The concept of informatics
HIPAA, computerized medical record purposes and components, differentiate types and systems
Nursing informatics
- integrates nursing science, computer science, and information science
- manages and communicates data, information, knowledge and wisdom
- supports/enhances decision making in all settings (but does NOT EVER dictate our practice)
- it is important to implement HAND HYGIENE when using devices
HIPAA and Nursing Informatics
- be careful not to violate HIPAA- protect patient health records!
- Clients have the right to: view their health records, make correction, know how their info is used or shared
- social networking poses ethical dilemmas for healthcare providers-be mindful of breaches of confidentiality and violations of HIPAA
Computerized medical records
-enhanced digital form of a client’s paper chart
Purpose of computerized medical records
- unifies client’s entire health history
- multidisciplinary and portable
- included functionality:::
- client support: they can access their own record
- health info and data
- administrative processes
- results management
- reporting/documentation
- secure electronic communication and connectivity
- order management (Computerized Physician Order Entry (CPOE))
- decision support
Computerized Medical Records: electronic medical records
similar to electronic chart; focus on diagnosis and treatment
Computerized medical records: electronic health records
broader view of client’s health; multidisciplinary
- we can record the nursing process through EHR’s
- real time documentation is best practice
Healthcare Information Systems: clinical information systems
- allows multiple disciplines to access client’s chart simultaneously
- allows nurses to record and access client data for use in nursing process
Healthcare Information Systems: administrative systems
- support/management on business side of healthcare
- organize human resources, financial data, materials managed, risk management, quality performance, intranet
- Example: staff scheduling, patient billing - useful in private practices as well as large healthcare facilities
Healthcare Information Systems: geographic information systems
- uses location to capture, manage, and analyze data-relies on GPS
- used by policy makers, researchers, and public health professionals
- determines best responses to patient problems
- troubleshoot issues and come up with ways to prevent that from happening
- tools to show where care is provided and where services are needed
Healthcare Information Systems list
clinical, administrative, and geographical administrative systems
Healthcare Policies and Nursing Informatics
- knowledge of informatics is mandatory for all healthcare professionals
- the government promotes use of electronic healthcare records
- Goal: all americans will have electronic healthcare records by 2014
- The tiger initiative
- HITECH Act
Healthcare Policies and Nursing Informatics: Tiger initiative
- technology informatics guiding educational reform
- primary objective: develop a U.S. nursing workforce capable of using information technology to improve the delivery of healthcare
- minimum set of competencies that nurses must meet regarding intelligence in nursing informatics
- See detailed report in Sakai
Healthcare Policies and Nursing Informatics: HITECH Act
- The Health Information Technology for Economic and Clinical Health Act (2009)
- promotes the adoption and meaningful use of health information technology
- installing informatics in healthcare is not sufficient, we have to be able to know how to use it-> Only way that it will make a REAL difference
Ergonomics:
study and design of work environment that maximizes productivity by reducing operator fatigue and discomfort
Ergonomic Considerations:
-repetitive strain injury and computer vision syndrome can happen so use good ergonomics
- Good ergonomics for computer use::
- maintain a good posture
- keep keyboard and mouse within easy reach
- position monitors just below eye level
- use light force when typing
- customize fonts for comfort
- take breaks
- use proper lighting, reduce glare
Telehealth
- Use of telecommunication technologies and computers to exchange info between client and provider
- especially helps clients in remote or rural areas who have limited access to healthcare
- Applications:
- consults w/specialist
- cloud-based provider appts
- health coaches
- used to manage acute or chronic conditions
-can dehumanize patient healthcare (not necessarily right or wrong, up to the patient)
- Barriers:
- administrator reluctance
- poor connectivity/lack of availability of broadband internet
- licensure restrictions
- $$$ (insurance company may not cover cost)
- older adults may be reluctant to use technology
- client unawareness
Information Pyramid
bottom to top: data, information, knowledge, wisdom
Information Pyramid: Data
characters, numbers, or facts gathered for analysis and possibly later action (BP reading of 160/90)
Information Pyramid: Information
interpreted data (BP is high)
Information Pyramid: knowledge
synthesis of information from several sources to produce a single concept (client has HTN)
Information Pyramid: Wisdom
occurs when knowledge is used appropriately to manage and solve problems (knowing interventions to manage HTN)
Client Education and E-Health
- this is where we utilize info that is retrieved online or through a mobile device
- improve a person’s health or health care
- a lot of people will look online for healthcare before they see a professional
- be sure to document that client education
- when can obtain education materials through the computer and they can be printed and reviewed with client and family
- use standardized material that is in the patient’s own language
- a nurse must assess health literacy!!!
- review education in person and make sure clients UNDERSTANDS
Client education and E-health: a lot of people will look online for healthcare before they see a professional: list examples
- online consumer medical info: research on specific medical problems, not alway accurate so you should evaluate website quality!
- online client medical info
- patient portals where you can schedule apps, communicate with your provider, look up lab results, etc
- online administrative tools
- new-client paperwork and questionnaires
- reminders of apps or vaccinations
- providers access to client insurance info
Clinical Decision Support Systems
- tools to supplement decision making in client care, designed to be integrated into the EHR
- prompts, alarms, reminders, or order sets that help enhance patient care and catch mistakes, identifies patients at risk for certain diseases
- DO NOT DICTATE PATIENT CARE, JUST ENHANCE IT
- use UNIFORM LANGUAGE-standardized language across all disciplines:
- JCO has a do not use list
- NANDA (for nursing diagnoses)
- SNOMED CT: combines nursing terminology with the standardized language of the EHR
-these support systems help close the gap b/w research and incorporating knowledge into practice
Clinical Decision Support Systems: Computers in Nursing Research
- with EHR, computers should be available to nurse in all settings
- research is easier! Through uniform language, the ability to query client records, and internet literature searches
Clinical Decision Support Systems: Quality assurance and utilization reviews
- be as accurate and timely as possible
- device integration is important, but use nursing judgement and critical thinking… never allow technology to take over your knowledge. TREAT THE PATIENT, NOT THE MONITOR!!!
- Outcome tracking: identifies faulty processes and assists in modifications that will improve client outcomes
- Utilization review: designed to eliminate inappropriate or unnecessary medical care… we don’t want to over treat patients ($$$)
Clinical Decision Support Systems: Dashboard
- presents info about healthcare facility’s key performance indicators
- displays info in an easy-to-read format including charts and graphs
- some info displayed in real time-EHR’s can track data and trends
Individual Information at Point of Care
- Referred to as an intervention or testing that takes place with a portable or handheld device
- allows bedside data entry and on-the-spot info about clients
- EX: using an accucheck to get blood sugar from a finger stick; vitals machine
- Remember: computer will never be able to replace face-to-face communication with anybody. Especially with a patient!!!
Professional behaviors:
- effective nursing actions that form helping relationships based on technical knowledge, expertise, ethical principles, and clinical reasoning
- academic integrity
- classroom/clinical behavior
Academic integrity
- undertaking and presenting work honestly without:
- cheating/plagiarism/falsifying academic records/misrepresenting facts
- attempt to or committing any act designed to give an unfair academic advantage
Classroom/clinical behavior
- arrive on time and in appropriate attire
- demonstrate safe and ethical behavior
- interact with others in a professional manner
Unprofessional behaviors
undermine an individuals credibility, negatively affect group morale, and may affect client outcome
- Include: confidentiality breach, substance abuse, discrimination, excessive absenteeism/tardiness
- abuse of power, sexual harassment, intimidation
Unprofessional behavior: abuse of power
attempts to use authority against another individual to one’s own advantage
Unprofessional behavior: sexual harassment
verbal, emotional, or physical conduct of sexual nature that is
Unprofessional behavior: intimidation
bullying, threatening, or forcing someone who is physically or emotionally weaker to do something in order to avoid retribution
Evidence-Based Practice: Components
- current, strong evidence
- client perspective
- clinical expertise
Evidence-Based Practice:Steps in Developing EBP
- develop a question: Background question and foreground
- retrieve evidence
- apply evidence
- evaluate evidence
Steps in Developing EBP: develop a question
- background question: knowledge based, general question that seeks info
- foreground: practice based, narrows facts and info about clinical issue
Steps in Developing EBP: retrieve evidence
literature review, source evaluation, can use databases
Steps in Developing EBP: apply evidence
- integrate and change practice for impact on client outcome
- if change is beneficial, fully integrate into standards of care
- expand EBP by sharing with colleagues
Steps in Developing EBP: Evaluate evidence
- validity: did it measure what it was supposed to?
- reliability: was there a consistent response?
- rate strength of evidence: identify the best choice
- Gold standard: large randomized controlled studies
- Lowest level: opinions of reviewers
The concept of clinical decision making: the nursing process
assess, diagnose, plan, implement, evaluate
The nursing process: assess
establishing a database about the client in order to manage needs
-collecting data, organizing data, and validating/analyzing data
The nursing process: diagnose
Providing the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
-describe a continuum of health: derivations from health, presence of risk factors, areas of enhanced personal growth
- Components of nursing diagnosis:
- diagnostic label: “what is the focus/subject of the problem?”
- etiology: “where did it come from? what is it related to?”
- defining characteristics: “what does it look like?”– s/s
The nursing process: Plan
referring to client’s assessment data and diagnoses for direction in formulating client goals, which become basis for nursing intervention. Nurse encourages client to participate actively in planning
The Nursing process: Plan (Goals)
Goals should be:
-client centered (not about nurse activities
-single in number for each nursing diagnosis
-Specific and concise single action
-Measurable/quantifiable
-Attainable/realistic for an individual client
-Relevant to individual
-Timely
(SMART)
The nursing process: Implement
Identify best priority interventions, implement those interventions
- independent interventions
- dependent interventions
- collaborative interventions
The nursing process: implement: independent interventions
activities that nurses are licensed to do within their scope of practice, unique to nursing
The nursing process: implement: dependent interventions
employed by the nurse under a physician’s orders, under supervision and includes collaboration
The nursing process: implement: collaborative interventions
reflect overlapping responsibilities and cooperative relationships among healthcare professionals
The nursing process: evaluate
Planned, ongoing, purposeful activity that utilizes client and other healthcare professionals to determine the client’s progress toward achievement of goals/outcomes and effectiveness of the nursing plan of care
- collect all data-> nurse and client will determine together whether goals were met, partially met, or not met at all
- at this point the nurse and client will decide whether to continuing, modifying, or terminate the nursing plan of care
- reassess and record new data as needed- new data may indicate new diagnosis, goals, and interventions
Prioritizing care: Problem Solving:
Is normal and expected of nurses in order to overcome obstacles and maintain flow of care for clients
- utilize nursing process (ADPIE), utilize trial and error, learn and adapt
- always make sure to prioritize the patients in order. ABCs ALWAYS come before anything else
- changes in the client’s condition, deterioration of status, or the complexities of a client’s condition can impact the urgency of care interventions and the order in which they need to be completed
- using the 4 levels of urgency factor to set priorities for care and identify what interventions ned to be done and in what order they should be accomplished
Prioritizing care: Problem solving: ABCs
ABC’s ALWAYS come before anything else
- Airway-> a patent airway so oxygen will have a pathway into the lungs for gas exchange and carbon dioxide can be expelled from the body
- Breathing-> an effective breathing pattern and respiratory effort to take in enough oxygen to meet cellular demands for oxygen throughout the body
- Circulation-> an effective circulatory system to deliver oxygen throughout the body and allow carbon dioxide removal through the pulmonary circulation network
Prioritizing care: Problem solving: 4 levels of urgency factors to set priorities for care
Nonacute level
- nonthreatening to life
- delay in doing interventions
- does not negatively impact client outcomes
Acute level
- low potential to become life threatening
- necessary interventions are scheduled, expected, and typical
Critical level
- potential to become life threatening
- quick recognition and rapid response needed to stop threat from becoming life-threatening
Imminent level
- life threatening
- interventions are needed immediately, now, STAT!!!
- know which tasks can be delegated and delegate them!!!
- manage your time wisely
TEAMSTEPPS: team structure
identification of the components of a multi-team system that must work together effectively to ensure patient safety
TEAMSTEPPS: communication
Structured process by which information is clearly and accurately exchanged among team members
- SBAR
- Call-out
- Check-back
- Handoff
- “I PASS THE BATON”
SBAR
A technique for communicating critical information that requires immediate attention and action concerning a patient’s condition
- Situation: what is going on with the patient?
- Background: what is the clinical background or context?
- Assessment: what do I think the problem is?
- Recommendation and Request: what should be done to correct it?
TEAMSTEPPS: communication: call-out
Strategy to communicate important or critical information
- informs all team members simultaneously during emergent situations
- helps team members anticipate next steps
- important to direct responsibility to a specific individual responsible for carrying out the task
Check-back
using closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended- double checking
Handoff
the transfer of information (along with authority and responsibility) during transitions in care across the continuum. It includes an opportunity to ask questions, clarify, and confirm (Ex. shift changes and patient transfers)
TEAMSTEPPS: communication: “I PASS THE BATON”
Strategy designed to enhance information exchange
- Introduction: introduce yourself and your role/job (include patient)
- PASS
- Patient: name, identifiers, age, sex, location
- Assessment: present chief complaint, vital signs, symptoms, and diagnoses
- Situation: current status/circumstances, including code status, level of (un)certainty, recent changes, and response to treatment
- Safety concerns: critical lab values/reports, socioeconomic factors, allergies, and alerts (falls, isolation, etc.)
- BATON
- Background: comorbidities, previous episodes, current medications, and family history
- Actions: explain what actions were taken or are required. Provide rationale.
- Timing: level or urgency and explicit timing and prioritization of actions
- Ownership: identify who is responsible (person/team), including patient/family members
- Next: what will happen next? anticipated changes? what is the plan? are there contingency plans?
TEAMSTEPPS: leadership
ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources
TEAMSTEPPS: sharing the plan
brief: short session prior to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
TEAMSTEPPS: monitoring and modifying the plan
huddle: Ad hoc meeting to re-establish situational awareness, reinforce plans already in place, and assess the need to adjust the plan
TEAMSTEPPS: reviewing the team’s performance
debrief: informal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors
TEAMSTEPPS: Stituation monitoring
process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning
TEAMSTEPPS: situation awareness
the state of “knowing what’s going on around you”
-a shared mental model results from each team member maintaining situational awareness and ensures that all team members are “on the same page”
TEAMSTEPPS: Cross-Monitoring
a harm error reduction strategy that involves monitoring actions of other team members, providing a safety net within the team, ensuring that mistakes or oversights are caught quickly and easily
-“watching each other’s back”
TEAMSTEPPS: I’M SAFE CHECKLIST
-each team member is responsible for assessing his or her own safety status
- I=illness
- M=medication
- S=stress
- A=alcohol and drugs
- F=fatigue
- E=eating and elimination
TEAMSTEPPS: mutual support
-ability to anticipate and support team member’s needs through accurate knowledge about their responsibilities and workload
TEAMSTEPPS: feedback
information provided to team members for the purpose of improving team performance. Should be timely, respectful, specific, directed toward improvement, and considerate
TEAMSTEPPS: advocacy and assertion
-Advocate for the patient: invoked when team members’ viewpoints don’t coincide with that of the decisionmaker
- assert a corrective action in a firm and respectful manner:
- make an opening
- state a concern
- state the problem (real or perceived)
- offer a solution
- reach agreement on next steps
-Two challenge rule
TEAMSTEPPS: advocacy and assertion: two challenge rule
empowers all team members to “stop the line” if they sense or discover an essential safety breach. It is your responsibility to assertively voice concern at least two times to ensure that it has been heard and the team member being challenged must acknowledge that concern has been heard
TEAMSTEPPS: advocacy and assertion: CUS
- I am CONCERNED!
- I am UNCOMFORTABLE!
- This is a SAFETY ISSUE!
TEAMSTEPPS: advocacy and assertion: DESC Script
A constructive approach for managing and resolving conflict
- Describe the specific situational or behavior; provide concrete data
- Express how the situation makes you feel/what your concerns are
- Suggest other alternatives and seek agreement
- Consequences should be stated in terms of impact on established team goals; strive for consensus
Communication: Therapeutic Communication techniques
- empathizing
- attentive listening
- physical attending
- using silence
- reflecting
- imparting information
-AVOID SELF DISCLOSURE!!! client is the focus, not you
Empathizing
Active listening skill that you are taught throughout your education… being able to put yourself in someone else’s situation
-should not transfer your own feelings into the situation
Attentive listening
Mindful listening, using all senses, MOST important technique in therapeutic communication
- active process that requires energy and concentration
- verbal and nonverbal
Physical Attending
Manner of being present to another or being with another
-face person squarely, adopt an open posture, lean towards the person, maintain good eye contact, try to be relatively relaxed
Using silence
You don’t have to respond every time
-Goal is to provide a therapeutic purpose such as: encouraging client to communicate with the nurse, allowing the client time to think about what has been said or to make connections, allowing the client the necessary time to collect personal thoughts, time to consider possible alternatives
Reflecting
What takes place when the nurse repeats the client’s verbal or nonverbal messages for the client’s benefit
Reflecting content
repeating clients statement, often overused
Reflecting feelings
Verbalizes feelings that are implied in the client’s content, respect the client’s opinions, helps ID any latent or connotative meanings that can clarify or distort the content that is communicated
Imparting Information
nurse is helping client by supplying additional data for consideration
Communication: Documentation
- Nursing documentation should describe the ongoing status of the patient and reflect the full range of the nursing process, should be comprehensive and continuous
- SOAP Note
Communication: handoff communication
The transfer of info (along with authority and responsibility) during transitions in care across the continuum
- Can occur at change of shift, bedside, over the telephone, etc…
- Standardize critical content
- Hardwire within your system
- Allow opportunity to ask questions
- Reinforce quality and measurement
- Educate and coach
ADPIE: Diagnosis
- nursing diagnosis and problem statement are interchangeable terms
- NANDA= north american nursing diagnosis association
- Can have 1 part; 2 part; 3 parts
- 1 part: problem (diagnostic label) only
- 2 part: problem and etiology (“related to”)
- 3 part: (“PES”) Problem; etiology; signs and symptoms (defining characteristics)
ADPIE
assessment, diagnosis, planning, implementation, evaluation
ADPIE: implementation
-for every goal, nursing interventions need to be implemented
- interventions need to “match” the goal:
- low oxygen saturation: elevate head of bed; deep breath and cough
- pain: guided imagery; distraction; repositioning
- For example: do not include using distraction for low oxygen saturation: probably would not be effective
-interventions can include assessment and reassessment
- there must be some ACTIVE interventions:
- nurse must DO something
- if no active interventions, there will be little to evaluate
Critical Thinking: types of reasoning
-Deductive and inductive
Critical Thinking: Deductive reasoning
- moves from general to specific (top down)
- START with a CONCLUSION; analyze it for valid significance cues
- Example (disease process to signs and symptoms)
1. patient has pneumonia
2. nurse can deduce that patient would have increased sputum, decreased appetite, productive cough, low energy, etc…
Critical Thinking: Inductive reasoning
- moves from specific to general (bottom up)
- SIGNIFICANT CUES are put together to reach a CONCLUSION
- example: (signs and symptoms to disease process)
1. patient is experiencing increased sputum, decreased appetite, productive cough, low energy, etc…
2. Nurse can induce (come to the conclusion) that the patient has pneumonia
Communication No No’s
- do not give advice
- do not minimize or discount what the client is feeling
- do not change the subject or make light of what the client is talking about do not interrogate
- do not debate or disagree with the client
- aggressive
- passive
-do want to be assertive
Documentation: SOAP Note
- subjective data
- objective data
- assessment: interpretation of info this is measured or observed by use of the senses
- plan of care: your plan to resolve the stated problem
- interventions: specific interventions that have actually been performed
- evaluation: reassessment data
- revisions: any changes in plan or interventions
Documentation: change of shift
- type of handoff given to all nurses on the next shift, quick summary of client’s needs and details of care to be given
- follow a particular order, provide basic ID info, reason for admission or medical diagnosis, surgery date, lab tests, therapies in the last 24 hours, provide exact info, report special need for emotional support, include nurse prescribed and physician orders, summary of newly admitted clients, report on transfers, clearly state, best most important info at the end, and be concise
