National standards in local setting. Implementing electronic nursing and care messages at the University Hospital of North Norway

This thesis is an interpretive study examining national electronic Nursing and Care Messages (NUC messages) implemented into a local setting. From the outset the messages were created to support and enhance efficiency and quality for cross level communication when exchanging health information related to shared care. The study focuses on theory of standards and standardization as the NUC messages is to be perceived as a standard. Analytic tools from Actor Network Theory are used to examine the process of how the messages were created. This contributes to an in-depth understanding of the end-users experiences after implementation of NUC messages at the local setting, which is the University Hospital of North Norway. Findings are that even though the electronic messages enables a time efficient way of communication, the message standard still have features that negatively impacts the use of them. The NUC messages seem to have a weak inscription that makes the standard flexible and enables alternative use. Additionally, this flexibility implies that compliance to the standard is challenged. Despite various efforts from local actors in the national test and piloting phase, alternative and local translations of the standard have not been possible to negotiate after the messages were designed. The standard of NUC messages seem to have reached the state of irreversibility instantly when designed. The study examines how the standard of NUC messages regarding their naming, in-messages structures and messages pathway creates a tension when adopted into local practice with alternative requirements of communication in cross level care

How Does Nursing Staff Perceive the Use of Electronic Handover Reports? A Questionnaire-Based Study

Following the implementation of electronic nursing records in a psychogeriatric ward, we examined nursing staff's attitudes and perceptions to the implementation of an electronic handover routine. A web-based anonymous and secure questionnaire was distributed by e-mail to all nursing staff at a psychogeriatric ward at a university hospital. Most respondents were satisfied with the electronic handover, and they believed they managed to keep informed by the new routine. The simultaneous introduction of a morning meeting, to ensure a forum for oral professional discussion, was a success. A minority of staff did not fully trust the information conveyed in the electronic handover, and a significant proportion expressed a need for guidance in using the system. Staff that had a high level of trust in written reports believed these saved time, had little trouble finding time and a place to read the reports, and were more positive to the new handover routine

The interplay between global standards and local practice in nursing

Submitted manuscript version. Published version available at https://doi.org/10.1016/j.ijmedinf.2013.02.005.Purpose: The paper assesses the extent, form, and transformation of global nursing classifications (NANDA) in a nursing practice during a period of 5 years. Method: A longitudinal case study was used to trace implementation, adoption and use of nursing classifications as an integral part of an electronic nursing module. A mixed method of data collection was used, including semi-structured interviews, observation and document analysis. Results: A surprisingly high proportion of nursing diagnoses was consistent with the global standard, in spite of a gradual increase of user-generated concepts. This is elaborated more thoroughly through a co-constructing perspective, emphasizing how the global standard and the practice mutually shaped each other over several years. Conclusion: Standardization is an iterative process that is performed in close relationship with practice. The mutual interrelation between formal classifications (NANDA) and local practices are co-constructed in a dynamic interplay that evolves over time. In such a process, the use of local classifications and local strategies can be a means to bridge the gap between these two extreme points. Highlights: ► Extensive use of standardized classification after implementation of electronic care plan. ► Local classifications evolved during long-term use. ► Co-construction of classifications was used to bridge the gap between global classifications and local needs

How Does Nursing Staff Perceive the Use of Electronic Handover Reports? A Questionnaire-Based Study

Following the implementation of electronic nursing records in a psychogeriatric ward, we examined nursing staff 's attitudes and perceptions to the implementation of an electronic handover routine. A web-based anonymous and secure questionnaire was distributed by e-mail to all nursing staff at a psychogeriatric ward at a university hospital. Most respondents were satisfied with the electronic handover, and they believed they managed to keep informed by the new routine. The simultaneous introduction of a morning meeting, to ensure a forum for oral professional discussion, was a success. A minority of staff did not fully trust the information conveyed in the electronic handover, and a significant proportion expressed a need for guidance in using the system. Staff that had a high level of trust in written reports believed these saved time, had little trouble finding time and a place to read the reports, and were more positive to the new handover routine. Background Having adequate and up-to-date information and knowledge about patients is crucial in order to maintain continuity of care The electronic patient record (EPR) has recently become a key factor in the information flow, and it has been suggested that using information technology can be an effective method for improving quality, efficiency, and costs In the present study, we report on the attitudes and perceptions of nursing staff to the electronic handover routine at a ward in a Norwegian university hospital. Methods Study Ward Patients and Providers. The study was carried out at the Psychogeriatric Ward at the University Hospital of Northern Norway (UNN). The patients were 65 years or older and the hospitalization typically lasted 6-8 weeks. This is an inpatient ward with 14 beds that treats patients who are suffering from psychiatric disorders, including depression, psychosis, dementia, and anxiety disorders. The problems facing patients are complex, since most of the patients suffer from somatic illnesses in addition to the psychiatric illness. The patients are subjected to various types of tests (blood work, imaging, physical examination, psychological testing, etc.) and are diagnosed, and appropriate treatment is subsequently initiated. The work at the ward is highly interdisciplinary, and the clinical staff comprises psychiatrists, physicians, psychologists, nurses, assistant nurses, social workers, occupational therapists, physiotherapists, and some unskilled staff. The number of nursing staff on duty at the ward varies. Normally, there are 8 on the day shift, 6 on the evening shift, and 3 on the night shift. Nurses from all shifts were asked to participate in the study. Since the nursing work is based on primary nursing, that is, where a nursing team provides complete care for a small group of patients, the staff gets to know the patients well during the stay. Handover Routine and Electronic Nursing Documentation at the Ward. At the study ward, electronic nursing documentation was introduced in 2005. In 2008, a new handover routine was implemented. Instead of presenting all information orally (a 30 minute meeting at each handover covering all patients in the ward), staff would now read the relevant electronic nursing care plans regarding their own patients only. In addition, every morning, there was now a 30 minute meeting for professional discussion, usually covering 2-3 patients, but also including discussions not relating to specific patients. This type of meeting was only held during the morning shift. The main objective of the morning meeting was to provide an opportunity for discussion and reflection in relation to various nursing topics, and thus ensure the multifunctional aspect to the handover process Moreover, to facilitate the introduction of the new handover process and make a gradual transition to the new structure, it was decided to keep the oral handover on Monday mornings and Friday afternoons and also the oral handover between the evening and night shifts. The remaining traditional oral handovers were meant to supplement the new system where the nurses read the relevant electronic nursing care plans, and the nurses were required to read up on their own patients also when traditional oral handover meetings were arranged. Use of the new electronic system also required skills and knowledge of the use of the care plan in general, as well as the use of a standardized language. At the core of the nursing care plan was its shared terminology to describe the patient's problem (i.e., nursing diagnosis) and link this to one or more interventions. The classification systems of the North American Nursing Diagnosis Association (NANDA) and the Nursing Intervention Classification (NIC) were embedded in the system and had become an integrated part of the electronic documentation of nursing at the ward To secure the quality of the electronic nursing care plans during their implementation phase, support and supervision was offered by two specially trained nurses. They were available every day between 12 noon and 1.30 p.m. and could assist the other nursing staff in making sure that the nursing documentation was reliable and updated. The guidance was focused on nursing care plans in general and on use of the electronic records system. The Questionnaire. A questionnaire was designed in order to examine the attitudes and perceptions of the nursing staff to the new electronic handover practice. The questionnaire focused on issues related to perceived usefulness and perceived ease of use and was inspired by the technology acceptance model (TAM) Some of the items in the questionnaire used in the present study resembled items on the 6+6 item versions of the TAM questionnaires originally described by Davis [24], while other items were more specific to the circumstances of the study ward. The appropriateness of the questionnaireitems was discussed in a small group of project members, including clinicians, in order to increase the face validity of the questionnaire. Two of the group members (nurses that had working experience from the study ward) made a first version of the questionnaire, and two other group members International Journal of Telemedicine and Applications 3 (a nurse and a doctor, both with clinical and research experience) gave comments and suggestions; this process was repeated several times until the complete group was satisfied with the final result. The questionnaire was sent to all nursing staff in the form of an e-mail link to a secure web-based form. The researchers did not have access to information regarding who had responded to the questionnaire (and who had not). The questionnaire did not contain information that could be used to identify individual respondents, and all respondents were anonymous. The questionnaire consisted of 22 questions and covered different topics, including questions on satisfaction with the new handover practice and the perceived effectiveness and usefulness of the EPR system. There were also questions about how the respondents felt about the new morning meeting and questions relating to guidance and support with respect to the new handover routine as well as the EPR in general. Three possible options were provided to each question, with the response options low, medium, and high. The questionnaire also included an open commentary field. In the questionnaire, there was also information about the purpose of the survey, information stating that participation was voluntary, and that anonymity and confidentiality were assured. The study was approved by the Head of the Hospital Division and was in accordance with the regulations of the Hospital's Data Protection Officer. The survey sampled anonymous information about staff attitudes, and no patient information was sampled. Statistical Procedures. Data were analysed descriptively. In addition, a multiple regression analysis was performed in order to examine predictors of satisfaction with the new handover routine. Items entered as predictors in the model included whether the respondents found time and place to read, their trust in written documentation, whether they believed reading saved time, whether they believed other written sources were important, whether they believed morning meetings were important, whether they believed working on handover routines improved nursing standards, whether they felt independent in writing nursing documentation, and if they believed guidance was important in implementing the new routine. The results were analyzed using the statistics software SPSS 16.0. A significance level of P < .05 was employed. Results The Sample. Of the 34 that were eligible to participate, 32 responded, giving a response rate of 94%. 80% of the respondents had more than two years of work experience. The Electronic Handover. Seventy-five percent were very satisfied or satisfied with the electronic handover In this study, we did not ask which information sources they used, but earlier investigations at the ward have shown that the nursing care module in the EPR system has become the single most important element in the documentation work of the nursing staff The Morning Meeting. The other new intervention in the new handover process was the introduction of the morning meeting, and all the respondents felt that the morning meeting was important or very important to professional development, and they were also satisfied or very satisfied with the topics that were discussed during the meetings. Guidance. Interestingly, almost all (96.2%) the respondents considered the daily documentation guidance significant to their professional development. Although they had been using EPR and the electronic nursing module for several years, there were still many who needed guidance to use the EPR, to find nursing concepts, and to make changes in the care plans, and 15.4% felt they needed a lot of guidance. Predictors of Satisfaction with New Handover Routine. A multiple regression analysis was performed, where a set of variables (see Discussion The main finding in this study is that the nursing staff was satisfied with the electronic handover routine. They were content with being able to judge which information they needed and believed staff were kept updated on patients' needs. However, the implementation of the new electronic handover procedure has involved a paradigm shift in the information work at the ward; the structure of the handover has changed, and the focus has moved from oral to written information. The successful introduction of the new electronic handover is composed by multiple factors that provide new opportunities but also involve new challenges. The study has showed that some nursing staff need guidance in order to make use of the electronic nursing documentation system, including the electronic handover. Such a system for guidance should be in place in order to secure a smooth transition from an oral to an electronic handover practice. The study has demonstrated that a gradual implementation of a new handover process has been adopted by the users, and it is likely that one reason for a successful adoption was that local and professional needs were ensured The use of electronic care plans and nursing classifications has become a major factor in the information work at the ward, and our study shows that a majority of nursing staff rely on the written documentation. Reliable and accurate documentation was a prerequisite for changing the handover process. Before the implementation of the electronic nursing module, the documentation was incomplete, and the language used in the documentation was inaccurate and often included local (i.e., to the ward) jargon, as has been shown to be the case in other wards The study also shows that all were satisfied with the topics and the impact of the morning meetings on professional International Journal of Telemedicine and Applications 5 development. Typical topics for the meetings were different problems related to care issues, and the meetings provided an opportunity for collective reflection and the development of clinical judgment The regression analysis demonstrated several predictors of satisfaction with the new handover routine. Particularly interesting was the finding that those who had a high level of trust in written reports, believed these saved time, and had little trouble finding time and a place to read the reports were more positive to the new handover routine. While the small sample of the present study should be taken into consideration when analyzing the results, this finding could suggest that the successful (in terms of the satisfaction of the nursing staff) implementation of electronic nursing routines in part depends on nursing staff being used to written reports. Extrapolating from this idea, one can hypothesize/ speculate that wards that to a lesser extent have used written (i.e., pen and paper) reports will need more time and effort to successfully implement new electronic routines. There were limitations to the study. Although the response rate was quite high, the sample was relatively small and covered one ward only. Thus, it is problematic to claim that the findings of the present study reflect nurses' acceptance of electronic handovers in general. Studies with larger samples will be needed to verify the findings of the present study and to make more general claims about nurses' attitudes to electronic handovers. Moreover, several changes in ward routines were simultaneously introduced, that is, the new (electronic) handover routine and the new morning meeting. Although we believe it was necessary to make both changes at the same time, we do not know how satisfied the nursing staff would have been with the new handover routine without the new morning meeting. This study contributes to an increased understanding of the nursing handover per se and to the implementation of an e-health solution in clinical practice. Further studies should address implications of the electronic handover for issues such as the impact on the quality of patients' care, patients' satisfaction, and the impact on how information is shared within and across organizational boundaries. Conclusions Most of the nursing staff was satisfied with the electronic handover procedure although a minority was less trustful of written information. Introducing a forum for oral discussion on topics of importance to the staff 's professional development and securing sufficient guidance on how to use the system were perceived as central factors to success in the implementation

The interplay between global standards and local practice in nursing

Purpose: The paper assesses the extent, form, and transformation of global nursing classifications (NANDA) in a nursing practice during a period of 5 years. Method: A longitudinal case study was used to trace implementation, adoption and use of nursing classifications as an integral part of an electronic nursing module. A mixed method of data collection was used, including semi-structured interviews, observation and document analysis. Results: A surprisingly high proportion of nursing diagnoses was consistent with the global standard, in spite of a gradual increase of user-generated concepts. This is elaborated more thoroughly through a co-constructing perspective, emphasizing how the global standard and the practice mutually shaped each other over several years. Conclusion: Standardization is an iterative process that is performed in close relationship with practice. The mutual interrelation between formal classifications (NANDA) and local practices are co-constructed in a dynamic interplay that evolves over time. In such a process, the use of local classifications and local strategies can be a means to bridge the gap between these two extreme points. Highlights: ► Extensive use of standardized classification after implementation of electronic care plan. ► Local classifications evolved during long-term use. ► Co-construction of classifications was used to bridge the gap between global classifications and local needs