Infuse!_Volume 3_Number 1_ 2019

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Doctor of Philosophy

dissertationAs nurses, we seek to gain nursing wisdom and apply it in our daily practice, yet the process of practicing with wisdom has not been well explained for nursing. The purpose of this dissertation was to develop a theory of wisdom in action (WIA) for clinical nursing, beginning with a formal concept analysis. In Phase 1 (Aim 1), a preliminary theory was developed deductively using derivation and synthesis, based on theories and models from psychology, education, and nursing. Pertinent concepts were identified and nursing-specific definitions created. The theory included four dimensions: person-related factors, environment-related factors, knowledge, and wisdom. Separately, a constructivist grounded theory approach inductively captured the experience of wisdom in nursing practice (Aim 2), based on wisdom narratives from 30 emergency department nurses. The resulting grounded theory focused on two processes, technical and affective, juxtaposed on a foundation of expertise. New findings were the importance of affective characteristics such as emotional intelligence and confidence. Finally, the theories were synthesized into the Theory of Wisdom in Action for Clinical Nursing. The theory describes two antecedent dimensions, person-related and setting-related factors, and two types of wisdom processes. General wisdom processes apply to patient care and describe the actions nurses take during a stressful or uncertain event. Personal wisdom develops afterwards, as a feedback loop with reflection, discovery of meaning, and learning, followed by increased knowledge and confidence. Wisdom is critical for all areas of nursing practice. The Theory of Wisdom in Action for Clinical Nursing provides a working framework for translating wisdom in clinical nursing practice into theoretical and practical terms, depicting both the science and the art of nursing. This novel theory displays how nurses practice with wisdom, and reveals that wisdom in action requires clinical skills, experience, knowledge, and affective proficiency

Leveraging Clinical Preceptorship to Enhance Nursing Students’ Readiness in Digital Health

As technology continues to advance rapidly and digitalization becomes more prevalent in healthcare, the nursing profession must also adapt to these changes. The integration of informatics in nursing education and practice should serve as a catalyst for shaping future nursing leaders who can drive innovation, influence policy, and contribute to the advancement of healthcare. During the final stage of their undergraduate education, nursing students would have gained substantive knowledge and have been exposed to different digital health technologies and medical devices used in the delivery of clinical care. However, their ability to assimilate this knowledge and make sense of how nursing informatics and digital health relate to their practice roles may not be as readily visible to them. Nursing preceptors can play a vital role in assisting students discover the potential of technology in healthcare and nursing practice. Yet, despite the significance of clinical learning experiences and the important role nursing preceptors play in the development of nursing students, there is limited discussion in the literature with respect to their role in relation to digital health readiness among nursing students. The purpose of this discussion paper is to illuminate the importance of nursing informatics as a foundational knowledge base for Canadian nurses and argue the need for advancing clinical nursing education, particularly preceptorship experiences, as a potential pathway for enhancing nursing students’ readiness in digital health and to facilitate their transition into the Registered Nurse role in digitally enabled work environments. Résumé Alors que la technologie continue de progresser rapidement et que la numérisation devient de plus en plus répandue dans le domaine des soins de santé, la profession infirmière doit également s’adapter à ces changements. L’intégration de l’informatique dans la formation et la pratique en sciences infirmières devrait servir de catalyseur pour façonner les futurs responsables des sciences infirmières capables de stimuler l’innovation, d’influencer les politiques et de contribuer à l’avancement des soins de santé. Au cours de la dernière étape de leurs études de premier cycle, les étudiantes et étudiants en sciences infirmières auraient acquis des connaissances approfondies et auraient été exposés à différentes technologies en santé numérique et à des dispositifs médicaux utilisés dans la prestation de soins cliniques. Cependant, leur capacité à assimiler ces connaissances et à comprendre comment l’informatique infirmière et la santé numérique sont liées à leurs rôles en pratique n’est peut-être pas aussi visible pour eux. Les préceptrices et précepteurs en sciences infirmières peuvent jouer un rôle essentiel en aidant les étudiantes et étudiants à découvrir le potentiel de la technologie dans les soins de santé et la pratique infirmière. Pourtant, malgré l’importance des expériences d’apprentissage clinique et le rôle significatif que jouent les préceptrices et précepteurs en sciences infirmières dans le développement des étudiantes et étudiants, la littérature traite peu de leur rôle dans la préparation à la santé numérique. Le but de ce document de discussion est de mettre en lumière l’importance de l’informatique infirmière en tant que connaissances fondamentales pour les infirmières et infirmiers canadiens et de faire valoir la nécessité de faire progresser la formation clinique en sciences infirmières, en particulier les expériences de préceptorat, comme voie potentielle pour améliorer la préparation des étudiantes et étudiants en sciences infirmières à la santé numérique et pour faciliter leur transition vers le rôle d’infirmière ou d’infirmier œuvrant dans des environnements numériques de travail

Evolving Role of the Nursing Informatics Specialist.

The scope of nursing informatics practice has been evolving over the course of the last 5 decades, expanding to address the needs of health care organizations and in response to the evolution of technology. In parallel, the educational preparation of nursing informatics specialists has become more formalized and shaped by the requisite competencies of the role. In this chapter, the authors describe the evolution of nursing informatics roles, scope and focus of practice, and anticipated role responsibilities and opportunities for the future. Further, implications and considerations for the future are presented

Academic Health Science Centers and Health Disparities: A Qualitative Review of the Intervening Role of the Electronic Health Record and Social Determinants of Health

Literature on the magnitude of negative health outcomes from health disparities is voluminous. Defined as the health effects of racism, environmental injustice, forms of discrimination, biases in science, and sociological or socioeconomic predictors across populations, health disparities are part of an ongoing and complicated national problem that health equity programs are specifically designed to address. Academic Health Science Centers (AHC) institutions are a complex and unique educational-healthcare ecosystem that often serves as a safety net for patients in vulnerable and lower-income communities. These institutions are often viewed as one of the most uniquely positioned entities in the U.S. with an abundance of resources and networks to advance health equity as a high-impact goal and strategic imperative. Relatively little progress, however, has been made to better understand the potentially transformative nature of how digital health technologies (DHT)—such as mobile health apps, electronic health record (EHR) and electronic medical record (EMR) systems, smart ‘wearable’ devices, artificial intelligence, and machine learning—may be optimized to better capture and analyze social determinants of health (SDH) data elements in order to inform strategies to address health disparities. Even less has been explored about the challenging implementation of electronic SDH screening and data capture processes within AHCs and how they are used to better inform decisions for patient and community care. This research examines how AHC institutions, as complex education-healthcare bureaucracies, have prioritized this specific challenge amongst many other competing incentives and agendas in order to ultimately develop better evidence-based strategies to advance health equity. While there are clear moral, ethical, and clinical motives for improving health outcomes for vulnerable populations, when an AHC demonstrates that electronically screening and capturing SDH can improve the ability to understand the “upstream” factors impacting their patients\u27 health outcomes, this can inform and influence policy-level choices in government legislation directed at community-level factors. A qualitative thematic analysis of interview data from AHC administrators and leadership illustrates how AHCs have mobilized their EHR as a featured component of their healthcare delivery system to address health disparities, exposing other related, multifactorial dimensions of the Institution and region. Key findings indicated that: electronic SDH screening and updating workflow processes within an AHC’s clinical enterprise is a significant venture with multiple risks and the potential of failure. Universal adoption and awareness of SDH screening is hampered by notions of hesitancy, skepticism, and doubt as to an AHC’s ability to meaningfully extract and use the data for decision-support systems. Additional investment in resources and incentive structures for capturing SDH are needed for continued monitoring of patient health inequalities and community social factors. Data from this and future replicated studies can be used to inform AHC and government decisions around health and social protection, planning, and policy

A Study Identifying Information Technology Development Strategies for Nursing Professional Development Specialists Practicing in Healthcare Settings

The increased use of information systems (IS) in healthcare institutions, federal health information technology (IT) policy mandating the use of information systems in patient care, and the nursing informatics agenda force healthcare organizations to address the informatics competency of its workforce (Murphy, 2010). This study validates IT competencies for Nursing Professional Development (NPD) Specialists and determines self-directed, informal learning strategies for developing information technology competency. The NPD Specialist is responsible for the professional development of nursing caregivers in healthcare settings. This study validated 53 IT competencies for the NPD Specialist role in healthcare settings. The validated competencies include current healthcare technology, federal health IT policy, evidence-based practice, and other necessary topics within healthcare. This study regarded 41 competencies (of the 53 validated IT competencies) as high importance, or essential, to the NPD Specialists role in healthcare settings today. Strategies were also identified for developing the essential IT competencies. The NPD Specialists and leaders within healthcare organizations can use the validated essential IT competencies and development strategies from this study to build IT competency amongst its workforce (ANA, 2010)

Information Technology Resources for Precision Medicine

Healthcare delivery organizations have an opportunity to use insights from the emerging field of precision medicine to improve the quality of patient care; however, information technology resources to fully enable precision medicine are lacking. The specific problem was that people have limited information to use when making decisions regarding information technology resources for precision medicine in healthcare delivery organizations given the emerging state of precision medicine. The purpose of this Delphi study was to determine how a panel of precision medicine information technology experts view information technology resource importance and feasibility for precision medicine in healthcare delivery organizations. The research question asked how does a panel of precision medicine information technology experts view information technology resource importance and feasibility for precision medicine in healthcare delivery organizations. The resource-based view of the firm served as the conceptual framework. Data were collected in three consecutive rounds of questionnaires. Thematic analysis was performed to develop a list of information technology resources that were rated by participants in terms of importance and feasibility, which were analyzed to assess if there was consensus among the participants. Of the 159 information technology resources that were rated, 77 information technology resources were considered important and feasible. The study results could lead to positive social change at individual, organizational, and societal levels. At a societal level, the study results could give rise to positive social change by creating a shared vision of what is needed to fulfill information technology resource requirements for precision medicine in healthcare delivery organizations and enable progress toward improved healthcare quality

Characteristics of Complete and Incomplete Physicians’ Unlearning with Electronic Medical Record

This study examines the concept of unlearning, the process of disuse or replacement of an action, procedure or belief in favor of a new one, in the context of healthcare. Little is known about the true nature of unlearning and related learning change processes within the context of healthcare. The study of unlearning continues to be important not only due to the nature of the discipline itself, but physicians are required to support knowledge change for improved care quality. The study argues the introduction of new Health Information Technologies (HITs), such as EMRs, affect the unlearning process in physician providers. We address the following research question: “What are the characteristics of the unlearning process by physicians who are using EMRs?” using a qualitative case study methodology. Interviews, the primary data collection method and coding is mainly used for data analysis. Results show physician unlearning is characterized as either complete unlearning or incomplete unlearning