View Entire Collection
By Clinical Topic
By Journal
By Specialty
By Category
Asthma
COPD
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Magnet Recognition
Nursing Ethics - Fall 2011
Nutrition
Pneumonia
Renal Disease
Stroke
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
Healthcare information technology in US hospitals and ambulatory care centers continues to expand, and nurses are expected to effectively and efficiently utilize this technology. Researchers suggest that clinical information systems have expanded the realm of nursing to integrate technology as an element as important in nursing practice as the patient or population being served. This study sought to explore how medical surgical nurses make use of healthcare information technology in their current clinical practice and to examine the influence of healthcare information technology on nurses' clinical decision making. A total of eight medical surgical nurses participated in the study, four novice and four experienced. A conventional content analysis was utilized that allowed for a thematic interpretation of participant data. Five themes emerged: (1) healthcare information technology as a care coordination partner, (2) healthcare information technology as a change agent in the care delivery environment, (3) healthcare information technology-unable to meet all the needs, of all the people, all the time, (4) curiosity about healthcare information technology-what other bells and whistles exist, and (5) Big Brother is watching. The results of this study indicate that a new care partnership has emerged as the provision of nursing care is no longer supplied by a single practitioner but rather by a paired team, consisting of nurses and technology, working collaboratively in an interdependent relationship to achieve established goals.
Increasing numbers of hospitals and ambulatory care institutions in the United States are expanding the use and diffusion of healthcare information technology (HIT), including the electronic health record (EHR),1 causing a dramatic shift in the caregiving paradigm. Survey estimates suggest that approximately 27% of acute care hospitals and 12% of ambulatory care settings have adopted various forms of EHRs.2 Representing the largest portion of direct caregivers, RNs have been labeled the largest consumers of HIT.3 Because of their continuously interdependent working relationship, healthcare technology has become an integral component of contemporary workflow practices for nurses. Despite the safety and efficacy benefits provided by HIT, it has not been clearly substantiated that the presence of highly advanced HIT in the workplace truly influences a nurse's clinical decision making, thus potentially improving health outcomes.4
The term healthcare information technology refers to systems that serve as repositories for healthcare data that can be accessed by care providers for purposes of retrieval, transfer, communication, and/or analysis.3,5-7 Healthcare information technology has been used synonymously with other concepts such as clinical information system (CIS), creating confusion, and precise definitions of these terms are needed.
Weber4 presents six different characteristic descriptions of clinical decision support systems (CDSS), while more exist in other informatics and information technology (IT) research. Most readily applicable is the description of CDSS as heuristic-based computer software systems that are designed for clinician use to aid in clinical decision making.8 Utilizing embedded rules and decision-tree algorithms, this CIS element evaluates stored patient data to generate suggestions for clinician actions.9 Considering the proposed function of CDSS, it is essential for the nursing profession to evaluate the influence of CDSS on practice. Weber4 attempted to evaluate critical care nurse specialists' interaction with CDSS; however, no identifiable patterns of use could be identified that describe how the systems impacted their practice.
In the broadest sense, the term healthcare information technology is utilized for a multitude of healthcare-related functions including scheduling, maintaining inventory, personnel record keeping, tracking performance improvement data, and billing purposes. Clinical information systems as a subset of HIT have a more narrow focus toward providing support at the point of patient care, to gather, store, analyze, and make available clinical data for use by various members of the healthcare team. There are multiple components of clinical systems that exist, although each system is not inclusive of all components. Common applications of CISs include EHRs/electronic medical records (EMRs), CDSSs, computerized provider/physician order entry (CPOE), results reporting, and picture archiving.6
Computerized provider/physician order entry allows providers to electronically prescribe medications, laboratory tests, and/or procedures both from within a care institution as well as from remote locations such as provider offices, home, or from mobile handheld devices.6,8 The impact of a CPOE system was evaluated in surgical patients by Stone et al.10 The findings suggested that increased efficacy was realized relative to decreased time between order entry and nurse receipt; however, the percentage of medication errors remained comparably equivalent to those experienced prior to system implementation. This may be explained by the continued need for clinician evaluation of provider orders, despite their electronic format, to determine appropriateness for the patient considering the context of the clinical situation.
Nurses are responsible for documenting, interpreting, and acting on the voluminous amount of data maintained by CISs. It is imperative that they efficiently utilize HIT by effectively analyzing the data it yields to aid in their clinical decision making.11 The majority of CIS literature focuses on practitioners' acceptance and use, factors influencing successful system implementation, workflow considerations, and perceived and actual benefits.7,12-14 What remains to be further examined, however, is the interaction between nurses and technology since the infusion of more technology in the nursing workplace is likely to continue. However, the expense of purchasing, training, and updating healthcare technology is immense, and even more so in a less than robust economic climate. A typical nurse's 24/7 use of technology to support and deliver care must be maximized to be cost-effective.
A few studies have addressed the relationship between nurses and technology in practice and have similarly concluded that the value of technology is not determined by the technology itself, but rather by the user's appraisal of it.4,9 Unfortunately, the body of literature relative to the topic is narrow and was primarily explored prior to the proliferative implementation of EHRs.
The objective of this study was to address the gap in current literature relative to the relationship between nurses and technology in practice. Thus, the primary intent of this project was to explore nurses' experiences with HIT and to better discern if the new CDSSs enhanced nurses' clinical decision making. The specific questions of this study were to evaluate (1) how are medical surgical nurses utilizing HIT in their current clinical practice and (2) if nurses' clinical decision making is influenced by HIT.
The nursing literature has largely focused on the complexities experienced by nurses in their increased roles and responsibilities to manage healthcare technologies.7,15,16 Considering the necessity of managing clinical and technical knowledge, it is not surprising that the consequences of the interaction remain unknown. Research suggests that experienced nurses are better equipped to optimally incorporate technology into practice as opposed to their less experienced counterparts.17 Experienced nurses have also been found to possess refined clinical decision-making skills, thus enhancing their patient care abilities.18 Clinical decision support systems have been introduced to aid in clinicians' decision making, although questions have been raised regarding their effect on health outcomes. In other words, is there a true payoff or benefit from the technology?
The introduction of HIT and CISs has caused the realm of nursing to integrate technology as an element as important in nursing practice as the patient or population being served.19 As suggested by previous research, the provision of nursing care is no longer supplied by a single practitioner but rather by a paired team, consisting of nurses and technology, working collaboratively in an interdependent relationship to achieve established goals.
Existing nursing literature fails to adequately describe how nurses interact with HIT and its subsequent effect on decision-making patterns. Considering the true relationship between nurses and technology cannot be exclusively captured through quantitative measures, a qualitative description is essential in performing an adequate evaluation of their subjective experiences. The use of focus group interviews of both novice and experienced nurses provided an optimal platform for caregivers to share their experiences, while also allowing for exploration of the research questions. Use of this method in the current study allowed for the thematic description of subjective behaviors and experiences of nurses interacting with HIT by categorizing textual data and identifying patterns elucidated from participant narratives. This form of inquiry proved extremely beneficial for the study as the practical integration of technology in practice, and its perceived impact on day-to-day clinical decision making, was explicated through descriptions of use by end-users themselves.
Participants were recruited from the Acute Care Services Division of Northwest Hospital in Randallstown, MD. A part of the LifeBridge Health System, the institution is a 242-bed, not-for-profit community acute care hospital providing services for medical, surgical, behavioral health, rehabilitative, and hospice patients.20 The facility has currently adopted several aspects of the CIS including use of an EMR, CPOE, clinical decision support elements, results reporting, and picture archiving. A purposive sample was utilized for this study in an effort to elicit rich meaningful data. This method of sampling involves the deliberate selection of participants who have experience with the phenomena of interest and also possess traits of a contributable informant.21 The targeted populations were novice and experienced nurses regularly utilizing the Cerner CDSS (Cerner, Kansas City, MO) in their clinician workflow practices. Potential participants were unable to participate if they met any of the following exclusion parameters: (1) younger than 21 years or older than 75 years; (2) working in the hospital as a temporary or agency employee; (3) educationally prepared with a master's degree in nursing; (4) unable to read, speak, or understand English; (5) have a self-reported learning disability that interferes with the receipt or interpretation of information; or (6) currently a novice RN previously employed as a practical nurse. An invitation to join the study was extended to potential participants who (1) possess a current active license as an RN in the state of Maryland; (2) read, speak, and understand English; (3) were employed a minimum of 16 h/wk by the cooperating facility as a staff nurse on a medical-surgical unit; (4) were legally and cognitively competent to sign their own consent form to participate in a research study; and (5) have been employed either 2 years or less or 10 years or more as an RN in an inpatient hospital setting.
A focus group strategy was selected in order to engage nurses who were interacting with IT at various experience levels. Nurses were stratified into either the novice or experienced group, depending on their years of experience. Novice nurses were defined as those with less than 2 years' experience, while experienced nurses possessed more than 10 years' experience. The following questions/statements were used to guide the group interviews: (1) Tell me about your experiences utilizing the Cerner clinical documentation system in the clinical environment. (2) Can you describe how using the Cerner CDSS has affected your care? (3) Can you give specific examples of when the decision support system was helpful and when it was not helpful? (4) Can you talk about specific occurrences when the system has helped you in making a decision for your patients? (5) Describe for me times when it was not appropriate to follow the direction of the Cerner clinical documentation system. And (6) what do you think is the role of the CDSS in analyzing or interpreting patient data? Both focus group interviews were audio recorded and subsequently sent for professional transcription. In addition, demographic data were collected from each participant using an investigator-developed form. The form queried participants for information such as age, sex, educational level, months and/or years of experience as an RN, perception of Cerner training, and use of technology for purposes other than nursing care. Both the interview guide and demographic data form were reviewed for face validity by the research team.
Considering the limited amount of research available discussing the relationship between nursing and technology in clinical practice, a conventional inductive qualitative content analysis was utilized that allowed for a thematic interpretation of participant responses to emerge from the data. The analysis process closely followed the structured procedures detailed by Zhang and Wildemuth.22 Demographic data were maintained and analyzed with an SPSS statistical package (IBM, Armonk, NY), while transcribed data were managed with ATLAS.ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) qualitative data analysis software. The analysis process began with transcription of the data by a professional transcription service. The resulting records were compared against the focus group audio recordings to confirm accuracy and inclusiveness of all participant data. The participant data were independently reviewed and assigned preliminary codes by two nurse researchers. Utilizing electronic and telecommunication platforms, the two researchers met weekly until consensus about the coding schematic was achieved. Codes were subsequently grouped into categories and later counted for frequency of occurrence in each group. Dominant categories were grouped and pictorially recorded in a Venn diagram to identify ideas that were unique to novice or experienced nurses as well as those that were shared by both. Categories were later shared with a member of each of the focus groups to confirm interpretations and contribute to the authenticity of the data.
The results of this study are described and organized into three main sections. The first section describes the demographics of study participants. The second section includes the study themes and findings with excerpts from the two focus group interviews. Cited participant comments are identified by the group members professional experience level. Statements from members of the novice group are preceded by the letter "N," while excerpts from experienced group members are preceded by the letter "E." A conventional analysis was utilized that allowed for a thematic interpretation of participant data, and the five main themes that emerged from these data are presented. The third section describes support for study findings with existing studies in nursing literature.
A total of eight medical-surgical nurses participated in the study, four novice and four experienced. The mean age of the novice nurse was 37.5 years, while that of the experienced nurse was 43.5 years. A diverse group was represented in the sample, considering only 38% of participants were white, and the remaining 62% self-identified as African American or Asian. Six of the eight participants were academically prepared with an associate's degree in nursing representing 75% of the study sample. All of the respondents reported utilizing computer technology for personal functions other than those associated with work requirements. In addition, all of the participants denied ever attending classes or receiving instruction in nursing informatics. Only one of the eight respondents, an experienced nurse, reported using clinical applications on a PDA to aid in making patient care decisions. Table 1 provides an overview of the demographic data obtained from study participants.
Immediately evident from participant data is the presumption that the integration of HIT in the medical-surgical care setting has led to the partnering of nurses and technology in the provision of patient care. Both novice and experienced nurses described functions of the Cerner system relative to the retrieval of patient information, care orders, and scheduled tasks. Their reliance on Cerner for elements of care coordination is further supported by descriptions of care interruptions and task uncertainty when the system is not available.
One of the best advantages of the Cerner is that it sort of schedules your day for you because you know what you have to look ahead to, what you have to plan for. (N1)
If this computer suddenly lost, out of the blue, you are going to get lost too. (E1)
You are dependent on the computer. (E2)
When considering the decision support component of the IT, participants indicated that the yielded information was useful in their care coordination, but not equal to their independent reasoning. Despite their partnered relationship, both experienced and novice nurses perceived that decision elements of HIT play a supportive role to clinician knowledge and judgment but are incapable of replacing it.
It does make me go and look at the vital signs and other things that have been recorded. So, in that sense, it's good, but it's not accurate. (N1)
Yeah, I don't really use it as a decision trait for me. I still look at the initial diagnosis and what I get from report. (N2)
[horizontal ellipsis]You just have to do that old school nursing. Certain things that come up, and you just know your patient, and you are forced to think on it on your own instead of having that[horizontal ellipsis] (E1)
In discussing care patterns with use of the Cerner technology, nurses were able to describe a palpable conversion in the patient care environment. Many of these changes related to the transparency of user access, actions, and documentation that resulted in functional or workflow changes among members of the care team.
Save time for me because it's fast. (N1)
Prior to the introduction of EHRs, no definitive methods existed to assess which clinicians had access to health records to document care, revise forms, or place and update patient orders. As a result of the increased transparency provided by the Cerner system, users are more meticulous when viewing and documenting in electronic charts.
You cannot actually just open any patient because it will tell you opened it[horizontal ellipsis] it will actually guide you to just mind your own business. (E1)
Additional code categories supporting Cerner's influence in changing the care environment were the increased safety classification and the description of Cerner as both comprehensive and restrictive.
It provides a safer environment for the nurses, especially the MAR. When it used to be in the paper, there were more mistakes, more likely to have mistakes because the penmanship is not too legible when they describe it-more mistakes. (E2)
Despite the numerous positive elements identified by nurse users, there were a great deal of system limitations that subsequently necessitated creative thinking from the staff to achieve desired outcomes. When discussing Cerner's deficiency in meeting some clinical user needs, participants specifically referenced limited areas available for individualized documentation, template-based orders that did not entirely reflect the primary care provider's intent, and electronically scheduled medications resulting in schedules that are heuristically based as opposed to contextually driven.
The MAR, you cannot put there, those are not given because pharmacy has not delivered. (E3)
The time comes again,10:00 PM you give it, it is overloading the patient. Not only that it is going to charge the patient[horizontal ellipsis] it is not good for the system or the patient. (E4)
Would appreciate if we have more areas to type in a comment. (N2)
Nowhere you can write your own little note to something. (N4)
In these instances, the use of Cerner's system created a gap in the continuity of care. Subsequently, both experienced and novice nurses assumed responsibility for initiating system workarounds to repair fissures created by mandated use of the system.
When it [medication] is not due, sometimes it does not come up[horizontal ellipsis] I say OK no problem, I know what to do, you click on additional, you reschedule. (E2)
I reschedule the second dose of the medication, and then I return the medication, but I write on the medication already given. (E1)
I recently had a situation where the patient had the same medication ordered in different doses for the same time to be given. And I thought something couldn't be right. So I eventually called, and one of them was dc'd. (N4)
While not an idea shared by both groups, curiosity about various system elements was undoubtedly evident during the novice nurse interview. Throughout the discussion, the inexperienced nurses inquisitively commented on the multifaceted nature of the Cerner system. Users acknowledged that there were several system functions that went unused as well as documentation areas to which they have not been exposed.
Everyday I'm seeing something new that I didn't know was there before. (N3)
Probably a thousand more things it would do that we don't do every day. (N4)
In addition, the group gave feedback about which features that would aid in patient care activities.
Peculiar to the experienced nurses was their uneasiness with the increased transparency provided by use of EHRs and clinical decision support technology. Participants were comfortable and confident in their patient care responsibilities and conveyed a disdain for having to intricately balance predetermined demands for computer documentation that impeded their ability to prioritize patient care.
Sometimes it is the people around it. Sometimes, these people around it, like the performance evaluator or anything that looks into your work, sometimes it adds stress to yourself because they want us to put the assessment by this certain time. Of course, you cannot really do that one because you have to take care of your patient. (E3)
Experienced nurses expressed irritation with retribution from administrative nursing staff tracking documentation trends that did not comply with institutional policies and procedures.
Our names are going to be printed on the billboard if we do not do our patient response. (E4)
The perceived divide in priorities for clinical versus administrative staff resulted in the experienced nurses' view of performance improvement staff as oppositional team members. They are perceived as out of touch with the realities of direct care and subsequently more concerned with completing documentation than providing direct patient care.
They do not know what is going on, you are the one who knows what is going on, although they want to check. (E1)
Considering findings from data collected from both groups, nurses' clinical decision making is not overtly influenced by the use of HIT. Nurses interacting with the Cerner system in the cooperating facility utilized clinical decision support prompts as a signal to further evaluate and appraise patient needs and progress. Irrespective to the level of experience, the consensus was that the ultimate responsibility for making patient care decisions lay with the nurse, due to limited individualization of CDSS and its inability to critically judge evolving clinical dynamics. Despite working collaboratively, nurses regard their technological partners as subordinates.
While this research significantly contributes to the body of HIT literature, the study had limitations that should be considered when reviewing data. These limitations were relevant to the qualitative research design, sample size, and the contextual analysis. A relatively small sample may not represent the larger population of interest. In addition, the contextual and qualitative nature of this research could limit the applicability of findings to other settings.
Currently, insufficient literature exists regarding new and engaging IT for clinical care. Further exploration is needed regarding the integration of HIT to ensure optimal outcomes. Replication of the current study in varying clinical environments would assist in discovering perceptions of end-users experienced with different IT systems, as well as clinicians working in different care settings. In addition, the use of a clinical decision-making measurement tool to evaluate the influence of HIT on users would enhance the evidence pertaining to this research. The data generated from research on nurses' relationships to IT can guide HIT implementation efforts so that systems are not superimposed on existing workflow practices, but are effectively integrated to achieve improved patient outcomes.
The authors thank Fran Cornelius, PhD (Drexel University), and Jean Giddens, PhD (University of New Mexico), for their contributions to this work.
1. Taylor R, Bower A, Girosi F, Bigelow J, Fonkych K, Hillestad R. Promoting health information technology: is there a case for more-aggressive action? Health Aff. 2005; 24 (5): 1234-1245. [Context Link]
2. Bower AG. The diffusion and value of healthcare information technology. Santa Monica, CA: RAND Health; 2005. [Context Link]
3. Deese D, Stein M. The ultimate health care IT consumers: how nurses transform patient data into a powerful narrative of improved care. Nurs Econ. 2004; 22 (6): 336-341. [Context Link]
4. Weber S. Critical care nurse practitioners and clinical nurse specialists interface patterns with computer-based decision support systems. J Am Acad Nurse Pract. 2007; 19 (11): 580-590. [Context Link]
5. Barnard A, Gerber R. Understanding technology in contemporary surgical nursing: a phenomenographic examination. Nurs Inq. 1999; 6 (3): 157-166. [Context Link]
6. Medpac. Information Technology in Healthcare. Report to the Congress: New Approaches in Medicare. Washington, DC: Center for Medicare & Medicaid Services; 2004. [Context Link]
7. Zuzelo PR, Gettis C, Hansell AW, Thomas L. Describing the influence of technologies on registered nurses' work. Clin Nurse Spec. 2008; 22 (3): 132-142. [Context Link]
8. Hannah KJ, Ball MJ, Edwards MJA. Introduction to Nursing Informatics. 3rd ed. New York: Springer-Verlag; 2005. [Context Link]
9. Holroyd BR, Bullard MJ, Graham TA, et al.. Decision support technology in knowledge translation. Acad Emerg Med. 2007; 14 (11): 942-948. [Context Link]
10. Stone WM, Smith BE, Shaft JD, et al.. Impact of a computerized physician order-entry system. J Am Coll Surg. 2009; 208 (5): 960-967. [Context Link]
11. Kleiman S, Kleiman A. Technicity in nursing and the dispensation of thinking. Nurs Econ. 2007; 25 (3): 157-161. [Context Link]
12. Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly. 1989; 13 (3): 319-340. [Context Link]
13. McGrath KM, Bennett DM, Ben-Tovim DI, Boyages SC, Lyons NJ, O'Connell TJ. Implementing and sustaining transformational change in health care: lessons learnt about clinical process redesign. Med J Aust. 2008; 188 (6): S32-S35. [Context Link]
14. Prince SB, Herrin DM. The role of information technology in healthcare communications, efficiency, and patient safety application and results. J Nurs Adm. 2007; 37 (4): 184-187. [Context Link]
15. Almerud S, Alapack RJ, Fridlund B, Ekebergh M. Caught in an artificial split: a phenomenological study of being a caregiver in the technologically intense environment. Intensive Crit Care Nurs. 2008; 24 (2): 130-136. [Context Link]
16. Henderson A, Henderson A. The evolving relationship of technology and nursing practice: negotiating the provision of care in a high tech environment. Contemp Nurse. 2006; 22 (1): 59-65. [Context Link]
17. Tabak N, Bar-Tal Y, Cohen-Mansfield J. Clinical decision making of experienced and novice nurses. West J Nurs Res. 1996; 18 (5): 534-547. [Context Link]
18. Banning M. A review of clinical decision making: models and current research. J Clin Nurs. 2008; 17 (2): 187-195. [Context Link]
19. Huffman C, Sandelowski M. The nurse-technology relationship: the case of ultrasonography. J Obstetr Gynecol Neonatal Nurs. 1997; 26 (6): 673-682. [Context Link]
20. LifeBridge Health. http://www.lifebridgehealth.org/northwest.cfm. Accessed March 15, 2010. [Context Link]
21. Munhall PL. Nursing Research: A Qualitative Perspective. 4th ed. Boston, MA: Jones and Bartlett Publishers; 2007. [Context Link]
22. Zhang Y, Wildemuth B. Qualitative analysis of content. In: Wildemuth B, ed. Applications of Social Research Methods to Questions in Information and Library Science. Westport, CT: Libraries Unlimited; 2009. [Context Link]