42 Improving Usability, Safety and Patient Outcomes with Health Information Technology F. Lau et al. (Eds.) © 2019 The authors and IOS Press. This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0). doi:10.3233/978-1-61499-951-5-42 Advancing Telehealth Nursing Practice in Oncology: Factors Affecting Nurse Use of Electronic Symptom Management Guidelines
a,1 b Elizabeth M. BORYCKI , Gwenyth A. HUGHES , a,c a Janessa GRIFFITH , Jade McNEAL a School of Health Information Science, University of Victoria, Canada b Institute of Medical Science, University of Toronto, Canada
Abstract. Oncology, telehealth nursing practice is growing. There has been an increased use of telehealth systems to support patients living with cancer in the community. In this study we explore the impact of integrating electronic symptom management guidelines (eSMGs) and electronic health records (EHRs) upon oncology, telehealth nursing practice. Ten nurses participated in clinical simulations and post-clinical simulation interviews. Participants’ identified that several factors that influenced the use of SMGs including nursing experience and experience in using the eSMGs.
Keywords. Telehealth, nursing, health informatics, clinical simulations
Introduction
Electronic Symptom Management Guidelines (eSMGs) are increasingly being used by nurses to help patients self-manage their chronic illnesses and to provide patients with follow-up care during and after treatment. Guidelines are statements that make recommendations. Guidelines optimize patient care and are informed by a systematic review of the evidence-based literature. Symptom management guidelines focus on the prevention or treatment of the symptoms of disease (including the psychological, social and spiritual aspects of disease). eSMGs are guidelines that are provided in electronic form [1]. One of the key innovations in the area of eSMG use is the application of eSMG’s to cancer patients’ management in the context of oncology, nursing telehealth practice. Over the past few years, oncologic organizations that treat patients have integrated eSMG’s into telehealth nursing practice and electronic health record (EHR) system use with the intent of improving patient care and caregiver support in managing patient symptoms arising from cancer and its treatment. To better understand the impact of such an integration of eSMG’s and EHRs on nursing practice, a qualitative study was conducted. In this research the authors studied how nurses working in telehealth cancer care used eSMG’s and EHRs. Nurses were asked to participate in clinical simulations and/or interviews to learn about the effect of these technologies on their practice.
1 Elizabeth Borycki, Professor, School of Health Information Science. Email: [email protected] E.M. Borycki et al. / Advancing Telehealth Nursing Practice in Oncology 43
1. Background Literature Review
Symptom Management Guidelines (SMG’s) are an important support for nursing practice. Symptom management guidelines or clinical practice guidelines provide clinicians (e.g. physicians, nurses) with recommendations about the care of patients with specific health conditions [1]. Over the past 10 years, clinical practice guidelines have been translated into electronic form. Electronic clinical practice guidelines, a form of decision support, can be used by nurses at point of care to support decision-making. Decision support systems (DSS) can be active or passive. Active DSS provide suggestions and support using automated alerts or reminders that arise when a health care professional fails to complete parts of the EHR or order a laboratory test, diagnostic imaging test or medication, if there is a difference between the guideline and the ordering practice [2]. Passive DSS present information in a way that allows the health professional to view the information without disrupting the process of care [1,2]. eSMG’s, a type of passive DSS, are being increasingly integrated into oncology nurse telehealth practice; for example, as an: (1) external resource in the form of a guideline available via the World Wide Web (WWW) used in addition to an EHR, (2) embedded in the EHR as info-buttons, and (3) as an integrated DSS within an EHR [1,2]. To date research has demonstrated that the use of DSS can lead to reduced medication error rates, improved quality of patient care, reductions in the cost of care, changes in clinician actions and decision making, promotion of preventative screening and the use of evidence-based recommendations for prescribing of medications [2,3]. Much of this prior work has focused on physician and nurse use of DSS in acute care settings [2] and in telehealth settings with a focus on general health issues of citizen callers [4-6]. Fewer researchers have examined DSS’s use by oncology nurses in telehealth practice. In the current work, we examine the use of eSMG’s by telehealth nurses in oncology settings.
2. Methods
A mixed method study involving clinical simulations and interviews was conducted.
2.1. Sample
Oncology nurses who work in telehealth nursing settings were invited to participate in the study via email invitations and presentations at staff meetings at a large multi-site oncology treatment organization. A total of ten telehealth nurses agreed to participate in the study.
2.2. Setting
The clinical simulations were conducted in an office similar to the offices used by telehealth nurses. This was done to ensure the ecological validity of the clinical settings and the representativeness of the findings [5]. Study participants were seated at a desk, and provided with access to a telephone and computer that could be used to access the organization’s EHR and eSMG’s via a website [see 4-7] (see Figure 1 below).
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Figure 1. Clinical Simulation Setting
2.3. Materials
The EHR provided data about two types of fictitious oncology patients: a patient with constipation and a patient with febrile neutropenia. eSMGs provided information about managing constipation and febrile neutropenia. Expert clinicians selected one easy case (i.e. constipation) and one difficult case (i.e. febrile neutropenia) for nurses to respond to during the clinical simulation to obtain information about how nurses’ react to differing levels of patient case difficulty. The easy case was presented first and the difficult case was presented second to stimulate information seeking and to reduce learning and carryover effects [6,7]. After participants took part in clinical simulations, they were interviewed [8].
2.4. Procedure
After the oncology nurses consented to take part in the study, they received a phone call from an individual playing the role of a constipation patient first and then a patient who had febrile neutropenia. In each case, the actor described her symptoms while speaking with the nurse on the telephone. Nurses reviewed the EHR and the eSMG’s as they would in their work setting. The nurse and actor discussion was audio recorded. The nurses’ interactions with the EHR and eSMG’s were recorded using HyperCam® screen recording software. Following this, a short post-clinical simulation interview took place with each participant. All of these interviews were audio recorded. Participants were interviewed about verbalizations that the researcher did not understand, and any activity that the participants’ undertook while interacting with the eSMG’s and the EHRs that was not understood by the researcher for the constipation and the febrile neutropenia fictitious patient cases [8].
2.5. Analysis
All clinical simulation and post-clinical simulations interview recordings were transcribed. Transcripts were annotated with participant interactions with the eSMG’s and the EHR. Transcripts were later uploaded into NVivo®. Following this, the transcripts were coded using a content analysis approach. The unit of analysis consisted of words, phrases and paragraphs that represented one concept. These concepts were then classified into categories and themes using the constant comparative method. E.M. Borycki et al. / Advancing Telehealth Nursing Practice in Oncology 45
3. Findings
3.1. Demographic Characteristics
Ten nurses participated in the study (see Table 1 below). The average age of participants was 36.5 years. All were female and their level of education ranged from Baccalaureate prepared through to Masters. The average number of years participants’ worked was 6.4 years. Table 1. Demographic Characteristics Sample Characteristics Percentage (Frequency) Age Average Age = 36.5 Sex 100% Female Level of Education Bachelors of Nursing and Masters of Nursing Years of Nursing Experience Average – 6.1 years
3.2. Clinical Simulation and Post-Clinical Simulation Interview Results
Researcher reviews of clinical simulations revealed there was variability among nurses in terms of the type and amount of eSMG information used. Nurses identified that the guidelines supported their work and patient care, but that several factors influenced their use of the eSMGs in the post-clinical simulation interviews. Participants noted these factors influenced the frequency of eSMG’s use. For example, all of the nurses (n=10) identified that telehealth nurse and oncology nursing experience influenced their use of the eSMG’s. Nurse participants indicated that as their familiarity with telehealth nursing practice and/or the oncology increased, they relied less on the eSMGs to guide their work, having learned about patient symptom management over time. Experience in using the eSMG’s was also important. Experienced and novice nurses developed competencies in using the eSMG’s so they were used less often as the content of the guideline was learned over time. This knowledge also helped with quickly finding information. It was noted by some study participants that there was a need to be aware of updates to the guidelines so periodic checks of online guideline materials was necessary. Some participants suggested that the organization could develop ways to notify nurses of changes to the guidelines to enhance awareness of the presence of new information. In other cases participants stated that tools such as Google® scholar could be used to identify decision aids and other electronic guidelines for use in practice. Lastly, nurses noted that as the complexity of the patient’s condition increased so would the use of the guidelines to support decision making. These factors are outlined in the Table 2 below.
Table 2 . Factors Influencing Nurse Use of eSMG’s Factors Nurse experience in telehealth and oncology Nurse experience in using eSMGs The presence of updates and changes to the guidelines based on research evidence The availability of other electronic tools to provide additional information Complexity of the patient conditions.
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Both clinical simulations and post-clinical simulations enabled the collection of complementary data that provided differing types of insights and information about oncology, telehealth nurse use of eSMGs.
4. Conclusions
The use of eSMGs remains an important aspect of oncology, telehealth nursing practice in modern health care settings. Much of the research to date has focused on physician use of eSMG’s. Less research has examined the use of eSMGs in conjunction with EHRs and in oncology nurse telehealth practice settings. In this study, we learned that a number of factors influence the frequency of eSMG use. Broadly, these factors were nurse and patient-related as well as organizational in origin. The nurse’s clinical, telehealth and prior eSMG experience all influence how and when such guidelines are used. Alternatively, patient characteristics also have a role in influencing usage. The inherent uniqueness of each patient and the complexity of each patient’s health condition remains important. Others have suggested the complexity of a patient’s condition has an influence on eSMG use. Lastly, some nurses suggested that eSMG use was dependent on the availability of eSMG and other organizational tools that could be used by nurses. Limitations of this study include small sample size. In summary there remain a number of factors that influence technology use by oncology telehealth nurses. Future research needs to address the role of differing types of guideline representations on nurses’ acquisition and ability to use guideline-based knowledge while interacting with patients during a telephone call.
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