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WITH I.V. PIGGYBACK MEDICATIONS dangling from the I.V. pole attachment, the computer screen glowing brightly on top, and protected items tucked into cubbies, the "cart" (as I call it) rolled into my patient's room with me right behind it. "Hello, Mr. C! My name is Helene," I said, then finished introducing myself. I was ready.
The mobile nursing workstation, as the cart is formally called, was brimming with supplies, with medications in the drawers and essential patient identifiers easily visible on the screen. Holding a scanner in my hand, I was ready to administer medications.
My patient, an alert and oriented older man, stared intently and gestured toward the cart. "What's all this?"
The cart is taller than I am, so I had to peek around it to see his face. I'd bumped it against the wall and the end of the bed as I'd tried to navigate it into the room. Most likely, the room wasn't designed with this in mind. I heaved a sigh of relief that his visitors hadn't yet arrived because I doubted they'd fit around the cart. His eight morning medications were due, I'd just finished report, and my cart and I were meeting Mr. C for the first time. What an entrance!
This article explains some advantages these high-tech but potentially intimidating carts offer and suggests some ways to keep the caring in nursing while using them. No matter where you work in nursing or how comfortable you are with new technology, you'll want to help your patients feel cared for.
Electronic health records (EHRs) are being implemented at a dizzying pace, and nurses like me have been working hard to catch up before the implementation deadline.1 The Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act of 2009 is influencing healthcare facilities and providers to adopt EHRs. HITECH ties specific effective utilization criteria with financial incentives and time-sensitive deadlines.1
These computers and the carts to which they're attached are just the tip of the iceberg. Learning to use, navigate, and accurately document in the EHRs takes time, practice, and understanding. Meaningful use, a term from HITECH, involves much more than just pushing the buttons. It consists of staged sets of requirements that demonstrate correct implementation of health information technologies.2
In my role as a clinical nurse at an acute care facility, I need to input data as quickly and accurately as possible. These data serve two purposes: they document my patients' progress, and they contribute to the hospital's data set.2 The latter is being developed to address quality indicators and multiple other functionalities, leading back to that meaningful use requirement. The interdisciplinary contributions to the EHR allow for easier access, sharing of information, and collation of data while simultaneously facilitating the development and implementation of plans of care for patients.
Care? Where in all of this data management is caring?
As a nurse educator, I wonder if these carts, workstations, or computers are barriers to caring. As nurses implement new technologies, including EHRs, how can they enhance the nurse-patient relationship and demonstrate caring?
So, let's go back to my patient, Mr. C. He'd been very tolerant of my maneuvering up to this point. But when I reached for his arm with my scanner and it beeped, he said, "I feel like a meat package at the grocery store."
He clearly wasn't feeling human. I was shaken because caring is what I do and who I am. In my hurry to get everything done, had I inadvertently reduced my patient to a data stream with a bar code?
It was easy to see how I was missing the mark on caring for Mr. C. I needed to turn this interaction around. I told him I'd be right back and convinced the cart to leave the room without denting any furniture.
Luckily, a quick literature search yielded some help from researchers Tonges and Ray, who operationalized Swanson's Caring Theory when they developed the Carolina Care Model for the University of North Carolina Hospitals.3-5 I scanned the article looking for a solution. There, on the second page, was information I could use.
In essence, Swanson's Caring Theory combines nursing compassion (knowing and being with) and competence (doing for and enabling) with a culture of maintaining belief to lead to patient healing and well-being.4,5 When maintaining belief, nurses keep faith in others' abilities to move through transitions to have meaningful lives. By knowing others, nurses try to understand the meaning of events in others' lives. They're emotionally present to others by being with them. They do for others what they would do for themselves if they could. In enabling, nurses help others care for themselves and their loved ones.4,5 I could relate to this.
Because the cart with its computer and scanner was new and unfamiliar to Mr. C, I needed to add anticipatory guidance to my caring process. Explaining events to patients before they occur can help prepare them for unfamiliar procedures and technologies.
I turned the cart around and went back into the room, this time entering first and pulling the cart behind me. I reintroduced myself to Mr. C and explained that the computer on the cart would help me to document his information accurately.
Then, as I gingerly reached for the scanner, I explained that by using the bar code program in the computer, I'd be taking steps to improve the accuracy of medications administered to all my patients, including him. I told him I was committed to maintaining his safety and well-being.
I adjusted the screen so he could see his information as I did. We verified his name, birthdate, medical record number, and allergy profile. Scanning his armband produced a screen of medications to view. I pulled the medications out of his drawer and scanned them as well.
As we worked down the list, I explained the medications and offered patient-education materials for the new ones he'd be taking at home. Now the computer was becoming a tool for both of us. Mr. C asked for a printout listing his medications to give his wife. I easily accommodated him by pressing the print button, smiling with relief as I realized I didn't have to handwrite the long list.
The mobile nursing workstation or cart, with all its gadgets, can be imposing. I believe that both nurses and patients can transition to viewing these new technologies as helpful tools.
I know that with anticipatory guidance, I can help Mr. C and other patients like him acclimate to these technologies by using the knowing and maintaining belief described by Swanson.5 By returning to face my patient, deliberately making eye contact, and communicating effectively and therapeutically, I'm being present with him. During the shift, I updated his plan of care and administered his medications; I'm doing for him. Anticipating his discharge, I started teaching him what he'll need to know to care for himself by enabling his transfer home. All of these actions exemplify caring.
It's heartening to find research that resonates within me. The challenge for nurses is to integrate the use of EHRs, computers, and carts into our practice while purposefully maintaining our caring attitude.
Position the cart so that it doesn't block visualization and communication. Consider Swanson's Caring Theory as a base to operationalize caring interventions similar to the Carolina Care Model.3,5 Use anticipatory guidance to decrease patient anxiety and overcome nurses' reluctance to use the tools.
With deliberate attention to caring practices, nurses can reduce the barriers created by new technologies. As nurses develop and refine techniques for new technologies, best practices can be identified and incorporated into the instruction of future nurses as well.
1. U.S. Department of Health and Human Services. HHS announces next steps to promote use of electronic health records and health information exchange. 2012. http://www.hhs.gov/news/press/2012pres/08/20120823b.html. [Context Link]
2. Centers for Medicare and Medicaid Services. Meaningful use. 2013. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Me. [Context Link]
3. Tonges M, Ray J. Translating caring theory into practice: the Carolina Care Model. J Nurs Adm. 2011;41(9):374-381. [Context Link]
4. Swanson KM. Empirical development of a middle range theory of caring. Nurs Res. 1991;40(3):161-166. [Context Link]
5. Swanson KM. Nursing as informed caring for the well-being of others. Image J Nurs Sch. 1993;25(4):352-357. [Context Link]
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