Proposal to Bring Nursing Into the Information Age

Purpose: To address issues related to documentation of nursing care and propose a model that illustrates how nursing practice data, collected through the use of standardized languages, are useful to staff nurses, nurse administrators, researchers, and policy makers.
Significance: Obtaining information about nursing practice is critical in times of health care change and reform.
Conclusions: There are three main challenges: the level of detail to document, the inclusion of nursing language in critical paths, and the need for articulation among different nursing classifications.
Implications: With recent advances in nursing classifications, the documentation systems in nursing can now be improved and much of the previous waste and redundancy eliminated.     

Towards an evaluation framework for information quality management (IQM) practices for health information systems – evaluation criteria for effective IQM practices

Rationale, aims and objectives Poor information quality (IQ) must be understood as a business problem rather than systems problem. In health care organization, what is required is an effective quality management that continuously manages and reviews the factors influencing IQ in health information systems (HIS) so as to achieve the desired outcomes. Hence, in order to understand the issues of information quality management (IQM) practices in health care organizations, a more holistic evaluation study should be undertaken to investigate the IQM practices in health care organizations. It is the aim of this paper to identify the significant evaluation criteria that influence the production of good IQ in HIS. Methods Six selected frameworks and best practices both from health informatics and information systems literature have been reviewed to identify the evaluation criteria from the perspective of human, organizational and technological factors. Results From the review, it was found that human and organization factors are of greater significance in influencing HIS IQ. Our review depicts that there is still shortage in finding a comprehensive IQM evaluation framework. Thus, the criteria from the frameworks reviewed can be used in combination for more comprehensive evaluation criteria. Integrated IQM evaluation criteria for HIS are then proposed in this study. Conclusions Poor IQ is the result of complex interdependency within sociotechnical factors in health care organization and lack of formal and structured IQM practices. Thus, a feedback mechanism such as evaluation is needed to understand the issues in depth in the future.     

Using clinical data for nursing research and management in health services

Nurses generate large quantities of data at different operational levels in a health service organization. Administrative managerial data include the number of nursing hours per patient day and cost data related to nursing services while clinical data include the documentation of direct patient care only. In this paper, we explain standard clinical data elements in the HIS (Hospital Information System). The construction of the data is traced from patients' medical records to coding procedures within ICD (International Classification of Disease) classification and DRG (Diagnostic Related Groups) of casemix. Examples are given from Australian data and definitions, but much of the same information can be found in hospital information systems throughout the world. Practical applications that demonstrate how patient data can be used for research and management purposes in nursing are given. Finally, future directions and issues related to the use of datasets for nursing research are explored.     

Cardiopulmonary resuscitation for palliative care patients: a discussion of ethical issues

Medical advances have significantly improved the prognosis and life-expectancy for many patients with life-threatening illness. However, the ability to extend and prolong life increases the complexity of clinical decision-making, and this is particularly true in the context of palliative care. During the course of their illness, many patients with palliative care needs will require hospital admission. It is in this setting that ethical dilemmas are likely to arise regarding the use of life-prolonging measures such as cardiopulmonary resuscitation (CPR). This paper considers some of the ethical issues surrounding the use of CPR for palliative care patients in the hospital setting.     

A survey of nursing and medical staff views on the use of cardiopulmonary resuscitation in the hospice.

Research evidence suggests that cardiopulmonary resuscitation (CPR) would be indicated in very few hospice patients. However, with the increasing access and expansion of specialist palliative care services the question of CPR is becoming more important. In order to develop a policy in our unit we felt it was important to assess the understanding, attitudes and experience of the health care professionals involved. A semi-structured questionnaire regarding CPR issues, including case scenarios, was distributed to doctors and registered nurses in a palliative care unit. Thirty-seven (80%) of the questionnaires were returned. Ten per cent of respondents identified patients for whom they felt CPR would have been indicated in the event of an unexpected cardiac arrest. Thirty-two per cent could foresee the number of patients in this category increasing in the future. The majority of respondents indicated that CPR should be discussed in certain cases, however 86% had never done so. The success rate of CPR was frequently overestimated. Some respondents felt vulnerable as there was no existing written policy. Factors thought important in making decisions regarding CPR orders included: prognosis; patient's wishes; quality of life; and legal issues. CPR in palliative care units raises many practical and ethical concerns. Our survey shows that staff are aware of the small, but increasing, need for its consideration in certain cases. There was a wide range of views regarding the role of CPR with an overestimation of the chances of success and concerns regarding discussion of the issue with patients. When introducing a CPR policy in a palliative care unit, adequate education and a framework for decision making is required.     

Computerized Physician Order Entry and Online Decision Support

Computerized physician order entry (CPOE) and decision support systems (DSS) can reduce certain types of error but often slow clinicians and may increase other types of error. The net effect of these systems on an emergency department (ED) is unknown. The consensus participants combined published evidence with expert opinion to outline recommendations for success. These include seamless integration of CPOE and DSS into systems and workflow; ensuring access to Internet-based and other online support material in the clinical arena; designing systems specifically for the ED and measuring their impact to ensure an overall benefit; ensuring that CPOE systems provide error and interaction checking and facilitate weight- and physiology-based dosing; using interruptive alerts only for the highest-severity events; providing a simple, vendor-independent interface for institutional customization of CPOE alert thresholds; maximizing the use of automated systems and passive data capture; and ensuring the widespread availability of CPOE and DSS using secure wireless and portable technologies where appropriate. Decisions regarding CPOE and DSS in the ED should be guided by the ED chair or designee. Much of what is believed to be true regarding CPOE and DSS has not been adequately studied. Additional CPOE and DSS research is needed quickly, and this research should receive funding priority. DSS and CPOE hold great promise to improve patient care, but not all systems are equal. Evidence must guide these efforts, and the measured outcomes must consider the many factors of quality care.     

基于中医护理程序的移动护理信息系统在中医医院的构建和应用

[目的]以医院信息管理系统(hospital information system,HIS)为基础,移动手持电脑设备(personal digital assistant,PDA)为硬件,局域网为网络平台,基于中医护理程序建立医院护理信息管理系统,实现体现中医特色的中医院移动护理信息管理。[方法]依据中医护理程序,建立包括中医护理评估、中医护理辨证、中医护理施护、中医护理效果评价几个功能模块的护理管理信息系统,临床护士可随时对该系统进行信息处理、分析,对病人施行辨证施护和整体护理。[结果]实施基于中医护理程序的移动护理信息系统后,我院中医护理技术的运用、中医护理成效及护理满意度相关指标较实施前显著提高(P<0.05)。[结论]将中医护理程序融入移动护理信息系统应用到医院信息管理中,有力地提高了中医护理技术在我院临床护理工作中的应用,有效地提升了我院中医护理质量,同时提高了我院护理工作的满意度。     

Nursing morale: predictive variables among a sample of registered nurses in Australia

Aim  This study investigates the determinants of morale among Registered Nurses in Queensland, Australia.
Background  In light of the public discussions on the issues facing the future of nursing, it is critical to understand the factors that influence morale.
Methods  A 160-question instrument sought information from Registered Nurses on their perceptions of 'self', work and morale. A response rate of 41% was achieved ( n  = 343) from a convenience sample of three acute hospitals.
Results  Following binary logistic regression modelling for organizational morale, significant relationships were found with patient care provision and team interaction. Binary logistic regression modelling for personal morale revealed positive relationships with team interaction, consultation, professional recognition and lower levels of patient abuse.
Conclusion  The results point to a number of organizational and professional issues that can be considered by health care administrators and policy makers to develop workplaces that have a positive impact on the morale of nurses.     

Characteristics of deaths in paediatric intensive care: a 10-year study

Objective: To describe the patient mortality over a 10-year period in a paediatric intensive care unit (PICU) including patient demographics, length of stay, cause and mode of death and to compare these findings with pre-existing literature from the western world.
Design: A retrospective chart review.
Setting: A UK tertiary PICU.
Patients: All children who died in the PICU over a 10-year period between 1 November 1997 and 31 October 2007 ( n = 204).
Interventions: None.
Measurements and main results: Data recorded for each patient included patient demographics, length of stay and cause of death according to the International Classification of Disease-10 classification, and mode of death. Mode of death was assigned for each patient by placement in one of four categories: (i) brain death (BD), (ii) managed withdrawal of life-sustaining medical therapy (MWLSMT), (iii) failed cardiopulmonary resuscitation (CPR) and (iv) limitation of treatment (LT). Over the study period, findings showed a median length of stay of 2 days (IQR 0–5 days), with a mortality rate of 5%. The most common mode of death was MWLSMT ( n = 112, 54.9%) and this was consistent across the 10-year period. Linear regression analysis demonstrated no significant change in trend over the 10 years in each of the modes of death; BD ( p = 0.84), MWLSMT ( p = 0.88), CPR ( p = 0.35) and LT ( p = 0.67).
Conclusion: End-of-life care is an important facet of paediatric intensive nursing/medicine. Ten years on from the Royal College of Paediatrics and Child Health publication 'Withholding or withdrawing life sustaining treatment in children: A framework for practice', this study found managed withdrawal of MWLSMT to be the most commonly practised mode of death in a tertiary PICU, and this was consistent over the study period.     

Biology of cancer: Current issues and future prospects

The future of cancer treatment is limited only by the rate of progress made in understanding the biology of cancer. The future will present a considerable challenge to health care professionals to learn new theories, understand new terms, and expect different toxicities. The explosion of information and technology is exciting, yet frightening. The willingness of scientists, health care professionals, and consumers to deal with the ethical, financial, and political issues generated by this progress is gratifying. Because science has created such advances, the effort to deal with the outcomes is worthwhile but still difficult. The challenge to rapidly facilitate the sharing of the scientific and clinical advances has been recognized by the nation. A legislative mandate to create a way to store and analyze the vast data related to molecular biology, biochemistry, and genetics resulted in the National Center for Biotechnology Information. The development of automated systems to analyze genetic, environmental, biological, and chemistry information can only enhance future progress in the management of cancer.     

Development and Validation of a Mass Casualty Conceptual Model

Purpose: To develop and validate a conceptual model that provides a framework for the development and evaluation of information systems for mass casualty events.
Design: The model was designed based on extant literature and existing theoretical models. A purposeful sample of 18 experts validated the model. Open-ended questions, as well as a 7-point Likert scale, were used to measure expert consensus on the importance of each construct and its relationship in the model and the usefulness of the model to future research.
Methods: Computer-mediated applications were used to facilitate a modified Delphi technique through which a panel of experts provided validation for the conceptual model. Rounds of questions continued until consensus was reached, as measured by an interquartile range (no more than 1 scale point for each item); stability (change in the distribution of responses less than 15% between rounds); and percent agreement (70% or greater) for indicator questions.
Findings: Two rounds of the Delphi process were needed to satisfy the criteria for consensus or stability related to the constructs, relationships, and indicators in the model. The panel reached consensus or sufficient stability to retain all 10 constructs, 9 relationships, and 39 of 44 indicators. Experts viewed the model as useful (mean of 5.3 on a 7-point scale).
Conclusions: Validation of the model provides the first step in understanding the context in which mass casualty events take place and identifying variables that impact outcomes of care.
Clinical Relevance: This study provides a foundation for understanding the complexity of mass casualty care, the roles that nurses play in mass casualty events, and factors that must be considered in designing and evaluating information-communication systems to support effective triage under these conditions.     

The Development and Psychometric Evaluation of the Ethical Issues Scale

Purpose: To describe the Ethical Issues Scale (EIS), its conceptual development and psychometric evaluation, and its uses in determining how frequently nurses experience ethical issues in practice.
Design: The EIS was validated with a sample (N=2,090) of New England registered nurses (RNs) currently in practice. The sample was randomly split into two approximately equal samples. The calibration sample was used to derive the underlying components; the validation sample was used to confirm the component structure.
Methods: Psychometric analysis of the 35-item EIS included: (a) item analysis, (b) confirmatory principal components analysis (PCA), and (c) internal consistency reliability using Cronbach's alpha.
Results: Three components (end-of-life-treatment issues, patient care issues, and human rights issues) were demonstrated, confirming the original conceptually-derived structure. The calibration sample accounted for 42.4% of initially extracted common variance; the validation sample accounted for 41.5% of initially extracted common variance.
Conclusions: The three EIS subscales had satisfactory internal consistency reliability and factorial validity for use as independent scales in future studies.     

Outcomes assessment of clinical information system implementation: a practical guide

Healthcare information systems (HIS) play a vital role in quality of care and the organization's daily operations. Consequently, increasing numbers of clinicians have been involved in HIS implementation, particularly for clinical information systems (CIS). Implementation of these systems is a major organizational investment, and its outcomes must be assessed. The purpose of this article is to provide clinicians and frontline informaticians with a practical guide to assess these outcomes, focusing on outcome variables, assessment methods, and timing of assessment. Based on in-depth literature reviews and their empirical experiences, the authors identified 3 frequently used outcomes: user satisfaction, clinical outcomes, and financial impact. These outcomes have been assessed employing various methods, including randomized controlled trials, pre- and post-test studies, time and motion studies, surveys, and user testing. The timing for outcomes assessments varied depending on several factors, such as learning curves or patients conditions. In conclusion, outcomes assessment is essential for the success of healthcare information technology, and the CIS implementation team members must be prepared to conduct and/or facilitate these studies.     

Computer-based patient record systems

OBJECTIVES: To provide oncology nurses with an overview of computer-based patient record (CPR) systems, a key infrastructure requirement in information management that is essential to maintaining a scientific basis for health care. DATA SOURCES: Published articles, research studies, and review articles pertaining to CPR systems. CONCLUSIONS: Progress in hardware development, software applications, and interfaces combine to bring us multimedia patient record systems. Many obstacles have been overcome as standards have emerged and technologies conform to those standards. However, there has been limited success in implementation of such systems. Early acceptance of structured data and problem-oriented documentation set the framework for charting in the electronic record. IMPLICATIONS FOR NURSING PRACTICE: Oncology clinicians and cancer patients alike will realize greater efficiencies and increased quality in health care when the CPR is fully implemented.     

The need for nursing leadership in uncertain times

Background The world today is changing and being affected by advances in technology and communication, as well as changes in the political, economic, demographic and social environment. These changes also effect the delivery of health care services.
Aim A review of the literature was conducted to examine how the profession of nursing can ensure that it is involved in shaping the health care system of the future.
Key Issues to Emerge The nursing profession requires leadership which empowers nurses, enabling them to lead the profession into the next millennium. Pressures for change in health care delivery make the move from bureaucratic management to effective leadership essential. Development of an appropriate model of leadership will ensure that nurses play a pivotal role in the process of change.
Conclusion Transformational leadership is the model that will assist nursing to develop into an empowered profession with the potential to be a dominant voice in reshaping the health care system of the future.     

End-of-life care for older adults with dementia living in group homes in Japan

Aim:  The aim of this study was to elucidate the components of end-of-life care provided to older adults with dementia who live in group homes (GHs) in Japan.
Introduction:  The number of GHs in Japan is rapidly increasing. Although GHs were originally not established to care for elderly people with advanced-stage dementia, many residents remain in the GH even after their stage of dementia advances; thus, end-of-life care is required.
Methods:  Interviews were conducted with seven GH administrators on their experience in providing end-of-life care to their residents. The constant comparative approach was used for data collection and analysis.
Findings:  Four themes emerged as essential components of end-of-life care in the GH setting: (i) maintaining a familiar lifestyle; (ii) minimizing physical and mental discomfort; (iii) proactively utilizing desirable medical care; and (iv) collaborating with family members.
Conclusion:  The combination of the four components seems to be a unique characteristic of end-of-life care in GHs in Japan. These findings may be used to establish a framework for end-of-life care at GHs.     

Hemodynamics of Interposed Abdominal Compression during Human Cardiopulmonary Resuscitation

Objective: Clinical studies of interposed abdominal compression CPR (IAC-CPR) have had diverse outcomes. This study compared the hemodynamics of standard CPR and IAC-CPR in humans.
Methods: A 24-month prospective nonrandomized analysis of hemo-dynamic parameters was performed in a convenience cohort of 20 adults who had had out-of-hospital, nontraumatic, normothermic cardiac arrests. The study took place in the resuscitation unit of a large urban hospital. Thoracic aortic and right atrial catheters were inserted and pressures were recorded during standard CPR and IAC-CPR. Coronary perfusion pressures (CPPs) were determined during standard CPR and IAC-CPR. The patients were separated into two groups based upon their responses to IAC-CPR. Responders had increases in CPP during IAC-CPR; nonresponders had decreases or no change in CPP during IAC-CPR. Aortic relaxation, right atrial relaxation, aortic compression, and right atrial compression phase pressures were compared between the two groups.
Results: CPPs increased in 13 patients and decreased in seven patients. The mean change in CPP with IAC-CPR was an increase of 5.8 ± 15.1 torr. An elevated right atrial compression phase pressure (RaComp) during standard CPR was predictive of an increase in CPP during IAC-CPR (p = 0.047). In those patients who showed improvements in CPP during IAC-CPR, mean aortic relaxation phase pressures (AoRelax) increased by 9.5 ± 14.2 torr (p = 0.026) and mean right atrial relaxation phase pressures (RaRelax) decreased by 2.6 ± 6.2 torr (p = 0.099) during IAC-CPR.
Conclusions: The variable effects of IAC-CPR on CPP appear to be multifactorial. The improvement in CPP that occurred in responders to IAC-CPR was secondary to an increase in AoRelax as well as a decrease in RaRelax.     

The acceptability of an information leaflet explaining cardiopulmonary resuscitation policy in the hospice setting: a qualitative study exploring patients' views

BACKGROUND: Guidelines advise that patients receiving palliative care should be given realistic information about cardiopulmonary resuscitation (CPR) and encouraged to participate in decisions about this. For many patients attending a hospice, CPR is unlikely to be successful because of advanced disease. It is difficult to predict which patients would like to discuss CPR and whether such discussion might cause distress. AIM: This research set out to determine the acceptability and understanding of a patient information leaflet about CPR given to inpatients and day-unit patients in one hospice, and to seek patients' views on communication about resuscitation. METHODS: Semi-structured interviews were carried out with five hospice inpatients and one day-unit patient and analysed using interpretative phenomenological analysis for emergent themes. Results and conclusions: The leaflet was acceptable to the participants but was interpreted in the context of their understanding of their illness and prognosis. The leaflet alone is not a reliable method of communicating resuscitation policy and should be followed up by the opportunity to ask questions, if the patient wishes. Many factors influence patient choices about CPR. Realistic information about prognosis and about the risks and harms of CPR would allow patients to make a better-informed decision. However, if a patient prefers not to talk about their prognosis and end-of-life issues, then this should be respected.     

Barriers to evidence-based practice in primary care

Background.  Evidence-based practice is one of the most important underlying principles in modern health care. In the United Kingdom, successive governments have highlighted the fact that a quality health service is built upon the use of best evidence. Health professionals are becoming more accountable within clinical governance structures for the care they provide. The need to use robust research findings effectively is a critical component of their role. However, studies show that a number of barriers prevent the effective use of best available evidence.
Aim.  This study aimed to identify barriers to evidence-based practice in primary care.
Method.  A specially designed questionnaire was used to gather respondents' perceptions of the barriers to evidence-based practice. Data were collected in 2000/2001.
Findings.  Findings show that general practitioners (GPs) ranked barriers differently to community nurses. GPs believed that the most significant barriers to using evidence in practice were: the limited relevance of research to practice, keeping up with all the current changes in primary care, and the ability to search for evidence-based information. In contrast, the most significant barriers to the identified by community nurses were poor computer facilities, poor patient compliance and difficulties in influencing changes within primary care. This suggests that these two groups may require different strategies for barrier removal.
Conclusions.  Identifying barriers is just the first step to addressing issues surrounding the use of evidence-based practice. Extra resources will be needed if these barriers are to be tackled. However, if the resultant change improves the health and wellbeing of people and communities, then the extra costs would be offset by more efficient use of services.