February 26, 1997 Julie Rennecker

Overview Of Nursing

Distinguishing Nursing from Medicine

...to have charge of somebody's health...[Nursing] ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet--all at the least expense of vital power to the patient. [Nightingale, 1860 as cited in Shortliffe et al, 1990]

Nursing is primarily assisting the individual (sick or well) in the performance of those activities contributing to health, or [to] its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. It is likewise the unique contribution of nursing to help the individual to be independent of such assistance as soon as possible. [Henderson, 1960 as cited in Shortliffe et al, 1990]

...the diagnosis and treatment of human responses to actual or potential health problems [ANA, 1980 as cited in Shortliffe et al, 1990]
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Medicine focuses on disease and cure; symptom alleviation.

Nursing tend to focus on care: health promotion, teaching, comfort, coping, and promoting independence while also delivering the necessary medical treatments that will alleviate immediate symptoms.
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Except for general practitioners, pediatricians, gerontologists, and physiologists (Todd, is this the right spelling?), physicians tend to focus on one aspect of client condition. Nurses are trained to consider the physical, psychological, social, and spiritual condition of the client though at any stage of the client's life, there may be more emphasis on one aspect than another.
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Physicians see patients for short periods of time over many years (long series of snapshots). Nurses see patients for long periods of time over short life intervals (movie).

Aspects of Nursing Practice

a. Clinical nursing

- hospital

- home care

- community health

- clinic/MD office

- extended care

b. Nursing administration--managing resources including nurses, supplies, and physical resources to optimize patient care; includes scheduling, setting staff to patient ratios and staffing mix (licensed/unlicensed) and evaluating outcomes of these decisions

c. Nursing research and development

d. Nursing education

Barriers to Codifying Nursing Knowledge

a. Clinical nursing

- no single taxonomy of nursing knowledge and interventions

- Nursing Diagnosis

Examples:

a. Anticipatory grieving related to loss of reproductive capacity (pending hysterectomy) as evidenced by tearfulness, expressed concerns over being childless.

b. Activity intolerance related to limited pulmonary function (infection or disease) as evidenced by inability to comb hair without becoming breathless.

- a relatively new notion so no consensus among practicing nurses re: legitimacy

- development hindered by predominance of nursing practice occurring in hospital setting where focus/priority is given to current disease state

- NANDA--List of diagnoses developed inductively from extensive review of documentation of actual care delivery; Widely accepted by authorities in nursing community; internal logic problems; erratic use

- Ozbolt (et al?)--a deductive approach to diagnosis development; logically consistent; not widely accepted; developed for limited application (skin, extremities, self-care)

- Expansion of home care, hospitals need to justify costs, and increasing numbers of advanced nurse practitioners may increase momentum for further development and refinement

b. Nursing administration

- Hospital (and often home care) are 24 hour/day, 7 day/week operations

- Scheduling:

- Diversity in educational preparation of nurses

- RN: diploma, associate degree, bachelor degree, masters, doctoral

- LPN or LVN

- NA--EMT, medical technologists, surgical technologists

- Norms, laws, and standards for "basic consideration" vary widely across states and institutions

- Unpredictability: absenteeism; flux in patient census (current daily turnover can be 50-75%)

- Temporary staffing needs and temporary personnel

- Cost accounting--most hospitals have poor cost information systems so poor database for these decisions

- Service quality

- Most QA has focused on structure (# personnel, material resources, etc.) & process, little outcome data

- Narrative documentation makes data retrieval difficult

- Shorter length of stay (LOS) makes outcome evaluation even more difficult

Notes:

- TQI is pushing for an outcomes approach

- Some research has shown that the nurse does influence patient progress and outcome in L&D.

c. Research and Development

Issues similar to those for medical R&D and for nursing clinical and administration systems. Narrative, visual, vague data are difficult to codify and track.

HISTORY OF COMPUTERS IN NURSING

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1960's - 70's: scant literature; focused on how to educate nurses about computers or how to implement computers©

1980's "marked beginning of a new era of research in computer applications for nursing

- conferences

- increase in submissions to SCAMC by nurses

- 1983 Computers in Nursing

Clinical practice

Hospitals

- Most systems reflect a limited view of clinical nursing or were designed primarily to support nursing administration.

- Reasons for slow development (p. 255):

a. The view that the existence of a satisfactory comprehensive HIS must precede the development of a nursing system

b. The lack of agreement about and complete development of taxonomies in nursing.

c. The lack of computer resources in nursing.

d. The difficulty of attempting to develop isolated clinical applications in a profession dedicated to caring for patients' total health needs.

e. The lack of acceptable online environments within which to implement such tools.

- Prototypes--isolated systems; limited functionality (pre-surgical anxiety; skin & appendages)

- Technicon Medical Information System (TMIS)--first commercially usable system to include nursing care subsystem; did include care planning & evaluation but poor link between data and care plan

- COSTAR & PROMIS--ignored nursing process and automated Kardex

Kardex is an organized checklist of current patient treatments

- Specific applications developed outside comprehensive systems got little use due to poor access to computers and (I imagine) lack of integration into the workflow.

Community Health Nursing Systems

- Federal regulations in '60's increased requirements for documentation.

- First system--Patient Care Information System (PCIS)--Federally funded development to support community health nurses working on an Indian reservation: mobile population

- See list on page 257 of other successful systems--note that names suggest governmental funding for development

- Computer applications for nursing seem to have developed more rapidly outside the hospital setting

Nursing Administration

(Our text focuses primarily on scheduling--am not sure if that is because those are the only systems that have been developed for nsg administration?)

- Have not been able to demonstrate that these systems are more accurate than estimates made by the head nurse.

- Recommendations made by these systems reflect staffing needs "on average"--do not account well for the variation that occurs.

Nursing Education

- Simulations for hospital care: PLATO, Mr. Marshall

- Simulations for community health nursing: SYPH, GASTRO

- 1980's--shifts in incentives and technology advances making simulation development accessible to academic nurses (non-programmers) increased focus by faculty on computer applications

Fundamental Issues of NIS

1. The primary functions of NIS: record-keeping; decision support; evaluation (to refine decision support and facilitate research and education)

2. Primary barriers:

a. Absence of a taxonomy of knowledge

b. Deterministic approaches to developing care plans inappropriate; "radically tailorable" approaches eliminate the benefit of decision support.

c. Nursing addresses multiple domains of care--physical, psychological, social--difficult to integrate

d. Nursing data tend to be continuous rather than discrete.

Current State of NIS

Clinical Systems

- TMIS (Technicon)--circa 1970; lacks nursing knowledge; little connection between data and care plan

- IBM Patient Care System (PCS)--better automation of care plan development but still fails to use nursing data

- COMMES (Creighton On-Line Multiple Medical Expert System)--developed in university setting; NPC (Nursing Protocol Consultant) uses patient data and interacts with a knowledge base and recommends goals and objectives for care

- ULTICARE--a shell environment within which to embed nursing knowledge

Nursing Administration

- System styles set in the 70's

- Examples: NPAQ (previously Medicus)--uses patient classification & quality of care measures; GRASP & others also based on quality of care measures

- Problems with these systems: the basis for these systems, the tools for patient classification and quality of care evaluation, are poor

- COSTAR "shows promise"--QA audits built into the system

Nursing Education

- NEMAS--Nursing Education Modular Authoring System-- First (only?) explication of cognitive processes underlying nursing decision-making

- Licensure preparation & examination

- Simulations

Forces for the Future

- Pressure to decrease costs (decrease number and credentials of staff) and to validate expenses

- Shortening length of stay--more work to do in less time

- More diversity in delivery facilities--clinics, outpatient surgical facilities, etc.--makes continuity more difficult and more important.

- Codifying nursing knowledge is first step in developing decision support.

Additional notes:

- Time--How to document asynchronously and yet record activities for time when done

- Regulation--A great deal of nursing documentation is intended to satisfy regulations

- Litigation--While the voluminous nursing notes are rarely read during a patient stay, they are carefully combed during litigation-- "If it isn't written, it wasn't done."

- Regionalism--Before large conglomerates, hospitals competed only against similar institutions in their own cities. Consequently, there is a great deal of variation in the design and operation of the patient care aspects of healthcare.

- Centralization/Decentralization is a debate in constant flux in hospitals--poor cost accounting and inability to assign costs to certain "quality of life" factors for clients and workers keeps the issue open--lab, pharmacy, nursing, supplies, radiology, dietary.