Electronic Bedside Documentation and Nurse-Patient Communication: A Dissertation

Nurses are often the first members of the health care team with whom patients interact. The initial impression of the nurses’ receptiveness to the patients’ needs influences the patients’ views of their overall care. Researchers have suggested that understanding communication between individuals can provide the human link, or social element, to the successful implementation and use of electronic health records, including documentation (Lanham, Leykum, & McDaniel, 2012). Zadvinskis, Chipps, and Yen (2014) identified that the helpful features of bedside documentation systems were offset by the mismatch between the system and nurse’s workflow. The purpose of this micro-ethnography study was to explore the culture of nurse-patient interaction associated with electronic documentation at the bedside. Data were collected through passive participant observation, audio-taping of the nurse-patient interactions, and informal and semi-structured interviews with the nurses. A total of twenty-six observations were conducted on three nursing units at an urban healthcare facility in New England. These three units were occupied by similar patient populations and all patients required cardiac monitoring. Three themes consistently emerged from qualitative data analysis: the nurses paused during verbal communication, the nurses played a game of tag between the patient and the computer, and the nurses performed automatic or machine-like actions. The participants described these themes in the informal and semi-structured interviews. The nurses’ actions were observed during passive participant observation, and the audio-taped interactions supported these themes. Understanding the adaptation of caregiving necessitated by bedside electronic documentation will have a positive impact on developing systems that interface seamlessly with the nurses’ workflow and encourage patients’ active participation in their care

Using Existing Response Repertoires to Make Sense of Information System Implementation

The implementation of information systems (IS) in organizations often triggers new situations in which users experience a disruption of existing work patterns and routines. Sensemaking becomes central in making users’ meanings explicit, serving as a foundation for further actions and interactions with the new technology. The purpose of this paper is to study how users make sense of new technologies by building on existing response repertoires. Empirically, we present findings from a study of an Electronic Patient Record (EPR) system implementation in two Danish hospital wards. Our findings illustrate: (1) how doctors’ and nurses’ existing routines are disrupted by the new technology, (2) how identity construction plays an important part in the users’ meaning construction process, and (3) how self-fulfilling prophecies are formed as a natural part of their sensemaking. The study contributes to existing literature by providing a detailed account of how users’ early sensemaking of a technology influences their subsequent actions and reactions towards it. Our findings support managers in understanding users’ perceptions of a new technology, helping them in planning and executing the implementation process

Nurses’ Learning and Conceptualization of Technology used in Practice

How nurses conceptualize and learn about health technology used in practice was examined in this qualitative, interpretive-descriptive study. Traditionally, conceptualizations of technology used in the nursing profession have been viewed from either socially- or technically- centric perspectives that have clouded the real nature of nurse-technology interactions. For instance, current perspectives examining nurses’ use of technology typically ignore or minimize socio-technical considerations impacting technology acceptance and adoption by nurses. A research approach that embraced the mingling of social and material (sociomaterial) actors was used to address the following research questions: (a) How do nurses conceptualize health technology used in practice?, and, (b) How do nurses learn about health technology used in practice? The theoretical lens of Actor-Network Theory (ANT) provided the overall perspective and guided elements of data collection and analysis. ANT is aligned to a relational ontology, whereby both human and non-human participants (or actors) are viewed in symmetry (or as equals) during data analysis. Privilege during the analysis was, therefore, not automatically prescribed to either the human or non-human actors. Interviews, documents, and direct observation of nurses constituted the majority of the data collected for this study. Using an iterative data analysis process, themes were generated related to nurses’ conceptualization of and learning about technology used in practice. Technology was conceptualized by nurses to possess variation in naming, roles, and also engendered notions of action or praxis. Learning technology by nurses possessed elements resembling both processes and products. From these learning processes and products, salient strategies (e.g., indispensability, semblance, habituation) were developed by nurses in order to negotiate and use various health technologies for practice. Ultimately, learning of health technology by nurses appeared to actively influence, modify, and shape the role of health technology, and its subsequent use by human actors. Therefore, how nurses learn about technology should be considered during the planning, development, and evaluation of future technologies. End-users, like nurses, will rarely use a health technology to its fullest capability unless learning is congruent with the environmental context surrounding the technological actor. In light of these findings, recommendations for nursing education and professional practice related to the role and interpretation of health technology used by nurses in 2013 is also discussed, along with implications for future research

Comparison of the effectiveness of traditional nursing medication administration with the Color Coding Kids system in a sample of undergraduate nursing students

The problem of medication errors in hospitals and the vulnerability of pediatric patients to adverse drug events (ADE) was investigated and well substantiated. The estimated additional cost of inpatient care for ADE’s in the hospital setting alone was conservatively estimated at an annual rate per incident of 400,000 preventable events each incurring an extra cost of approximately $5,857. The purpose of the researcher was to compare the effectiveness of traditional nursing medication administration with the Color Coding Kids (CCK) system (developed by Broselow and Luten for standardizing dosages) to reduce pediatric medication errors. A simulated pediatric rapid response scenario was used in a randomized clinical study to measure the effects of the CCK system to the traditional method of treatment using last semester nursing students. Safe medication administration, workflow turnaround time and hand-off communication were variables studied. A multivariate analysis of variance was used to reveal a significant difference between the groups on safe medication administration. No significant difference between the groups on time and communication was found. The researcher provides substantial evidence that the CCK system of medication administration is a promising technological breakthrough in the prevention of pediatric medication errors

Supernurse:Nurses' workarounds informing the design of interactive technologies for home wound care

The increasing aging population needing homecare is leading to additional clinical work for homecare nurses. Wound care and documentation are substantial components of this work required to monitor patients and make appropriate clinical decisions. However, due to barriers in the systems that nurses are expected to use, and context of their activities, they create and use workarounds to get their job done. In this study, the most common themes of workarounds were identified and used to inform design iterations of a wound documentation application: SuperNurse. The exploratory and experimental design iterations involved homecare nurses, who expressed: curiosity, leading to further reflection; frustration, leading to identifying problems; and surprise, leading to identifying useful and easy to use designs. We found that nurse-centred design, informed by workarounds, led to using mobile, wearable, and speech recognition technology and improving ease of use and usefulness in SuperNurse

Exploring care for older people : district nurses’ experiences and clinical practice

Background and aim: The health care system needs to prepare in order to provide highquality care to a growing older population. In Sweden, much primary health care for older people is the responsibility of district nurses (DNs), but research into DNs’ clinical care has not been extensive. The general aim of this thesis was therefore to explore the clinical care DNs provide to older people and DNs’ experiences of this care, focusing on preventive home visits (PHVs), medication management, and leg ulcer care. Material and methods: The thesis includes five studies. Study I used qualitative content analysis to analyze data from group interviews with 20 DNs about their experiences of PHVs. In Study II, DNs used the Safe Medication Assessment (SMA) tool in PHVs with 113 people to identify factors related to unsafe medication management and to describe interventions used to improve the safety of medication management. Study III employed data from the Swedish Prescribed Drug Register on 671,940 community-dwelling older people to examine the extent and quality oftheir drug use. In Study IV, the electronic records of 97 patients before and 96 after the intervention were used to evaluate DNs' leg ulcer management. In Study V, grounded theory method was used to collect and analyze data from group interviews with 30 DNs about providing leg ulcer care in accordance with guidelines. Results: Study I found facilitators of and barriers to a successful health dialogue in the PHV. Three main themes illustrated professional dilemmas in the health dialogue that the DNs had to resolve to achieve the purpose of the PHV. In Study II, DNs found several factors related to unsafe medication management when they used the SMA during PHVs. DNs intervened to improve medication management in more than two-thirds of the visits. Study III found that the prevalence of most drug groups and ofinappropriate drug use increased with age. Polypharmacy and use of potentially inappropriate medications were already prevalent in 75- year-olds. Study IV found that nurses' documentation ofleg ulcer management was sparse and far from consistent with clinical guidelines. Study V resulted in a theoretical model that illustrates how DNs balance compensating, motivating, and compromising strategies to follow clinical guidelines as far as possible and provide leg ulcer care that is good enough. Conclusions: DNs experience facilitators ofand barriers to health dialogues during PHVs and must balance a personal and a professional approach, a task-oriented and person-oriented approach, and a salutogenic and a pathogenic approach. The proportion of people who use drugs in most drug groups and who take inappropriate drugs increases with age. Using the SMA tool in PHVs may help improve the safety of medication management in older people and may be appropriate at age 75 and age 80. DNs cannot always follow guidelines but try to adhere to a treatment plan that is acceptable to patient and that hopefully can lead to a healed leg ulcer

Nursing management of postoperative pain: perceived care and actual practice

Postoperative pain management is a major responsibility of nurses who provide care for patients recovering from surgery. In the postsurgical environment, the nurse has a pivotal role in assessing the patient with pain, implementing both doctor and nurseinitiated pain interventions and evaluating the patient's response to pain control treatments. Apart from its humanitarian utility, effective relief of postoperative pain is a critical element of a patient's postoperative recovery. Failure to manage pain effectively in the immediate postoperative period can produce undesirable immediate and longterm physical and psychological consequences that can severely disrupt an individual's quality of life. Despite the availability of multidimensional assessment measures, sophisticated pharmacological therapies and a greater range of complementary pain therapies, postoperative pain remains treated ineffectively by those professionally responsible for its management. In particular, evidence indicates that nurses are poor managers of their patients' postoperative pain. This thesis reports research that was conducted in two stages to explore, describe and analyse how nurses managed their patients' postoperative pain and their perceptions of factors that influenced this practice. A predominantly descriptive design was utilised in Stage 1 of the study to collect data from patients' hospital records and with a demographic questionnaire administered to nurses. This was complemented with interview data from nurses in Stage 2.Previous studies offer limited views of the clinical realities of nursing practice in postoperative pain management. From this perspective, there is a need for research that incorporates these realities to permit analysis of clinical practice and greater understanding therefore of the problem of poor postoperative pain management. The purpose of this study was to provide an illuminative and authentic account of nursing practice in postoperative pain management. For the first part of Stage 1, data were collected retrospectively from nurses' documented accounts of pain assessment and intervention over the first three postoperative days for 100 patients in a major adult acute care teaching hospital. Analysis of nurses' documented responses to patients' reports of postoperative pain revealed that less than one-third of all responses could be considered appropriate for pain management. In particular, nurses failed to provide any pharmacological relief for 53% of patients' reports or severe and excruciating pain. Exploration of the influence of nurses' professional characteristics of education and experience on pain management practice was then undertaken in part 2 of Stage 1 with the use of a demographic questionnaire distributed to 106 nurses who were identified as signatories to the documented responses identified in part 1. Results indicated that length of professional experience accounted for most variations in practice, with older, more experienced nurses managing pain more appropriately than their younger and less experienced colleagues. Irrespective of education or experience, however, nurses failed to respond appropriately to patients reporting excruciating pain.In Stage 2, in-depth interviews were conducted with 8 nurses caring for postoperative patients at the research site. Thematic content analysis revealed four major themes from nurses' perceptions of their practice of postoperative pain management that served to elucidate and enrich the findings of Stage 1 of the research. These were finding out about the patient's pain, making decisions about pain and pain management, individual factors affecting pain management, and interpersonal and organisational factors affecting pain management. This thesis provides an authentic account of nursing practice in postoperative pain management, and contributes understanding and insight into factors that provoke ineffective management of pain after surgery. It has implications for the development of intervention strategies aimed at improving nursing practice, at both individual and organisational levels, and suggests new directions for nursing education and research toward achieving optimum care and eliminating unnecessary pain for patients recovering from surgery

Procedural sedation: Policy, practice & knowledge

Diagnostic and invasive procedures performed outside of the operating room with nurse- administered procedural sedation are increasing. As procedural sedation practice national guidelines are evolving, there are inconsistent state regulations and a great deal of variability in staff training. These challenges lead to potential knowledge gaps and practice variation that create unsafe patient environments. A local hospital has continued to experience near miss events when procedural sedation is administered. In an attempt to investigate this issue and create improved practice, an organizational policy analysis was conducted. The aims of this project were to: 1) analyze current hospital policy content compared with AORN\u27s Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia; 2) propose policy changes based on content gaps and barrier analysis; 3) assess current team members\u27 knowledge with hospital policy for procedural sedation patient monitoring and knowledge of common procedural sedation medications; and 4) develop a plan for implementing policy changes and knowledge deficits identified. The Knowledge to Action framework activation cycle was used to guide policy analysis and practice change. The institution\u27s Procedural Sedation Committee served as the discussion forum and decision making body regarding policy change. A staff survey yielded information specific to medication knowledge and procedural sedation. Policy analysis identified the following gaps in the organizational policy: a lack of objective patient assessment scoring for discharge readiness; the need for potential extended recovery times for specific patient populations; patient monitoring with capnography; pre-procedural patient education components; nurse knowledge expectations and nursing involvement in performance improvement activities. Results of the project include implementation of the Aldrete discharge readiness assessment tool, a change in policy specific to extended recovery for specific patient populations and implementation of a decision tree to determine when procedural sedation was occurring. During this project, it was discovered that additional exploration is needed regarding nurse’s procedural sedation medication and practice knowledge in order to create the next intervention that will lead to best practice

Examining professionals' and parents' views of using transanal irrigation with children: Understanding their experiences to develop a shared health resource for education and practise

Irrigation as a bowel management approach has been reportedly used with children for more than 20 years. Parents managing their child's chronic bowel problem have previously been shown to have increased emotional stress. The aim of this study was to explore professionals' (n = 24) understanding and parents' (n = 18) experiences of using transanal irrigation with children at home as a mid to longer term bowel management approach. This study was underpinned by action research methodology and used mixed methods determined by an action research group of parents, professionals, researchers, a voluntary sector worker, commercial representative and independent observer. Data informed the study outcome which was the development and evaluation of a shared health resource to support professionals in their holistic approach when prescribing transanal irrigation and guide parents in the areas of education, management, problem solving, support and goal setting. The resource includes constructed case studies from parents of their experiences to inform choice and decision-making between parents and professionals. The shared health resource provides an approach to initiating and evaluating transanal irrigation and is available in a paper format from key Internet sites across hospital, community and voluntary services