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This paper discusses a definition of the content of the computerized nursing data base developed by the Nursing Department for the Clinical Center Medical Information System at the National Institutes of Health in Bethesda, Maryland. The author describes the theoretical framework for the content and presents a model to describe the organization of the nursing data components in relation to the process of nursing care delivery. Nursing documentation requirements of Nurse Practice Acts, American Nurses Association Standards of Practice and the Joint Commission on Accreditation of Hospitals are also addressed as they relate to this data base. The advantages and disadvantages of such an approach to computerized documentation are discussed.

A prequisite to designing computer-aided information systems to support nurse decision making is to identify the kinds of decisions nurses make and to specify the data and the knowledge required to make those decisions. Perrow's (1970) models of organizational technologies, which consider the variability of stimuli and the nature of search procedures for deciding what to do about the stimuli, offer a useful approach to analyzing nurse decision making. Different assumptions about stimuli and search procedures result in different models of nursing, each with its own requirements for a knowledge base and a data base. Professional standards of nursing practice generally assume that clients are unique and therefore treat the stimuli with which nurses deal are highly varied. Existing nursing information systems, however, have been designed as though the stimuli had little variability. Nurses involved in developing the next generation of computer systems will need to identify appropriate models of nursing and to specify the data bases as knowledge bases accordingly.

A prototype program of doctoral study has been developed at the University of Maryland School of Nursing to prepare students with nursing expertise in the conceptualization and research of computer based information systems in hospitals, industry and other health care organizations. The graduate will be prepared to design effective nursing information systems; create innovative information technology; conduct research regarding integration of technology with nursing practice, administration, and education; and develop theoretical, practice, and evaluation models for nursing informatics.

A task force appointed by the American Board of Neuroscience Nursing conducted a role delineation study to define current practice in neuroscience nursing. The results were used to validate the content matrix for future Certified Neuroscience Registered Nurse (CNRN) examinations. The study employed a survey design for which the Nursing Intervention Classification taxonomy was the guiding theoretical framework. The eligible sample include all current CNRNs and all members of the American Association of Neuroscience Nursing. An invitation to participate in an online survey was successfully emailed to 2,462 neuroscience nurses; the survey was completed by 477 respondents. They rated the performance and importance of 175 neuroscience nursing activities. On the basis of data analysis conducted by Schroeder Measurement Technologies, Inc., the task force recommended revisions to the CNRN examination matrix to reflect current practice in neuroscience nursing.

Nurses prepare knowledge representations, or summaries of patient clinical data, each shift. These knowledge representations serve multiple purposes, including support of working memory, workload organization and prioritization, critical thinking, and reflection. This summary is integral to internal knowledge representations, working memory, and decision-making. Study of this nurse knowledge representation resulted in development of a taxonomy of knowledge representations necessary to nursing practice.

This paper describes the methods used to elicit the knowledge representations and structures necessary for the work of clinical nurses, described the development of a taxonomy of this knowledge representation, and discusses translation of this methodology to the cognitive artifacts of other disciplines. Understanding the development and purpose of practitioner’s knowledge representations provides important direction to informaticists seeking to create information technology alternatives. The outcome of this paper is to suggest a process template for transition of cognitive artifacts to an information system.

Background

Radiotherapy (RT) units are high-tech nursing environments. In Sweden, RT registered nurses (RNs) provide and manage RT in close collaboration with other professional groups, as well as providing nursing care for patients with cancer. Communication demands on these RNs are thus particularly complex. In this study, we aimed to better understand problems, strengths and change needs related to professional communication with and within the RT department, as a basis for developing a situation-specific intervention.

Methods

Focus groups discussions (FGDs) were conducted with different professional (RNs, assistant nurses, physicians, engineers and physicists) and user stakeholders. Transcripts of the FGDs were inductively analyzed by a team of researchers, to generate clinically relevant and useful data.

Results

These findings give insight into RT safety climate and are presented under three major headings: Conceptualization of professional domains; Organization and leadership issues; and Communication forms, strategies and processes. The impact of existing hierarchies, including how they are conceptualized and acted out in practice, was noted throughout these data. Despite other differences, participating professionals agreed about communication problems related to RT, i.e. a lack of systems and processes for information transfer, unclear role differentiation, a sense of mutual disrespect, and ad hoc communication taking place ‘on the fly’. While all professional groups recognized extensive communication problems, none acknowledged the potential negative effects on patient safety or care described in the FGD with patient representatives. While RNs often initially denied the existence of a hierarchy, they placed themselves on a hierarchy in their descriptions, describing their own role as passive, with a sense of powerlessness. Potential safety hazards described in the FGDs include not reporting medical errors and silently ignoring or actively opposing new guidelines and regulations.

Conclusions

There is a risk that RNs who view themselves as disenfranchised within an organization will act with passive resistance to change, rather than as change promoters. As interventions to strengthen teams cannot be stronger than the weakest link, RNs may need support in the transition “from silence to voice” in order to take a position of full professional responsibility in a multi-professional health care team.

The development of nursing knowledge should give structure and form to the practice of nursing. The development of Nursing Process Theory resulted from early nursing observations and inferences from nursing practice that resulted in formal data accumulation processes, mutual correspondence between nurses and patients, and exchange of information. The development of the nursing process discipline helped to substantiate the need for professional nursing services. The shifts towards examining the links between processes and outcomes, professional accountability, and classification of distinct nursing functions have influenced the development of information systems. The Nurse—Patient Trajectory Framework described in this paper may be used to show the relationships between the virtual information system and the real world that it affects. The framework is visualized along two separate and distinct nurse and patient trajectories.

Purpose:

To explore the role of genetic association studies in risk assessment for common complex diseases.

Organizing Framework:

An introduction to the types of genetic association studies is followed by a discussion of their potential use in risk assessment for age-related macular degeneration and type 2 diabetes mellitus. The benefits and limitations of this burgeoning technology are explored and related to nursing practice and scholarship.

Conclusions:

Nurses in practice must be prepared to assist clients with decisions about seeking and interpreting results from genetic association studies and nurse researchers must apply current guidelines for conducting robust studies and applying the results of such studies in clinical practice.

Clinical Relevance:

Data collected from genetic association studies will increasingly be used to identify novel prevention and treatment strategies for many complex diseases. An understanding of the principles that underlie this new science is essential for nurses in all areas of clinical practice as they design, test, and implement appropriate intervention and prevention strategies based on genetic association studies.

Nurses are challenged to find and use reliable, credible information to support clinical decision-making and to meet expectations for evidence-based nursing practice. This project targeted practicing public health and school nurses, teaching them how to access and critically evaluate web-based information resources for frontline practice. Health sciences librarians partnered with nursing faculty to develop two participatory workshops to teach skills in searching for and evaluating web-based consumer and professional practice resources. The first workshop reviewed reliable, credible consumer web-resources appropriate to use with clients, using published criteria to evaluate website credibility. In the second workshop, nurses were taught how to retrieve and evaluate health-related research from professional databases to support evidence-based nursing practice. Evaluation data indicated nurses most valued knowing about the array of reliable, credible web-based health information resources, learning how to evaluate website credibility, and understanding how to find and apply professional research literature to their own practice.

AIMS

Adolescent dating abuse is not specifically described by any current nursing theory, and this paper presents discussion of some existing theories that could inform a nursing theory of adolescent dating abuse. To account for the effects of gender, this discussion is limited to young women.

BACKGROUND

Adolescent dating abuse is an important and understudied international issue for nursing. Theoretical frameworks can support development of nursing scholarship for such issues. No single theory yet exists within nursing to explain the experiences and health ramifications of dating abuse among young women.

DATA SOURCES

A summary table of theories is provided. Literature was gathered via database search and bibliographic snowballing from reference lists of relevant articles. Included literature dates from 1982 through 2010.

DISCUSSION

Theories of relationship formation and function are discussed, including attachment, investment, feminist and gender role conflict theories. Betrayal trauma theory is considered as a mechanism of injury following an abusive dating experience.

IMPLICATIONS FOR NURSING

Gender, relationship, and adolescence combine in a complex developmental moment for young women. To improve nursing care for those at risk for or in the throes of abusive relationships, it is critical to develop specific nursing approaches to understanding these relationships.

CONCLUSION

Existing theories related to relationship and traumatic experiences can be combined in the development of a nursing theory of adolescent dating abuse among young women.

The Canadian Health Outcomes for Better Information and Care (C-HOBIC) project introduced systematic use of standardized clinical nursing terminology for patient assessments. Implemented so far in three Canadian provinces, C-HOBIC comprises an innovative model for large-scale capture of standardized nursing-sensitive clinical outcomes data within electronic health records (EHRs). To support this activity, nursing assessment and outcomes concepts were mapped to the International Classification for Nursing Practice (ICNP®). By comparing serial data on a patient across multiple time points, the C-HOBIC model can generate nursing-sensitive patient outcome reports. A principle benefit of the C-HOBIC model is that it provides nurses with information critical to planning for and evaluating patient care. Inclusion of nursing information in either provincial databases or EHRs in three Canadian provinces promotes continuity of patient care across sectors of the healthcare systems in those provinces and also facilitates aggregation and analysis by administrators and policy makers. The C-HOBIC model provides standardized, consistent, interoperable clinical information that reflects nursing practice throughout the Canadian healthcare System.

End-of-life nursing encompasses many aspects of care: pain and symptom management, culturally sensitive practices, assisting patients and their families through the death and dying process, and ethical decisionmaking. Advocacy has been identified as a key core competency for the professional nurse, yet the literature reveals relevant barriers to acquiring this skill. Challenges exist, such as limitations in nursing school curricula on the death and dying process, particularly in multicultural settings; differing policies and practices in healthcare systems; and various interpretations of end-of-life legal language. Patricia Benner's conceptual model of advocacy behaviors in end-of-life nursing provides the framework in which nurses can become effective patient advocates. Developing active listening and effective communication skills can enhance the nurse-patient trust relationship and create a healing environment.

Design: This paper reports on a qualitative study which was undertaken to explore the way in which nurses obtain consent prior to nursing care procedures. Focus groups were carried out to obtain background data concerning how consent is obtained. Critical incidents were collected through in depth interviews as a means of focusing on specific incidents in clinical practice.

Setting: Two teaching hospitals in England.

Participants: Purposive sample of qualified nurses.

Results: When a patient refuses nursing care, nurses respond by giving information until the patient finally accedes to the procedure. Nurses will go to great lengths to achieve patients' agreement to the procedure, but the extent to which the agreement remains voluntary cannot be ascertained by the data collected in this study. If the patient does not eventually agree to a procedure, there is evidence that nurses will administer the care in the absence of consent.

Conclusions: Nurses are concerned to obtain the patient's consent prior to the administration of nursing care but if this cannot be achieved do not regard obtaining consent as an absolute requirement. Consent is preferred, but not considered essential. Nurses have some understanding of the principles of informed consent but do not apply them to everyday clinical nursing practice.

The PEN&PAD model for clinical record systems has been successfully used for medical records in both General Practice and hospital-based care. This paper describes experiences of using the model for developing computer-based nursing records. Results from this work show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient's care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit, their uses of information, and also provided them with some tools to assist in this task.

Building upon the foundation of the Structured Narrative electronic health record (EHR) model, we applied theory-based (combined Technology Acceptance Model and Task-Technology Fit Model) and user-centered methods to explore nurses’ perceptions of functional requirements for an electronic nursing documentation system, design user interface screens reflective of the nurses’ perspectives, and assess nurses’ perceptions of the usability of the prototype user interface screens. The methods resulted in user interface screens that were perceived to be easy to use, potentially useful, and well-matched to nursing documentation tasks associated with Nursing Admission Assessment, Blood Administration, and Nursing Discharge Summary. The methods applied in this research may serve as a guide for others wishing to implement user-centered processes to develop or extend EHR systems. In addition, some of the insights obtained in this study may be informative to the development of safe and efficient user interface screens for nursing document templates in EHRs.

Objectives: This research was conducted to provide new insights on clinical nurses' and nursing students' current use of health resources and libraries and deterrents to their retrieval of electronic clinical information, exploring implications from these findings for health sciences librarians.

Methods: Questionnaires, interviews, and observations were used to collect data from twenty-five nursing students and twenty-five clinical nurses.

Results: Nursing students and clinical nurses were most likely to rely on colleagues and books for medical information, while other resources they frequently cited included personal digital assistants, electronic journals and books, and drug representatives. Significantly more nursing students than clinical nurses used online databases, including CINAHL and PubMed, to locate health information, and nursing students were more likely than clinical nurses to report performing a database search at least one to five times a week.

Conclusions and Recommendations: Nursing students made more use of all available resources and were better trained than clinical nurses, but both groups lacked database-searching skills. Participants were eager for more patient care information, more database training, and better computer skills; therefore, health sciences librarians have the opportunity to meet the nurses' information needs and improve nurses' clinical information-seeking behavior.

The American Nurses' Association has set eight Standards of Nursing Practice related to the nursing process. Computer-aided information systems intended to facilitate the nursing process must be designed to promote adherence to these professional standards. For each of the eight standards, the paper tells how a hypothetical expert system could help nurses to meet the standard. A prototype of such an expert system is being developed. The paper describes issues in conceptualizing clinical decision-making and developing decision strategies for the prototype system. The process of developing the prototype system is described.

Background

Careful hand hygiene (HH) is the single most important factor in preventing the transmission of infections to patients, but compliance is difficult to achieve and maintain. A lack of understanding of the processes involved in changing staff behaviour may contribute to the failure to achieve success. The purpose of this study was to identify nurses’ and administrators’ perceived barriers and facilitators to current HH practices and the implementation of a new electronic monitoring technology for HH.

Methods

Ten key informant interviews (three administrators and seven nurses) were conducted to explore barriers and facilitators related to HH and the impact of the new technology on outcomes. The semi structured interviews were based on the Theoretical Domains Framework by Michie et al. and conducted prior to intervention implementation. Data were explored using an inductive qualitative analysis approach. Data between administrators and nurses were compared.

Results

In 9 of the 12 domains, nurses and administrators differed in their responses. Administrators believed that nurses have insufficient knowledge and skills to perform HH, whereas the nurses were confident they had the required knowledge and skills. Nurses focused on immediate consequences, whereas administrators highlighted long-term outcomes of the system. Nurses concentrated foremost on their personal safety and their families’ safety as a source of motivation to perform HH, whereas administrators identified professional commitment, incentives, and goal setting. Administrators stated that the staff do not have the decision processes in place to judge whether HH is necessary or not. They also highlighted the positive aspects of teams as a social influence, whereas nurses were not interested in group conformity or being compared to others. Nurses described the importance of individual feedback and self-monitoring in order to increase their performance, whereas administrators reported different views.

Conclusions

This study highlights the benefits of using a structured approach based on psychological theory to inform an implementation plan for a behavior change intervention. This work is an essential step towards systematically identifying factors affecting nurses’ behaviour associated with HH.

Background

In Canada, workforce shortages in the health care sector constrain the ability of the health care system to meet the needs of its population and of its health care professionals. This issue is of particular importance in peripheral regions of Quebec, where significant inequalities in workforce distribution between regions has lead to acute nursing shortages and increased workloads. Information and communication technologies (ICTs) are innovative solutions that can be used to develop strategies to optimise the use of available resources and to design new nursing work practices. However, current knowledge is still limited about the real impact of ICTs on nursing recruitment and retention. Our aim is to better understand how work practice reorganization, supported by ICTs, and particularly by telehealth, may influence professional, educational, and organizational factors relating to Quebec nurses, notably those working in peripheral regions.

Methods/Design

First, we will conduct a descriptive study on the issue of nursing recruitment. Stratified sampling will be used to select approximately twenty innovative projects relating to the reorganization of work practices based upon ICTs. Semi-structured interviews with key informants will determine professional, educational, and organizational recruitment factors. The results will be used to create a questionnaire which, using a convenience sampling method, will be mailed to 600 third year students and recent graduates of two Quebec university nursing faculties. Descriptive, correlation, and hierarchical regression analyses will be performed to identify factors influencing nursing graduates' intentions to practice in peripheral regions. Secondly, we will conduct five case studies pertaining to the issue of nursing retention. Five ICT projects in semi-urban, rural, and isolated regions have been identified. Qualitative data will be collected through field observation and approximately fifty semi-structured interviews with key stakeholders.

Discussion

Data from both parts of this research project will be jointly analysed using triangulation of researchers, theoretical approaches, methods, and results. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the nursing recruitment and retention.

Information has become a capital good and is focused on outcomes. Clinical guidelines are being developed to standardize care for populations, but patient preferences also need to be known when planning individualized care. Information technologies can be used to retrieve both types of information. The concern is that nurses are not adequately prepared to manage information using technology. This paper presents five strategic directions recommended by the National Advisory Council on Nurse Education and Practice (Department of Health and Human Services, Division of Nursing) to enhance nurses' preparation to use and develop information technology. The recommendations are 1) to include core informatics content in nursing curricula, 2) to prepare nurses with specialized skills in informatics, 3) to enhance nursing practice and education through informatics projects, 4) to prepare nursing faculty in informatics, and 5) to increase collaborative efforts in nursing informatics. The potential impact of these strategic directions on patients is discussed.

OBJECTIVES

To identify barriers to and facilitators of the diffusion of clinical practice guidelines (CPGs) and clinical protocols in nursing homes (NHs).

DESIGN

Qualitative analysis.

SETTING

Four randomly selected community nursing homes.

PARTICIPANTS

NH staff, including physicians, nurse practitioners, administrative staff, nurses, and certified nursing assistants (CNAs).

MEASUREMENTS

Interviews (n = 35) probed the use of CPGs and clinical protocols. Qualitative analysis using Rogers’ Diffusion of Innovation stages-of-change model was conducted to produce a conceptual and thematic description.

RESULTS

None of the NHs systematically adopted CPGs, and only three of 35 providers were familiar with CPGs. Confusion with other documents and regulations was common. The most frequently cited barriers were provider concerns that CPGs were ‘‘checklists’’ to replace clinical judgment, perceived conflict with resident and family goals, limited facility resources, lack of communication between providers and across shifts, facility policies that overwhelm or conflict with CPGs, and Health Insurance Portability and Accountability Act regulations interpreted to limit CNA access to clinical information. Facilitators included incorporating CPG recommendations into training materials, standing orders, customizable data collection forms, and regulatory reporting activities.

CONCLUSION

Clinicians and researchers wishing to increase CPG use in NHs should consider these barriers and facilitators in their quality improvement and intervention development processes.

Despite the fact that nursing informatics is entering its third decade as a specialty within nursing, many definitions still exist to describe the field. This paper offers a rationale for a definition for nursing informatics and a critical analysis of past definitions. An organizing framework of technology-oriented, conceptual, and role-oriented definitions is used to critique these definitions. Subsequently, a revised definition is proposed. This evolutionary definition integrates critical concepts from past work and adds components that are currently missing—patients, information communication, information structures, and decision making. A separate role specification for informatics nurse specialists is provided.

Objective

To provide an outcomes-evaluation of an intervention to strengthen professional nursing practice in Russian and Armenian hospitals.

Design

The Nursing Quality Improvement Initiative using Forces of Magnetism to develop professional nurse practice was implemented in four hospitals in Russia and Armenia. Cross-sectional survey data were collected at two time points from 840 nurses in wave 1 and 859 nurses in wave 2. Comparisons were undertaken between targeted units in each hospital compared to non-targeted units, and each hospital served as its own control in surveys that took place in year one and three of the demonstration.

Methods

Descriptive information on the nurse samples were derived from survey items. Changes in characteristics of nurse practice environments, nurse-reported patient care quality, and nurse burnout in Russia and Armenia, overall and separately for targeted and non targeted units, were tested using chi-square statistics and difference of means tests.

Findings

Practice environment features, such as nurses’ involvement in hospital affairs, better collegial relationships with physicians, more support for nursing care from administration, and continuity of nursing care improved after the intervention. Resource adequacy indicators did not change over the demonstration period. There were favorable changes in indicators of patient care quality, though differences in changes in targeted and non-targeted units were equivocal.

Conclusions

Changes consistent with evolving professional nursing practice were associated with program implementation. Forces of Magnetism appear to have the same potential for transforming nursing practice in countries with fewer resources as in wealthier Western countries.

Clinical Relevance

Magnet Recognition, an evidence-based best practice for improving the nursing care environment developed in Western countries was feasible to implement in countries with transitioning economies, limited resources, and truncated professional nursing education.

Although an unambiguous and consistent representation is the foundation of data reuse, a locally developed documentation system such as nursing flowsheets often fails to meet the requirement. This article presents the domain modeling process of the ICU nursing flowsheet to clarify the meaning that its contents represent and the lessons learned during the activity. This study has been done as a first step toward reusing the data documented in a computerized nursing flowsheet for an algorithmic decision making. Following the ontology development processes proposed by other researchers a conceptual model was developed using Protégé. Then the existing information model was refined by fully specifying the embedded information structures and by establishing linkages to the conceptual model at the finest-grained concept level. Domain knowledge that the experienced nurses provided was critical to correctly interpret the meaning of the flowsheet contents as well as to verify the newly developed models. This study reassured the importance of the roles of a nurse informatician to develop a computerized nursing documentation system that accurately represents the information needs in nursing practice.

The arrival of a computerized medical information system on the health care scene has created new performance demands on nurses. Not only must nurses be able to use the computer to document medical and nursing care, but they must be able to contribute to the overall design of the nursing data base. This paper describes how nurses must be educated to perform these new job responsibilities. Discussion will center on the educational process developed by the Clinical Center at the National Institutes of Health to meet the needs of its nurses to design a nursing data base and learn the technical skill required to utilize a computerized medical information system. Recommendations are offered to the academic community charged with the formal education of nursing professionals and the staff development and continuing educational planners who share the accountability for educating the already licensed nurses.