Karen Dunn Lopez

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information

OBJECTIVE To examine information flow, a vital component of a patients care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement. DESIGN This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staffs communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices. RESULTS Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patients electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication. CONCLUSION The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patients plan.

Current state of pain care for hospitalized patients at end of life.

We report findings on the current state of pain care in hospitals for end-of-life (EOL) patients using longitudinal data from 8 diverse medical–surgical units located in 4 different Midwestern hospitals over 24 months. We identified 1425 EOL care episodes, 596 (41.3%) of which had a pain diagnosis. The percentage of EOL patients with pain varied significantly across units (P < .001) and was even lower (27.7%) for those with “acute confusion.” Additionally, 30% of EOL patients had severe or significant pain at death or discharge to hospice and only 42.7% actually met the expected pain-related outcome ratings. Pain often improved within 48 hours of admission (P < .005), the improvement, however, stagnated following this initial time period (P = .92). A sizable gap between pain science and clinical practice continues.

Integrative review of clinical decision support for registered nurses in acute care settings

Objective: To report on the state of the science of clinical decision support (CDS) for hospital bedside nurses. Materials and Methods: We performed an integrative review of qualitative and quantitative peer-reviewed original research studies using a structured search of PubMed, Embase, Cumulative Index to Nursing and Applied Health Literature (CINAHL), Scopus, Web of Science, and IEEE Xplore (Institute of Electrical and Electronics Engineers Xplore Digital Library). We included articles that reported on CDS targeting bedside nurses and excluded in stages based on rules for titles, abstracts, and full articles. We extracted research design and methods, CDS purpose, electronic health record integration, usability, and process and patient outcomes. Results: Our search yielded 3157 articles. After removing duplicates and applying exclusion rules, 28 articles met the inclusion criteria. The majority of studies were single-site, descriptive or qualitative (43%) or quasi-experimental (36%). There was only 1 randomized controlled trial. The purpose of most CDS was to support diagnostic decision-making (36%), guideline adherence (32%), medication management (29%), and situational awareness (25%). All the studies that included process outcomes (7) and usability outcomes (4) and also had analytic procedures to detect changes in outcomes demonstrated statistically significant improvements. Three of 4 studies that included patient outcomes and also had analytic procedures to detect change showed statistically significant improvements. No negative effects of CDS were found on process, usability, or patient outcomes. Discussion and Conclusions: Clinical support systems targeting bedside nurses have positive effects on outcomes and hold promise for improving care quality; however, this research is lagging behind studies of CDS targeting medical decision-making in both volume and level of evidence.

Characterizing the structure and content of nurse handoffs

Effective communication during nurse handoffs is instrumental in ensuring safe and quality patient care. Much of the prior research on nurse handoffs has utilized retrospective methods such as interviews, surveys and questionnaires. While extremely useful, an in-depth understanding of the structure and content of conversations, and the inherent relationships within the content is paramount to designing effective nurse handoff interventions. In this paper, we present a methodological framework-Sequential Conversational Analysis (SCA)-a mixed-method approach that integrates qualitative conversational analysis with quantitative sequential pattern analysis. We describe the SCA approach and provide a detailed example as a proof of concept of its use for the analysis of nurse handoff communication in a medical intensive care unit. This novel approach allows us to characterize the conversational structure, clinical content, disruptions in the conversation, and the inherently phasic nature of nurse handoff communication. The characterization of communication patterns highlights the relationships underlying the verbal content of nurse handoffs with specific emphasis on: the interactive nature of conversation, relevance of role-based (incoming, outgoing) communication requirements, clinical content focus on critical patient-related events, and discussion of pending patient management tasks. We also discuss the applicability of the SCA approach as a method for providing in-depth understanding of the dynamics of communication in other settings and domains.

Nurses' Numeracy and Graphical Literacy: Informing Studies of Clinical Decision Support Interfaces.

We present findings of a comparative study of numeracy and graph literacy in a representative group of 60 practicing nurses. This article focuses on a fundamental concern related to the effectiveness of numeric information displayed in various features in the electronic health record during clinical workflow. Our findings suggest the need to consider numeracy and graph literacy when presenting numerical information as well as the potential for tailoring numeric display types to an individuals cognitive strengths.

Use of Simulation to Study Nurses' Acceptance and Nonacceptance of Clinical Decision Support Suggestions.

Our long-term goal was to ensure nurse clinical decision support works as intended before full deployment in clinical practice. As part of a broader effort, this pilot project explored factors influencing acceptance/nonacceptance of eight clinical decision support suggestions displayed in an electronic health record–based nursing plan of care software prototype. A diverse sample of 21 nurses participated in this high-fidelity clinical simulation experience and completed a questionnaire to assess reasons for accepting/not accepting the clinical decision support suggestions. Of 168 total suggestions displayed during the experiment (eight for each of the 21 nurses), 123 (73.2%) were accepted, and 45 (26.8%) were not accepted. The mode number of acceptances by nurses was seven of eight, with only two of 21 nurses accepting all. The main reason for clinical decision support acceptance was the nurse’s belief that the suggestions were good for the patient (100%), with other features providing secondary reinforcement. Reasons for nonacceptance were less clear, with fewer than half of the subjects indicating low confidence in the evidence. This study provides preliminary evidence that high-quality simulation and targeted questionnaires about specific clinical decision support selections offer a cost-effective means for testing before full deployment in clinical practice.

Nurse Continuity and Hospital-Acquired Pressure Ulcers: A Comparative Analysis Using an Electronic Health Record "big Data" Set

BackgroundLittle research demonstrating the association between nurse continuity and patient outcomes exists despite an intuitive belief that continuity makes a difference in care outcomes. ObjectiveThe aim of this study was to examine the association of nurse continuity with the prevention of hospital-acquired pressure ulcers (HAPU). MethodsA secondary use of data from the Hands on Automated Nursing Data System (HANDS) was performed for this comparative study. The HANDS is a nursing plan of care data set containing 42,403 episodes documented by 787 nurses, on nine units, in four hospitals and includes nurse staffing and patient characteristics. The HANDS data set resides in a “big data” relational database consisting of 89 tables and 747 columns of data. Via data mining, we created an analytic data set of 840 care episodes, 210 with and 630 without HAPUs, matched by nursing unit, patient age, and patient characteristics. Logistic regression analysis determined the association of nurse continuity and additional nurse-staffing variables on HAPU occurrence. ResultsPoor nurse continuity (unit mean continuity index = .21–.42 [1.0 = optimal continuity]) was noted on all nine study units. Nutrition, mobility, perfusion, hydration, and skin problems on admission, as well as patient age, were associated with HAPUs (p < .001). Controlling for patient characteristics, nurse continuity, and the interactions between nurse continuity and other nurse-staffing variables were not significantly associated with HAPU development. DiscussionPatient characteristics including nutrition, mobility, and perfusion were associated with HAPUs, but nurse continuity was not. We demonstrated a high level of variation in the degree of continuity between patient episodes in the HANDS data, showing that it offers rich potential for future study of nurse continuity and its effect on patient outcomes.

Toward a More Robust and Efficient Usability Testing Method of Clinical Decision Support for Nurses Derived From Nursing Electronic Health Record Data

PURPOSE To develop methods for rapid and simultaneous design, testing, and management of multiple clinical decision support (CDS) features to aid nurse decision-making. METHODS We used quota sampling, think-aloud and cognitive interviews, and deductive and inductive coding of synchronized audio video data and archival libraries. FINDINGS Our methods and organizational tools allowed us to rapidly improve the usability, understandability, and usefulness of CDS in a generalizable sample of practicing nurses. CONCLUSIONS The method outlined allows the rapid integration of nursing terminology based electronic health record data into routine workflow and holds strong potential for improving patient outcomes. IMPLICATIONS FOR NURSING PRACTICE The methods and organizational tools for development of multiple CDS system features can be used to translate knowledge into practice.

Are we talking about the same patient

The objective of this study is to determine the degree of similarities between the clinical terms used by physicians and nurses in their documentation.

Expanding potential of radiofrequency nurse call systems to measure nursing time in patient rooms.

OBJECTIVE: The objective of this study was to determine the utility and feasibility of using data from a nurse call system equipped with radiofrequency identification data (RFID) to measure nursing time spent in patient rooms. BACKGROUND: Increasing the amount of time nurses spend with hospitalized patients has become a focus after several studies demonstrating that nurses spend most of their time in nondirect care activities rather than delivering patient care. Measurement of nursing time spent in direct care often involves labor-intensive time and motion studies, making frequent or continuous monitoring impractical. METHODS: Mixed methods were used for this descriptive study. We used 30 days of data from an RFID nurse call system collected on 1 unit in a community hospital to examine nurses time spent in patient rooms. Descriptive statistics were applied to calculate this percentage by role and shift. Data technologists were surveyed to assess how practical the access of data would be in a hospital setting for use in monitoring nursing time spent in patient rooms. RESULTS: The system captured 7393 staff hours. Of that time, 7% did not reflect actual patient care time, so these were eliminated from further analysis. The remaining 6880 hours represented 91% of expected worked time. RNs and nursing assistants spent 33% to 36% of their time in patient rooms, presumably providing direct care. CONCLUSIONS: Radiofrequency identification data technology was found to provide feasible and accurate means for capturing and evaluating nursing time spent in patient rooms. Depending on the outcomes per unit, leaders should work with staff to maximize patient care time.