Mariann Fossum

Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly.

BACKGROUND Computerized decision support systems (CDSSs) have been shown to help health care professionals to avoid errors and improve clinical practice and efficiency in health care. Little is known about its influence on nursing practice and outcomes for residents in nursing homes. AIM The aim of this study was to evaluate the effects on the risk for and prevalence of pressure ulcers (PUs) and malnutrition of implementing a CDSS to improve prevention and care of PUs and also to improve nutrition in the elderly in nursing homes. DESIGN SETTING AND PARTICIPANTS The study used a quasi-experimental design with two intervention groups and one control group. A convenience sample of residents from 46 units in 15 nursing homes in rural areas in Norway was included. A total of 491 residents participated at baseline in 2007 and 480 residents at follow-up in 2009. METHODS The intervention included educational sessions in prevention of PUs and malnutrition for registered nurses (RNs) and nursing aides (NAs) in the two intervention groups. In addition, one intervention group (intervention group 1) had a CDSS integrated into the electronic healthcare record (EHR) based on two research-based risk assessment instruments: the Risk Assessment Pressure Scale (RAPS) for PU risk screening and the Mini Nutritional Assessment (MNA(®)) scale for screening nutritional status. In each participating nursing home trained RNs and NAs examined all residents who consented to participate on the RAPS and the MNA(®) scale. This examination included a skin assessment and details about PUs were collected. RESULTS The proportion of malnourished residents decreased significantly in intervention group 1 between the two data collection periods (2007 and 2009). No other significant effects of the CDSS on resident outcomes based on the RAPS and MNA(®) scores were found. CONCLUSION CDSSs used by RNs and NAs in nursing homes are still largely unexplored. A CDSS can be incorporated into the EHR to increase the meaningful use of these computerized systems in nursing home care. The effects of CDSS on healthcare provider workflow, clinical decision making and communication about preventive measures in nursing home practice still need further exploration. Based on results from our study, recommendations would be to increase both sample size and the number of RNs and NAs who participate in CDSS education programs.

An evaluation of the usability of a computerized decision support system for nursing homes

BACKGROUND Computerized decision support systems (CDSSs) have the potential to significantly improve the quality of nursing care of older people by enhancing the decision making of nursing personnel. Despite this potential, health care organizations have been slow to incorporate CDSSs into nursing home practices. OBJECTIVE This study describes facilitators and barriers that impact the ability of nursing personnel to effectively use a clinical CDSS for planning and treating pressure ulcers (PUs) and malnutrition and for following the suggested risk assessment guidelines for the care of nursing home residents. METHODS We employed a qualitative descriptive design using varied methods, including structured group interviews, cognitive walkthrough observations and a graphical user interface (GUI) usability evaluation. Group interviews were conducted with 25 nursing personnel from four nursing homes in southern Norway. Five nursing personnel participated in cognitive walkthrough observations and the GUI usability evaluation. Text transcripts were analyzed using qualitative content analysis. RESULTS Group interview participants reported that ease of use, usefulness and a supportive work environment were key facilitators of CDSS use. The barriers identified were lack of training, resistance to using computers and limited integration of the CDSS with the facilitys electronic health record (EHR) system. Key findings from the usability evaluation also identified the difficulty of using the CDSS within the EHR and the poorly designed GUI integration as barriers. CONCLUSION Overall, we found disconnect between two types of nursing personnel. Those who were comfortable with computer technology reported positive feedback about the CDSS, while others expressed resistance to using the CDSS for various reasons. This study revealed that organizations must invest more resources in educating nursing personnel on the seriousness of PUs and poor nutrition in the elderly, providing specialized CDSS training and ensuring that nursing personnel have time in the workday to use the CDSS.

Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game

BACKGROUND Serious games (SGs) are a type of simulation technology that may provide nursing students with the opportunity to practice their clinical reasoning and decision-making skills in a safe and authentic environment. Despite the growing number of SGs developed for healthcare professionals, few SGs are video based or address the domain of home health care. AIMS This paper aims to describe the design, development, and usability evaluation of a video based SG for teaching clinical reasoning and decision-making skills to nursing students who care for patients with chronic obstructive pulmonary disease (COPD) in home healthcare settings. METHODS A prototype SG was developed. A unified framework of usability called TURF (Task, User, Representation, and Function) and SG theory were employed to ensure a user-centered design. The educational content was based on the clinical decision-making model, Blooms taxonomy, and a Bachelor of Nursing curriculum. A purposeful sample of six participants evaluated the SG prototype in a usability laboratory. Cognitive walkthrough evaluations, a questionnaire, and individual interviews were used for the usability evaluation. The data were analyzed using qualitative deductive content analysis based on the TURF framework elements and related usability heuristics. RESULTS The SG was perceived as being realistic, clinically relevant, and at an adequate level of complexity for the intended users. Usability issues regarding functionality and the user-computer interface design were identified. However, the SG was perceived as being easy to learn, and participants suggested that the SG could serve as a supplement to traditional training in laboratory and clinical settings. CONCLUSIONS Using video based scenarios with an authentic COPD patient and a home healthcare registered nurse as actors contributed to increased realism. Using different theoretical approaches in the SG design was considered an advantage of the design process. The SG was perceived as being useful, usable, and satisfying. The achievement of the desired functionality and the minimization of user-computer interface issues emphasize the importance of conducting a usability evaluation during the SG development process.

Triage assessment of registered nurses in the emergency department.

UNLABELLED Standardised triage systems have been implemented in emergency departments (EDs) to improve the efficacy of assessment strategies as performed by registered nurses (RNs). However, the exact effect the standardised triage systems have on the decision-making process remains unclear. AIM To evaluate decision making in the triage setting before and after implementation of the Medical Emergency Triage and Treatment System Adult in one hospitals ED. METHODS A descriptive intervention design with a quantitative approach. A total of 655 patients before and 413 patients after the intervention were included. A questionnaire was used to evaluate how the RNs assessed the patients before intervention while the emergency patient records were used for data collection after intervention. RESULTS Before the intervention, a majority of the assessments were founded on signs and symptoms and medical diagnoses, whereas vital parameters were rarely used. After the intervention, nearly two thirds of the patients were assessed according to a triage system with vital parameters and standardised algorithm for symptoms and signs included in the assessment procedure. CONCLUSION Implementing a standardised triage system, including vital parameters and standardised algorithms for signs and symptoms, increased the use of vital parameters and signs and symptoms for decision making and acuity assignment.

Evaluation of the Norwegian Version of the Mini Nutritional Assessment (MNA®) among Older Nursing Home Patients:

Background: The Mini Nutritional Assessment (MNA®) is a well-known clinical scale that is often used for nutritional screening of older people in different settings recommended by several international clinical and scientific organizations. Aims: The aims of this article were: 1) to translate the MNA® from English to Norwegian and 2) to test the Norwegian version of the instrument for reliability and validity in a small sample of older nursing home patients. Methods: The English version of the MNA® was translated according to recommended procedures. A convenience sample of 26 older nursing home patients was screened with the MNA® by 10 registered nurses. Reliability and validity of the instrument were assessed. Results: Support for reliability and validity was shown in the study group. Conclusion: Positive support for sufficient quality of the Norwegian version of the MNA® was shown, but further testing of the instrument is needed.

Clinical decision support systems to prevent and treat pressure ulcers and under-nutrition in nursing homes

Clinical decision support systems (CDSSs) are believed to have the potential to improve care and change the behavior of health personnel. The project has focused on developing a CDSS to support prevention of pressure ulcer and undernutrition that is completely integrated in the electronic health record in nursing homes. Nursing staff have been involved in all phases in the development of the CDSS, which at present is ready to be implemented and systematically evaluated.

A serious game for teaching nursing students clinical reasoning and decision-making skills

The aim of this study was to design and pilot-test a serious game for teaching nursing students clinical reasoning and decision-making skills in caring for patients with chronic obstructive pulmonary disease. A video-based serious game prototype was developed. A purposeful sample of six participants tested and evaluated the prototype. Usability issues were identified regarding functionality and user-computer interface. However, overall the serious game was perceived to be useful, usable and likable to use.

Nurses' Use of Computerized Clinical Guidelines to Improve Patient Safety in Hospitals.

Computerized clinical guidelines are frequently used to translate research into evidence-based behavioral practices and to improve patient outcomes. The purpose of this integrative review is to summarize the factors influencing nurses’ use of computerized clinical guidelines and the effects of nurses’ use of computerized clinical guidelines on patient safety improvements in hospitals. The Embase, Medline Complete, and Cochrane databases were searched for relevant literature published from 2000 to January 2013. The matrix method was used, and a total of 16 papers were included in the final review. The studies were assessed for quality with the Critical Appraisal Skills Program. The studies focused on nurses’ adherence to guidelines and on improved patient care and patient outcomes as benefits of using computerized clinical guidelines. The nurses’ use of computerized clinical guidelines demonstrated improvements in care processes; however, the evidence for an effect of computerized clinical guidelines on patient safety remains limited.

Agility Activities for Children in a Municipality in Norway

The aim of this study was to investigate whether agility activity with dogs can be used to motivate less active children in physical activity and how such activity is experienced by parents and handlers. Data were collected through qualitative interviews with handlers and parents of the participating children. Agility with dogs appeared to motivate less active children to participate in, and endure, demanding physical activity. Joy and bonding with the dog appeared to be key elements in the motivational process. Motivation, initiation, and sustainment of activity over time are beneficial for children.

A Usability Evaluation of an Electronic Health Record System for Nursing Documentation Used in the Municipality Healthcare Services in Norway

The paper presents a usability evaluation of the Graphical User Interface (GUI) of an Electronic Health Record System (EHR). The topic of interest was to explore the system’s usability in the context of nursing process documentation. A cognitive walk through approach was used. The data were analyzed with content analysis and the results show that challenges identified were related to navigating and finding information in the system. Even though there were problems in progressing from one phase to another in nursing process documentation, the system represented some types of predictability and consistency in the functions. Education, training and support are needed to be able to use the EHR for nursing documentation. Mandating standardization regarding format, content and terminology to improve the EHR systems functionality regarding facilitate nursing process documentation is recommended.