modular structured and very fast multiuser database environment for in- and outpatient documentation. It automatically generates a lot of reports for clinical day to day business. Statistical routines will help the user reflecting his work and its quality. Documentation of clinical trials according to the GCP guidelines can be done by ODS using the internet or offline datasharing. As ODS is the synthesis of a computer based patient administration system and an oncological documentation database, it represents the basis for the construction of the electronical patient chart as well as the digital documentation of clinical trials. The introduction of this new technology to physicians and nurses has to be done slowly and carefully, in order to increase motivation and to improve the results.
Strategies Nurse Managers Used to Offset Challenges during Electronic Medical Records Implementation: A Case Study

ERIC Educational Resources Information Center

Easterling, Latasha

2015-01-01

The purpose of this qualitative, descriptive case study was to discover successful approaches used, by nurse managers, to reduce barriers during the implementation of electronic medical record system in one hospital. Fourteen nurse managers were interviewed from an academic health science center in Mississippi. A pilot study was conducted to…
A tool to measure nurse efficiency and value.

PubMed

Landry, M T; Landry, H T; Hebert, W

2001-07-01

Home care nurses who have multiple roles can increase their value by validating their contributions and work efficiency. This article presents a method for tracking nurse efficiency for those who are paid on an hourly basis, and provides a mechanism to document their contributions to the home care agency.
AACC Nursing Survey.

ERIC Educational Resources Information Center

American Association of Community Colleges, Washington, DC.

This document, presented in the form of PowerPoint print outs, indicates a total of 420 (nearly 60%) associate degree nursing (ADN) programs responded to a survey conducted by the American Association of Community Colleges' (AACC) Nursing and Allied Health Initiative (NAHI) for 2003. The sample is representative based on urbanicity and region.…
Registered Nurse (Associate Degree).

ERIC Educational Resources Information Center

Ohio State Univ., Columbus. Center on Education and Training for Employment.

This document, which is designed for use in developing a tech prep competency profile for the occupation of registered nurse (with an associate degree), lists technical competencies and competency builders for 19 units pertinent to the health technologies cluster in general and 5 units specific to the occupation of registered nurse. The following…
The burden of bureaucracy.

PubMed

Lomas, Clare

Paperwork is commonly cited as one of the worst features of nurses' jobs. While some documentation is essential, much form-filling could be done more efficiently or delegated to non-nursing staff. Some organisations are revolutionising how nurses handle bureaucratic tasks, releasing them to improve their practice and spend more time at the bedside.
Enhancing Student Learning: RN CAT Advisement Program.

ERIC Educational Resources Information Center

Donaldson, Susan K.

This document describes a community college advisement program that was implemented to improve the student pass rate for the national nursing licensure examination. The nursing faculty at Manatee Community College (Florida) recently instituted an advisement system during the final semester of the two-year nursing program. First, students were…
Quality indicators for initial licensure and discipline in nursing laws in South Korea and North Carolina.

PubMed

Kim, K K; Kjervik, D K; Foster, B

2014-03-01

The Korean regulatory framework of nursing licensure reflects that of the USA, but its content differs in some of the powers related to quality assurance. This article compares regulatory quality indicators and describes core standards in nursing regulations that are related to both initial licensure and discipline for three groups: the National Council of State Boards of Nursing, the North Carolina and the South of Korea. A descriptive, comparative law design is used to examine the differences and similarities in the quality indicators and core standards found in three documents: the National Council of State Boards of Nursing Model Act, the North Carolina Nursing Practice Act and the Korean Medical Service Act for registered nurses. The findings indicate that ten quality indicators and two standards appear in study objects. Although most of the quality indicators are common to all documents, some differences are found in terms of the scope of criminal background checks and the range of grounds for disciplinary action. These findings cannot be generalized in the USA because although the North Carolina nursing act was selected as an example of US nursing laws, nursing laws differ somewhat across states. This comparative study shows a clear opportunity to develop indicators that acknowledge the important areas of competence and good moral character and how they can improve patient safety in Korea. This study provides recommendations for Korean nursing legislative redesign and pointers for other jurisdictions to consider. © 2013 International Council of Nurses.
Pain Management Practices in a Pediatric Emergency Room (PAMPER) Study: interventions with nurses.

PubMed

Le May, Sylvie; Johnston, C Celeste; Choinière, Manon; Fortin, Christophe; Kudirka, Denise; Murray, Louise; Chalut, Dominic

2009-08-01

Children's pain in emergency departments (EDs) is poorly managed by nurses, despite evidence that pain is one of the most commonly presenting complaints of children attending the ED. Our objectives were 2-fold: to verify if tailored educational interventions with emergency pediatric nurses would improve nurses' knowledge of pain management and nurses' pain management practices (documentation of pain, administration of analgesics, nonpharmacological interventions). This intervention study with a pre-post design (baseline, immediately after the intervention [T-2], and 6 months after intervention [T-3]) used a sample of nurses (N = 50) and retrospective chart reviews of children (N = 450; 150 charts reviewed each at baseline, T-2, and T-3) who presented themselves in the ED with a diagnosis known to generate moderate to severe pain (burns, acute abdominal pain, deep lacerations, fracture, sprain). Principal outcomes: nurses' knowledge of pain management (Pediatric Nurses Knowledge and Attitudes Survey [PNKAS] on pain) and nurses' clinical practices of pain management (Pain Management Experience Evaluation [PMEE]). Response rate on the PNKAS was 84% (42/50) at baseline and 50% (21/42) at T-2. Mean scores on PNKAS were 28.2 (SD, 4.9; max, 42.0) at baseline and 31.0 (SD, 4.6) at T-2. Results from paired t test showed significant difference between both times (t = -3.129, P = 0.005). Nurses who participated in the capsules improved their documentation of pain from baseline (59.3%) to T-2 (80.8%; chi = 12.993, P < 0.001) as well as from baseline (59.3%) to T-3 (89.1%; chi = 29.436, P < 0.001). In addition, nurses increased their nonpharmacological interventions from baseline (16.7%) to T-3 (31.9%; chi = 8.623, P = 0.003). Finally, we obtained significant differences on pain documentation between the group of nurses who attended at least 1 capsule and the group of nurses who did not attend any capsule at both times (T-2 and T-3; chi = 20.424, P < 0.001; chi = 33.333, P < 0.001, respectively). The interventions contributed to the improvement of the nurses' knowledge of pain management and some of the practices over time. We believe that an intervention tailored to nurses' needs and schedule has more impact than just passive diffusion of educational content.
Implementation of a closed-loop reporting system for critical values and clinical communication in compliance with goals of the joint commission.

PubMed

Parl, Fritz F; O'Leary, Mandy F; Kaiser, Allen B; Paulett, John M; Statnikova, Kristina; Shultz, Edward K

2010-03-01

Current practices of reporting critical laboratory values make it challenging to measure and assess the timeliness of receipt by the treating physician as required by The Joint Commission's 2008 National Patient Safety Goals. A multidisciplinary team of laboratorians, clinicians, and information technology experts developed an electronic ALERTS system that reports critical values via the laboratory and hospital information systems to alphanumeric pagers of clinicians and ensures failsafe notification, instant documentation, automatic tracking, escalation, and reporting of critical value alerts. A method for automated acknowledgment of message receipt was incorporated into the system design. The ALERTS system has been applied to inpatients and eliminated approximately 9000 phone calls a year made by medical technologists. Although a small number of phone calls were still made as a result of pages not acknowledged by clinicians within 10 min, they were made by telephone operators, who either contacted the same physician who was initially paged by the automated system or identified and contacted alternate physicians or the patient's nurse. Overall, documentation of physician acknowledgment of receipt in the electronic medical record increased to 95% of critical values over 9 months, while the median time decreased to <3 min. We improved laboratory efficiency and physician communication by developing an electronic system for reporting of critical values that is in compliance with The Joint Commission's goals.
Government chief nursing officers' perceptions of barriers to using research on staffing.

PubMed

Baernholdt, M; Lang, N M

2007-03-01

Current global healthcare problems include nursing shortages contributing to low nurse staffing. Low nurse staffing is associated with poor patient and nurse outcomes, but research utilization using these findings especially at the policy level remains slow. To assess high-ranking government nurses' perceptions of barriers to using research on nurse staffing. An electronic information message about the impact of nurse staffing was presented to government chief nursing officers (CNOs) from 110 countries. The CNOs' perceptions of local barriers to utilizing these research findings were then assessed in an electronic survey. The four factors that influence the first two stages of Rogers's five-stage model of diffusion were examined. The factors, characteristics of the adopter, organization, innovation and communication, were measured using an adapted version of the BARRIERS scale. Barriers were present in all four characteristics. The top barrier was lack of reports and studies in one place. Other barriers were lack of cooperation within the organization and lack of awareness of the research findings. Differences according to Gross National Income were also noted. The CNOs and other health policy advisors can use the findings in planning for adequate nurse staffing. Development of electronic newsletters with summaries of pertinent research for CNOs and other policy advisors is needed. Future studies on nurse staffing are warranted. They should focus on other settings and how best to share research findings with policymakers.
[Integration of the nursing process in the electronic health record in an university hospital].

PubMed

Guadarrama-Ortega, D; Delgado-Sánchez, P; Martínez-Piedrola, M; López-Poves, E M; Acevedo-García, M; Noguera-Quijada, C; Camacho-Pastor, J L

To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation. Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed. In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained. In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report. Copyright © 2017 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.
Invasive blood pressure recording comparing nursing charts with an electronic monitor: a technical report.

PubMed

Wong, Benjamin T; Glassford, Neil J; Bion, Victoria; Chai, Syn Y; Bellomo, Rinaldo

2014-03-01

Blood pressure management (assessed using nursing charts) in the early phase of septic shock may have an effect on renal outcomes. Assessment of mean arterial pressure (MAP) values as recorded on nursing charts may be inaccurate. To determine the difference between hourly blood pressure values as recorded on the nursing charts and hourly average blood pressure values over the corresponding period obtained electronically from the bedside monitor. We studied 20 patients with shock requiring vasopressor support and invasive blood pressure monitoring. Hourly blood pressure measurements were recorded on the nursing charts over a 12-hour period. Blood pressure values recorded every 10 minutes were downloaded from electronic patient monitors over the corresponding period. The hourly average of the 10-minute blood pressure values was compared with the measurements recorded on the nursing charts. We assessed 240 chart readings and 1440 electronic recordings. Average chart MAP was 72.54 mmHg and average electronic monitor MAP was 71.54 mmHg. MAP data from the two sources showed a strong correlation (ρ0.71, P < 0.005). Bland-Altman assessment revealed acceptable agreement, with a mean bias of 1mmHg and 95% limits of agreement of -11.76 mmHg and 13.76 mmHg. Using average data over 6 hours, 95% limits of agreement narrowed to -6.79mmHg and 8.79mmHg. With multiple measurements over time, mean blood pressure as recorded on nursing charts reasonably approximates mean blood pressure recorded on the monitor.
A usability evaluation exploring the design of American Nurses Association state web sites.

PubMed

Alexander, Gregory L; Wakefield, Bonnie J; Anbari, Allison B; Lyons, Vanessa; Prentice, Donna; Shepherd, Marilyn; Strecker, E Bradley; Weston, Marla J

2014-08-01

National leaders are calling for opportunities to facilitate the Future of Nursing. Opportunities can be encouraged through state nurses association Web sites, which are part of the American Nurses Association, that are well designed, with appropriate content, and in a language professional nurses understand. The American Nurses Association and constituent state nurses associations provide information about nursing practice, ethics, credentialing, and health on Web sites. We conducted usability evaluations to determine compliance with heuristic and ethical principles for Web site design. We purposefully sampled 27 nursing association Web sites and used 68 heuristic and ethical criteria to perform systematic usability assessments of nurse association Web sites. Web site analysis included seven double experts who were all RNs trained in usability analysis. The extent to which heuristic and ethical criteria were met ranged widely from one state that met 0% of the criteria for "help and documentation" to states that met greater than 92% of criteria for "visibility of system status" and "aesthetic and minimalist design." Suggested improvements are simple yet make an impact on a first-time visitor's impression of the Web site. For example, adding internal navigation and tracking features and providing more details about the application process through help and frequently asked question documentation would facilitate better use. Improved usability will improve effectiveness, efficiency, and consumer satisfaction with these Web sites.
Interventions of the nursing diagnosis „Acute Pain“ – Evaluation of patients' experiences after total hip arthroplasty compared with the nursing record by using Q-DIO-Pain: a mixed methods study

PubMed

Zanon, David C; Gralher, Dieter; Müller-Staub, Maria

2017-01-01

Background: Pain affects patients' rehabilitation after hip replacement surgery. Aim: The study aim was to compare patients' responses, on their received pain relieving nursing interventions after hip replacement surgery, with the documented interventions in their nursing records. Method: A mixed methods design was applied. In order to evaluate quantitative data the instrument „Quality of Diagnoses, Interventions and Outcomes“ (Q-DIO) was further developed to measure pain interventions in nursing records (Q-DIO-Pain). Patients (n = 37) answered a survey on the third postoperative day. The patients' survey findings were then compared with the Q-DIO-Pain results and cross-validated by qualitative interviews. Results: The most reported pain level was „no pain“ (NRS 0 – 10 Points). However, 17 – 50 % of patients reported pain levels of three or higher and 11 – 22 % of five or higher in situations of motion / ambulation. A significant match between patients' findings and Q-DIO-Pain results was found for the intervention „helping to adapt medications“ (n = 32, ICC = 0.111, p = 0.042, CI 95 % 2-sided). Otherwise no significant matches were found. Interviews with patients and nurses confirmed that far more pain-relieving interventions affecting „Acute Pain“ were carried out, than were documented. Conclusions: Based on the results, pain assessments and effective pain-relieving interventions, especially before or after motion / ambulation should be improved and documented. It is recommended to implement a nursing standard for pain control.
The Impact of Electronic Knowledge-Based Nursing Content and Decision-Support on Nursing-Sensitive Patient Outcomes

DTIC Science & Technology

2015-02-01

with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ADDRESS. 1...the impact of an electronic innovation must include a description of the sociotechnical context as well as the process and outcome metrics for...dissemination, will have a positive effect on nursing knowledge, use of evidence-based practices, and the achievement of nurse-sensitive patient outcomes
Impact of revisions to the F-Tag 309 surveyors' interpretive guidelines on pain management among nursing home residents.

PubMed

Lapane, Kate L; Quilliam, Brian J; Chow, Wing; Kim, Myoung S

2012-05-01

On 31 March 2009, the US Centers for Medicare & Medicaid Services (CMS) provided revised guidance for meeting compliance in the evaluation and management of pain in nursing home residents, known as F-Tag 309. The aim of the study was to estimate the extent to which implementation of revisions to the surveyors' interpretive guidelines for F-Tag 309 improved recognition and management of pain among nursing home residents. The impact of the revisions to guidance on F-Tag 309 on pain in nursing home residents was investigated. The study was quasi-experimental in design and included 174 for-profit nursing homes in 19 US states. Nursing home residents with ≥2 Minimum Data Set (MDS) assessments between 1 January 2007 and 30 March 2009 (before the revisions to the guidelines; n = 8449) and between 31 March 2009 and 31 December 2009 (after the revisions; n = 1400) were included. The MDS assessments provided information on pain, analgesic use and cognitive, functional and emotional status. Separate logistic regression models that adjusted for clustering effects of residents residing in nursing homes provided estimates of the relationship between the implementation of the revisions to F-Tag 309 and the prevalence of pain and its management. Pain was more likely to be documented in the period after the revisions were implemented. The odds of pain being documented on at least one of two consecutive MDS assessments increased after the revisions to the guidelines were implemented (adjusted odds ratio [OR] 1.15; 95% confidence interval [CI] 1.01, 1.31). Increases in scheduled analgesic prescription were observed in the post-revision era (adjusted OR 1.38; 95% CI 1.21,1.57). The implementation of revisions to the surveyors' interpretive guidelines for F-Tag 309 improved recognition and management of pain as well as analgesic use in nursing home residents with documented non-cancer pain. Use of directed language as part of the surveyors' interpretive guidelines may be a viable approach to stimulating improvements in pain documentation and management.
Applied nursing informatics research - state-of-the-art methodologies using electronic health record data.

PubMed

Park, Jung In; Pruinelli, Lisiane; Westra, Bonnie L; Delaney, Connie W

2014-01-01

With the pervasive implementation of electronic health records (EHR), new opportunities arise for nursing research through use of EHR data. Increasingly, comparative effectiveness research within and across health systems is conducted to identify the impact of nursing for improving health, health care, and lowering costs of care. Use of EHR data for this type of research requires use of national and internationally recognized nursing terminologies to normalize data. Research methods are evolving as large data sets become available through EHRs. Little is known about the types of research and analytic methods for applied to nursing research using EHR data normalized with nursing terminologies. The purpose of this paper is to report on a subset of a systematic review of peer reviewed studies related to applied nursing informatics research involving EHR data using standardized nursing terminologies.
Nurse Educators' Consensus Opinion on Using an Academic Electronic Health Record: A Delphi Study

ERIC Educational Resources Information Center

Hanson, Darlene S.

2013-01-01

The purpose of this study was to determine the opinions of nurse educators in the state of North Dakota (ND) who were using the academic Electronic Health Record (EHR) known as SimChart. In this dissertation research study, factors that either hindered or facilitated the introduction of SimChart in nursing programs in ND were examined.…
Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies.

PubMed

Ivory, Catherine H

2016-07-01

The use of standard terminologies is an essential component for using data to inform practice and conduct research; perinatal nursing data standardization is needed. This study explored whether 76 distinct process elements important for perinatal nursing were present in four American Nurses Association-recognized standard terminologies. The 76 process elements were taken from a valid paper-based perinatal nursing process measurement tool. Using terminology-supported browsers, the elements were manually mapped to the selected terminologies by the researcher. A five-member expert panel validated 100% of the mapping findings. The majority of the process elements (n = 63, 83%) were present in SNOMED-CT, 28% (n = 21) in LOINC, 34% (n = 26) in ICNP, and 15% (n = 11) in CCC. SNOMED-CT and LOINC are terminologies currently recommended for use to facilitate interoperability in the capture of assessment and problem data in certified electronic medical records. Study results suggest that SNOMED-CT and LOINC contain perinatal nursing process elements and are useful standard terminologies to support perinatal nursing practice in electronic health records. Terminology mapping is the first step toward incorporating traditional paper-based tools into electronic systems.

Evaluation of Efficiency Improvement in Vital Documentation Using RFID Devices.

PubMed

Kimura, Eizen; Nakai, Miho; Ishihara, Ken

2016-01-01

We introduced medical devices with RFID tags and the terminal with RFID reader in our hospital. Time study was conducted in two phases. In phase I, nurses round as usual, and in phase II, the nurse round the ward with a terminal installed on a cart. This study concluded that RFID system shortens the time for vital sign documentation. However, deploying the terminals at every bedside did not contribute the more time reduction.
National nursing strategies in seven countries of the Region of the Americas: issues and impact.

PubMed

Shasanmi, Rebecca O; Kim, Esther M; Cassiani, Silvia Helena De Bortoli

2015-07-01

To identify and examine the current national nursing strategies and policy impact of workforce development regarding human resources for health in seven selected countries in the Region of the Americas: Argentina, Canada, Costa Rica, Jamaica, Mexico, Peru, and the United States. A review of available literature was conducted to identify publicly-available documents that describe the general backdrop of nursing human resources in these seven countries. A keyword search of PubMed was supplemented by searches of websites maintained by Ministries of Health and nursing organizations. Inclusion criteria limited documents to those published in 2008-2013 that discussed or assessed situational issues and/or progress surrounding the nursing workforce. Nursing human resources for health is progressing. Canada, Mexico, and the United States have stronger nursing leadership in place and multisectoral policies in workforce development. Jamaica shows efforts among the Caribbean countries to promote collaborative practices in research. The three selected countries in Central and South America championed networks to revive nursing education. Yet, overall challenges limit the opportunities to impact public health. The national nursing strategies prioritized multisectoral collaboration, professional competencies, and standardized educational systems, with some countries underscoring the need to align policies with efforts to promote nursing leadership, and others, focusing on expanding the scope of practice to improve health care delivery. While each country wrestles with its specific context, all require proper leadership, multisectoral collaboration, and appropriate resources to educate, train, and empower nurses to be at the forefront.
Knowledge, Practices, and Perceived Barriers Regarding Cancer Pain Management Among Physicians and Nurses In Korea: A Nationwide Multicenter Survey

PubMed Central

Jho, Hyun Jung; Kim, Yeol; Kong, Kyung Ae; Kim, Dae Hyun; Choi, Jin Young; Nam, Eun Jeong; Choi, Jin Young; Koh, Sujin; Hwang, Kwan Ok; Baek, Sun Kyung; Park, Eun Jung

2014-01-01

Purpose Medical professionals’ practices and knowledge regarding cancer pain management have often been cited as inadequate. This study aimed to evaluate knowledge, practices and perceived barriers regarding cancer pain management among physicians and nurses in Korea. Methods A nationwide questionnaire survey was administered to physicians and nurses involved in the care of cancer patients. Questionnaire items covered pain assessment and documentation practices, knowledge regarding cancer pain management, the perceived barriers to cancer pain control, and processes perceived as the major causes of delay in opioid administration. Results A total of 333 questionnaires (149 physicians and 284 nurses) were analyzed. Nurses performed pain assessment and documentation more regularly than physicians did. Although physicians had better knowledge of pain management than did nurses, both groups lacked knowledge regarding the side effects and pharmacology of opioids. Physicians working in the palliative care ward and nurses who had received pain management education obtained higher scores on knowledge. Physicians perceived patients’ reluctance to take opioids as a barrier to pain control, more so than did nurses, while nurses perceived patients’ tendency to under-report of pain as a barrier, more so than did physicians. Physicians and nurses held different perceptions regarding major cause of delay during opioid administration. Conclusions There were differences between physicians and nurses in knowledge and practices for cancer pain management. An effective educational strategy for cancer pain management is needed in order to improve medical professionals’ knowledge and clinical practices. PMID:25144641
Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC).

PubMed

Rabelo-Silva, Eneida Rejane; Dantas Cavalcanti, Ana Carla; Ramos Goulart Caldas, Maria Cristina; Lucena, Amália de Fátima; Almeida, Miriam de Abreu; Linch, Graciele Fernanda da Costa; da Silva, Marcos Barragan; Müller-Staub, Maria

2017-02-01

To assess the quality of the advanced nursing process in nursing documentation in two hospitals. Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. Cross-sectional study. A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2. Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2. The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies. © 2016 John Wiley & Sons Ltd.
Using education and support strategies to improve the way nurses assess regular and transient pain - A quality improvement study of three hospitals.

PubMed

Peterson, Anna; Carlfjord, Siw; Schaller, Anne; Gerdle, Björn; Larsson, Britt

2017-07-01

Systematic and regular pain assessment has been shown to improve pain management. Well-functioning pain assessments require using strategies informed by well-established theory. This study evaluates documented pain assessments reported in medical records and by patients, including reassessment using a Numeric Rating Scale (NRS) after patients receive rescue medication. Documentation surveys (DS) and patient surveys (PS) were performed at baseline (BL), after six months, and after 12 months in 44 in-patient wards at the three hospitals in Östergötland County, Sweden. Nurses and nurse assistants received training on pain assessment and support. The Knowledge to Action Framework guided the implementation of new routines. According to DS pain assessment using NRS, pain assessment increased significantly: from 7% at baseline to 36% at 12 months (p<0.001). For PS, corresponding numbers were 33% and 50% (p<0.001). According to the PS, the proportion of patients who received rescue medication and who had been reassessed increased from 73% to 86% (p=0.003). The use of NRS to document pain assessment after patients received rescue medication increased significantly (4% vs. 17%; p<0.001). After implementing education and support strategies, systematic pain assessment increased, an encouraging finding considering the complex contexts of in-patient facilities. However, the achieved assessment levels and especially reassessments related to rescue medication were clinically unsatisfactory. Future studies should include nursing staff and physicians and increase interactivity such as providing online education support. A discrepancy between documented and reported reassessment in association with given rescue medication might indicate that nurses need better ways to provide pain relief. The fairly low level of patient-reported pain via NRS and documented use of NRS before and 12 months after the educational programme stresses the need for education on pain management in nursing education. Implementations differing from traditional educational attempts such as interactive implementations might complement educational programmes given at the work place. Standardized routines for pain management that include the possibility for nurses to deliver pain medication within well-defined margins might improve pain management and increase the use of pain assessments. Further research is needed that examines the large discrepancy between patient-reported pain management and documentation in the medical recording system of transient pain. Copyright © 2017 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
Fundamental Nursing: Process-Oriented Guided-Inquiry Learning (POGIL) Research

ERIC Educational Resources Information Center

Roller, Maureen C.

2015-01-01

Measuring the effect of a Process-Oriented Guided-Inquiry Learning (POGIL) implementation in a fundamental baccalaureate-nursing course is one way to determine its effectiveness. To date, the use of POGIL from a research perspective in fundamental nursing has not been documented in the literature. The purpose of the study was to measure the…
A Research Collaboration between a Catholic University School of Nursing and Healthcare System: Process and Model

ERIC Educational Resources Information Center

Georges, Jane M.; Gonzales, Lucia; Aube, Patti; Connelly, Cynthia D.

2013-01-01

Collaborations between diverse Catholic organizations will be important in fulfilling the goals contained in the Institute of Medicine (IOM) 2010 document, "The Future of Nursing: Leading Change, Advancing Health." This article describes a qualitative research study examining the partnership between a graduate-level school of nursing in…
Nursing Research and Practice with Refugees. Southeast Asian Refugee Studies. Bibliography. Occasional Papers, Number 10.

ERIC Educational Resources Information Center

Muecke, Marjorie A.

This 99-item bibliography gathers the widely dispersed nursing literature on refugees, including unpublished master's degree theses and conference proceedings. Nurse researchers, more than researchers in other health care fields, have undertaken exploratory studies to document and interpret the health beliefs and health care practices of various…
School Nurses' Perceived Barriers to Discussing Weight with Children and Their Families: A Qualitative Approach

ERIC Educational Resources Information Center

Steele, Ric G.; Wu, Yelena P.; Jensen, Chad D.; Pankey, Sydni; Davis, Ann M.; Aylward, Brandon S.

2011-01-01

Background: Previous studies have documented the presence of specific barriers to school nurses' communications with families about weight-related health. The purpose of the present study was to contribute to the literature by further analyzing, using focus group methodology, school nurses' perceived barriers to addressing weight-related health…
Draft Model Curriculum in Nursing Education for Alcohol and Other Drug Abuse.

ERIC Educational Resources Information Center

Naegle, Madeline A.; Burns, Elizabeth M.

This document contains three model curricula in nursing education for alcohol and other drug abuse, one graduate and one baccalaureate level from New York University's (NYU) Division of Nursing, and the third combining graduate and undergraduate level curricula for Ohio State University (OSU). The NYU undergraduate curriculum contains a pilot test…
Records--The Achilles' Heel of School Nursing: Answers to Bothersome Questions

ERIC Educational Resources Information Center

Schwab, Nadine C.; Pohlman, Katherine J.

2004-01-01

This article addresses practice issues related to school health records and school nursing documentation. Because the issues have been posed by practicing school nurses, the article is in Question and Answer (Q&A) format. Specifically, the questions addressed concern the following: ownership and storage location of student health records when…
Defining, Delivering, and Documenting the Outcomes of Case Management by School Nurses

ERIC Educational Resources Information Center

Engelke, Martha Keehner; Guttu, Martha; Warren, Michelle B.

2009-01-01

Case management is a component of school nurse practice that provides an opportunity to demonstrate the contribution that school nurses make to the health and academic success of children, particularly children with chronic health conditions. However, case management programs vary in their mission and scope, leading to confusion about what it…
Migration of Nurses from Sub-Saharan Africa: A Review of Issues and Challenges

PubMed Central

Dovlo, Delanyo

2007-01-01

Objective To assess the impact of out-migration of nurses on the health systems in sub-Saharan Africa (SSA). Setting The countries of SSA. Design and Methods Review of secondary sources: existing publications and country documents on the health workforce; documents prepared for the Joint Learning Initiative Global Human Resources for Health report, the World Health Organization (AFRO) synthesis on migration, and the International Council of Nurses series on the global nursing situation. Analysis of associated data. Principal Findings The state of nursing practice in SSA appears to have been impacted negatively by migration. Available (though inadequate) quantitative data on stocks and flows, qualitative information on migration issues and trends, and on the main strategies being employed in both source and recipient countries indicate that the problem is likely to grow over the next 5–10 years. Conclusions Multiple actions are needed at various policy levels in both source and receiving countries to moderate negative effects of nurse emigration in developing countries in Africa; however, critically, source countries must establish more effective policies and strategies. PMID:17489920
[Information system for supporting the Nursing Care Systematization].

PubMed

Malucelli, Andreia; Otemaier, Kelly Rafaela; Bonnet, Marcel; Cubas, Marcia Regina; Garcia, Telma Ribeiro

2010-01-01

It is an unquestionable fact, the importance, relevance and necessity of implementing the Nursing Care Systematization in the different environments of professional practice. Considering it as a principle, emerged the motivation for the development of an information system to support the Nursing Care Systematization, based on Nursing Process steps and Human Needs, using the diagnoses language, nursing interventions and outcomes for professional practice documentation. This paper describes the methodological steps and results of the information system development - requirements elicitation, modeling, object-relational mapping, implementation and system validation.
Hot off the Press for Perioperative Nurses.

PubMed

Fisher, Mona Guckian

2017-06-01

I am delighted to bring you the Perioperative Care Collaborative (PCC) National Core Curriculum for Perioperative Nursing 2017, whose purpose is 'influencing and supporting clinical policies into perioperative practice'. This is a very important document for nurses working within operating theatre settings. Since the dissolution of the English National Board (ENB), perioperative nurses have not had access to appropriate professional courses in line with what had been previously available.
Technology Acceptance of Electronic Medical Records by Nurses

ERIC Educational Resources Information Center

Stocker, Gary

2010-01-01

The purpose of this study was to evaluate the Technology Acceptance Model's (TAM) relevance of the intention of nurses to use electronic medical records in acute health care settings. The basic technology acceptance research of Davis (1989) was applied to the specific technology tool of electronic medical records (EMR) in a specific setting…
Quality and efficiency successes leveraging IT and new processes.

PubMed

Chaiken, Barry P; Christian, Charles E; Johnson, Liz

2007-01-01

Today, healthcare annually invests billions of dollars in information technology, including clinical systems, electronic medical records and interoperability platforms. While continued investment and parallel development of standards are critical to secure exponential benefits from clinical information technology, intelligent and creative redesign of processes through path innovation is necessary to deliver meaningful value. Reports from two organizations included in this report review the steps taken to reinvent clinical processes that best leverage information technology to deliver safer and more efficient care. Good Samaritan Hospital, Vincennes, Indiana, implemented electronic charting, point-of-care bar coding of medications prior to administration, and integrated clinical documentation for nursing, laboratory, radiology and pharmacy. Tenet Healthcare, during its implementation and deployment of multiple clinical systems across several hospitals, focused on planning that included team-based process redesign. In addition, Tenet constructed valuable and measurable metrics that link outcomes with its strategic goals.
Multidisciplinary Optimization of Oral Chemotherapy Delivery at the University of Wisconsin Carbone Cancer Center.

PubMed

Mulkerin, Daniel L; Bergsbaken, Jason J; Fischer, Jessica A; Mulkerin, Mary J; Bohler, Aaron M; Mably, Mary S

2016-10-01

Use of oral chemotherapy is expanding and offers advantages while posing unique safety challenges. ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offer a framework for improving oral chemotherapy practice at the University of Wisconsin Carbone Cancer Center. With the goal of improving safety, quality, and uniformity within our oral chemotherapy practice, we conducted a gap analysis comparing our practice against ASCO/Oncology Nursing Society guidelines. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Recommendations and process changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, and standardizing documentation for dose modification. Revised processes allow pharmacists to review all orders for oral chemotherapy, and they support monitoring adherence and toxicity by using a library of scripted materials. Between August 2015 and January 2016, revised processes were implemented across the University of Wisconsin Carbone Cancer Center clinics. The following are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle monitoring of adherence and toxicity was achieved. We closed significant gaps between institutional practice and published standards for our oral chemotherapy practice and experienced steady improvement and sustainable performance in key metrics. We created an electronic definition of oral chemotherapies that allowed us to leverage our electronic health records. We believe our tools are broadly applicable.
Multidisciplinary Optimization of Oral Chemotherapy Delivery at the University of Wisconsin Carbone Cancer Center

PubMed Central

Bergsbaken, Jason J.; Fischer, Jessica A.; Mulkerin, Mary J.; Bohler, Aaron M.; Mably, Mary S.

2016-01-01

Purpose: Use of oral chemotherapy is expanding and offers advantages while posing unique safety challenges. ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offer a framework for improving oral chemotherapy practice at the University of Wisconsin Carbone Cancer Center. Methods: With the goal of improving safety, quality, and uniformity within our oral chemotherapy practice, we conducted a gap analysis comparing our practice against ASCO/Oncology Nursing Society guidelines. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Recommendations and process changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, and standardizing documentation for dose modification. Revised processes allow pharmacists to review all orders for oral chemotherapy, and they support monitoring adherence and toxicity by using a library of scripted materials. Results: Between August 2015 and January 2016, revised processes were implemented across the University of Wisconsin Carbone Cancer Center clinics. The following are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle monitoring of adherence and toxicity was achieved. Conclusion: We closed significant gaps between institutional practice and published standards for our oral chemotherapy practice and experienced steady improvement and sustainable performance in key metrics. We created an electronic definition of oral chemotherapies that allowed us to leverage our electronic health records. We believe our tools are broadly applicable. PMID:27858570
Challenges for Nurses Caring for Patients With Peripherally Inserted Central Catheters in Skilled Nursing Facilities

PubMed Central

Harrod, Molly; Montoya, Ana; Mody, Lona; McGuirk, Helen; Winter, Suzanne; Chopra, Vineet

2016-01-01

Objectives To understand frontline nurses’ (registered nurses and licensed practical nurses), unit nurse managers’ and skilled nursing facility (SNF) administrators’ perceived preparedness in providing care for patients with peripherally inserted central catheters (PICCs) in SNFs. Design An exploratory, qualitative pilot study. Setting Two community based SNFs. Participants Patients, frontline nurses (registered nurses and licensed practical nurses), unit nurse managers and SNF administrators. Methods Over 36-weeks, we observed and conducted informal interviews with 56 patients with PICCs and their nurses focusing on PICC care practices and documentation. In addition, we collected baseline PICC data including placement indication (e.g., antimicrobial administration), placement setting (hospital vs. SNF), and dwell time. We then conducted focus groups with frontline nurses and unit nurse managers and semi-structured interviews with SNF administrators to evaluate perceived preparedness for PICC care. Data were analyzed using a descriptive analysis approach. Results During weekly informal interviews and observations variations in documentation were observed. Differences between patient-reported PICC concerns (quality-of-life) and those described by frontline nurses were noted. Deficiencies in communication between hospitals and SNFs with respect to device care, date of last dressing change and PICC removal time were also noted. During focus group sessions, perceived inadequacy of information at the time of care transitions, limited availability of resources to care for PICCs and gaps in training and education were highlighted as barriers in improving practice and safety. Conclusion Our study suggests that practices for PICC care in SNFs can be improved. Multimodal strategies that enhance staff education, improve information exchange during care transitions and increase resource availability in SNFs appear necessary to enhance PICC care and patient safety. PMID:27603747

A budget model to determine the financial health of nursing education programs in academic institutions.

PubMed

Donnelly, Gloria

2005-01-01

In the allocation of resources in academic settings, hierarchies of tradition and status often supersede documented need. Nursing programs sometimes have difficulty in getting what they need to maintain quality programs and to grow. The budget is the crucial tool in documenting nursing program needs and its contributions to the entire academic enterprise. Most nursing programs administrators see only an operating expense budget that may grow or shrink by a rubric that may not fit the reality of the situation. A budget is a quantitative expression of how well a unit is managed. Educational administrators should be paying as much attention to analyzing financial outcomes as they do curricular outcomes. This article describes the development of a model for tracking revenue and expense and a simple rubric for analyzing the relationship between the two. It also discusses how to use financial data to improve the fiscal performance of nursing units and to leverage support during times of growth.
The Use of the Academic Electronic Medical Record (EMR) to Develop Critical Thinking Skills in an Associate Degree Nursing Mobility Program

ERIC Educational Resources Information Center

Wlodyga, Linda J.

2010-01-01

In an attempt to prepare new graduate nurses to meet the demands of health care delivery systems, the use of computer-based clinical information systems that combine hands-on experience with computer based information systems was explored. Since the introduction of Electronic Medical Records (EMR) nearly two decades ago, the demand for nurses to…
Incidence and management of arthralgias in breast cancer patients treated with aromatase inhibitors in an outpatient oncology clinic.

PubMed

Menas, Pamela; Merkel, Douglas; Hui, Wendy; Lawton, Jessica; Harper, Abigail; Carro, George

2012-12-01

Aromatase inhibitors (AIs) are routinely used as first-line adjuvant treatment of breast cancer in postmenopausal women with hormone receptor positive tumors. The current recommended length of treatment with an AI is 5 years. Arthralgias have been frequently cited as the primary reason for discontinuation of AI therapy. Various treatment strategies are proposed in literature, but a standardized treatment algorithm has not been established. The initial purpose of this study was to describe the incidence and management of AI-induced arthralgias in patients treated at Kellogg Cancer Center (KCC). Further evaluation led to the development and the implementation of a treatment algorithm and electronic medical record (EMR) documentation tools. The retrospective chart review included 206 adult patients with hormone receptor positive breast cancer who were receiving adjuvant therapy with an AI. A multidisciplinary treatment team consisting of pharmacists, collaborative practice nurses, and physicians met to develop a standardized treatment algorithm and corresponding EMR documentation tool. The treatment algorithm and documentation tool were developed after the study to better monitor and proactively treat patients with AI-induced arthralgias. RESULTS/ CONCLUSIONS: The overall incidence of arthralgias at KCC was 48% (n = 98/206). Of these patients, 32% were documented as having arthralgias within the first 6 months of therapy initiation. Patients who reported AI-induced arthralgias were younger than patients who did not report AI-induced arthralgias (61 vs. 65 years, p = 0.002). There was no statistical difference in the incidence of arthralgias in patients with a history of chemotherapy (including taxane therapy) compared to those who did not receive chemotherapy (p = 0.352). Of patients presenting with AI-induced arthralgias, 41% did not have physician-managed treatment documented in the EMR. A standardized treatment algorithm and electronic chart documentation tools were then developed by the multidisciplinary team.
Nursing Students' Use of Electronic and Social Media: Law, Ethics, and E-Professionalism.

PubMed

Westrick, Susan J

2016-01-01

This article discusses the promotion of professionalism in nursing students with regard to the use of electronic and social media. Misuse of social media can lead to disciplinary actions and program dismissal for students and to legal actions and lawsuits for nursing programs. Programs are concemed about breaches of patient confidentiality and release of private or inappropriate information that jeopardizes clinical placements and relationships. The American Nurses Association Code of Ethics and National Council of State Boards of Nursing social media guidelines provide a foundation for promoting e-professionalism in students. Recent law cases involving students who were dismissed from nursing programs due to social media misuse are analyzed. Schools need policies that clearly establish expectations and the consequences of misuse of social media platforms. Lessons learned from the legal cases presented provide further guidance for both nursing students and nursing programs.
Use of Electronic Documentation for Quality Improvement in Hospice

PubMed Central

Cagle, John G.; Rokoske, Franziska S.; Durham, Danielle; Schenck, Anna P.; Spence, Carol; Hanson, Laura C.

2015-01-01

Little evidence exists on the use of electronic documentation in hospice and its relationship to quality improvement practices. The purposes of this study were to: (1) estimate the prevalence of electronic documentation use in hospice; (2) identify organizational characteristics associated with use of electronic documentation; and (3) determine whether quality measurement practices differed based on documentation format (electronic vs. nonelectronic). Surveys concerning the use of electronic documentation for quality improvement practices and the monitoring of quality-related care and outcomes were collected from 653 hospices. Users of electronic documentation were able to monitor a wider range of quality-related data than users of nonelectronic documentation. Quality components such as advanced care planning, cultural needs, experience during care of the actively dying, and the number/types of care being delivered were more likely to be documented by users of electronic documentation. Use of electronic documentation may help hospices to monitor quality and compliance. PMID:22267819
The evaluation of the compatibility of electronic patient record (EPR) system with nurses' management needs in a developing country.

PubMed

Kahouei, Mehdi; Zadeh, Jamileh Mahdi; Roghani, Panoe Seyed

2015-04-01

In a developing country like Iran, wasting economic resources has a number of negative consequences. Therefore, it is crucial that problems of introducing new electronic systems be identified and addressed early to avoid failure of the programs. The purpose of this study was to evaluate head nurses' and supervisors' perceptions about the efficiency of the electronic patient record (EPR) system and its impact on nursing management tasks in order to provide useful recommendations. This descriptive study was performed in teaching hospitals affiliated to Semnan University of Medical Sciences, Iran. An anonymous self-administered questionnaire was developed. Head nurses and supervisors were included in this study. It was found that the EPR system was immature and was not proportionate to the operational level. Moreover, few head nurses and supervisors agreed on the benefits of the EPR system on the performance of their duties such as planning, organizing, budgeting, and coordinating. It is concluded that in addition to the technical improvements, the social and cultural factors should be considered to improve the acceptability of electronic systems through social marketing in the different aspects of nursing management. It is essential that health information technology managers emphasize on training head nurses and supervisors to design technology corresponding to their needs rather than to accept poorly designed technology. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
[A major game in the re-organization of the Professional Nursing School].

PubMed

de Amorin, Wellington Mendonça; Barreira, Ieda de Alencar

2007-01-01

This is a historical-social description study supported on the thought of Pierre Bourdieu based on documental analysis. It describes the sanitarists and psychiatrists' actions from the reformulation of Education and Public Health Ministry into Education and Health Ministry in the beginning of New State and analyse the fight's strategies of the main agents to take advantage on their proposals of Professional Nursing School's reorganization. The fight's strategies that psychiatrists, sanitarists and certificated nurses had used to stake their projects, characterized a difficult battle inserted in a hard major game. The analyse of the ten course's months of the main document shows the conflict between those agents to impose a new rule to the school.
Dimensions of caring: a qualitative analysis of nurses' stories.

PubMed

Hudacek, Sharon S

2008-03-01

The purpose of this qualitative, phenomenological study is to describe dimensions of caring as they relate to and clarify the practice of professional nursing. Nurses are unique caregivers, and their work at the bedside and in the community matters. What nurses do as they care for patients is multi-dimensional, complex, and essential. Two hundred stories written by nurses were analyzed using Giorgi's methodology for existential phenomenology. Their stories indicate that nursing goes far beyond technical skills. Seven dimensions of caring that define professional nursing practice were found: caring, compassion, spirituality, community outreach, providing comfort, crisis intervention, and going the extra distance. The nurses' stories demonstrate that the dimensions of caring that define professional nursing practice are universal. Documentation of nurse's stories facilitates reflective and thoughtful practice, while clarifying the essential components of nursing.
Nurse manager engagement: what it means to nurse managers and staff nurses.

PubMed

Gray, Linda R; Shirey, Maria R

2013-01-01

To describe what nurse manager engagement means to nurse managers and staff nurses by incorporating an organizational dashboard to document engagement outcomes. Retaining engaged nurse managers is crucial for individual performance and organizational outcomes. However, nurse manager engagement is currently underreported in the literature. Existing data from the 2010 Employee Opinion Survey at the Baylor University Medical Center in Dallas, Texas, were used to measure staff engagement among 28 nurse managers and 1497 staff nurses. The data showed a 21% gap between manager and staff nurse engagement levels, with managers showing higher engagement levels than staff. No clear depiction of nurse manager engagement emerged. Consequently, an expanded definition of nurse manager engagement was developed alongside a beginning dashboard of engagement outcomes. The findings have implications for overcoming barriers that affect staff nurse engagement, improving outcomes, and creating definitions of nurse manager engagement.
Falls documentation in nursing homes: agreement between the minimum data set and chart abstractions of medical and nursing documentation.

PubMed

Hill-Westmoreland, Elizabeth E; Gruber-Baldini, Ann L

2005-02-01

To assess the agreement between falls as recorded in the Minimum Data Set (MDS) and fall events abstracted from chart documentation of elderly nursing home (NH) residents. Secondary analysis of data from a longitudinal panel study. Fifty-six randomly selected NHs in Maryland stratified by facility size and geographic region. Four hundred sixty-two NH residents, aged 65 and older, in NHs for 1 year. Falls were abstracted from resident charts and compared with MDS fall variables. Fall events data obtained from other sources of chart documentation were matched for the corresponding periods of 30 and 180 days before the 1-year MDS assessment date. For a 30-day period, concordance between the MDS and chart abstractions of falls occurred in 65% of cases, with a kappa coefficient of 0.29 (P<.001), indicating fair agreement. Concordance occurred between the sources for 75% of cases for a 180-day period, with a kappa of 0.50 (P<.001), indicating moderate agreement. During the 180-day period, chart abstractions showed that 49% of the sample fell, whereas the MDS revealed that only 28% fell. An analysis of residents whose falls the MDS missed indicated that these residents had significantly more activity of daily living impairment and significantly less unsteady gait and cane/walker use. The MDS underreported falls. Nurses completing MDS assessments must carefully review residents' medical records for falls documentation. Future studies should use caution when employing MDS data as the only indicator of falls.
School Nurses' Role in Asthma Management, School Absenteeism, and Cost Savings: A Demonstration Project

ERIC Educational Resources Information Center

Rodriguez, Eunice; Rivera, Diana Austria; Perlroth, Daniella; Becker, Edmund; Wang, Nancy Ewen; Landau, Melinda

2013-01-01

Background: With increasing budget cuts to education and social services, rigorous evaluation needs to document school nurses' impact on student health, academic outcomes, and district funding. Methods: Utilizing a quasi-experimental design, we evaluated outcomes in 4 schools with added full-time nurses and 5 matched schools with part-time nurses…
A Handbook for Coordinators and Teachers of 75 Hour Nurse Aide Course. Revised.

ERIC Educational Resources Information Center

Iowa Univ., Iowa City. Coll. of Education.

This document consists of revised editions of both a handbook for coordinators and teachers of a 75-hour nurse aide course and the nurse aide curriculum itself. The handbook's stated purpose is to assist health coordinators in community colleges and secondary health occupations instructors to offer the course. Introductory materials include…
Research and Its Relationship to Nurse Education: Focus and Capacity.

ERIC Educational Resources Information Center

Newell, Robert

2002-01-01

Examination of two British mental health journals and a government document on the future of nursing found a lack of focus on clinical research and little reference to the role of research and development in practice. The increasing importance of evidence-based practice demands a strategy for developing nurses' capacity to understand, undertake,…
The Nurse as a Primary Health Care Provider. And: The Nurse Practitioner: An Annotated Bibliography.

ERIC Educational Resources Information Center

Perry, Lesley

Issues and present trends related to the preparation and the expanded role of the nurse and physician's assistant in meeting health needs are the major concerns of part one, representing 100 pages of the document. Issues discussed include: (1) manpower considerations, (2) definition of responsibilities, training needs, and requirements, (3)…
Graduation and Withdrawal from RN Programs. A Report of the Nurse Career-Pattern Study.

ERIC Educational Resources Information Center

Knopf, Lucille

Based on a larger longitudinal study, this document examines three nursing groups--those entering schools preparing registered nurses in 1962, 1965, and 1967. It describes and compares those who graduated and those who withdrew before graduation and examines the reasons why the students withdraw from both the students' and the program directors'…
Experience of Adjunct Novice Clinical Nursing Faculty: An Interpretive Case Study

ERIC Educational Resources Information Center

Mann, Carol

2013-01-01

The purpose of this qualitative interpretive case study was to describe the experience of adjunct novice clinical nursing faculty who has less than three years teaching experience or feels novice in this setting. The nursing shortage in the United States is well documented and is forecasted to have significant impacts on the health care delivery…
The Place of Race in Cultural Nursing Education: The Experience of White BSN Nursing Faculty

ERIC Educational Resources Information Center

Holland, Ann Elizabeth

2011-01-01

The growing cultural diversity in the United States confronts human service professions such as nursing with challenges to fundamental values of social justice and caring. Non-White individuals have experienced long-documented and persistent disparities in health outcomes and receipt of health care services when compared to whites. Medical…
Multilevel library instruction for emerging nursing roles.

PubMed

Francis, B W; Fisher, C C

1995-10-01

As new nursing roles emerge that involve greater decision making than in the past, added responsibility for outcomes and cost control, and increased emphasis on primary care, the information-seeking skills needed by nurses change. A search of library and nursing literature indicates that there is little comprehensive library instruction covering all levels of nursing programs: undergraduate, returning registered nurses, and graduate students. The University of Florida is one of the few places that has such a multilevel, course-integrated curriculum in place for all entrants into the nursing program. Objectives have been developed for each stage of learning. The courses include instruction in the use of the online public access catalog, printed resources, and electronic databases. A library classroom equipped with the latest technology enables student interaction with electronic databases. This paper discusses the program and several methods used to evaluate it.
Challenges for Nurses Caring for Individuals with Peripherally Inserted Central Catheters in Skilled Nursing Facilities.

PubMed

Harrod, Molly; Montoya, Ana; Mody, Lona; McGuirk, Helen; Winter, Suzanne; Chopra, Vineet

2016-10-01

To understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs. Exploratory, qualitative pilot study. Two community based SNFs. Residents with PICCs, frontline nurses (RNs, LPNs), unit nurse managers, and SNF administrators. Over 36 weeks, 56 residents with PICCs and their nurses were observed and informally interviewed, focusing on PICC care practices and documentation. In addition, baseline PICC data were collected on placement indication (e.g., antimicrobial administration), placement setting (hospital vs SNF), and dwell time. Focus groups were then conducted with frontline nurses and unit nurse managers, and semistructured interviews were conducted with SNF administrators to evaluate perceived preparedness for PICC care. Data were analyzed using a descriptive analysis approach. Variations in documentation were observed during weekly informal interviews and observations. Differences were noted between resident self-reported PICC concerns (quality of life) and those described by frontline nurses. Deficiencies in communication between hospitals and SNFs with respect to device care, date of last dressing change, and PICC removal time were also noted. During focus group sessions, perceived inadequacy of information at the time of care transitions, limited availability of resources to care for PICCs, and gaps in training and education were highlighted as barriers to improving practice and safety. Practices for PICC care in SNFs can be improved. Multimodal strategies that enhance staff education, improve information exchange during care transitions, and increase resource availability in SNFs appear necessary to enhance PICC care and safety. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.
Use of electronic monitoring in clinical nursing research.

PubMed

Ailinger, Rita L; Black, Patricia L; Lima-Garcia, Natalie

2008-05-01

In the past decade, the introduction of electronic monitoring systems for monitoring medication adherence has contributed to the dialog about what works and what does not work in monitoring adherence. The purpose of this article is to describe the use of the Medication Event Monitoring System (MEMS) in a study of patients receiving isoniazid for latent tuberculosis infection. Three case examples from the study illustrate the data that are obtained from the electronic device compared to self-reports and point to the disparities that may occur in electronic monitoring. The strengths and limitations of using the MEMS and ethical issues in utilizing this technology are discussed. Nurses need to be aware of these challenges when using electronic measuring devices to monitor medication adherence in clinical nursing practice and research.

Impact of Information and Communication Technologies on Nursing Care: Results of an Overview of Systematic Reviews

PubMed Central

Rouleau, Geneviève; Côté, José; Payne-Gagnon, Julie; Hudson, Emilie; Dubois, Carl-Ardy

2017-01-01

Background Information and communication technologies (ICTs) are becoming an impetus for quality health care delivery by nurses. The use of ICTs by nurses can impact their practice, modifying the ways in which they plan, provide, document, and review clinical care. Objective An overview of systematic reviews was conducted to develop a broad picture of the dimensions and indicators of nursing care that have the potential to be influenced by the use of ICTs. Methods Quantitative, mixed-method, and qualitative reviews that aimed to evaluate the influence of four eHealth domains (eg, management, computerized decision support systems [CDSSs], communication, and information systems) on nursing care were included. We used the nursing care performance framework (NCPF) as an extraction grid and analytical tool. This model illustrates how the interplay between nursing resources and the nursing services can produce changes in patient conditions. The primary outcomes included nurses’ practice environment, nursing processes, professional satisfaction, and nursing-sensitive outcomes. The secondary outcomes included satisfaction or dissatisfaction with ICTs according to nurses’ and patients’ perspectives. Reviews published in English, French, or Spanish from January 1, 1995 to January 15, 2015, were considered. Results A total of 5515 titles or abstracts were assessed for eligibility and full-text papers of 72 articles were retrieved for detailed evaluation. It was found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing care themes (ie, indicators) were influenced by the use of ICTs, including time management; time spent on patient care; documentation time; information quality and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra and interprofessional collaboration; nurses’ competencies and skills; nurse-patient relationship; assessment, care planning, and evaluation; teaching of patients and families; communication and care coordination; perspectives of the quality of care provided; nurses and patients satisfaction or dissatisfaction with ICTs; patient comfort and quality of life related to care; empowerment; and functional status. Conclusions The findings led to the identification of 19 indicators related to nursing care that are impacted by the use of ICTs. To the best of our knowledge, this was the first attempt to apply NCPF in the ICTs’ context. This broad representation could be kept in mind when it will be the time to plan and to implement emerging ICTs in health care settings. Trial Registration PROSPERO International Prospective Register of Systematic Reviews: CRD42014014762; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014762 (Archived by WebCite at http://www.webcitation.org/6pIhMLBZh) PMID:28442454
Impact of Information and Communication Technologies on Nursing Care: Results of an Overview of Systematic Reviews.

PubMed

Rouleau, Geneviève; Gagnon, Marie-Pierre; Côté, José; Payne-Gagnon, Julie; Hudson, Emilie; Dubois, Carl-Ardy

2017-04-25

Information and communication technologies (ICTs) are becoming an impetus for quality health care delivery by nurses. The use of ICTs by nurses can impact their practice, modifying the ways in which they plan, provide, document, and review clinical care. An overview of systematic reviews was conducted to develop a broad picture of the dimensions and indicators of nursing care that have the potential to be influenced by the use of ICTs. Quantitative, mixed-method, and qualitative reviews that aimed to evaluate the influence of four eHealth domains (eg, management, computerized decision support systems [CDSSs], communication, and information systems) on nursing care were included. We used the nursing care performance framework (NCPF) as an extraction grid and analytical tool. This model illustrates how the interplay between nursing resources and the nursing services can produce changes in patient conditions. The primary outcomes included nurses' practice environment, nursing processes, professional satisfaction, and nursing-sensitive outcomes. The secondary outcomes included satisfaction or dissatisfaction with ICTs according to nurses' and patients' perspectives. Reviews published in English, French, or Spanish from January 1, 1995 to January 15, 2015, were considered. A total of 5515 titles or abstracts were assessed for eligibility and full-text papers of 72 articles were retrieved for detailed evaluation. It was found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing care themes (ie, indicators) were influenced by the use of ICTs, including time management; time spent on patient care; documentation time; information quality and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra and interprofessional collaboration; nurses' competencies and skills; nurse-patient relationship; assessment, care planning, and evaluation; teaching of patients and families; communication and care coordination; perspectives of the quality of care provided; nurses and patients satisfaction or dissatisfaction with ICTs; patient comfort and quality of life related to care; empowerment; and functional status. The findings led to the identification of 19 indicators related to nursing care that are impacted by the use of ICTs. To the best of our knowledge, this was the first attempt to apply NCPF in the ICTs' context. This broad representation could be kept in mind when it will be the time to plan and to implement emerging ICTs in health care settings. PROSPERO International Prospective Register of Systematic Reviews: CRD42014014762; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014762 (Archived by WebCite at http://www.webcitation.org/6pIhMLBZh). ©Geneviève Rouleau, Marie-Pierre Gagnon, José Côté, Julie Payne-Gagnon, Emilie Hudson, Carl-Ardy Dubois. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 25.04.2017.
Occupational stress and coping strategies among emergency department nurses of China.

PubMed

Lu, Dong-Mei; Sun, Ning; Hong, Su; Fan, Yu-ying; Kong, Fan-ying; Li, Qiu-jie

2015-08-01

Emergency department(ED) nurses work in a rapidly changing environment with patients that have wide variety of conditions. Occupational stress in emergency department nurses is a common problem. The purpose of this study was to describe the relationship between coping strategies and occupational stress among ED nurses in China. A correlational, cross-sectional design was adopted. Two questionnaires were given to a random sample of 127 ED nurses registered at the Heilongjiang Nurses' Association. Data were collected from the nurses that worked in the ED of five general hospitals in Harbin China. Occupational stress and coping strategies were measured by two questionnaires. A multiple regression model was applied to analyze the relationship between stress and coping strategies. The stressors of ED nurses mainly come from the ED specialty of nursing (2.97±0.55), workload and time distribution (2.97±0.58). The mean score of positive coping strategies was 2.19±0.35, higher than the norm (1.78±0.52). The mean score of negative coping strategies was 1.20±0.61, lower than the norm (1.59±0.66), both had significant statistical difference (P<0.001). Too much documents work, criticism, instrument equipment shortage, night shift, rank of professional were the influence factors about occupational stress to positive coping styles. Too much documents work, and medical insurance for ED nurses were the influential factors on occupational stress to negative coping styles. This study identified several factors associated with occupational stress in ED nurses. These results could be used to guide nurse managers of ED nurses to reduce work stress. The managers could pay more attention to the ED nurse's coping strategies which can further influence their health state and quality of nursing care. Reducing occupational stress and enhancing coping strategies are vital not only for encouraging nurses but also for the future of nursing development. Copyright © 2015. Published by Elsevier Inc.
Nursing education reform in South Africa – lessons from a policy analysis study

PubMed Central

Blaauw, Duane; Ditlopo, Prudence; Rispel, Laetitia C.

2014-01-01

Background Nursing education reform is identified as an important strategy for enhancing health workforce performance, and thereby improving the functioning of health systems. Globally, a predominant trend in such reform is towards greater professionalisation and university-based education. Related nursing education reform in South Africa culminated in a new Framework for Nursing Qualifications in 2013. Objective We undertook a policy analysis study of the development of the new Nursing Qualifications Framework in South Africa. Design We used a policy analysis framework derived from Walt and Gilson that interrogated the context, content, actors, and processes of policy development and implementation. Following informed consent, in-depth interviews were conducted with 28 key informants from national and provincial government; the South African Nursing Council; the national nursing association; nursing academics, managers, and educators; and other nursing organisations. The interviews were complemented with a review of relevant legislation and policy documents. Documents and interview transcripts were coded thematically using Atlas-ti software. Results The revision of nursing qualifications was part of the post-apartheid transformation of nursing, but was also influenced by changes in the education sector. The policy process took more than 10 years to complete and the final Regulations were promulgated in 2013. The two most important changes are the requirement for a baccalaureate degree to qualify as a professional nurse and abolishing the enrolled nurse with 2 years training in favour of a staff nurse with a 3-year college diploma. Respondents criticised slow progress, weak governance by the Nursing Council and the Department of Health, limited planning for implementation, and the inappropriateness of the proposals for South Africa. Conclusions The study found significant weaknesses in the policy capacity of the main institutions responsible for the leadership and governance of nursing in South Africa, which will need to be addressed if important nursing education reforms are to be realised. PMID:25537941
Nursing education reform in South Africa--lessons from a policy analysis study.

PubMed

Blaauw, Duane; Ditlopo, Prudence; Rispel, Laetitia C

2014-01-01

Nursing education reform is identified as an important strategy for enhancing health workforce performance, and thereby improving the functioning of health systems. Globally, a predominant trend in such reform is towards greater professionalisation and university-based education. Related nursing education reform in South Africa culminated in a new Framework for Nursing Qualifications in 2013. We undertook a policy analysis study of the development of the new Nursing Qualifications Framework in South Africa. We used a policy analysis framework derived from Walt and Gilson that interrogated the context, content, actors, and processes of policy development and implementation. Following informed consent, in-depth interviews were conducted with 28 key informants from national and provincial government; the South African Nursing Council; the national nursing association; nursing academics, managers, and educators; and other nursing organisations. The interviews were complemented with a review of relevant legislation and policy documents. Documents and interview transcripts were coded thematically using Atlas-ti software. The revision of nursing qualifications was part of the post-apartheid transformation of nursing, but was also influenced by changes in the education sector. The policy process took more than 10 years to complete and the final Regulations were promulgated in 2013. The two most important changes are the requirement for a baccalaureate degree to qualify as a professional nurse and abolishing the enrolled nurse with 2 years training in favour of a staff nurse with a 3-year college diploma. Respondents criticised slow progress, weak governance by the Nursing Council and the Department of Health, limited planning for implementation, and the inappropriateness of the proposals for South Africa. The study found significant weaknesses in the policy capacity of the main institutions responsible for the leadership and governance of nursing in South Africa, which will need to be addressed if important nursing education reforms are to be realised.
Use of a remote clinical decision support service for a multicenter trial to implement prediction rules for children with minor blunt head trauma.

PubMed

Goldberg, Howard S; Paterno, Marilyn D; Grundmeier, Robert W; Rocha, Beatriz H; Hoffman, Jeffrey M; Tham, Eric; Swietlik, Marguerite; Schaeffer, Molly H; Pabbathi, Deepika; Deakyne, Sara J; Kuppermann, Nathan; Dayan, Peter S

2016-03-01

To evaluate the architecture, integration requirements, and execution characteristics of a remote clinical decision support (CDS) service used in a multicenter clinical trial. The trial tested the efficacy of implementing brain injury prediction rules for children with minor blunt head trauma. We integrated the Epic(®) electronic health record (EHR) with the Enterprise Clinical Rules Service (ECRS), a web-based CDS service, at two emergency departments. Patterns of CDS review included either a delayed, near-real-time review, where the physician viewed CDS recommendations generated by the nursing assessment, or a real-time review, where the physician viewed recommendations generated by their own documentation. A backstopping, vendor-based CDS triggered with zero delay when no recommendation was available in the EHR from the web-service. We assessed the execution characteristics of the integrated system and the source of the generated recommendations viewed by physicians. The ECRS mean execution time was 0.74 ±0.72 s. Overall execution time was substantially different at the two sites, with mean total transaction times of 19.67 and 3.99 s. Of 1930 analyzed transactions from the two sites, 60% (310/521) of all physician documentation-initiated recommendations and 99% (1390/1409) of all nurse documentation-initiated recommendations originated from the remote web service. The remote CDS system was the source of recommendations in more than half of the real-time cases and virtually all the near-real-time cases. Comparisons are limited by allowable variation in user workflow and resolution of the EHR clock. With maturation and adoption of standards for CDS services, remote CDS shows promise to decrease time-to-trial for multicenter evaluations of candidate decision support interventions. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Implementing Routine Health Literacy Assessment in Hospital and Primary Care Patients

PubMed Central

Cawthon, Courtney; Mion, Lorraine C.; Willens, David E.; Roumie, Christianne L.; Kripalani, Sunil

2014-01-01

Background Patients with inadequate health literacy often have poorer health outcomes and increased utilization and costs, compared to those with adequate health literacy skills. The Institute of Medicine has recommended that health literacy assessment be incorporated into health care information systems, which would facilitate large-scale studies of the effects of health literacy, as well as evaluation of system interventions to improve care by addressing health literacy. As part of the Health Literacy Screening (HEALS) study, a brief health literacy screen (BHLS) was incorporated into the electronic health record (EHR) at a large academic medical center. Methods Changes were implemented to the nursing intake documentation across all adult hospital units, the emergency department, and three primary care practices. The change involved replacing previous education screening items with the BHLS. Implementation was based on a quality improvement framework, with a focus on acceptability, adoption, appropriateness, feasibility, fidelity and sustainability. Support was gained from nursing leadership, education and training was provided, a documentation change was rolled out, feedback was obtained, and uptake of the new health literacy screening items was monitored. Results Between November 2010 and April 2012, there were 55,611 adult inpatient admissions, and from November 2010 to September 2011, 23,186 adult patients made 39,595 clinic visits to the three primary care practices. The completion (uptake) rate in the hospital for November 2010 through April 2012 was 91.8%. For outpatient clinics, the completion rate between November 2010 and October 2011 was 66.6%. Conclusions Although challenges exist, it is feasible to incorporate health literacy screening into clinical assessment and EHR documentation. Next steps are to evaluate the association of health literacy with processes and outcomes of care across inpatient and outpatient populations. PMID:24716329
Leadership mentoring in nursing research, career development and scholarly productivity: A systematic review.

PubMed

Hafsteinsdóttir, Thóra B; van der Zwaag, Angeli M; Schuurmans, Marieke J

2017-10-01

Although nursing has been an academic discipline for decades, the infrastructure for nursing research in many countries is still fragile and struggling. Postdoctoral nurses have difficulties developing sustaining careers in nursing research due to lack of career opportunities. Considerable research has been conducted on leadership and mentoring in various areas of nursing. We aimed to systematically review the literature investigating leadership programs and mentoring for postdoctoral nurse researchers, as well as the influence of leadership and mentoring on research productivity, research career development, leadership knowledge and skills, the nurses' health and well-being, staff relationships, work culture and collaboration, salaries and postdoctoral nurses' experiences. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was conducted. The electronic databases PubMed, CINAHL and EMBASE were searched without time limits for eligible studies up to January 2016. Reference lists of included articles were also searched manually and authors were contacted to inquire about other relevant papers. Two authors independently assessed eligibility of studies for inclusion. Titles and abstracts were matched with the inclusion criteria: studies investigating leadership and mentoring programs for postdoctoral nurses and leadership and mentoring influencing research productivity, and career development; and leadership knowledge and skills and other outcomes. The quality of the studies was appraised using the Centre for Evidence-Based Medicine for surveys, the Critical Appraisal Skill Program Qualitative Appraisal Checklist for qualitative studies, and a critical appraisal list for mixed methods studies. Any disagreements were resolved by consensus. Data were extracted by two reviewers. We screened 1775 titles and abstracts, resulting in 15 studies, which included quantitative, descriptive, qualitative and mixed methods designs and involved 3855 postdoctoral nurses. Two studies presenting mentoring programs for postdoctoral nurses were identified. Other studies investigated the influence of mentoring on various outcomes. The findings showed a positive influence of mentoring on research productivity, including increase in publications and grant writing and research career development, improved leadership skills and knowledge. Furthermore, mentoring positively influenced nurses' health and well-being, staff relationships, work culture and collaboration. Postdoctoral nurses' experience of mentoring, mentorship, leadership and peer-support is essential in supporting ongoing research activity. Although there is a lack of studies with robust designs investigating leadership and mentoring programs, our results document some evidence of mentoring's influence on research productivity, career development and other outcomes of postdoctoral nurses. Copyright © 2017 Elsevier Ltd. All rights reserved.
Slipping through the net: the paradox of nursing's electronic theses and dissertations.

PubMed

Macduff, C; Goodfellow, L M; Nolfi, D; Copeland, S; Leslie, G D; Blackwood, D

2016-06-01

The study's main aim was to gain in-depth understanding of how nurse scholars engage with electronic theses and dissertations. Through elicitation of opinions about challenges and opportunities, and perceptions of future development, the study also aimed to influence the design of a new international web-based forum for learning and sharing information on this topic. Electronic theses and dissertations provide an opportunity to radically change the way in which graduate student research is presented, disseminated and used internationally. However, as revealed by a multi-national survey in 2011, many nurse scholars in vanguard universities have little awareness of how to find and exploit this ever-expanding global knowledge resource that is increasingly available free in full text format. Within this context more detailed understandings of nurse scholars' thinking and actions are required. A qualitative approach using a semi-structured interview guide was utilized to elicit perceptions from 14 nurse scholars. Thematic analysis of the interviewees' responses identified six major themes: initial exposure and effect; searching; accessing; handling; using; and evaluation. Insights were gained about the value of these resources and behaviours in using them as exemplars for structure, format and methodology. Despite the small study size, the findings added valuable new insights to the overview gained from the 2011 survey. These have been used to inform development of a new global initiative: the International Network for Electronic Theses and Dissertations in Nursing. Featuring an educational website (www.inetdin.net), this initiative aims to support and challenge nursing's policy makers, practitioners and especially educators to utilize this neglected but exponentially increasing wellspring of international nursing knowledge. © 2016 International Council of Nurses.
The Hidden Lives of Nurses' Cognitive Artifacts.

PubMed

Blaz, Jacquelyn W; Doig, Alexa K; Cloyes, Kristin G; Staggers, Nancy

2016-09-07

Standardizing nursing handoffs at shift change is recommended to improve communication, with electronic tools as the primary approach. However, nurses continue to rely on personally created paper-based cognitive artifacts - their "paper brains" - to support handoffs, indicating a deficiency in available electronic versions. The purpose of this qualitative study was to develop a deep understanding of nurses' paper-based cognitive artifacts in the context of a cancer specialty hospital. After completing 73 hours of hospital unit field observations, 13 medical oncology nurses were purposively sampled, shadowed for a single shift and interviewed using a semi-structured technique. An interpretive descriptive study design guided analysis of the data corpus of field notes, transcribed interviews, images of nurses' paper-based cognitive artifacts, and analytic memos. Findings suggest nurses' paper brains are personal, dynamic, living objects that undergo a life cycle during each shift and evolve over the course of a nurse's career. The life cycle has four phases: Creation, Application, Reproduction, and Destruction. Evolution in a nurse's individually styled, paper brain is triggered by a change in the nurse's environment that reshapes cognitive needs. If a paper brain no longer provides cognitive support in the new environment, it is modified into (adapted) or abandoned (made extinct) for a different format that will provide the necessary support. The "hidden lives" - the life cycle and evolution - of paper brains have implications for the design of successful electronic tools to support nursing practice, including handoff. Nurses' paper brains provide cognitive support beyond the context of handoff. Information retrieval during handoff is undoubtedly an important function of nurses' paper brains, but tools designed to standardize handoff communication without accounting for cognitive needs during all phases of the paper brain life cycle or the ability to evolve with changes to those cognitive needs will be underutilized.
Care zoning in a psychiatric intensive care unit: strengthening ongoing clinical risk assessment.

PubMed

Mullen, Antony; Drinkwater, Vincent; Lewin, Terry J

2014-03-01

To implement and evaluate the care zoning model in an eight-bed psychiatric intensive care unit and, specifically, to examine the model's ability to improve the documentation and communication of clinical risk assessment and management. Care zoning guides nurses in assessing clinical risk and planning care within a mental health context. Concerns about the varying quality of clinical risk assessment prompted a trial of the care zoning model in a psychiatric intensive care unit within a regional mental health facility. The care zoning model assigns patients to one of 3 'zones' according to their clinical risk, encouraging nurses to document and implement targeted interventions required to manage those risks. An implementation trial framework was used for this research to refine, implement and evaluate the impact of the model on nurses' clinical practice within the psychiatric intensive care unit, predominantly as a quality improvement initiative. The model was trialled for three months using a pre- and postimplementation staff survey, a pretrial file audit and a weekly file audit. Informal staff feedback was also sought via surveys and regular staff meetings. This trial demonstrated improvement in the quality of mental state documentation, and clinical risk information was identified more accurately. There was limited improvement in the quality of care planning and the documentation of clinical interventions. Nurses' initial concerns over the introduction of the model shifted into overall acceptance and recognition of the benefits. The results of this trial demonstrate that the care zoning model was able to improve the consistency and quality of risk assessment information documented. Care planning and evaluation of associated outcomes showed less improvement. Care zoning remains a highly applicable model for the psychiatric intensive care unit environment and is a useful tool in guiding nurses to carry out routine patient risk assessments. © 2013 John Wiley & Sons Ltd.
Development and deployment of a health information system in transitional countries (croatian experience).

PubMed

Stevanovic, Ranko; Pristas, Ivan; Ivicevic Uhernik, Ana; Stanic, Arsen

2005-01-01

Croatian Primary Health Care Information System pilot project, conducted between 2001 and 2003, aimed to develop and deploy a health information system based on the latest technologies which would improve the quality of primary health care and rationalise the consumption. 60 primary health care teams (physician and nurse) were equipped with PCs and connected via central server to the main national health insurer, state treasury and public health institute. Developed information system enabled rapid retrieval of documents, replacement of manual data input and a real-time insight into needed information as well as prompt interventions within the system. The project also introduced electronic smart cards for physicians and nurses, so that at each medical check-up the information system verified both the ensuree's and the physician's or nurse's status and rights.Based on the experiences from the pilot project, plan has been made for comprehensive health information system at national level which would connect primary health care teams, hospitals, laboratories, dentistries, health insurance companies, state treasury, public health institutes and electronic health records database. Its major goals are more rapid diagnostics, accuracy in prescribing therapy, standardisation of the good practice as well as better utilisation of capacities, shorter waiting times and shorter stays in hospitals, which would lead to improvement in overall health care quality and better control over the health care consumption. Estimated 5-year investment for installing such system would be 125 million EUR. However, information system could save substantially more and yield a return of investment in only two years.As information system for primary health care should be a strategic component of every health care reform and development plan, we can recommend our model, based on the results of the pilot project, to other transitional countries.
The professional profile of UFBA nursing management graduate students.

PubMed

Paiva, Mirian Santos; Coelho, Edméia de Almeida Cardoso; Nascimento, Enilda Rosendo do; Melo, Cristina Maria Meira de; Fernandes, Josicelia Dumêt; Santos, Ninalva de Andrade

2011-12-01

The objective of the present study was to analyze the professional profile of the nursing graduate students of Federal University of Bahia, more specifically of the nursing management area. This descriptive, exploratory study was performed using documental research. The data was collected from the graduates' curriculum on the Lattes Platform and from the graduate program documents, using a form. The study population consisted of graduates enrolled under the line of research The Organization and Evaluation of Health Care Systems, who developed dissertations/theses addressing Nursing/Health Management. The data were stored using Microsoft Excel, and then transferred to the STATA 9.0 statistical software. Results showed that most graduates are women, originally from the State of Bahia, and had completed the course between 2000 and 2011; faculty of public institutions who continued involved in academic work after completing the course. These results point at the program as an academic environment committed to preparing researchers.
Orienting and Onboarding Clinical Nurse Specialists: A Process Improvement Project.

PubMed

Garcia, Mayra G; Watt, Jennifer L; Falder-Saeed, Karie; Lewis, Brennan; Patton, Lindsey

Clinical nurse specialists (CNSs) have a unique advanced practice role. This article describes a process useful in establishing a comprehensive orientation and onboarding program for a newly hired CNS. The project team used the National Association of Clinical Nurse Specialists core competencies as a guide to construct a process for effectively onboarding and orienting newly hired CNSs. Standardized documents were created for the orientation process including a competency checklist, needs assessment template, and professional evaluation goals. In addition, other documents were revised to streamline the orientation process. Standardizing the onboarding and orientation process has demonstrated favorable results. As of 2016, 3 CNSs have successfully been oriented and onboarded using the new process. Unique healthcare roles require special focus when onboarding and orienting into a healthcare system. The use of the National Association of Clinical Nurse Specialists core competencies guided the project in establishing a successful orientation and onboarding process for newly hired CNSs.
Charge auditing from a nursing perspective.

PubMed

Obert, S J

1990-01-01

Many third-party payors, which include commercial health and auto insurance companies and workmen's compensation carriers, are requesting access to their clients' itemized patient statements and medical records for verifying accuracy of charges and documentation of services rendered. If even a portion of the payment is withheld until the audit is completed, slowing of cash flow results. A slow cash flow may ultimately have profound effects on the quality, or even availability, of patient care. Hospitals are finding it cost effective to have someone within their institution audit patient accounts and medical records to identify problem areas that may result in denial of payment. Nurses are being recruited to perform these audits because of their knowledge of documentation standards and patient account charging procedures. With this background, the nurse auditor is also able to assess educational needs of the nursing staff and work collaboratively with other departments to correct deficiencies.
Psychometric Testing of the Self-Efficacy for Interdisciplinary Plans of Care Scale.

PubMed

Molle, Elizabeth; Froman, Robin

2017-01-01

Computerized interdisciplinary plans of care have revitalized nurse-centric care plans into dynamic and meaningful electronic documents. To maximize the benefits of these documents, it is important to understand healthcare professionals' attitudes, specifically their confidence, for making computerized interdisciplinary care plans useful and meaningful documents. The purpose of the study was to test the psychometric properties of the Self-Efficacy for Interdisciplinary Plans of Care instrument intended to measure healthcare professionals' self-efficacy for using such documents. Content validity was assessed by an expert review panel. Content validity indices ranged from 0.75 to 1.00, with a scale CVI of 0.94. A sample of 389 healthcare providers completed the 14-item instrument. Principal axis factoring was used to assess factor structure. The exploratory factor analysis yielded a single-factor structure accounting for 71.76% of covariance. Cronbach internal consistency coefficient for the single factor solution was .97. The corrected item-total correlations ranged from 0.71 to 0.90. The coefficient of stability, during a 2-week period, with a subset of the sample (n = 38), was estimated at 0.82. The results of this study suggest that the Self-Efficacy for Interdisciplinary Plans of Care has sturdy reliability and validity for measuring the self-efficacy of healthcare providers to make computerized interdisciplinary plans of care meaningful and useful documents.
Piloting an information literacy program for staff nurses: lessons learned.

PubMed

Rosenfeld, Peri; Salazar-Riera, Noraliza; Vieira, Dorice

2002-01-01

Intrinsic to all models of evidence-based practice is the need for information literacy and the critical assessment of information. As part of a house-wide evidence-based practice initiative, the objective of this pilot project was to develop the information literacy skills of staff nurses to increase their ability to find and assess available electronic resources for clinical decision making. An intensive care unit was chosen to pilot a unit-based approach to educate staff nurses to perform patient care-related electronic literature searches. An additional goal was to determine the effectiveness of unit-based training sessions on the frequency and quality of electronic literature searches by participating nurses. In addition to the unit-based instruction, nursing and library staff collaborated to develop a Web-based tutorial to supplement and reinforce the content of the training sessions. A pretest-post-test design was used to evaluate the initiative and to assess the effect of the educational intervention over time. Among the lessons learned from this pilot study was that unit-based instruction presents significant obstacles for effective learning of new technological skills for staff nurses.
Electronic Medical Record-Based Radiation Oncology Toxicity Recording Instrument Aids Benchmarking and Quality Improvement in the Clinic.

PubMed

Albuquerque, Kevin; Rodgers, Kellie; Spangler, Ann; Rahimi, Asal; Willett, DuWayne

2018-03-01

The on-treatment visit (OTV) for radiation oncology is essential for patient management. Radiation toxicities recorded during the OTV may be inconsistent because of the use of free text and the lack of treatment site-specific templates. We developed a radiation oncology toxicity recording instrument (ROTOX) in a health system electronic medical record (EMR). Our aims were to assess improvement in documentation of toxicities and to develop clinic toxicity benchmarks. A ROTOX that was based on National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0) with flow-sheet functionality was developed in the EMR. Improvement in documentation was assessed at various time intervals. High-grade toxicities (ie, grade ≥ 3 by CTCAE) by site were audited to develop benchmarks and to track nursing and physician actions taken in response to these. A random sample of OTV notes from each clinic physician before ROTOX implementation was reviewed and assigned a numerical document quality score (DQS) that was based on completeness and comprehensiveness of toxicity grading. The mean DQS improved from an initial level of 41% to 99% (of the maximum possible DQS) when resampled at 6 months post-ROTOX. This high-level DQS was maintained 3 years after ROTOX implementation at 96% of the maximum. For months 7 to 9 after implementation (during a 3-month period), toxicity grading was recorded in 4,443 OTVs for 698 unique patients; 107 episodes of high-grade toxicity were identified during this period, and toxicity-specific intervention was documented in 95%. An EMR-based ROTOX enables consistent recording of treatment toxicity. In a uniform sample of patients, local population toxicity benchmarks can be developed, and clinic response can be tracked.
Collaboration as a process and an outcome: Consumer experiences of collaborating with nurses in care planning in an acute inpatient mental health unit.

PubMed

Reid, Rebecca; Escott, Phil; Isobel, Sophie

2018-04-14

This qualitative study explores inpatient mental health consumer perceptions of how collaborative care planning with mental health nurses impacts personal recovery. Semi-structured interviews were conducted with consumers close to discharge from one unit in Sydney, Australia. The unit had been undertaking a collaborative care planning project which encouraged nurses to use care plan documentation to promote person-centred and goal-focussed interactions and the development of meaningful strategies to aid consumer recovery. The interviews explored consumer understandings of the collaborative care planning process, perceptions of the utility of the care plan document and the process of collaborating with the nurses, and their perception of the impact of collaboration on their recovery. Findings are presented under four organizing themes: the process of collaborating, the purpose of collaborating, the nurse as collaborator and the role of collaboration in wider care and recovery. Consumers highlighted the importance of the process of developing their care plan with a nurse as being as helpful for recovery as the goals and strategies themselves. The findings provide insights into consumers' experiences of care planning in an acute inpatient unit, the components of care that support recovery and highlight specific areas for mental health nursing practice improvement in collaboration. © 2018 Australian College of Mental Health Nurses Inc.
Legal principles of confidentiality and other public interests: Part 1.

PubMed

Fullbrook, Suzanne

The principles of confidentiality are of paramount importance to nurses and all health professionals. This is explicitly so as the Common Law recognizes confidentiality and supports its importance. However, current practice must take cognizance of the realities of 21st century healthcare delivery - we live in an age of electronic data that is potentially very difficult to keep secret. New rules, protocols and guidelines are being formulated, and regulatory bodies such as the Nursing and Midwifery Council (NMC) reflect such rules in their codes of professional conduct. There is, however, a debate that is suggesting that the rules that relate to confidentiality may need to expand or even bend a little as innovate ways of obtaining, storing, utilizing and communicating data continue to occupy the minds of government and those who formulate legal principles (British Medical Association, 2005). This series of three articles will explore these issues. The first part is a review of case law that explores the fundamental legal principles that underpin confidentiality. The second will concentrate on a review of the guidelines that are to be found in professional regulatory documentation - the NMC and the General Medical Council as they relate to the legal principles. The third and last part will review and reflect on issues that relate expressly to the implementation of electronic patient records, with a review of appropriate statutory legislation and principles of common law.

Integrating experiential learning into a double degree masters program in nursing and health informatics.

PubMed

Borycki, Elizabeth M; Frisch, Noreen; Kushniruk, Andre W; McIntyre, Marjorie; Hutchinson, David

2012-01-01

In Canada there are few nurses who have advanced practice competencies in nursing informatics. This is a significant issue for regional health authorities, governments and electronic health record vendors in Canada who are implementing electronic health records. Few Schools of Nursing provide formalized opportunities for nurses to develop informatics competencies. Many of these opportunities take the form of post-baccalaureate certificate programs or individual undergraduate or graduate level courses in nursing. The purpose of this paper will be to: (1) describe the health and human resource issues in this area in Canada, (2) provide a brief overview of the design and development of a new, innovative double degree program at the intersection of nursing and health informatics that interleaves cooperative learning, (3) describe the integration of cooperative learning into this new program, and (4) outline the lessons learned in integrating cooperative education into such a graduate program.
Tubing misconnections--a systems failure with human factors: lessons for nursing practice.

PubMed

Simmons, Debora; Graves, Krisanne

2008-12-01

In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.
Critical Behaviors in Psychiatric-Mental Health Nursing. Volume 1: A Survey of Mental Health Nursing Practices.

ERIC Educational Resources Information Center

Jacobs, Angeline Marchese; And Others

This document describes the methodology followed in obtaining abstracts (see volumes 2 and 3) of more than 8,000 critical behaviors of nurses and attendants in delivering care in 50 psychiatric and mental health facilities throughout the country. The abstracts were derived from reports of actual observations by 1,785 mental health practitioners in…
Coverage, universal access and equity in health: a characterization of scientific production in nursing.

PubMed

Mendoza-Parra, Sara

2016-01-01

to characterize the scientific contribution nursing has made regarding coverage, universal access and equity in health, and to understand this production in terms of subjects and objects of study. this was cross-sectional, documentary research; the units of analysis were 97 journals and 410 documents, retrieved from the Web of Science in the category, "nursing". Descriptors associated to coverage, access and equity in health, and the Mesh thesaurus, were applied. We used bibliometric laws and indicators, and analyzed the most important articles according to amount of citations and collaboration. the document retrieval allowed for 25 years of observation of production, an institutional and an international collaboration of 31% and 7%, respectively. The mean number of coauthors per article was 3.5, with a transience rate of 93%. The visibility index was 67.7%, and 24.6% of production was concentrated in four core journals. A review from the nursing category with 286 citations, and a Brazilian author who was the most productive, are issues worth highlighting. the nursing collective should strengthen future research on the subject, defining lines and sub-lines of research, increasing internationalization and building it with the joint participation of the academy and nursing community.
Nursing service innovation: A case study examining emergency nurse practitioner service sustainability.

PubMed

Fox, Amanda; Gardner, Glenn; Osborne, Sonya

2018-02-01

This research aimed to explore factors that influence sustainability of health service innovation, specifically emergency nurse practitioner service. Planning for cost effective provision of healthcare services is a concern globally. Reform initiatives are implemented often incorporating expanding scope of practice for health professionals and innovative service delivery models. Introducing new models is costly in both human and financial resources and therefore understanding factors influencing sustainability is imperative to viable service provision. This research used case study methodology (Yin, ). Data were collected during 2014 from emergency nurse practitioners, emergency department multidisciplinary team members and documents related to nurse practitioner services. Collection methods included telephone and semi-structured interviews, survey and document analysis. Pattern matching techniques were used to compare findings with study propositions. In this study, emergency nurse practitioner services did not meet factors that support health service sustainability. Multidisciplinary team members were confident that emergency nurse practitioner services were safe and helped to meet population health needs. Organizational support for integration of nurse practitioner services was marginal and led to poor understanding of service capability and underuse. This research provides evidence informing sustainability of nursing service models but more importantly raises questions about this little explored field. The findings highlight poor organizational support, excessive restrictions and underuse of the service. This is in direct contrast to contemporary expanding practice reform initiatives. Organizational support for integration is imperative to future service sustainability. © 2017 John Wiley & Sons Ltd.
Juggling confidentiality and safety: a qualitative study of how general practice clinicians document domestic violence in families with children.

PubMed

Drinkwater, Jessica; Stanley, Nicky; Szilassy, Eszter; Larkins, Cath; Hester, Marianne; Feder, Gene

2017-06-01

Domestic violence and abuse (DVA) and child safeguarding are interlinked problems, impacting on all family members. Documenting in electronic patient records (EPRs) is an important part of managing these families. Current evidence and guidance, however, treats DVA and child safeguarding separately. This does not reflect the complexity clinicians face when documenting both issues in one family. To explore how and why general practice clinicians document DVA in families with children. A qualitative interview study using vignettes with GPs and practice nurses (PNs) in England. Semi-structured telephone interviews with 54 clinicians (42 GPs and 12 PNs) were conducted across six sites in England. Data were analysed thematically using a coding frame incorporating concepts from the literature and emerging themes. Most clinicians recognised DVA and its impact on child safeguarding, but struggled to work out the best way to document it. They described tensions among the different roles of the EPR: a legal document; providing continuity of care; information sharing to improve safety; and a patient-owned record. This led to strategies to hide information, so that it was only available to other clinicians. Managing DVA in families with children is complex and challenging for general practice clinicians. National integrated guidance is urgently needed regarding how clinicians should manage the competing roles of the EPR, while maintaining safety of the whole family, especially in the context of online EPRs and patient access. © British Journal of General Practice 2017.
Juggling confidentiality and safety: a qualitative study of how general practice clinicians document domestic violence in families with children

PubMed Central

Drinkwater, Jessica; Stanley, Nicky; Szilassy, Eszter; Larkins, Cath; Hester, Marianne; Feder, Gene

2017-01-01

Background Domestic violence and abuse (DVA) and child safeguarding are interlinked problems, impacting on all family members. Documenting in electronic patient records (EPRs) is an important part of managing these families. Current evidence and guidance, however, treats DVA and child safeguarding separately. This does not reflect the complexity clinicians face when documenting both issues in one family. Aim To explore how and why general practice clinicians document DVA in families with children. Design and setting A qualitative interview study using vignettes with GPs and practice nurses (PNs) in England. Method Semi-structured telephone interviews with 54 clinicians (42 GPs and 12 PNs) were conducted across six sites in England. Data were analysed thematically using a coding frame incorporating concepts from the literature and emerging themes. Results Most clinicians recognised DVA and its impact on child safeguarding, but struggled to work out the best way to document it. They described tensions among the different roles of the EPR: a legal document; providing continuity of care; information sharing to improve safety; and a patient-owned record. This led to strategies to hide information, so that it was only available to other clinicians. Conclusion Managing DVA in families with children is complex and challenging for general practice clinicians. National integrated guidance is urgently needed regarding how clinicians should manage the competing roles of the EPR, while maintaining safety of the whole family, especially in the context of online EPRs and patient access. PMID:28137783
Methodological tools for the collection and analysis of participant observation data using grounded theory.

PubMed

Laitinen, Heleena; Kaunonen, Marja; Astedt-Kurki, Päivi

2014-11-01

To give clarity to the analysis of participant observation in nursing when implementing the grounded theory method. Participant observation (PO) is a method of collecting data that reveals the reality of daily life in a specific context. In grounded theory, interviews are the primary method of collecting data but PO gives a distinctive insight, revealing what people are really doing, instead of what they say they are doing. However, more focus is needed on the analysis of PO. An observational study carried out to gain awareness of nursing care and its electronic documentation in four acute care wards in hospitals in Finland. Discussion of using the grounded theory method and PO as a data collection tool. The following methodological tools are discussed: an observational protocol, jotting of notes, microanalysis, the use of questioning, constant comparison, and writing and illustrating. Each tool has specific significance in collecting and analysing data, working in constant interaction. Grounded theory and participant observation supplied rich data and revealed the complexity of the daily reality of acute care. In this study, the methodological tools provided a base for the study at the research sites and outside. The process as a whole was challenging. It was time-consuming and it required rigorous and simultaneous data collection and analysis, including reflective writing. Using these methodological tools helped the researcher stay focused from data collection and analysis to building theory. Using PO as a data collection method in qualitative nursing research provides insights. It is not commonly discussed in nursing research and therefore this study can provide insight, which cannot be seen or revealed by using other data collection methods. Therefore, this paper can produce a useful tool for those who intend to use PO and grounded theory in their nursing research.
[Connections among nursing, nutrition and social work, pioneering female careers in the healthcare area].

PubMed

Aperibense, Pacita Geovana Gama de Sousa; Barreira, Ieda de Alencar

2008-09-01

This is a historical-social research about the emergence of the nutrition and social work professions between the 1930's and the mid 20th century. This study analyzes the circumstances involved in the beginning of both courses, nutrition and social work, at Anna Nery School/FURJ and compares the work developed by nurses, nutritionists, and social workers at the time. The primary research sources are found at School of Nursing Anna Nery Archives Center/FURJ and among other documents they include written documents and oral speeches. The secondary sources were articles, books, and theses. The analyses of these texts and documents showed that the school played a decisive role in the emergence of these new professions, which contributed to a better organization and operation of health services and to a more complete care provision to the clients. At the same time, their feminine characteristics appeared to benefit the insertion of women in qualified work positions in the mental health area.
A scoping review of training and deployment policies for human resources for health for maternal, newborn, and child health in rural Africa.

PubMed

Murphy, Gail Tomblin; Goma, Fastone; MacKenzie, Adrian; Bradish, Stephanie; Price, Sheri; Nzala, Selestine; Rose, Annette Elliott; Rigby, Janet; Muzongwe, Chilweza; Chizuni, Nellisiwe; Carey, Amanda; Hamavhwa, Derrick

2014-12-16

Most African countries are facing a human resources for health (HRH) crisis, lacking the required workforce to deliver basic health care, including care for mothers and children. This is especially acute in rural areas and has limited countries' abilities to meet maternal, newborn, and child health (MNCH) targets outlined by Millennium Development Goals 4 and 5. To address the HRH challenges, evidence-based deployment and training policies are required. However, the resources available to country-level policy makers to create such policies are limited. To inform future HRH planning, a scoping review was conducted to identify the type, extent, and quality of evidence that exists on HRH policies for rural MNCH in Africa. Fourteen electronic health and health education databases were searched for peer-reviewed papers specific to training and deployment policies for doctors, nurses, and midwives for rural MNCH in African countries with English, Portuguese, or French as official languages. Non-peer reviewed literature and policy documents were also identified through systematic searches of selected international organizations and government websites. Documents were included based on pre-determined criteria. There was an overall paucity of information on training and deployment policies for HRH for MNCH in rural Africa; 37 articles met the inclusion criteria. Of these, the majority of primary research studies employed a variety of qualitative and quantitative methods. Doctors, nurses, and midwives were equally represented in the selected policy literature. Policies focusing exclusively on training or deployment were limited; most documents focused on both training and deployment or were broader with embedded implications for the management of HRH or MNCH. Relevant government websites varied in functionality and in the availability of policy documents. The lack of available documentation and an apparent bias towards HRH research in developed areas suggest a need for strengthened capacity for HRH policy research in Africa. This will result in enhanced potential for evidence uptake into policy. Enhanced alignment between policy-makers' information needs and the independent research agenda could further assist knowledge development and uptake. The results of this scoping review informed an in-depth analysis of relevant policies in a sub-set of African countries.
Nursing informatics, outcomes, and quality improvement.

PubMed

Charters, Kathleen G

2003-08-01

Nursing informatics actively supports nursing by providing standard language systems, databases, decision support, readily accessible research results, and technology assessments. Through normalized datasets spanning an entire enterprise or other large demographic, nursing informatics tools support improvement of healthcare by answering questions about patient outcomes and quality improvement on an enterprise scale, and by providing documentation for business process definition, business process engineering, and strategic planning. Nursing informatics tools provide a way for advanced practice nurses to examine their practice and the effect of their actions on patient outcomes. Analysis of patient outcomes may lead to initiatives for quality improvement. Supported by nursing informatics tools, successful advance practice nurses leverage their quality improvement initiatives against the enterprise strategic plan to gain leadership support and resources.
[The nursing course of Universidade Federal de Juiz de Fora: 1977-1979].

PubMed

Figueiredo, Mariangela Aparecida Gonçalves; Baptista, Suely de Souza

2009-01-01

Historic-social research aiming at: characterize the nursing superior teaching in Juiz de Fora city and to discuss the reason and motivations which determined the creation of Nursing Course of the Universidade Federal de Juiz de Fora. Primary source: written documents and oral testimony. The results discussion was guided by Pierre Bourdieu. In the 1970's, Education Ministry Department of University Subjects undertook efforts to create nursing courses in federal universities. As the process of negotiation meant to incorporate Hermantina Beraldo Nursing College to Universidade Federal de Juiz de Fora failed, in 1978 a Department of Nursing was bind to UFJF Medical College and, in 1970, the Nursing Course of this same university started functioning.
The use of electronic devices for communication with colleagues and other healthcare professionals - nursing professionals' perspectives.

PubMed

Koivunen, Marita; Niemi, Anne; Hupli, Maija

2015-03-01

The aim of the study is to describe nursing professionals' experiences of the use of electronic devices for communication with colleagues and other healthcare professionals. Information and communication technology applications in health care are rapidly expanding, thanks to the fast-growing penetration of the Internet and mobile technology. Communication between professionals in health care is essential for patient safety and quality of care. Implementing new methods for communication among healthcare professionals is important. A cross-sectional survey was used in the study. The data were collected in spring 2012 using an electronic questionnaire with structured and open-ended questions. The target group comprised the nursing professionals (N = 567, n = 123) in one healthcare district who worked in outpatient clinics in publically funded health care in Finland. Nursing professionals use different electronic devices for communication with each other. The most often used method was email, while the least used methods were question-answer programmes and synchronous communication channels on the Internet. Communication using electronic devices was used for practical nursing, improving personnel competences, organizing daily operations and administrative tasks. Electronic devices may speed up the management of patient data, improve staff cooperation and competence and make more effective use of working time. The obstacles were concern about information security, lack of technical skills, unworkable technology and decreasing social interaction. According to our findings, despite the obstacles related to use of information technology, the use of electronic devices to support communication among healthcare professionals appears to be useful. © 2014 John Wiley & Sons Ltd.
Capturing district nursing through a knowledge-based electronic caseload analysis tool (eCAT).

PubMed

Kane, Kay

2014-03-01

The Electronic Caseload Analysis Tool (eCAT) is a knowledge-based software tool to assist the caseload analysis process. The tool provides a wide range of graphical reports, along with an integrated clinical advisor, to assist district nurses, team leaders, operational and strategic managers with caseload analysis by describing, comparing and benchmarking district nursing practice in the context of population need, staff resources, and service structure. District nurses and clinical lead nurses in Northern Ireland developed the tool, along with academic colleagues from the University of Ulster, working in partnership with a leading software company. The aim was to use the eCAT tool to identify the nursing need of local populations, along with the variances in district nursing practice, and match the workforce accordingly. This article reviews the literature, describes the eCAT solution and discusses the impact of eCAT on nursing practice, staff allocation, service delivery and workforce planning, using fictitious exemplars and a post-implementation evaluation from the trusts.
Clinical decision support improves quality of telephone triage documentation - an analysis of triage documentation before and after computerized clinical decision support

PubMed Central

2014-01-01

Background Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. Methods We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. Results Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). Conclusions CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care. PMID:24645674
Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support.

PubMed

North, Frederick; Richards, Debra D; Bremseth, Kimberly A; Lee, Mary R; Cox, Debra L; Varkey, Prathibha; Stroebel, Robert J

2014-03-20

Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed to determine if it results in improved care.
Identifying Nursing Interventions in a Cancer Screening Program Using Nursing Interventions Classification Taxonomy.

PubMed

Benito, Llucia; Lluch, María Teresa; Falcó, Anna Marta; García, Montse; Puig, Montse

2017-04-01

This study aimed to investigate which Nursing Interventions Classification (NIC) labels correspond to specific nursing interventions provided during cancer screening to establish a nursing documentation system. This descriptive study was conducted to identify and classify the interventions that cancer screening nurses perform based on an initial list. The initial list was grouped into 15 interventions that corresponded to four domains and eight classes. The study found expert consensus regarding the duties of cancer screening nurses and identified 15 interventions that should be implemented in clinical practice for cancer screening care, according to the NIC taxonomy. This study is the first step in developing indicators to assess nursing performance in cancer screening, and it helps to establish the core competency requirements for cancer screening nurses. © 2015 NANDA International, Inc.
Electronic medical record in cardiology: a 10-year Italian experience.

PubMed

Carpeggiani, Clara; Macerata, Alberto; Morales, Maria Aurora

2015-08-01

the aim of this study was to report a ten years experience in the electronic medical record (EMR) use. An estimated 80% of healthcare transactions are still paper-based. an EMR system was built at the end of 1998 in an Italian tertiary care center to achieve total integration among different human and instrumental sources, eliminating paper-based medical records. Physicians and nurses who used EMR system reported their opinions. In particular the hospital activity supported electronically, regarding 4,911 adult patients hospitalized in the 2004- 2008 period, was examined. the final EMR product integrated multimedia document (text, images, signals). EMR presented for the most part advantages and was well adopted by the personnel. Appropriateness evaluation was also possible for some procedures. Some disadvantages were encountered, such as start-up costs, long time required to learn how to use the tool, little to no standardization between systems and the EMR technology. the EMR is a strategic goal for clinical system integration to allow a better health care quality. The advantages of the EMR overcome the disadvantages, yielding a positive return on investment to health care organization.
Adverse nurse outcomes: correlation to nurses' workload, staffing, and shift rotation in Kuwaiti hospitals.

PubMed

Al-Kandari, Fatimah; Thomas, Deepa

2008-08-01

This study was conducted to identify adverse outcomes to nurses in relation to their daily patient load, nursing care activities, staffing, and shift rotation. A structured questionnaire was used to collect data from medical and surgical nurses (N = 784). Skipping tea/coffee breaks (95%), feeling responsible for more patients than they could safely care for (87%), inadequate help available (86%), inadequate time to document care (80%), verbal abuse by a patient or a visitor (77%), and concern about quality of care (71%) were the major reported adverse outcomes related to short staffing, increased patient load, and increased nursing care activities.
A collective case study of nursing students with learning disabilities.

PubMed

Kolanko, Kathrine M

2003-01-01

This collective case study described the meaning of being a nursing student with a learning disability and examined how baccalaureate nursing students with learning disabilities experienced various aspects of the nursing program. It also examined how their disabilities and previous educational and personal experiences influenced the meaning that they gave to their educational experiences. Seven nursing students were interviewed, completed a demographic data form, and submitted various artifacts (test scores, evaluation reports, and curriculum-based material) for document analysis. The researcher used Stake's model for collective case study research and analysis (1). Data analysis revealed five themes: 1) struggle, 2) learning how to learn with LD, 3) issues concerning time, 4) social support, and 5) personal stories. Theme clusters and individual variations were identified for each theme. Document analysis revealed that participants had average to above average intellectual functioning with an ability-achievement discrepancy among standardized test scores. Participants noted that direct instruction, structure, consistency, clear directions, organization, and a positive instructor attitude assisted learning. Anxiety, social isolation from peers, and limited time to process and complete work were problems faced by the participants.

Participant action research with bedside nurses to identify NANDA-International, Nursing Interventions Classification, and Nursing Outcomes Classification categories for hospitalized persons with diabetes.

PubMed

Minthorn, Crista; Lunney, Margaret

2012-05-01

Experienced bedside nurses identified 14 nursing diagnoses, 78 interventions, and 76 health outcomes for hospitalized persons with diabetes. Using these terms, the nursing department revised the standards of care and the electronic health record. Nurses' engagement in generating knowledge translated to increased interest in research. This methodology is recommended for other agencies. Copyright © 2012 Elsevier Inc. All rights reserved.
Use of Clinical Health Information Technology in Nursing Homes: Nursing Home Characteristics and Quality Measures

ERIC Educational Resources Information Center

Spinelli-Moraski, Carla

2014-01-01

This study compares quality measures among nursing homes that have adopted different levels of clinical health information technology (HIT) and examines the perceived barriers and benefits of the adoption of electronic health records as reported by Nursing Home Administrators and Directors of Nursing. A cross-sectional survey distributed online to…
Innovations in Master's Nursing Education: New Ways of Learning for the Marketplace. Proceedings of the American Association of Colleges of Nursing Annual Conference on Master's Education (7th, San Antonio, Texas, December 4-6, 1997).

ERIC Educational Resources Information Center

American Association of Colleges of Nursing, Washington, DC.

This proceedings document presents eight papers given at a 1997 conference on nursing education at the master's degree level. The papers are: (1) "Reality of the Marketplace for Advanced Practice Nursing" (Mary Elizabeth Mancini); (2) "Providing Faculty with the Skills to Teach in a Changing World" (Diane Skiba); (3) "Charting New Territory:…
Traditional classroom education versus computer-based learning: how nurses learn about pressure ulcers.

PubMed

Esche, Carol Ann; Warren, Joan I; Woods, Anne B; Jesada, Elizabeth C; Iliuta, Ruth

2015-01-01

The goal of the Nurse Professional Development specialist is to utilize the most effective educational strategies when educating staff nurses about pressure ulcer prevention. More information is needed about the effect of computer-based learning and traditional classroom learning on pressure ulcer education for the staff nurse. This study compares computer-based learning and traditional classroom learning on immediate and long-term knowledge while evaluating the impact of education on pressure ulcer risk assessment, staging, and documentation.
Development of the role of public health nurses in addressing child and family poverty: a framework for action.

PubMed

Cohen, Benita E; Reutter, Linda

2007-10-01

The purpose of this paper is to invite dialogue about how public health nurses could best address child and family poverty. Their current role is reviewed and a framework for expanding this role is presented. The negative health consequences of poverty for children are well-documented worldwide. The high levels of children living in poverty in wealthy industrialized countries such as Canada should be of concern to the health sector. What role(s) can public health nurses play in addressing child and family poverty? A review of scholarly literature from Canada, the United States of America and the United Kingdom was conducted to ascertain support for public health nurses' roles in reducing poverty and its effects. We then reviewed professional standards and competencies for nursing practice in Canada. The data were collected between 2005 and 2006. Numerous nursing scholars have called for public health nurses to address the causes and consequences of poverty through policy advocacy. However, this role was less likely to be identified in professional standards and competencies, and we found little empirical evidence documenting Canadian public health nurses' efforts to engage in this role. Public health nurses' roles in relation to poverty focus primarily on assisting families living in poverty to access appropriate services rather than directing efforts at the policy level. Factors associated with this limited involvement are identified. We suggest that the conceptual framework developed by Blackburn in the United Kingdom offers direction for a more fully developed public health nursing role. Prerequisites to engaging in the strategies articulated in the framework are discussed. Given more organizational support and enhanced knowledge and skills, public health nurses could be playing a greater role in working with others to make child and family poverty history.
The Basic Documentation for Psycho-Oncology (PO-Bado): an innovative tool to combine screening for psychological distress and patient support at cancer diagnosis.

PubMed

Stadelmaier, Nena; Duguey-Cachet, Odile; Saada, Yael; Quintard, Bruno

2014-03-01

The Basic Documentation for Psycho-Oncology (PO-Bado) is a semi-directive instrument for assessing psychosocial difficulties in cancer patients. It is based on subjective status and not on degree of symptom severity. Our objectives were to assess whether use of the PO-Bado during post-cancer-diagnosis consultations improves the quality of communication by establishing a supportive relationship between nurses and patients and to assess nurses' satisfaction of their communication skills. Data were collected from post-diagnosis 'bad-news' consultations across four Cancer treatment centres in South West France. Eleven nurses who had never used the PO-Bado ('inexperienced group') received training on the instrument (short-form). Twenty-one pre-training consultations without the PO-Bado were recorded and compared with 21 post-training consultations with the PO-Bado. Twenty consultations with four nurses with experience using the PO-Bado ('experienced group') were included for between-group comparisons. Nurses' satisfaction was evaluated through semi-directive consultations at the end of the study and completed by a visual analogue scale. We transcribed and analysed 62 consultations. We observed greater use of techniques encouraging patient expression in consultations with PO-Bado-experienced nurses (p < 0.01); after PO-Bado training for 'inexperienced' nurses (p < 0.05) and less use of non-encouraging techniques after PO-Bado training for 'inexperienced' nurses (p < 0.01). Nurses felt more satisfied with their communications skills after PO-Bado training and stated that they felt more competent, particularly for referrals to psychologists. The PO-Bado is beneficial for the quality of the communication between nurses and patients at bad-news delivery consultations and for the satisfaction of nurses with regard to their relational skills. Copyright © 2013 John Wiley & Sons, Ltd.
Deconstructing Clinical Workflow: Identifying Teaching-Learning Principles for Barcode Electronic Medication Administration With Nursing Students.

PubMed

Booth, Richard G; Sinclair, Barbara; Strudwick, Gillian; Brennan, Laura; Morgan, Lisa; Collings, Stephanie; Johnston, Jessica; Loggie, Brittany; Tong, James; Singh, Chantal

The purpose of this quality improvement project was to better understand how to teach medication administration underpinned by an electronic medication administration record (eMAR) system used in simulated, prelicensure nursing education. Methods included a workflow and integration analysis and a detailed process mapping of both an oral and a sublingual medication administration. Procedural and curriculum development considerations related to medication administration using eMAR technology are presented for nurse educators.
Technology-based strategies for promoting clinical reasoning skills in nursing education.

PubMed

Shellenbarger, Teresa; Robb, Meigan

2015-01-01

Faculty face the demand of preparing nursing students for the constantly changing health care environment. Effective use of online, classroom, and clinical conferencing opportunities helps to enhance nursing students' clinical reasoning capabilities needed for practice. The growth of technology creates an avenue for faculty to develop engaging learning opportunities. This article presents technology-based strategies such as electronic concept mapping, electronic case histories, and digital storytelling that can be used to facilitate clinical reasoning skills.
Formalizing nursing knowledge: from theories and models to ontologies.

PubMed

Peace, Jane; Brennan, Patricia Flatley

2009-01-01

Knowledge representation in nursing is poised to address the depth of nursing knowledge about the specific phenomena of importance to nursing. Nursing theories and models may provide a starting point for making this knowledge explicit in representations. We combined knowledge building methods from nursing and ontology design methods from biomedical informatics to create a nursing representation of family health history. Our experience provides an example of how knowledge representations may be created to facilitate electronic support for nursing practice and knowledge development.
[Development and validation of an instrument for initial nursing assessment].

PubMed

Fernández-Sola, Cayetano; Granero-Molina, José; Mollinedo-Mallea, Judith; de Gonzales, María Hilda Peredo; Aguilera-Manrique, Gabriel; Ponce, Mara Luna

2012-12-01

The objective of this study, conducted in Bolivia from April to July of 2008, is the design and validation of an initial nursing assessment instrument to be used in clinical and educational environments in Santa Cruz (Bolivia). Twelve Bolivian nurses participated; both document analysis as well as consensus techniques were used to determine the categories and criteria to be assessed. Categories included in the nursing assessment instrument are a physical assessment and the eleven Gordon's Functional Health Patterns. The nursing assessment instrument stands out as being concise, easy to complete and utilizing a nursing approach. It does not include items for advanced nursing assessment. However, it incorporates items regarding lifestyle and the patient's autonomy. The nursing assessment instrument contributes to improving the quality of clinical records, supports the nursing diagnosis and implementation of the nursing process, promotes the nurse's role and helps to standardize practice.
Educating Nurses in the Design and Use of a Nursing Data Base

PubMed Central

Carlsen, Ruth H.

1982-01-01

The arrival of a computerized medical information system on the health care scene has created new performance demands on nurses. Not only must nurses be able to use the computer to document medical and nursing care, but they must be able to contribute to the overall design of the nursing data base. This paper describes how nurses must be educated to perform these new job responsibilities. Discussion will center on the educational process developed by the Clinical Center at the National Institutes of Health to meet the needs of its nurses to design a nursing data base and learn the technical skill required to utilize a computerized medical information system. Recommendations are offered to the academic community charged with the formal education of nursing professionals and the staff development and continuing educational planners who share the accountability for educating the already licensed nurses.
Nurse education regarding agitated patients and its effects on clinical practice.

PubMed

Ozdemir, Leyla; Karabulut, Erdem

This study identified the impact of an education program on nurses' practices for agitated patients and documented the changes in practice after completion of the training. Eighteen cardiac intensive care nurses were included to the study. Prior to nurses' participation in an education program, a pre-test indicating nurses' current practices for 40 agitated patients was evaluated with the 'Nurse Practice Form'. After the pre-test data collection period was completed, the 2-day training program on caring for agitated patients was conducted. The last step of the study was evaluation of post-test nurses' practices for 40 agitated patients using the 'Nurse Practice Form'. The findings indicated that instead of pre-test nurses' use of physical restraints for controlling agitated patients without a physician order, none of post-test nurses applied them. The training program provided nurses the knowledge and skills needed to evaluate and to manage the causes of agitation.
Challenges of Documenting Schoolchildren's Psychosocial Health: A Qualitative Study

ERIC Educational Resources Information Center

Clausson, Eva K.; Berg, Agneta; Janlöv, Ann-Christin

2015-01-01

The aim of this study was to explore school nurses' experience of challenges related to documenting schoolchildren's psychosocial health in Sweden. Six focus group discussions were carried out. Areas for discussions included questions about situations, especially challenging to document as well as what constrains and/or facilitates documenting…
The relationship of staffing and work environment with implicit rationing of nursing care in Swiss nursing homes--A cross-sectional study.

PubMed

Zúñiga, Franziska; Ausserhofer, Dietmar; Hamers, Jan P H; Engberg, Sandra; Simon, Michael; Schwendimann, René

2015-09-01

Implicit rationing of nursing care refers to the withdrawal of or failure to carry out necessary nursing care activities due to lack of resources, in the literature also described as missed care, omitted care, or nursing care left undone. Under time constraints, nurses give priority to activities related to vital medical needs and the safety of the patient, leaving out documentation, rehabilitation, or emotional support of patients. In nursing homes, little is known about the occurrence of implicit rationing of nursing care and possible contributing factors. The purpose of this study was (1) to describe levels and patterns of self-reported implicit rationing of nursing care in Swiss nursing homes and (2) to explore the relationship between staffing level, turnover, and work environment factors and implicit rationing of nursing care. Cross-sectional, multi-center sub-study of the Swiss Nursing Home Human Resources Project (SHURP). Nursing homes from all three language regions of Switzerland. A random selection of 156 facilities with 402 units and 4307 direct care workers from all educational levels (including 25% registered nurses). We utilized data from established scales to measure implicit rationing of nursing care (Basel Extent of Rationing of Nursing Care), perceptions of leadership ability and staffing resources (Practice Environment Scale of the Nursing Work Index), teamwork and safety climate (Safety Attitudes Questionnaire), and work stressors (Health Professions Stress Inventory). Staffing level and turnover at the unit level were measured with self-developed questions. Multilevel linear regression models were used to explore the proposed relationships. Implicit rationing of nursing care does not occur frequently in Swiss nursing homes. Care workers ration support in activities of daily living, such as eating, drinking, elimination and mobilization less often than documentation of care and the social care of nursing homes residents. Statistically significant factors related to implicit rationing of care were the perception of lower staffing resources, teamwork and safety climate, and higher work stressors. Unit staffing and turnover levels were not related to rationing activities. Improving teamwork and reducing work stressors could possibly lead to less implicit rationing of nursing care. Further research on the relationship of implicit rationing of nursing care and resident and care worker outcomes in nursing homes is requested. Copyright © 2015 Elsevier Ltd. All rights reserved.
Forensic nursing. Applications in the occupational health setting.

PubMed

Pozzi, C L

1996-11-01

1. Nurses are inherent investigators through the use of observation, data gathering, and documentation techniques. 2. Occupational health nurses may be involved in assisting with or evaluating workplace accidents, injuries, and deaths. These investigations may be the only critical information gathered. 3. Accurate and through investigations are critical for clients, physicians, insurance companies, medical investigators, law enforcement, legal proceedings, and the company. Utilizing improper techniques during accident investigations could potentially dismiss a litigation case or lead to hazardous situations. 4. The occupational health nurse can improve practices related to investigations by understanding and learning more about forensic nursing.
A nursing data base for initial patient assessment.

PubMed

Hartman, D; Knudson, J

1991-01-01

The introduction of nursing diagnoses at Saddleback Memorial Medical Center, Laguna Hills, CA, resulted in the nursing process becoming the basis for the documentation system. However, the medical model or body system remained the organizational structure for nursing data collection and narrative charting. The need for a model that would aid in identification and treatment of illness and not negatively affect the nursing process was the impetus behind the selection of Gordon's functional health patterns as the assessment format. These patterns provide a standard method for data collection and a holistic approach to assessment and diagnosis.
Practical Nursing. Ohio's Competency Analysis Profile.

ERIC Educational Resources Information Center

Ohio State Univ., Columbus. Vocational Instructional Materials Lab.

Developed through a modified DACUM (Developing a Curriculum) process involving business, industry, labor, and community agency representatives in Ohio, this document is a comprehensive and verified employer competency profile for practical nursing. The list contains units (with and without subunits), competencies, and competency builders that…
Nurses' Perceptions of the Electronic Health Record

ERIC Educational Resources Information Center

Crawley, Rocquel Devonne

2013-01-01

The implementation of electronic health records (EHR) by health care organizations has been limited. Despite the broad consensus on the potential benefits of EHRs, health care organizations have been slow to adopt the technology. The purpose of this qualitative phenomenological study was to explore licensed practical and registered nurses'…
Informed consent: Part II.

PubMed

Murphy, E K

1988-05-01

Although the legal responsibility to inform and obtain the patient's consent lies with the surgeon, the agency may have a duty to ensure that the patient's consent has been obtained. Agency liability is limited to those cases in which the agency knew (or should have known) that informed consent was not obtained. It is still unclear whether agencies have an affirmative duty to ensure that consent has been obtained. If this duty does exist, it appears that a policy requiring documentation in the medical record of the patient's consent meets this requirement. It is clear that whatever the extent of the agency's duty, it does not include the duty to give the patient information or assess his or her level of understanding. Court opinions discourage anyone but the physician from doing so. A nurse's legal responsibility is limited to following agency policy. Courts have not recognized any independent nurse duty beyond that which accrues to them as employees of the agency. Perioperative nurses often provide the final checkpoint that consent has been obtained and documented before the procedure begins. This unique position raises additional legal concerns if the agency's policy is not followed or if the premedicated patient arrives without proper consent documentation in the record. Perioperative nursing concerns will be discussed next month in Part III.
Evaluation of the mining techniques in constructing a traditional Chinese-language nursing recording system.

PubMed

Liao, Pei-Hung; Chu, William; Chu, Woei-Chyn

2014-05-01

In 2009, the Department of Health, part of Taiwan's Executive Yuan, announced the advent of electronic medical records to reduce medical expenses and facilitate the international exchange of medical record information. An information technology platform for nursing records in medical institutions was then quickly established, which improved nursing information systems and electronic databases. The purpose of the present study was to explore the usability of the data mining techniques to enhance completeness and ensure consistency of nursing records in the database system.First, the study used a Chinese word-segmenting system on common and special terms often used by the nursing staff. We also used text-mining techniques to collect keywords and create a keyword lexicon. We then used an association rule and artificial neural network to measure the correlation and forecasting capability for keywords. Finally, nursing staff members were provided with an on-screen pop-up menu to use when establishing nursing records. Our study found that by using mining techniques we were able to create a powerful keyword lexicon and establish a forecasting model for nursing diagnoses, ensuring the consistency of nursing terminology and improving the nursing staff's work efficiency and productivity.

Spinal cord testing: auditing for quality assurance.

PubMed

Marr, J A; Reid, B

1991-04-01

A quality assurance audit of spinal cord testing as documented by staff nurses was carried out. Twenty-five patient records were examined for accuracy of documented testing and compared to assessments performed by three investigators. A pilot study established interrater reliability of a tool that was designed especially for this study. Results indicated staff nurses failed to meet pre-established 100% standard in all categories of testing when compared with investigator's findings. Possible reasons for this disparity are discussed as well as indications for modifications in the spinal testing record, teaching program and preset standards.
Nursing record systems: effects on nursing practice and health care outcomes.

PubMed

Currell, R; Wainwright, P; Urquhart, C

2000-01-01

A nursing record system is the record of care planned and/or given to individual patients/clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice. To assess the effects of nursing record systems on nursing practice and patient outcomes. We searched The Cochrane Library, MEDLINE, Cinahl, Sigle, and databases of the Royal College of Nursing, King's Fund, the NHS Centre for Reviews and Dissemination, and the Institute of Electrical Engineers up to August 1999; and OCLC First Search, Department of Health database, NHS Register of Computer Applications and the Health Visitors' Association database up to the end of 1995. We hand searched the Journal of Nursing Administration (1971-1999), Computers in Nursing (1984-1999), Information Technology in Nursing (1989-1999) and reference lists of articles. We also hand searched the major health informatics conference proceedings. We contacted experts in the field of nursing informatics, suppliers of nursing computer systems, and relevant Internet groups. Randomised trials, controlled before and after studies and interrupted time series comparing one kind of nursing record system with another, in hospital, community or primary care settings. The participants were qualified nurses, students or health care assistants working under the direction of a qualified nurse and patients receiving care recorded and/or planned using nursing record systems. Two reviewers independently assessed trial quality and extracted data. Six trials involving 1407 people were included. In three studies of client held records, there were no overall positive or negative effects, although some administrative benefits through fewer missing notes were suggested. A paediatric pain management sheet study showed a positive effect on the children's pain intensity. A computerised nursing care planning study showed a negative effect on documented nursing care planning. A controlled before-and-after study of two paper nursing record systems showed improvement in meeting documentation standards. No evidence was found of effects on practice attributable to changes in record systems. Although there is a paucity of studies of sufficient methodological rigour to yield reliable results in this area, it is clear from the literature that it is possible to set up randomised trials or other quasi-experimental designs needed to produce evidence for practice. The research undertaken so far may have suffered both from methodological problems and faulty hypotheses.
Frequency of postlicensure registered nurse boundary violations with patients in the state of Ohio: a comparison based on type of prelicensure registered nurse education.

PubMed

Jones, Jeffrey S; Fitzpatrick, Joyce J; Drake, Virginia K

2008-12-01

Nurse-Patient boundary violations remain a problem. Efforts to address the problem through postlicensure education and stronger disciplinary measures are well documented. However, efforts to understand this problem based on prelicensure components are less studied. Using data from The Ohio Board of Nursing from 2002 to 2006, the difference in frequency of incidents of violations between associate degree-prepared registered nurses and baccalaureate degree-prepared registered nurses was studied. A statistically significant difference was found through chi-square analysis: Associate degree-prepared nurses had higher frequency of boundary violations. Further studies on prelicensure curricular influences on registered nurses' postlicensure behavior, particularly in relation to curricular content focused on interpersonal skill development, are recommended.
Resonant leadership and workplace empowerment: the value of positive organizational cultures in reducing workplace incivility.

PubMed

Laschinger, Heather K Spence; Wong, Carol A; Cummings, Greta G; Grau, Ashley L

2014-01-01

Nursing leaders are indispensable in creating positive nursing work environments that retain an empowered and satisfied nursing workforce. Positive and supportive leadership styles can lower patient mortality and improve nurses' health, job satisfaction, organizational commitment, emotional exhaustion, and intent to stay in their position. The results of this study support the role of positive leadership approaches that empower nurses and discourage workplace incivility and burnout in nursing work environments. The findings also provide empirical support for the notion of resonant leadership, a relatively new theory of relationship-focused leadership approaches. This research adds to the growing body of knowledge documenting the key role of positive leadership practices in creating healthy work environments that promote retention of nurses in a time of a severe nursing shortage.
Building nursing intellectual capital for safe use of information technology: a systematic review.

PubMed

Poe, Stephanie S

2011-01-01

Information technology is integral to health care delivery. Nurse leaders recognize the need to build intellectual capital (knowledge, skills, and experience) in use and oversight of electronic health records despite financial constraints on indirect care time. A systematic literature review was conducted to answer the question, "What are the best practices to build nursing intellectual capital for use of IT for safe clinical care?" Evidence was translated to support a planned electronic health record rollout.
Association of comorbidities with home care service utilization of patients with heart failure while receiving telehealth.

PubMed

Radhakrishnan, Kavita; Jacelon, Cynthia S; Bigelow, Carol; Roche, Joan P; Marquard, Jenna L; Bowles, Kathryn H

2013-01-01

Comorbidities adversely impact heart failure (HF) outcomes. Telehealth can assist healthcare providers, especially nurses, in guiding their patients to follow the HF regimen. However, factors, including comorbidity patterns, that act in combination with telehealth to reduce home care nursing utilization are still unclear. The purpose of this article was to examine the association of the comorbidity characteristics of HF patients with nursing utilization along with withdrawal from telehealth service during an episode of tele-home care. A descriptive, correlational study design using retrospective chart review was used. The sample comprised Medicare patients admitted to a New England home care agency who had HF as a diagnosis and had used telehealth from 2008 to 2010. The electronic documentation at the home care agency served as the data source, which included Outcome and Assessment Information Set data of patients with HF. Logistic and multiple regression analyses were used to analyze data. The sample consisted of 403 participants, of whom 70% were older than 75 years, 55% were female, and 94% were white. Comorbidities averaged 5.19 (SD, 1.92), ranging from 1 to 11, and nearly 40% of the participants had 5 or more comorbidities. The mean (SD) nursing contacts in the sample was 9.9 (4.7), ranging from 1 to 26, and 52 (12.7%) patients withdrew from telehealth service. For patients with HF on telehealth, comorbidity characteristics of anemia, anxiety, musculoskeletal, and depression were significantly associated with nursing utilization patterns, and renal failure, cancer, and depression comorbidities were significantly associated with withdrawal from telehealth service. Knowledge of the association of comorbidity characteristics with the home care service utilization patterns of patients with HF on telehealth can assist the home health nurse to develop a tailored care plan that attains optimal patient outcomes. Knowledge of such associations would also focus home care resources, avoiding redundancy of resource utilization in this era of strained healthcare resources.
Preferred information sources for clinical decision making: critical care nurses' perceptions of information accessibility and usefulness.

PubMed

Marshall, Andrea P; West, Sandra H; Aitken, Leanne M

2011-12-01

Variability in clinical practice may result from the use of diverse information sources to guide clinical decisions. In routine clinical practice, nurses privilege information from colleagues over more formal information sources. It is not clear whether similar information-seeking behaviour is exhibited when critical care nurses make decisions about a specific clinical practice, where extensive practice variability exists alongside a developing research base. This study explored the preferred sources of information intensive care nurses used and their perceptions of the accessibility and usefulness of this information for making decisions in clinically uncertain situations specific to enteral feeding practice. An instrumental case study design, incorporating concurrent verbal protocols, Q methodology and focus groups, was used to determine intensive care nurses' perspectives of information use in the resolution of clinical uncertainty. A preference for information from colleagues to support clinical decisions was observed. People as information sources were considered most useful and most accessible in the clinical setting. Text and electronic information sources were seen as less accessible, mainly because of the time required to access the information within the documents. When faced with clinical uncertainty, obtaining information from colleagues allows information to be quickly accessed and applied within the context of a specific clinical presentation. Seeking information from others also provides opportunities for shared decision-making and potential validation of clinical judgment, although differing views may exacerbate clinical uncertainty. The social exchange of clinical information may meet the needs of nurses working in a complex, time-pressured environment but the extent of the evidence base for information passed through verbal communication is unclear. The perceived usefulness and accessibility of information is premised on the ease of use and access and thus the variability in information may be contributing to clinical uncertainty. Copyright ©2011 Sigma Theta Tau International.
Climate Change, Climate Justice, and Environmental Health: Implications for the Nursing Profession.

PubMed

Nicholas, Patrice K; Breakey, Suellen

2017-11-01

Climate change is an emerging challenge linked to negative outcomes for the environment and human health. Since the 1960s, there has been a growing recognition of the need to address climate change and the impact of greenhouse gas emissions implicated in the warming of our planet. There are also deleterious health outcomes linked to complex climate changes that are emerging in the 21st century. This article addresses the social justice issues associated with climate change and human health and discussion of climate justice. Discussion paper. A literature search of electronic databases was conducted for articles, texts, and documents related to climate change, climate justice, and human health. The literature suggests that those who contribute least to global warming are those who will disproportionately be affected by the negative health outcomes of climate change. The concept of climate justice and the role of the Mary Robinson Foundation-Climate Justice are discussed within a framework of nursing's professional responsibility and the importance of social justice for the world's people. The nursing profession must take a leadership role in engaging in policy and advocacy discussions in addressing the looming problems associated with climate change. Nursing organizations have adopted resolutions and engaged in leadership roles to address climate change at the local, regional, national, and global level. It is essential that nurses embrace concepts related to social justice and engage in the policy debate regarding the deleterious effects on human health related to global warming and climate change. Nursing's commitment to social justice offers an opportunity to offer significant global leadership in addressing the health implications related to climate change. Recognizing the negative impacts of climate change on well-being and the underlying socioeconomic reasons for their disproportionate and inequitable distribution can expand and optimize the profession's role in education, practice, research, and policy-making efforts to address climate change. © 2017 Sigma Theta Tau International.
Pediatric cardiac surgery Parent Education Discharge Instruction (PEDI) program: a pilot study.

PubMed

Staveski, Sandra L; Zhelva, Bistra; Paul, Reena; Conway, Rosalind; Carlson, Anna; Soma, Gouthami; Kools, Susan; Franck, Linda S

2015-01-01

In developing countries, more children with complex cardiac defects now receive treatment for their condition. For successful long-term outcomes, children also need skilled care at home after discharge. The Parent Education Discharge Instruction (PEDI) program was developed to educate nurses on the importance of discharge teaching and to provide them with a structured process for conducting parent teaching for home care of children after cardiac surgery. The aim of this pilot study was to generate preliminary data on the feasibility and acceptability of the nurse-led structured discharge program on an Indian pediatric cardiac surgery unit. A pre-/post-design was used. Questionnaires were used to evaluate role acceptability, nurse and parent knowledge of discharge content, and utility of training materials with 40 nurses and 20 parents. Retrospective audits of 50 patient medical records (25 pre and 25 post) were performed to evaluate discharge teaching documentation. Nurses' discharge knowledge increased from a mean of 81% to 96% (P = .001) after participation in the training. Nurses and parents reported high levels of satisfaction with the education materials (3.75-4 on a 4.00-point scale). Evidence of discharge teaching documentation in patient medical records improved from 48% (12 of 25 medical records) to 96% (24 of 25 medical records) six months after the implementation of the PEDI program. The structured nurse-led parent discharge teaching program demonstrated feasibility, acceptability, utility, and sustainability in the cardiac unit. Future studies are needed to examine nurse, parent, child, and organizational outcomes related to this expanded nursing role in resource-constrained environments. © The Author(s) 2014.
Feasibility of using the Omaha System to represent public health nurse manager interventions.

PubMed

Monsen, Karen A; Newsom, Eric T

2011-01-01

To test the feasibility of representing public health nurse (PHN) manager interventions using a recognized standardized nursing terminology. A nurse manager in a Midwest local public health agency documented nurse manager interventions using the Omaha System for 5 months. ANALYTIC STRATEGY: The data were analyzed and the results were compared with the results from a parallel analysis of existing PHN intervention data. Interventions for 79 "clients" (projects, teams, or individuals) captured 76% of recorded work hours, and addressed 43% of Omaha System problems. Most problems were addressed at the "community" level (87.1%) versus the "individual" level (12.9%). Nursing practice differed between the 2 knowledge domains of public health family home visiting nursing and public health nursing management. Standardized nursing terminologies have the potential to represent, describe, and quantify nurse manager interventions for future evaluation and research. © 2011 Wiley Periodicals, Inc.
Relationships among NANDA-I diagnoses, nursing outcomes classification, and nursing interventions classification by nursing students for patients in medical-surgical units in Korea.

PubMed

Noh, Hyun Kyung; Lee, Eunjoo

2015-01-01

The purpose of this study was to identify NANDA-I, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC; NNN) linkages used by Korean nursing students during their clinical practice in medical-surgical units. A comparative descriptive research design was used to measure the effects of nursing interventions from 153 nursing students in South Korea. Nursing students selected NNN using a Web-based nursing process documentation system. Data were analyzed by paired t-test. Eighty-two NANDA-I diagnoses, 116 NOC outcomes, and 163 NIC interventions were identified. Statistically significant differences in patients' preintervention and postintervention outcome scores were observed. By determining patient outcomes linked to interventions and how the degree of outcomes change after interventions, the effectiveness of the interventions can be evaluated. © 2014 NANDA International, Inc.
The Role of School Nurses, Challenges, and Reactions to Delegation Legislation: A Qualitative Approach.

PubMed

Lineberry, Michelle; Whitney, Elizabeth; Noland, Melody

2018-06-01

Passage of new laws, national standards regarding delegation, and the recommendation for at least one full-time nurse in every school have provided more visibility to the role of school nurses. Recent legislative amendments in Kentucky presented an opportunity to examine how the role of the school nurse is changing. Aims were to describe the (1) role of school nurses in Kentucky, (2) impact of school nurses, (3) challenges faced by school nurses, and (4) impact of budget cuts and legislation. Three focus groups were conducted. School nurses faced challenges of limited time and resources, communication barriers, and multiple documentation requirements. Nurses' greatest impacts were their availability, recognition of psychosocial problems and health concerns, and connection with resources. Nurses had not yet encountered many changes due to new legislation that expanded delegation of diabetes-related tasks to unlicensed school personnel, but some had concerns about possible negative effects while others expressed support.
Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges

PubMed

Jones, Terry L

2016-05-31

Nurses have a social responsibility to evaluate the effect of nursing practice on patient outcomes in the areas of health promotion; injury and illness prevention; and alleviation of suffering. Quality assessment initiatives are hindered by the paucity of available data related to nursing processes and patient outcomes across these three domains of practice. Direct care nurses are integral to self-regulation for the discipline as they are the best source of information about nursing practice and patient outcomes. Evidence supports the assumption that nurses do contribute to prevention of adverse events but there is insufficient evidence to explain how nurses contribute to these and/or other patient outcomes. The purposes of this article are to examine the imperatives, ideal conditions, history, and challenges related to effective outcome measurement in nursing. The article concludes with recommendations for action to move quality assessment forward, such as substantial investment to support adequate documentation of nursing practice and patient outcomes.
Negotiating Access to Health Information to Promote Students' Health.

PubMed

Radis, Molly E; Updegrove, Stephen C; Somsel, Anne; Crowley, Angela A

2016-04-01

Access to student health information, such as immunizations, screenings, and care plans for chronic conditions, is essential for school nurses to fulfill their role in promoting students' health. School nurses typically encounter barriers to accessing health records and spend many hours attempting to retrieve health information. As a result, nurses' time is poorly utilized and students may suffer adverse outcomes including delayed school entry. In response to this pressing public health issue, a school medical advisor and director of school nurses in a local health department successfully negotiated access for school nurses to three health record systems: a state immunization tracking system, an electronic lead surveillance program, and an electronic health record system. This negotiation process is presented within a framework of the Theory of Diffusion of Innovation and provides a strategy for other school nurses seeking access to student health information. © The Author(s) 2015.
BT-Nurse: computer generation of natural language shift summaries from complex heterogeneous medical data.

PubMed

Hunter, James; Freer, Yvonne; Gatt, Albert; Reiter, Ehud; Sripada, Somayajulu; Sykes, Cindy; Westwater, Dave

2011-01-01

The BT-Nurse system uses data-to-text technology to automatically generate a natural language nursing shift summary in a neonatal intensive care unit (NICU). The summary is solely based on data held in an electronic patient record system, no additional data-entry is required. BT-Nurse was tested for two months in the Royal Infirmary of Edinburgh NICU. Nurses were asked to rate the understandability, accuracy, and helpfulness of the computer-generated summaries; they were also asked for free-text comments about the summaries. The nurses found the majority of the summaries to be understandable, accurate, and helpful (p<0.001 for all measures). However, nurses also pointed out many deficiencies, especially with regard to extra content they wanted to see in the computer-generated summaries. In conclusion, natural language NICU shift summaries can be automatically generated from an electronic patient record, but our proof-of-concept software needs considerable additional development work before it can be deployed.
BT-Nurse: computer generation of natural language shift summaries from complex heterogeneous medical data

PubMed Central

Freer, Yvonne; Gatt, Albert; Reiter, Ehud; Sripada, Somayajulu; Sykes, Cindy; Westwater, Dave

2011-01-01

The BT-Nurse system uses data-to-text technology to automatically generate a natural language nursing shift summary in a neonatal intensive care unit (NICU). The summary is solely based on data held in an electronic patient record system, no additional data-entry is required. BT-Nurse was tested for two months in the Royal Infirmary of Edinburgh NICU. Nurses were asked to rate the understandability, accuracy, and helpfulness of the computer-generated summaries; they were also asked for free-text comments about the summaries. The nurses found the majority of the summaries to be understandable, accurate, and helpful (p<0.001 for all measures). However, nurses also pointed out many deficiencies, especially with regard to extra content they wanted to see in the computer-generated summaries. In conclusion, natural language NICU shift summaries can be automatically generated from an electronic patient record, but our proof-of-concept software needs considerable additional development work before it can be deployed. PMID:21724739
Nurse Aide. Ohio's Competency Analysis Profile.

ERIC Educational Resources Information Center

Ohio State Univ., Columbus. Vocational Instructional Materials Lab.

Developed through a modified DACUM (Developing a Curriculum) process involving business, industry, labor, and community agency representatives in Ohio, this document is a comprehensive and verified employer competency profile for nurses' aides. The list contains units (with and without subunits), competencies, and competency builders that identify…
Mentorship: A Joint Perspective from a Deployed Environment

DTIC Science & Technology

2010-03-01

Registered Nurses ( AORN ) defines mentorship as: “The developmental relationship between an experienced person and a less-experienced person referred to as...Room Nurses. AORN Journal, 88(2), 175-6. Retrieved October 24, 2009, from Research Library. (Document ID: 1538599441). 17 Lori Leffler, Mentorship
Clinical Workflow Observations to Identify Opportunities for Nurse, Physicians and Patients to Share a Patient-centered Plan of Care

PubMed Central

Collins, Sarah A.; Gazarian, Priscilla; Stade, Diana; McNally, Kelly; Morrison, Conny; Ohashi, Kumiko; Lehmann, Lisa; Dalal, Anuj; Bates, David W.; Dykes, Patricia C.

2014-01-01

Patient- and Family-Centered Care (PFCC) is essential for high quality care in the critical and acute-specialty care hospital setting. Effective PFCC requires clinicians to form an integrated interprofessional team to collaboratively engage with the patient/family and contribute to a shared patient-centered plan of care. We conducted observations on a critical care and specialty unit to understand the plan of care activities and workflow documentation requirements for nurses and physicians to inform the development of a shared patient-centered plan of care to support patient engagement. We identified siloed plan of care documentation, with workflow opportunities to converge the nurses plan of care with the physician planned To-do lists and quality and safety checklists. Integration of nurses and physicians plan of care activities into a shared plan of care is a feasible and valuable step toward interprofessional teams that effectively engage patients in plan of care activities. PMID:25954345
A case study of the introduction of the International Classification for Nursing Practice(®) in Poland.

PubMed

Kilańska, D; Gaworska-Krzemińska, A; Grabowska, H; Gorzkowicz, B

2016-09-01

The development of a nursing practice, improvements in nurses' autonomy, and increased professional and personal responsibility for the medical services provided all require professional documentation with records of health status assessments, decisions undertaken, actions and their outcomes for each patient. The International Classification for Nursing Practice is a tool that meets all of these needs, and although it requires continuous evaluation, it offers professional documentation and communication in the practitioner and researcher community. The aim of this paper is to present a theoretical critique of an issue related to policy and experience of the current situation in Polish nursing - especially of the efforts to standardize nursing practices through the introduction and development of the Classification in Poland. Despite extensive promotion and training by International Council of Nurses members worldwide, there are still many countries where the Classification has not been implemented as a standard tool in healthcare facilities. Recently, a number of initiatives were undertaken in cooperation with the local and state authorities to disseminate the Classification in healthcare facilities. Thanks to intense efforts by the Polish Nurses Association and the International Council of Nurses Accredited Center for ICNP(®) Research & Development at the Medical University of Łódź, the Classification is known in Poland and has been tested at several centres. Nevertheless, an actual implementation that would allow for national and international interoperability requires strategic governmental decisions and close cooperation with information technology companies operating in the country. Discussing the barriers to the implementation of the Classification can improve understanding of it and its use. At a policy level, decision makers need to understand that use Classification in eHealth services and tools it is necessary to achieve interoperability. © 2016 International Council of Nurses.

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