Information Systems & Technology Debra Kirkley Maribeth Stein

Nurses and Clinical Technology: Sources of Resistance And Strategies for Acceptance

To explore the specific reasons behind this resis- Executive Summary tance, an electronic roundtable was conducted fol- ᮣ Many organizations in the process of introducing lowed by phone interviews with nurse leaders at four online clinical documentation and other nursing health care organizations: three in the United States functionality have experienced resistance — at and one in the United Kingdom. The goal was to elic- least initially — from the nursing staff. it candid opinions and anecdotes from nurse execu- ᮣ Rather than meeting these objections individual- tives on the front lines of technology initiatives. ly, implementing clinical information systems (CIS) requires organization-wide change manage- These individuals are nurse leaders in organizations ment initiatives that put the need for automated that have successfully made the leap to automated processes in a global perspective. systems, and their experiences provide insight into ᮣ A roundtable discussion with nurse leaders identifying and circumventing the obstacles that can revealed that cultural and societal factors may arise during technology rollouts. play a larger role in nurses’ willingness to The respondents focused on three fundamental embrace the CIS than attitudes toward computers questions: themselves. •Why are some nurses reluctant to adopt CIS? •Can you identify the types of nurses who are more SMOREHEALTHCAREorganizations seeking or less likely to embrace CIS? improvements in patient safety and increases •What are successful methods to overcome this in productivity take the plunge to adopt clin- resistance? ical information systems (CIS), an increasing Within the framework of these questions, several Anumber of nurse executives face the prospect of getting consistent themes emerged from the discussions, their staffs engaged with using information technology most relating to the idea that resistance has less to do (IT) to directly support nursing workflow. with specific functionality of the technology — Significant change can be unsettling for employ- screen design or the mouse, for example — than with ees in any setting, and health care certainly is no dif- cultural factors such as lack of time and loyalty to the ferent. Many organizations in the process of intro- historic model of paper documentation. The follow- ducing online clinical documentation and other ing is a discussion of those themes, which highlights nursing functions have experienced resistance — at direct feedback from respondents with the hopes of least initially — from the nursing staff. Rather than suggesting opportunities for further inquiry. meeting these objections individually, implementing CIS requires organization-wide change management Why Are Nurses Reluctant to Adopt Clinical initiatives that put the need for automated processes Information Systems? in a global perspective. According to a 2004 Nielsen/Net Ratings study, Despite recognition that user response largely nearly 75% of Americans — more than 200 million determines the success of a technology implementa- people — have access to the Internet from home, tion, and the fact that significant resources are spent using the Internet to shop, conduct research, and on strategic programs to promote acceptance, there is communicate via e-mail, among other activities. As a dearth of research examining the factors that con- personal computers, the Internet, and ATMs become tribute to nurses’ resistance to CIS. In one of the most more ubiquitous, roundtable respondents said that recent studies on nurses’ opposition to IT, Timmons nurses also are increasingly familiar with fundamen- (2003) found that resistance takes a variety of forms tal activities such as typing on a keyboard, using a and is a complex, multidimensional phenomenon mouse, or navigating multiple screens. worthy of additional study. “In the past 5 years, comfort or experience with computers has become much less of an issue. Now that nurses have more experience with computer DEBRA KIRKLEY, PhD, RN, is former Director of Nursing technology in varied aspects of life, we’re not seeing Informatics, IDX Systems Corporation, Seattle, WA. the computer phobia we saw 10 years ago,” said MARIBETH STEIN, MN, MBA, RN, is Director of Sales Operations, Demi Rewick of PeaceHealth, an integrated delivery IDX Systems Corporation, Seattle, WA. network in the Pacific Northwest.

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216 NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 So why does a nurse, who may enjoy browsing always ‘user friendly,’ can become time consuming. for the latest New York Times best seller on Practitioners feel that they are somewhat taken away Amazon.com, recoil at the announcement that she from the important roles as a nurse for yet again more soon will be charting online? administration.” Respondents and researchers attribute initial For some nurses, time pressure may contribute to resistance to a wide array of factors, often from spec- incomplete documentation on paper. If nurses in an ulative fears or perceptions of the system prior to organization have routinely “saved time” by submit- actually using it. Because these points of resistance ting incomplete paper documentation, then the are cultural in nature, it takes a global change man- “completeness” of documentation ensured by a good agement program to overcome them. While it’s technology implementation may actually take more impractical to tackle each single reason independent- time. Studies support the idea that a CIS may not ly, many organizations have successfully developed reduce the time a nurse spends on documentation, strategic internal communication programs that but also suggest that technology use helps to increase address points of resistance as a whole. the quality of the data and charting compliance Nurses do not resist technology itself. What they (Fraenkel, Cowie, & Daley, 2003). The payoff is a resist is the addition of one more item to their work- complete medical record; an outcome essential to day. A significant point of resistance may come down patient safety. to the nurses’ fear that online charting will take more There are steps that organizations can take to time than paper charting. According to Timmons help nurses make up the additional time spent on the (2003), the most common criticism from nurses about more comprehensive documentation. Building in CIS was that the systems were time consuming. timesavers by eliminating redundancy, replacing Last year, the Institute of Medicine (IOM, 2003) human activities (for example, phone calls, referrals) published Keeping Patients Safe: Transforming the with electronic alternatives, and ensuring compli- Work Environments of Nurses, calling for substantial ance with documentation standards by using system improvements to nurses’ work environments to capabilities such as required fields that must be filled increase patient safety. A cornerstone of the report is in by the user all are effective methods. the idea that currently most nurses’ schedules are Jan Wilson of Lehigh Valley Hospital and Health overloaded, and they must care for an inordinate Network (LVHHN) also argues that some disdain for number of patients on any given shift. In addition to online clinical documentation comes not from docu- a hefty patient load, nurses must deal with increas- menting on the computer, but from the act of docu- ingly acute populations, as well as more complex menting itself. documentation requirements. The thought of adding “Nurses don’t see a benefit in general for docu- one more task to an already frantic day can justifiably mentation; they see it as a legal necessity,” Wilson seem daunting. said. “Do nurses like documenting on paper? No. Do According to Mary Ann Anderson of Wake Forest nurses like doing it online any better? No.” University Baptist Medical Center (the Medical Clinicians’ reluctance to document is often Center), when the organization first undertook its thought of as a new problem, but that is hardly the major implementation effort 9 years ago, some nurs- case. While paper-based records are today considered es were wary of using the new technology. the gold standard in documentation, patient-centered “In the beginning, nurses can see a computer as hospital care records did not even exist in the early getting in the way because they have so many com- 1900s. At the turn of the century, the only records of peting initiatives,” she said. “They think, ‘I’ve got a care maintained were the occasional entries made in patient who needs medication, I have to get them on a physician’s private notebook, kept in his office to a bed pan, and answer a doctor’s questions — and aid his research. now I have to log in and input information, too?’” It was not until 1919, when the American College This is even more apparent on busy critical care of Surgeons decided “they could only guarantee high units, said Kimberly Evans at the Medical Center. quality surgical care by setting minimal standards for “Nurses in ICU settings have an even higher frequen- the hospitals in which their surgeons worked” that a cy of activities; they’re taking vital signs every 15 new standard was born (Timmermans & Berg, 2003, minutes instead of every 4 hours,” she said. “Nurses p. 42). One of their “core criteria was the presence of in those settings feel they don’t have time to deal a complete, accessible and accurate record for all with the computer because their patients are more patients, which had to be kept by the hospital, rather critical.” than the individual physician” (pp. 36-37). Sharon Pickup of Chelsea and Westminster Physicians adamantly resisted this standard, as they Hospital (London, UK) agreed. “Nurses, as you know, could not see value in changing their recordkeeping are often under pressure to perform daily tasks; often routines. “Doctors complained about the prolifera- within impossible time frames,” she said. “Added tion of pre-formatted forms, in which they only had pressure to use clinical technology, which is not to fill in a few words or even just select a term from a

NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 217 pregiven list” (pp. 42-43). with the patient to radiology, but when the patient This echoes the complaints about online docu- returns, the chart is gone,” she said. “Now, nurses no mentation we hear today, suggesting that it may not longer panic because they think a critical flowsheet be the forms, systems, or tools clinicians are reject- or care plan is lost.” ing. Rather it may be the legacy of a historical cultur- Immediate access to centralized information, al resistance to the imposition of change, particularly especially that submitted by other clinicians, has severe when clinicians fail to see the payoff for com- made a significant impact on streamlining nurses’ pliance. workflow at the Medical Center and encouraging A CIS does not always yield an instant payoff. enthusiasm for the system, Anderson said. Clinical Starting with the oft-cited IOM study, To Err is documentation and other nursing functionality aside, Human (2000), numerous industry reports herald the the organization’s adoption of computerized physi- use of automated clinical technology as a necessity to cian order entry (CPOE) has been critical. improve patient safety and reduce medical errors. “The units up on CPOE — that’s sent shock This year, the California HealthCare Foundation waves through the nursing community,” she said. released a report that estimates the state could save “The physician puts the order in, and it gets to the more than $3.2 billion annually and would reduce nurse immediately. This also has placed more the yearly number of medication-related injuries by accountability on the nurse to be responsible for nearly 250,000 statewide if California health care orders; in the past, the unit secretary was the inter- clinics adopt clinical information systems to handle mediary and gave reminders.” medication ordering and diagnostic tests (Johnson, According to Wilson of LVHHN, one technology Pan, Walker, Bates, & Middleton, 2004). initiative more conducive to instant gratification is Nurse executives and managers often espouse the medication administration record and wireless patient safety and reductions in health care delivery medication barcode charting. Despite the fact that costs as major reasons to implement electronic med- scanning the patient’s wristband and medication bar- ical records, online clinical documentation, and code actually adds extra steps to the administration other CIS functions. However, staff nurses still mak- process, the turnaround in attitude comes very quick- ing their way up the learning curve of these systems ly. This is due in part to the immediate alerts that — and dealing with associated delays to their work- nurses receive prior to a potential error; they can see flow — often find it more difficult to see these high- right away that the system is working. level incentives immediately. “Nurses love electronic medication administra- “Recognition of a payoff can be slow in coming,” tion; it helps them organize their work better and take Rewick said. “We need to avoid portraying clinical IT care of their patients, so they see that as a benefit,” as instantly improving speed and efficiency for nurs- she said. “Nurses who have been alerted prior to a es. Although that becomes true down the road, you potential error swear by it. Before we rolled out wire- just can’t talk about it right out of the box.” less medication barcode charting to all units, the That can begin to change, however, as nurses nurses did not want to float to those that weren’t yet become more familiar with the system. According to live on the technology.” a study conducted at one of PeaceHealth’s facilities, Nurses are used to paper: It’s convenient, dis- St. Joseph Hospital in Bellingham, WA, nurses using creet, and tangible. While computers themselves may online clinical documentation reduced time spent on not be a significant deterrent, some resistance does charting functions by 50%, freeing up an additional originate from the fundamental difference between 1.5 hours per 12-hour shift that could be spent on recording information on a piece of paper and patient care (IDX Systems Corp., 2002). inputting it electronically. In addition, a study specifically focused on the Most seasoned nurses were educated to docu- quality benefits and staff perceptions of a CIS in a 12- ment on paper charts, and portability itself can be a bed intensive care unit found significant improve- significant issue. Nurses recognize that paper is more ments in key quality indicators, positive nursing staff convenient to carry around with them, and they are perceptions, and positive resource implications 7 accustomed to folding up and tucking the piece of months post-implementation of the system (Fraenkel paper in their pocket, or carrying it on a clipboard et al., 2003). Thus, quality and satisfaction indicators from room to room. Conversely, computers — even may improve over time, a reflection, perhaps, of when available on a rolling cart — are simply not as growing comfort with the system. small or portable. In addition, the prominence of a Drama Choplin of the Medical Center said that computer screen visible to the patient can pose a over time, nurses might begin to find that the quality problem, especially for a nurse still transitioning to of the data is better and more legible with an elec- full competence on use of the system. tronic system, and that they no longer need to waste “Paper is discreet. The computer makes the nurse time chasing down lost or misplaced charts. “With documenting more visible. When the nurse has a big paper charts, a nurse may send information along screen and keyboard, and the physician and patient

218 NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 are watching her enter information, it can make her use this to obtain information (often for audit) to feel uncomfortable. People are staring at her while assist their practice,” Pickup said, referring to those she’s trying to navigate this new workflow,” nurses who serve as champions of the system, usual- Anderson said. “And the last thing a nurse wants is ly by playing the role of an early adopter and helping for the patient to question her competency.” other nurses develop their skills. Finally, nurses reported to the roundtable respon- Anderson agreed. “It depends on interests. Some dents that they appreciated the ability to hold a com- people are just techno-geeks. They just have that pleted chart in their hands, which provides tangible computer mind, but don’t necessarily have to have an evidence of patient care documentation, a tactile ele- IS background,” she said. ment felt to be missing when patient information is Dillon, Lending, Crews, and Blankenship (2003) captured and viewed electronically. found that self-efficacy — a user’s confidence that she “Nurses are trained to be able to flip through a has the ability to successfully navigate an informa- chart, and doing that electronically is not as intu- tion system — influences adoption of the system. itive,” Rewick said. “They’ll say, ‘I need my paper,’ They surveyed 139 nurses and found that the use of and raise their hands in a holding gesture.” technology in a variety of forms, including average Still, most nurses overcome this initial uncer- levels of expertise in general computer use and soft- tainty, Evans said. “For all nurses, the initial change ware applications (word processing, e-mail, and in the workflow is most stressful and they’re most Internet searches) was associated with higher levels resistant then,” she said. “Once they get up to speed of self-efficacy. on a new activity, they become more comfortable. On the flip side, some older nurses, even those Three months later the reaction is, ‘Oh, I love this!’” without computer backgrounds, are better able to Anderson described nurses’ wariness of the new visualize how incremental changes in workflow con- technology when they implemented the system 9 tribute to the big picture of patient safety. years ago. But today, having overcome their initial “Being a superuser has almost nothing to do with skepticism, nurses at her institution have come to knowledge of computers or automation,” Rewick depend on using online clinical documentation, the said. “They see the big picture, understand the work- medication administration record, and other nursing flow, and are respected by their peers. There’s no functionality. “A majority of our nurses would specific demographic. Some of the best superusers become upset if we took the computer away from are people in their 50s.” them now. We’ve evolved into a different culture,” Overall, determination and a willingness to she said. embrace change are key. Rewick believes that those who latch onto the CIS do so because they embrace Who Is Most Likely to Embrace the CIS? change, and in general support methods to improve At first blush, the older set is often assumed most care delivery. resistant; but beware of generalizing. While some “They are the folks who are always looking for respondents attest that if there were a trend for those innovative ways to improve care processes, and to who were most likely to reject the system, it may tend streamline documentation processes,” she said. toward older nurses, many caveats were found in “They understand the principles of clinical quality those statements. improvement and how to apply them. They don’t “On the whole, there may be a trend toward shrink from change.” someone older,” Anderson said. “Of course, you can’t “We had some older people that struggled, but generalize, but if we were to trend it out, characteris- really became committed to learning about the com- tically, the older generation has the most resistant puter system and now have excelled,” Anderson users.” However, the message from most of these said. “You’re talking about someone that naturally nurse executives, including Anderson, is that there is gravitates toward the equipment, and wants to make no typical demographic (no certain age or back- it better.” ground) that defines which nurses are most likely to According to Anderson, it is helpful to recognize latch onto a clinical information system. that nurses may self-select toward active participa- “I have not found a certain demographic. I tion in a technology project, and empowering them to haven’t found that older nurses find it more difficult. do so can improve an organization’s successful adop- Sometimes their learning curve may be a bit longer, tion. “We tried identifying superusers by screening but I don’t know that I see a specific age group,” individuals from a unit that we thought would do Anderson said. “I’ve had young staff nurses that have well in that role,” she said. “Those who were really almost gone into anxiety attacks in class.” committed did work well, but those who were simply Being computer-savvy can help. Many factors can chosen by a manager did not. When things got busy, play into a nurse’s willingness to use the system, their leadership and support waned.” including an affinity for computers. As a result, the institution organized a documen- “Superusers are usually people who enjoy IT and tation committee consisting of volunteers from the

NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 219 nursing staff. These individuals bridge any commu- “We rely on our management structure to be our nication gaps between caregivers using the system superusers; usually it’s the educator or patient care and the IT staff to ensure the system meets clinicians’ coordinator on the unit who promotes the CIS. The needs for workflow and design. system is a goal of the institution, so this is part of their job,” Wilson said. “To the staff, we may say, ‘We What Can We Do to Overcome Resistance and have to do this.’ But we provide them the reasoning Encourage Success? behind it, and reinforce that message during training, Many individual obstacles to immediate accep- and they accept it.” tance are beyond the control of nurse leaders. We Incentives and compensation also are a part of cannot erase the history of educating nurses to docu- the solution, Wilson said. When the organization ment care on paper, nor is it possible to circumvent brings a new unit online, nurses already familiar with the inevitable learning curve associated with a new the system help serve as resources, and are compen- system. sated accordingly. However, implementing key steps as part of a Solid training and support are a significant part large-scale change management program can ease the of Chelsea and Westminster’s strategy as well, accord- process for nurses, help make the CIS more desirable, ing to Pickup. “The fact is, we have to use (the CIS), and encourage nurses to recognize the value proposi- as it incorporates electronic patient records; so basi- tion that the system offers. cally it is a necessity to use it and not a choice,” she Enlist nurses in every step of the process. “One of said. “We have training courses for new staff and a the most important things is to involve the nursing support team available.” staff in decisions about workflow in creating the pro- Give nurses a clear view of the continuum of care gram,” said Evans of the Medical Center. and how they fit in. “Demonstrate how information The organization did just that, creating a staff flows across the continuum of care, so that nurses devoted to bridging the gap between nurses and IT. In understand how their contribution to the electronic addition to documentation committee volunteers, the record adds to the larger picture of the patient’s care. Medical Center created the nursing clinical informa- This is invaluable in bringing nurses onboard with tion systems (NCIS) team to manage front-line con- the CIS,” Rewick said. tact with all clinical staff throughout the system The ability to see the patient’s medical history design, training, implementation, and IT support across the entire continuum of care is a significant processes. All NCIS members are registered nurses, payoff, and enabling nurses to see they have that and although some came directly from the clinical power at their fingertips will help to increase their staff, all now focus solely on supporting information enthusiasm for the system. Rewick contends that a system (IS) functions, education, and development. nurse’s ability to see the complete picture is directly Throughout the project, the organization’s IS ana- proportional to the amount of information that an lysts have met weekly with NCIS members to discuss organization puts online. everything from workflow issues to screen changes to “If an organization only puts clinical documenta- nurse reporting needs. Today, the NCIS has trained tion online, nurses won’t feel the advantages of see- more than 3,000 staff nurses on core nursing func- ing the comprehensive patient record as acutely as if tionality, including online results reporting and clin- they can review radiology results, for example, or any ical documentation, medication charting and initial other care that is being provided by others,” she said. patient assessments, and other applications. “If they can see from the inpatient setting what has Communicate the big picture, and provide incen- happened in an outpatient clinic, they’ll be able to tives for a job well done. According to the panel, get a holistic view of the patient. In turn, this also when organizations talk about efficiency gains from helps raise awareness and perceptions among other the get-go, they may be setting themselves up for fail- clinical disciplines of nurses’ responsibilities and ure; nurses simply do not see an increase in efficien- contributions.” cy at first. Provide the right functionality and hardware at “You need to be upfront and honest about the the right place at the right time. “We need to devote ultimate goal of implementing a CIS: increasing time to developing tools that truly add value for access to information for all caregivers. This can nurses,” Rewick says. require an additional time investment in some areas, Across the board, nurse leaders cite creating but faster access to information saves time for the functionality that realistically supports and enhances entire team,” Rewick said. a nurse’s workflow, opens channels of communica- At LVHHN, where nurse managers are selected tion, and unlocks doors to useful information as a top (rather than volunteer) to serve in the superuser role, priority. providing ample resources to explain the benefits of A well-designed, intuitive interface that “thinks the system and answer questions one-on-one help get like a nurse thinks” is key. Again, this provides these nurses engaged. ample reason to involve nurses in the design and

220 NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 development process, garnering their feedback on how to ensure the interface will support workflow. An Overview of the “You have to cut down on the number of screens Roundtable Participants that nurses have to go through to accomplish some- thing. Keep the screens simple, but not so simple that the nurse needs to go through 20 (screens),” SHARON PICKUP, RGN, is a Pre-Operative Wilson said. “Also, make it easy for them to jump Assessment Nurse, Chelsea and Westminster Hospital, between screens that show related clinical informa- London, UK, a leading teaching facility with 547 beds, tion.” and one of five main teaching centers for the Imperial Make a variety of devices available in convenient School of Medicine. places. “Location, location, location. Convenient access to devices is at least as important as well- JAN WILSON, MS, RN, is Manager of Clinical designed clinical systems,” Rewick said. “Also, pro- Services Informatics, Lehigh Valley Hospital and Health vide a variety of device options that work well. Some Network (LVHHN), Allentown, PA. In 2001, LVHHN, a people want to sit down, others want to roll a laptop network of three Magnet-certified community hospitals around, others want to hold a notebook. The more in Pennsylvania, embarked on an initiative to adopt a options you can provide, the more people will latch completely integrated CIS. Today, the system spans on to what feels comfortable.” the entire medication cycle — from a physician order- Wilson agreed that ease of access is key to accep- ing a medication via computerized physician order tance. LVHHN gives all of its nurses their own lap- entry (CPOE) to a pharmacist dispensing the drug, to a tops. “We realized this was not going to work if nurs- nurse using wireless barcode administration to verify es had to log in and out all the time, or if they had to medication accuracy at the bedside. share and then wait for a device to become avail- able,” she said. “All the nurses’ laptops are labeled. DEMI REWICK, RN, is Director of Clinical The nurses position the laptops on one side of the Applications, Healthcare Improvement Division, hallway, and have thoroughly trained the doctors not PeaceHealth. An integrated delivery network with six to run off with them.” acute care hospitals, five medical practices, and a range Position the CIS as an information center. of other facilities in the Pacific Northwest, PeaceHealth According to Rewick, it is critical that the clinical has built a sophisticated community health record system serve as a gateway to information; not only to (CHR) that makes a patient’s complete medical record the patient’s electronic medical record, but to other — both inpatient and ambulatory — instantly accessi- clinical resources, including policy and procedure ble to clinicians across three states. The CHR was the manuals, medication information resources, patient basis for a Robert Wood Johnson “Pursuing teaching materials, and journals and texts. Perfection” grant to develop pilot disease management Before PeaceHealth went live with its CIS, nurses programs for diabetes and congestive heart failure. there worked online with e-mail and viewed meeting Since implementing the diabetes program 6 years ago, notes in the organization’s Intranet. When it came adherence to guidelines for care has tripled among time for implementation, they already felt comfort- patients in two of PeaceHealth’s facilities. able using the computer. “People were drawn to the computer,” Rewick MARY ANN ANDERSON, MSN, RN, is Director of said. “They need to view it as an information center; Nursing, Clinical Systems; KIMBERLY EVANS, RN, is the more they can successfully do with the system Nursing Clinical Systems Educator; and DRAMA initially, the less scary it is to use the computer for CHOPLIN, RN, is Nursing Clinical Systems Specialist, clinical information.” all of Wake Forest University Baptist Medical Center Looking ahead, Rewick comments on the impor- (the Medical Center). In 1995, the Medical Center, an tance of expert rules capabilities, which enable clini- integrated delivery network in Winston-Salem, NC, cal information systems to interact with clinicians implemented an integrated clinical system to create a during patient care, providing alerts regarding lifetime electronic patient record. After first building a patient safety and quality of care, updates on best foundation with core nursing functionality, including nursing practices, and other information that sup- online results reporting and clinical documentation, ports nursing workflow without being overly obtru- wireless medication administration charting, and sive. patient assessments, the Medical Center moved for- She said that with the growth and development ward with CPOE. It has seen a significant decrease in of expert rules, clinical systems have the power to adverse drug events (ADEs) on its first two pilot units exponentially improve the capabilities available to as a result. From the first and second quarters of 2002 nurses via paper records. “Think about the way that to the same time period in 2003, the Medical Center an online bookstore works. Once you order books, reduced preventable ADEs by as much as 72%. based on what you’ve ordered, it suggests other titles

NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 221 for you to consider,” she said. “We don’t yet have an (Greiner & Knebel, p. 45). The informatics competency equivalent in the CIS. It should say, ‘Based on the is further defined as the ability to use information tech- things you’ve used before with this patient, try this. nology in providing patient care to communicate, man- Do you think the patient might have this problem, age knowledge, mitigate error, and support decision based on the symptoms you’ve listed here?’ It’s com- making. ing gradually, but it’s moving slowly.” Rewick argued that an increase in hands-on train- Industry organizations are pursuing projects to cre- ing with the CIS in school is critical to support efforts ate libraries of expert rules to be shared among health to adopt these systems industry-wide. “We have yet care organizations, and develop functionality that gives to see nurses coming out of nursing school where a clinicians access to online clinical resources via the clinical system has been part of the process of learn- CIS, based on the patient and condition they are treat- ing how to document care. When this does happen, ing. According to the respondents, these types of ini- it’s in the context of their clinical time on nursing tiatives will resonate with nurses seeking more infor- units,” she said. “I believe that more time should be mation in the context of care delivery. spent in nursing schools helping students under- In addition to developing expert rules that accu- stand the power of automated systems; not only to rately suggest appropriate nursing interventions, document care, but how data can be used to improve Rewick suggests using them to focus on eliminating care for patients.” the need to perform routine care tasks that may not contribute to an individual patient’s health. “For Conclusion example, we need to develop algorithms that would As we’ve seen in these discussions with nurse define intervals for taking vital signs or other inter- leaders, cultural and societal factors may play a larger ventions, based on that specific patient’s condition, role in nurses’ willingness to embrace the CIS than nursing and medical diagnoses,” she said. “Often, we attitudes toward computers themselves. As with any do things because we have always done them, not major change, one can assume that in 1919 the first because there is research-based evidence that they paper charts were far from perfect, but they served should be done for that individual.” their core purpose of giving institutions data that Introduce information systems in nursing school. could be retrieved and analyzed. Over the course of “Being exposed to technology in the educational set- history, the health care system made paper records ting makes a huge impact,” Wilson said. “We have more complete and easier to use. So it will be with several bachelor’s of science of nursing programs and technology. associate degree programs that [send students] to the To garner nurses’ acceptance of technology, it is hospital, and they give medications and do the same important to recognize and address the barriers they charting as staff nurses. If they use the system, and face, to help them see the benefits of undertaking such see their instructors doing the same thing, I think it a massive change, and engage them in the idea that in makes a big difference for the students’ decision in the long run, automated clinical systems will enable selecting the hospital they’ll work for. I love it when them to improve the quality of care delivery. With they have that experience, because it makes my train- ongoing research in this area, nurse leaders will con- ing easier.” tinue to enhance the collective understanding of con- This idea is well supported by Staggers, tributing factors, and develop even more successful Thompson, and Snyder-Halpern (2001) who argue that strategies to earn nurses’ support for new technology.$ clinicians need to move beyond basic computer litera- cy skills and focus on information synthesis and analy- REFERENCES sis. They argue that, “Formal programs of study should American Nurses Association. (2001). Scope and standards of nursing informatics practice. Washington, DC: American be shifted from teaching basic computer skills to focus- Nurses Publishing. ing on high level cognitive functions to manage clini- Dillon, T.W., Lending, D., Crews II, T.R., & Blankenship, R. (2003). cal information with technology” (p. 79). Nursing self-efficacy of an integrated clinical and administra- The American Nurses Association (2001) recog- tive information system. CIN: Computers, Informatics, Nursing, 21(4), 198-205. nizes that “informatics competencies are needed by Fraenkel, D.J., Cowie, M., & Daley, P. (2003). Quality benefits of an all nurses, whether or not they specialize in nursing intensive care clinical information system. Critical Care informatics. As nursing environments become ubiq- Medicine, 31(1), 120-125. uitous computing environments, all nurses must be Greiner, A., & Knebel, E. (2003). Health professions education: A both information and computer literate.” bridge to quality. Washington, DC: The Institute of Medicine, National Academies Press. Similarly, the IOM in its 2003 report, Health IDX Systems Corp. (2002). Realizing VOI from online clinical nurs- Professions Education: A Bridge to Quality, states, “All ing documentation. Seattle, WA: Author. health professionals should be educated to deliver Institute of Medicine. (2000). To err is human: Building a safer patient-centered care as members of an interdiscipli- health system. Washington, DC: National Academies Press. nary team, emphasizing evidence-based practice, qual- ity improvement approaches, and informatics” continued on page 195

222 NURSING ECONOMIC$/July-August 2004/Vol. 22/No. 4 impartial way to justify changes in monitor these findings closely staffing principles. American Journal current nursing assignments as and remain alert for new settings of Nursing, 99(4), 50-51. Haas, S. & Hackbarth, D. (1995). well as predict staffing needs for where the AIS will prove useful. Dimensions of the staff nurse role in future shifts. The tool enhances ambulatory care: Part IV – Developing nurses’ critical thinking skills Conclusion nursing intensity measures, standards, with regard to patient assign- Because there are a limited clinical ladders, and QI programs. ments, time management, organi- number of tools to quantify nurs- Nursing Economic$, 13(5), 285-294. Haas, S., & Gold, C. (1997). Supervision of zation, and prioritization. These ing workload in ambulatory care, unlicensed assistive workers in ambu- functions are often difficult to an AIS was developed to measure latory settings. Nursing Economic$, define and deal with due to the direct and indirect nursing care 15(1), 57-59. varying perceptions among indi- requirements. The easy-to-use Haas, S.A., Hackbarth, D.P., Kavanagh, J.A., & Vlasses, F. (1995). Dimensions of the vidual nurses. The AIS assists tool reflects severity of illness and staff nurse role in ambulatory care: nurses in managing patient loads complexity of care. Ambulatory Part II – Comparison of role dimen- by allowing them to prepare for care nurses use the tool to articu- sions in four ambulatory care settings. the anticipated intensity of care. late patient needs, assist with Nursing Economic$, 13(3), 152-165. Nurses can put processes in place resource allocation, and use criti- Jones, A., Cusack, G., & Chisholm, L. (2004). Patient intensity in an ambulatory to foster a smooth transition. The cal thinking skills to distinguish oncology research center: A step for- tool also allows nurses to delin- between system and staffing ward for the field of ambulatory care. eate patient care issues from sys- issues. Ambulatory care nurse Nursing Economic$, 22(3), 120-123. tem issues. Many times, patient managers can use the tool to eval- Krapohl, G.L., & Larson, E. (1996). The impact of unlicensed assistive person- care is delayed due to other ancil- uate the need for additional FTEs nel on nursing care delivery. Nursing lary services. The AIS helps nurses and to improve performance. The Economic$, 14(2), 99-110, 122. determine why patient treatments tool can also be used to qualita- Richter, P., & Felix, K.G. (1999). Adding value may be delayed. Performance tively identify other activities that by expanding RN roles in ambulatory improvement audits allow manage- promote smooth unit functioning. care. Nursing Economic$, 17(4), 225-228. Schim, S.M., Thornburg, P., & Kravutske, ment to identify and correct staff The AIS provides nursing leaders M.E. (2001). Time, tasks and talents in learning deficits in critical thinking and direct care providers with ambulatory care nursing. Journal of skills. another avenue to ensure ade- Nursing Administration, 31(6), 311-315. quate staffing and positive patient Schroeder, C.A., Trehearne, B., & Ward, D. Incorporating AIS in Other (2000a). Expanded role of nursing in outcomes.$ ambulatory managed care Part I: Settings Literature, role development and justifi- The AIS has now been piloted REFERENCES cation. Nursing Economic$, 18(1), 14-19. Barter, M., McLaughlin, F.E., & Thomas, S. Schroeder, C.A., Trehearne, B., & Ward, D. in all outpatient day hospitals and A. (1994). Use of unlicensed assistive most clinics throughout the clini- (2000b). Expanded role of nursing in personnel by hospitals. Nursing ambulatory managed care Part II: cal center. The tool has been Economic$, 12(2), 82-87. Impact on outcomes of costs, quality, adapted to many ambulatory set- Cusack, G., Jones-Wells, A., & Chisholm, L. provider and patient satisfaction. tings in the clinical center, and (2004). Patient intensity in an ambula- Nursing Economic$, 18(2), 71- 78. tory oncology research center: A step can serve as a model for future Summers, B.L.Y., & Chisholm, L.M. (1997). forward for the field of ambulatory Opportunities and challenges for research in staffing methodologies care. Nursing Economic$, 22(2), 58-63. oncology nursing in ambulatory can- in ambulatory care. Over time the Gallagher, R.M., Kany, K. A., Rowell, P.A., cer care. Oncology Nursing Updates, initial data produced by the AIS & Peterson, C. (1999). ANA’s nurse 4(1), 1-14. has lead to refinement of the tool, helped identify stakeholders to champion the project, and spurred Information Systems & Technology changes to foster smooth clinic continued from page 222 flow. One such change involved Institute of Medicine. (2003). Keeping patients safe: Transforming the work environment of moving many treatments/proce- nurses. Washington, DC: National Academies Press. dures from the outpatient clinic Johnson, D., Pan, E., Walker, J., Bates, D.W., & Middleton, B. (2004). Patient safety in the setting to the day-hospital setting, physicians office: Assessing the value of ambulatory CPOE. Prepared by Center for and reserving clinic visits for Information Technology Leadership for the California Healthcare Foundation. patient screening/consultations, Retrieved from http://www.chcf.org/documents/ihealth/PatientSafetyInPhysiciansOfficeACPOE.pdf assessment, and treatment deci- Staggers, N., Thompson, C., & Snyder-Halpern, R. (2001). History and trends in clinical sion making. In this regard the AIS information systems in the United States. Journal of Nursing Scholarship, 33(1), 75-81. tool has proved best for those Timmons, S. (2003). Nurses resisting information technology. Nursing Inquiry, 10(4), 257- areas that provide numerous treat- 269. Timmermans, S., & Berg, M. (2003). The gold standard: The challenge of evidence-based ments because it is in those set- medicine and standardization in health care. Philadelphia: Temple University Press. tings that patient intensity is con- tinually changing. We continue to

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