Driven by an urgent need to improve the safety and quality of care provided in our increasingly complex health care system, health information technology has taken a central role in the health care system. The technology used at the point of care undoubtedly changes the process of nurse and patient interactions. These technologies have the potential to improve patient care while helping clinicians harness the explosive knowledge growth accelerating us into the 21st century. However, both clinicians and patients experience frustration and negativity associated with our increased dependence on technology. How has our technology-rich environment influenced the caring behaviors identified as the core of nursing practice? This article will explore these issues, examine and discuss solutions offered in the scientific literature, and make suggestions for future research.

DRIVEN by an urgent need to improve the safety and quality of care provided in our increasingly complex health care system, health information technology has taken a central role in the health care system. These technologies have the potential to improve patient care while helping clinicians harness the explosive knowledge growth accelerating us into the 21st century. However, both clinicians and patients experience frustration and negativity associated with our increased dependence on technology. The technology used at the point of care undoubtedly changes the process of nurse and patient interactions. The recent nursing literature has begun to explore issues surrounding these changes. Because caring is a core value in nursing and the human interactions between nurse and patient are now occurring in the midst of a myriad of new technologies, these questions seem vital to maintaining the critical care nurse's identity as patient-centered care provider.

BACKGROUND

Over the past decade several major national reports, including the Institute of Medicine's landmark 2001 report1 and the Robert Wood Johnson Foundation's Quality and Safety Education for Nurses initiative2 have issued calls for radical change in health care, emphasizing the role of informatics in shaping the future. Health care professionals in practice, education, and research are increasingly searching for innovations to improve safety, quality, and efficiency centered on increased technology, including technologies at the point of care. In 2009, congress passed the Health Information Technology for Economic and Clinical Health Act which invests billions of dollars to promote the increased use of electronic medical records and further accelerate innovations in the use of health information technology (IT).3 Many of these technologies already permeate nursing care in the critical care setting and their use is expected to increase.

Most agree that health IT has the potential for tremendous benefits. A recent review of the literature by Buntin and colleagues3 shows predominantly positive results from studies that examined health IT outcomes. Their research looked at peer-reviewed studies that described outcomes from health IT such as electronic health records (EHR), computerized provider order entry, clinical decision-support systems, e-prescribing, and information retrieval among others. They reviewed 154 studies and found 92% of them to have either positive or mixed-positive results. The largest numbers of positive study outcomes were related to efficiency and effectiveness of care with patient satisfaction, care processes and patient safety having fewer positive measurable outcomes. Nurses have identified specific advantages to health IT such as improved interdisciplinary and handoff communication and increased independent functioning due to fuller access to information.4 Yet despite the tremendous potential benefit, health care providers have experienced frustrations with the use of health IT and widespread implementation by hospitals and physicians has been limited.5

O'Malley specifically notes that "adding an EHR to the clinical encounter can further distract clinicians from patients."5^(p1091) Carter and colleagues6 noted that novice nurses seem to be overwhelmed by the technological requirements of caring for patients. Their concern was that patient-centered care was being overshadowed by new tasks related to technology. In a qualitative study conducted using nurse and patient interviews and participant observation, Alliex and Irurita7 describe the phenomena of technology prominence and technology awareness in which nurses sometimes feel hindered in their interactions with patients in technology-rich environments. Nurses are concerned that increasing the technology used in caregiving will impair the connection between patient and nurse. Although health IT certainly is not uniformly a barrier to patient-centered care, and in fact, it has the potential to increase the amount of time nurses spend with patients,8 a proactive approach by nurses, educators, researchers, designers, and informaticists in preserving the essence of caring in the technology-rich environment is vital.

CONCEPTUAL UNDERPINNINGS

To maintain a patient-centered focus in the technologically advanced critical care environment, nurses must have a unique focus on keeping the patient at the center of care. In fact, caring is often seen as the central focus of the nursing profession. Defining what is meant by "caring" has been the subject of much debate in the nursing literature. Multiple theorists have grappled with this concept including Leininger, Orem, and Watson, among others.9 In recent years, scholars have noted that the concepts and meaning of caring may need to be redefined in the context of changes in the ways nursing practice is carried out in the 21st century.10

Galvin11 presents some very relevant ideas specifically for nurses in critical care. She holds that health care is in danger of being dominated by an "audit culture" with an overly technical bent relying primarily on predictions made based on evidence from instruments. The critical care unit may be one of the most difficult environments in health care to keep the patient at the center of care. Galvin11 notes that expert critical care nurses must balance the importance of "the 'hand' (technical skills) and 'head' (protocols and evidence) and heart (ethical and human dimensions)."

Without doubt, nursing must firmly remain an evidence-based profession and health IT supports that practice. Using technology with skill to manage the information necessary to care for patients in an expert way is in fact a manifestation of caring. Simpson9 suggests that it is possible that technology can actually enhance interpersonal relations by creating efficiency, accountability, data aggregation, security, completeness, and anonymity. However, the essence of nursing practice cannot be reduced to simply responding to each situation from an evidence base. There are limits of traditional evidence in knowing what to do next in complex situations, situations that require contextualization, clinical reasoning, and judgment.12 Even when patients are critically ill, with lines, tubes, drips and drains, the human experience is not isolated from the environment. The essence of caring in the midst of the complexities of point-of-care technology must be maintained. The nursing profession may need new ways of demonstrating caring behaviors to patients in modern health care environments.

SOLUTIONS FROM THE CURRENT SCIENTIFIC LITERATURE

The nursing literature has begun to explore and describe possible interventions to maintain caring practices in the midst of a technology-rich environment (see Table 1). Researchers have found that added effort is needed to maintain a focus on the humanistic needs of the patient in the presence of increased technology. Perhaps this is most obvious among interactions between nurses and patients in critical care. Alliex and Irurita7 conducted a qualitative study using grounded theory methods to interview nurses and patients over an 18-month period in an attempt to study the phenomenon of nurse-patient interaction in the presence of technology. They describe the process of maximizing used by nurses, which was defined as "making the most of the interaction opportunity presented to the nurse."7^(p35)Maximizing consisted of maintaining presence, minimizing the impact of technology, and individualizing interactions. Many of these themes are echoed by other authors. Connecting with patients in ways that communicate genuine concern, including active listening, eye contact, and creative use of self are characteristic of a caring environment.6

Table 1. Caring Behaviors in the Technology-Rich Environment

Nurses minimized the impact of technology by conducting what the researchers labeled as dual interactions. Although performing technology-related tasks, the nurse verbally interacted with the patients, making conversation or talking about the patient's care. Furthermore, nurses used appropriate humor when interacting to humanize the interactions, allowing both nurse and patient to experience normal human emotions and minimize the importance of the technology in that moment. Nurses attempted to understate technology by simplifying explanations of its use and giving general information. Nurses manipulated the technology's physical presence, sights, and sounds to further minimize its centrality in the interaction.7 They individualized interactions to help maintain a caring presence. This consisted of responding to individual preferences, speaking to the patient even when simply entering the care area to respond to an alarm, giving attention to small details, and maintaining a positive, kind, and caring demeanor.7

Carter and colleagues6 questioned whether nurses' caring practices were diminished in a highly technology-driven environment. The researchers surveyed nurses and patients and conducted a focus group of nursing staff to explore this question in a large Midwestern inpatient institution. They identified major themes from respondents to include relationships of care and context of caring. Among other things, relationship of care included making key connections with the patient. This went beyond spending time with the patient to include being present, demonstrating a genuine concern, and active listening. The context of caring had to do with the environmental infrastructure encompassing organizational cultures, unit physical environment, and workload. A pervasive focus on caring by all care providers and hospital staff was identified as vital to promoting a culture of caring. The overall findings of this research indicated that even though the pace of work in a highly technological environment has increased, the nurses still very much valued caring as fundamental to their practice. The overall guiding principle of their findings was the idea that "caring begets caring."6^(p61) Nurses in today's health care environments must work hard at caring for each other by maintaining the teamwork and personal support needed to sustain a group of colleagues during periods when the demands of care in a constantly changing environment stress the system.

Wolf and colleagues13 examined ways that nurses can address the patient's perception of technology in health care, especially related to EHRs. They developed a sensitivity-teaching tool to help staff implement a new EHR system in an acute care hospital. They noted that the patient and family's perception is more than sensory input and also includes the selection, organization, and interpretation of that input.13 Their work began with a concern about how patients and their families would perceive a care provider using a computer at the bedside and whether clinicians would be sensitive to these perceptions. They noted that "clinicians' verbal and nonverbal communications about their comfort level with documenting at the bedside, ability to interact with technology, and reactions to patient concerns could also aid or deter the success of the EHR."13^(p113) Normal human reactions to frustrations with new computer systems might include exasperation, negative comments, and anger on the part of the nurse. These types of reactions could well be perceived by patients as a threat to safe, quality care.

These concerns led to the development of a patient sensitivity team at this 250-bed hospital made up of champions from various areas of the hospital who helped develop and conduct training called the Patient First educational tool.13 The scenarios in this training addressed possible perceptions patients or families might have related to the EHR. One possible perception was that staff members using computers were playing games, reading email, surfing the Web or looking at information unrelated to their care. They noted that staff members might think that electronically documenting care quickly and quietly at the bedside might seem appropriate but this could be viewed as the nurse being rude or not concerned with the patient. They reminded nursing staff of basic, foundational nursing care concepts such as always greeting and making introductions, making eye contact, offering to address needs, and explaining what care is taking place. Nurses in critical care work in some of the most highly technological environments in health care. This area of nursing practice may need a renewed focus on fundamental nursing concepts.

Another scenario depicted a staff member's frustration when encountering an interruption in functioning with the electronic documentation.13 Sighing, cringing, gestures, negative comments, and other actions related to frustration might indicate to patients a serious problem that could hinder their care. Patients and family members may not realize the source of frustration is the system and not their specific personal care. Nurses must be in control of their verbal and nonverbal responses to technical frustrations. When problems arise, a calm response to the situation with an explanation of the problem and how the nurse will work to resolve it can alleviate negative perceptions.

These same concerns may relate to other bedside technology such as the personal digital assistant (PDA). Lee14 conducted 14 in-depth patient interviews to explore their perception of nurses' bedside use of PDAs. Her findings indicate that patients see the benefit of these technologies but want more information about their use. They have concerns about privacy and accuracy and very much value nursing care over technology use. One patient's poignant comment summarizes themes heard in several studies.

To use PDAs or not, I think that depends on [hospital] administration requirements. As patients, we only want nurses to be nice to us, or to be tender in caring for us. That's it. That's what they should do, and this is all we want. As to what tools or devices they use, from my point of view as a patient, it is not that important.14^(p109)

Patients in this study, like others previously reported, emphasized the importance of providing explanations of bedside technology. Consumers use computers and PDAs in everyday life for a variety of functions. Explaining their purpose in patient care provides the needed context for the patent. It is well documented that patients desire and prefer that nurses explain all aspects of the care environment, including bedside technology use. Patients in this study suggested that nurses should explain that using the PDA does not mean nurses are not giving patient care their full attention.14

An important part of optimizing care processes in the midst of technology is physical and system design. Nurses should be able to face their patients when possible to promote eye contact and conversation. System design can also enhance care processes. In a survey by Sensmeier,4 nurses noted that while there are many health IT benefits, there are new problems created with their implementation. Many hospital systems now have information silos as a result of multiple electronic systems. When asked what single change they would like to make to the health IT in their system, most nurses said they wanted a complete electronic documentation system, not a combination of multiple systems, some paperless and other electronic. Streamlining systems to facilitate more intuitive processes will improve care processes and will facilitate patient-centered care.

Sensmeier4 also emphasizes the role of the nurse informaticists in helping to optimize technology systems. These practitioners are well versed in the potential benefits, barriers and challenges of bedside technology systems. They can help assess needs, influence design, facilitate implementation, and troubleshoot integration and interoperability issues. This new cadre of nursing practice experts can play an important role in keeping patients at the center of technology-rich environments.

NEEDS FOR THE FUTURE

Practice

Nurses in practice are challenged to provide expert nursing care using fundamental concepts that are now being applied in new, and rapidly changing environments. New strategies are needed to provide patient-centered care in technology rich environments such as the critical care unit. A focus on basic human connections, supportive work teams, access to technology and information experts, sensitivity training and participation in design processes are going to be essential to the future of nursing practice. As new systems are implemented and nurses receive training on those systems, they also need an emphasis on keeping the patient at the center of care. Nursing practice will increasingly rely on clinical nurse specialists and nursing informaticists in the future to help with design and implementation of technology systems.4,15

Education

Nursing education must continue to prepare students for the technology driven practice settings of modern health care. Nursing education in the future will require increasing emphasis on caring practices while interacting in a technology-rich environment. Students have increasing opportunities to practice these behaviors using simulation.16 Using simulation, students can practice using electronic medical records, PDAs, bar code medication administration, and other technologies while interacting with their patients. Simulation allows students to practice documentation and communication skills simultaneously and gives an opportunity for students to practice decision making, critical thinking, and problem solving. Nurse educators need more resources for simulation including the increased financial and staff resources needed to design, conduct, and debrief simulation events. Electronic medical record systems that are both realistic and practical for educators must also be more readily available and cost-effective.

Research

More research is needed in the area of caring in the nurse-patient relationship in general. In a recent systematic review of the nursing literature, it was demonstrated that there is lack of congruence of perceptions between patients and nurses with regard to caring.10 In light of the changes in how nursing practice is carried out in highly technological environments, more research on how technology impacts caring behaviors is needed. Nurses may practice nursing using behaviors that they perceive as caring whereas patients' perceptions may be quite different. Nurses may alter patterns of communication with patients due to technology that either help or hurt the caring relationship. These behaviors need to explicated and disseminated in the nursing literature.

More knowledge is also needed in the area of nursing education practices that promote caring. What teaching/learning strategies help students develop caring behaviors related to technology? How can we increase the student's exposure to electronic documentation and other technologies both in the clinical setting and the simulation laboratory? What types of simulation and debriefing scenarios help students learn how to manage technology while demonstrating caring for the patient?

Design

The design and function of the nurse's work environment has received augmented attention recently with the evolution of decentralized care models, LEAN process improvement strategies, budget cuts, health reform legislation, and technological advances. Many health care organizations are investing in IT to improve accuracy, transparency, and benefit from government subsidies related to IT adoption creating the new technology rich paradigm. Nurse's workflow, productivity and point-of-care interactions have elevated as top initiatives for health care improvement. Although compelling evidence-based design principles address the relationship between the built environment and improved patient outcomes, little research exists today concerning the impact of technology and the built environment related to patient outcomes with the exception of medication administration. Studies and literature do exist related to medication administration and safety procedures that consistently demonstrate statistical significance in decreasing the number of medication errors in hospitals.

As mentioned previously, the context of caring relates to the environmental infrastructure encompassing organizational cultures, unit physical environment, and workload. To focus on key design features of the physical environment that involve technology, implications include the following: location of clinical documentation, nurse call communication controls and devices, patient/family controls and devices, and point-of-care monitoring and medical devices (Figures 1-4). The effects of each of these "Technology Touch Points" requires more intensive individualized research to determine the impact of technology on the patient and family experience, the technology design intent as it supports the nurse's function and workflow, and ultimately patient outcomes (Table 2). A collaborative team approach (Table 3) with an overall strategic governance platform will ensure the appropriate stakeholders in the key decisions for consistent intentional technology design.

Figure 1. Mobile communication device.

Figure 4. Clinical alcove for documentation.

Table 2. Technology Touch Points in Critical Care Environments

Table 3. Key Collaboration Participants for Successful Optimization of Technology Planning and Implementation

Maintaining patient-centered care for the future will require an intentional, multidisciplinary approach. Nurses are well positioned to influence design and construction, education, research, and practice to preserve the caring environment. Patients and their families are relying on us to keep our focus on them.

Figure 2. Boom for critical care.

Figure 3. Computers/workstations on wheels.

REFERENCES

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caring; caring behaviors; health care design; health information technology; mobile technology; point of care technology