Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process

The objective of this study was to analyze the impact of medication ordering and administration functions of CPOE on doctor-nurse communications and cooperation. We performed an extensive analysis of the work situations in several departments of three different hospitals. One of the hospitals is still using paper-based orders, the second one is currently implementing a patient care information system (PCIS), but the analysis was carried out with paper-based orders. The third hospital has a PCIS installed with available medication ordering functions. We used standard methods from cognitive psychology to analyze physicians, and nurses' activity, communications and cooperation. This approach was combined with a usability analysis of both work systems, paper and computer-based. The paper-based situation is characterized by a synchronous cooperation with a distributed decision-making where physicians and nurses rely mostly on verbal communications to coordinate their actions; paper order sheets are weakly structured and poorly support the documentation task. In the computer situation, physicians and nurses work in an asynchronous mode, and leave to the system the coordination of their actions. Orders are exhaustively documented but some data may be misinterpreted. Some of these problems are due to usability flaws of the Human Computer Interface. We conclude with recommendations for usability improvement of CPOE systems, combined with recommendations for the organization of doctor-nurse communication when implementing such systems.     

Challenging the information gap--the patients transfer from hospital to home health care

The purpose of this paper is to identify the information that nurses in hospitals exchange with nurses in home health care (HHC), and what nurses perceive to be the most significant information to exchange. METHOD: Nurses have an obligation to support and ensure continuity of patient care and to prevent an information gap when patients are transferred from one organizational of health care delivery to another organizational level, for example, from hospital to home health care. In an ongoing prospective study, nurses' pre-electronic nursing discharge note and their assessment of the information it was necessary to exchange at the same time was audited and analyzed. The results show variation in the completeness and content of the nursing discharge note. Nurses' understanding of the scope and content of information to be transmitted varies widely according to the context and the organizational health care level they work within. The implementation of an electronic nursing discharge note creates the opportunity to identify the accurate information elements that must be documented and exchanged between the nurses to ensure patient safety and inter-organizational continuity of care.     

Nursing education and practice

Three issues directly influence the relationship between nurses and physicians: the nature of nursing practice, the education of registered nurses, and the American Medical Association (AMA) proposal for registered care technicians. Many conflicts among nurses, physicians, and health care administrators result from nurses' defining their practice in terms of their patients' needs, and nurses may differ from other health care professionals in interpreting those needs. Nursing education programs--in hospital schools of nursing, community colleges, and baccalaureate colleges--should focus their programs and objectives so as to prepare their graduates for different health care settings. For example, an associate degree program would emphasize preparation for home health care, long-term care, or acute care. The AMA proposal to create a new nursing category--registered care technologist--complicates rather than helps the relationship between physicians and nurses and confuses the issues of providing patient care. Suggestions are offered for alleviating the nursing shortage and resolving much of the continuing conflict between nurses and physicians.     

The status of IT service management in health care - ITIL® in selected European countries

Background

Electronic documentation handling may facilitate information flows in health care settings to support better coordination of care among Health Care Providers (HCPs), but evidence is limited. Methods that accurately depict changes to the workflows of HCPs are needed to assess whether the introduction of a Critical Care clinical Information System (CCIS) to two Intensive Care Units (ICUs) represents a positive step for patient care. To evaluate a previously described method of quantifying amounts of time spent and interruptions encountered by HCPs working in two ICUs.

Methods

Observers used PDAs running the Work Observation Method By Activity Timing (WOMBAT) software to record the tasks performed by HCPs in advance of the introduction of a Critical Care clinical Information System (CCIS) to quantify amounts of time spent on tasks and interruptions encountered by HCPs in ICUs.

Results

We report the percentages of time spent on each task category, and the rates of interruptions observed for physicians, nurses, respiratory therapists, and unit clerks. Compared with previously published data from Australian hospital wards, interdisciplinary information sharing and communication in ICUs explain higher proportions of time spent on professional communication and documentation by nurses and physicians, as well as more frequent interruptions which are often followed by professional communication tasks.

Conclusions

Critical care workloads include requirements for timely information sharing and communication and explain the differences we observed between the two datasets. The data presented here further validate the WOMBAT method, and support plans to compare workflows before and after the introduction of electronic documentation methods in ICUs.     

Data mining issues and opportunities for building nursing knowledge

Health care information systems tend to capture data for nursing tasks, and have little basis in nursing knowledge. Opportunity lies in an important issue where the knowledge used by expert nurses (nursing knowledge workers) in caring for patients is undervalued in the health care system. The complexity of nursing's knowledge base remains poorly articulated and inadequately represented in contemporary information systems. There is opportunity for data mining methods to assist with discovering important linkages between clinical data, nursing interventions, and patient outcomes. Following a brief overview of relevant data mining techniques, a preterm risk prediction case study illustrates the opportunities and describes typical data mining issues in the nontrivial task of building knowledge. Building knowledge in nursing, using data mining or any other method, will make progress only if important data that capture expert nurses' contributions are available in clinical information systems configurations.     

Ten years after "privatization" in primary health care

Ten years after the privatization in primary health care its disadvantages have been noticed making it less quality and consequently increasing the costs of total health care of the patient. Current organization makes family practitioners inaccessible to the patient during a part of the day. Emergency health care and hospital emergency services are ever more burdened with the work that should be done by family practitioners, thus becoming hardly accessible in emergencies. Medical nurses are mostly occupied with administrative work, family practitioners are partly doing the work that should be done by nurses, while clinical specialists are doing the job of family practitioners. They all work a lot but they do the jobs that should not be in their domain and that are much under the level of their education. Health care becomes ineffective, below-quality and expensive. It is necessary to redefine the tasks of all health care participants starting from family practitioners, and to redefine the role of medical center. Solving the legal position of family practitioners working in "lease", introduction of the combined form of payment in family practice, and the possibility of interacting association of physicians could help eliminate the problems and promote the quality of health care.     

Design of a summary screen for an ICU patient data management system

The paper describes a used-centred design for the summary screen of a computerised ICU patient data management system (PDMS). The screen also forms the resting state display, or default screen, and provides the principal navigation tool to other functionality within the system. The design process identified the most frequent potential users of this screen to be the nurses. Their tasks and the information resources required to perform them were analysed. The analysis identified that the nurses' main task of planning and implementing patient care required an awareness of a set of physiological parameters which provided an overview of the patient's general condition. Novel formats are proposed for displaying the trends in physiological parameters and these have been incorporated into a proposed screen design. These display formats have been evaluated by ICU nurses; they were adjudged to be clear, relevant, easy to learn and simple to use. Nurses considered the content of the screen, and the display formats used, to be suitable for maintaining an awareness of a patient's state during routine patient management.     

Families and intensive care nurses: comparison of perceptions.

This study compared family members' and nurses' perceptions on families' needs when a relative was hospitalized in an intensive care unit (ICU). Family members (N = 32) and nurses (N = 23) complete equivalent 44-item questionnaires. Both family members and nurses agreed that the greatest needs of families were anxious at admission (P less than 0.05). Families and nurses seemed satisfied in the Participation/Information and Emotional Support categories, but more disagreements were noted in these areas. More nurses perceived families as not wanting to participate in patient care (P less than 0.003), felt that families did not have enough time to visit (P less than 0.004), believed that families were comfortable expressing their feelings (P less than 0.02) but thought families were uncomfortable asking questions (P less than 0.01). It was concluded that families be prepared for the patient's condition and appearance, and for the hospital milieu in order to cope more effectively with excessive stress in time of crisis. Concordance in perceived needs of family members and care providers may lead to greater need satisfaction and it is advocated that both the patient and the family (rather than the patient alone) be the focus of treatment because of the relationship between social support and patient recovery.     

Practice nurses: social and occupational characteristics

Three hundred practice nurses in the West Midlands responded to a questionnaire survey about their social and occupational characteristics. The nurses were mainly married women with children and had had considerable hospital experience. They were largely satisfied with their job and felt that their own general practitioner colleagues were supportive, though doctors in general might not be so. Large variations in patterns of work were revealed and in some cases there was a considerable extension of the traditional nursing role. Almost two-thirds of practice nurses were undertaking breast and vaginal examinations, 70% were carrying out cervical smears and a number of nurses were diagnosing, investigating and managing common ailments. Nurses expressed a desire for further extension of their role to allow them to undertake broader aspects of patient care and to be less task-centred, but felt that they would require further training to do so. There was evidence of a need for better definition of the practice nurse's role and for more support from health authorities and the nurses' own professional body.     

Communication during ward rounds in internal medicine. An analysis of patient-nurse-physician interactions using RIAS

OBJECTIVE: Describe the content and of mode of patient-physician-nurse interactions during ward-rounds in Internal Medicine. METHODS: In 267/448 patients, 13 nurses, and 8 physicians from two wards in General Internal Medicine 448 interactions on ward rounds were tape recorded by observers. After exclusion of interactions with more than three participants (N=150), a random sample of 90 interactions was drawn. Data were analysed with a modified RIAS version that allowed for the registration of a third contributor and for the assessment of the direction of a communicative action (e.g.: nurse-->patient, etc.). Furthermore, time spent per individual patient was registered with a stop-watch. RESULTS: A total of 12,078 utterances (144 per ward round) were recorded. Due to problems with the comprehensibility of some interactions the final data set contains 71 ward round interactions with 10,713 utterances (151 per ward round interaction). The average time allotted to an individual patient during ward-rounds was 7.5 min (range: 3-16 min). The exchange of medical information is the main topic in physicians (39%) and nurses (25%), second common topic in patients (28%), in whom communicative actions like agreement or checking are more common (30% patients/25% physicians/22% nurses). Physicians and patients use a substantial number of communicative actions (1397/5531 physicians; 1119/3733 patients). Patients receive about 20 bits of medical or therapeutic information per contact during ward-rounds. CONCLUSIONS: If ward rounds serve as the central marketplace of information nurses' knowledge is under-represented. Further research should try to determine whether the quality of patient care is related to a well balanced exchange of information, to which nurses, physicians, and patients contribute their specific knowledge. PRACTICE IMPLICATIONS: Given the fact that in-patients in Interna Medicine usually present complex problems, the exchange of factual information, expectations, and concepts is of paramount importance. We hope that this paper is going to direct the attention of the scientific community to the characteristics of ward-rounds because they will remain the central marketplace of communication in hospital.     

The development of a nursing subset of patient problems to support interoperability

Background

Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information.

Methods

Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives.

Results

Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier.

Conclusions

To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning.

     

A longitudinal study of usability in health care: does time heal?

We report from a longitudinal laboratory-based usability evaluation of a health care information system. The purpose of the study was to inquire into the nature of usability problems experienced by novice and expert users, and to see to what extend usability problems of a health care information system may or may not disappear over time, as the nurses get more familiar with it-if time heals poor design? As our method for studying this, we conducted a longitudinal study with two key studies. A usability evaluation was conducted with novice users when an electronic patient record system was being deployed in a large hospital. After the nurses had used the system in their daily work for 15 months, we repeated the evaluation. Our results show that time does not heal. Although some problems were not experiences as severe, they still remained after 1 year of extensive use. On the basis of our findings, we discuss implications for evaluating usability in health care.     

‘I beg your pardon?’ Nurses’ experiences in facilitating doctors’ learning process – An interview study

Objective

Working alongside specialized palliative care nurses brings about learning opportunities for general practitioners. The views of these nurses toward their role as facilitator of learning is unknown. The aim of this study is to clarify the views and preferences of these nurses toward their role as facilitator of physicians’ learning.

Methods

Qualitative study based on semi-structured interviews. We interviewed 21 palliative care nurses in Belgium who were trained in the role of learning facilitator. Data were analyzed using Grounded Theory principles.

Results

First all interviewees shared the conviction that patient care is their core business. Secondly two core themes were defined: nurses’ preferences toward sharing knowledge and their balancing between patient care and team care. Combining these themes yielded a typology of nurses’ behavioral style: the clinical expert-style, the buddy-style, the coach-style and the mediator-style.

Conclusions

Palliative care nurses’ interpretation of the role as facilitator of general practitioners’ learning diverges according to personal characteristics and preferences.

Practice implications

Asking clinical expert nurses to become a facilitator of other professional's learning requires personal mentoring during this transition. Nurses’ preferences toward practice behavior should be taken into account.     

门急诊静脉输注中药注射剂环节的质量控制与管理效果

目的:加强对门急诊输液室护士在静脉输注中药注射剂(traditional Chinese medicine injection,TCMI)输液过程中的环节管理,减少静脉输注TCMI的药品不良反应(adverse drug reaction,ADR)发生率.方法:总结导致静脉输注TCMI的ADR发生的因素,制订并落实护士配液的相关制度,执行《药品使用说明》的相关要求,加强对护士的培训和管理,将这些措施应用于门急诊输液患者的治疗和护理的工作中.结果:加强静脉输注TCMI的护理环节管理后,望京医院门急诊输注TCMI的不良反应发生率由2013年的0.024％,降至2015年的0％.结论:通过加强对护士的培训、对患者的告知和强化护理安全等多个环节的管理,可以有效减少TCMI在使用过程中ADR的发生率.     

Assessing Safety Attitudes among Healthcare Providers after a Hospital-Wide High-Risk Patient Care Program

Purpose

Cardiopulmonary resuscitation (CPR) is commonly performed in high-risk, high intensity situations and is therefore a good procedure around which to develop and implement safety culture strategies in the hospital. The purpose of this study was to evaluate the impact of a hospital-wide quality improvement program on the management of sudden cardiac arrests by assessing healthcare providers'' attitudes towards patient safety.

Materials and Methods

This study was designed as a prospective cohort study at a single academic medical center. The comprehensive hospital-based safety program included steps to identify areas of hazard, partner units with the Resuscitation Committee, and to conduct a Safety Attitudes Questionnaire (SAQ). The SAQ evaluated 35 questions in seven domains to assess changes in patient safety culture by comparing the results before and after the hospital-wide high risk patient care improvement program.

Results

The response rates of the pre- and post-SAQ survey were 489 out of 1121 (43.6%) and 575 out of 1270 (45.3%), respectively. SAQ survey responses revealed significant improvement in all seven domains of the questionnaire (p-values of 0.006 and lower). In a subgroup analysis, doctors and nurses showed improvement in five domains. Both doctors and nurses did not show improvement in the "sharing information" domain.

Conclusion

A hospital-wide quality improvement program for high-risk, high reliability patient care involving CPR care was shown to be associated with a change in healthcare providers'' attitudes towards patient safety. Through an immersive and active program on CPR care, change in healthcare providers'' attitudes towards patient safety was initiated.