Form and Function Using Technology to Augment the Nursing Process
What is the form and function of nursing? And, what role does technology play in delivering quality care?
The function of nursing is delivering services to patients; the form refers to the medium in which the function is realized—the ways in which nurses and other healthcare staff deliver effective, high quality care.
Orem defines nursing as “a human service designed to overcome human limitations in self-care action for health-related reasons.” Roy calls nursing “a process of analyses and action, related to the care of the ill or potentially-ill person.” Essentially, nursing refers to the dynamic relationship between a nurse and his/her client(s) for which the nurse provides care—physical, emotional, and education based on identifiable needs. Patients consist of those residing within facilities or those who receive communitybased services. Nursing is a time-honoured tradition of service and while the form of the service may change, and indeed should, nurses are first and foremost providers of care. Such is true for the entire family of nursing staff, from registered staff to personal care aides to allied health providers.
The Evolution of the Forms of Nursing
Because nursing is a practice discipline, it draws information from many different bodies of knowledge. Over time, it became increasingly necessary to develop its own body of knowledge through research to provide an accurate and reliable basis for providing care (client centred practice printout). This led to the development and exploration of such nursing models & theories as Orem's Self-Care Model, Roy's Adaptation Model and Neuman's Healthcare System Model. All of these models and theories provide a model for the practice of nursing.
In the latter half of the twentieth century, a movement within nursing began to define itself as a profession rather than an occupation. Nursing became a self-regulated profession throughout North America in the early 1960's through the establishment of Nursing Acts in provincial and state legislatures. Thus, nurses were given the legal authority to define, monitor and enforce education and competence standards, define a code of ethics with the overall purpose of protecting the public interest (RNABC, RNANS, CNO).
Professional nursing practice is exhibited through life-long learning, public and professional responsibility and accountability, the application of evidence-based knowledge and a focus on the client (CNO). These are extrapolated through the nursing process, “…a method of clinical problem solving which ensures a systematic approach to…care…(consisting) of four steps: assessment, planning, implementation and evaluation.” (client-centred care). This cyclical process is scientific in nature and gives rise to the nursing care plan, which specifies a problem, states an objective and outlines actions to achieve the objective. Through a review process the actions can be deemed effective or ineffective. Thus, nursing practice moved away from being taskoriented to being evidence-based where problems are approached in a methodical way, resulting in scientifically proven remedies. The days of a nurse acting only upon intuition were coming to an end and health care staff began to provide measurable observations for the conditions of their patients.
Technology as a Nursing Form
As demand for information continues to increase, the use of technology in all aspects of health is becoming more and more critical. Government demands more information to justify funding. Enter technology as a form to aid the nursing process…
Nursing informatics has become an accepted term for the study and design of nursing information systems. According to one definition (Ball & Hannah, 1988, p. 81): "The term nursing informatics can be operationally defined as referring to the use of information technologies in relation to any of the functions that are within the purview of nursing and are carried out by nurses in the performance of their duties." While early studies focused on nursing research and nursing literature, the study of nursing information systems (dating from the mid-1960s) turned its attention to understanding practitioners as creators and users of knowledge. Familiar studies by Hammond et al. (1966), Notter (1969), and Lock-heed Missiles and Space Company (1969) focused on nursing information systems and provide typical examples of the studies conducted during this period.
Data, information, and knowledge constitute the content of professional communication. Nurses deliver and manage patient care through continuous communication with patients and their families, other nurses, and medical and hospital staff. They study the patient's record and add their observations to it. They monitor instruments that report on the patient's condition. They perform tests and review the results of tests performed by others. In all these communication activities, nurses give and receive data, information, and knowledge.
According to Blum (1986), data refers to discrete entities that are objectively described without interpretation. Information refers to data that are interpreted, organized, and structured. Knowledge refers to information that has been synthesized so that interrelationships are identified and formalized. Where one term represents all three types of content, it is usually information, as in nursing information systems.
The design of effective nursing information systems is predicated on a clear representation and understanding of nursing information needs. Information needs refer to the types and amounts of information that must be available for the successful performance of nursing tasks. Through technology, health care staff have the ability to capture data from a variety of sources and assemble it in more comprehensive documents than ever before, staff have more information at their fingertips than once thought possible. As well, staff can report on this information in any number of ways faster than ever before.
As technology continues to change the way health care staff deliver and document care, so technology itself continues to change. Technology as a form for doing any business is changing rapidly. The shift from mainframe text-based systems to systems that use powerful relational databases with a graphical user interface has resulted in rapid development of new technology and integration with different systems is common. And, while new technology is exciting, one must consider the overall value the technology offers. In terms of value, we need to look at the way in which the technology, if it were implemented, would enhance the practice of nursing, as opposed to how the technology looks or how cool it may be.
Assessing the Value of Technology
The Internet maybe the largest system exposure the public has ever experienced. It is highly visible and has generated a league of .com millionaires making the lure of the technology exciting. Many business applications have been developed for the Internet to provide the consumer with the latest news and information, opportunities to purchase everything from a new car to pieces of the wall that separated east and west.
New portable wireless devices allow you to receive e-mail, get stock prices and browse Web sites from the theatre or the parking lot, or while boarding the ferry to Vancouver Island. One must look to these new and emerging technologies to see if they support the foundation of the practice to which they are applied, in this case, nursing. The onus of determining what technology is effective, for what purpose and how to implement said technology has fallen on the shoulders of health industry professionals.
When evaluating technology in health care, it is imperative the system is based on established practice standards. For Health Records, the scientific process of assessment, planning, implementing and evaluating are the foundation of the Nursing process. The chart provides the tool to document this process. An electronic Health Record must be based on the same sound process. The technology used must be reliable and be demonstrable.
Wireless devices allow for easy movement of technology to the point of care regardless of location and, many times, at reduced costs over traditional wired networks. Imagine a facility with a few portable workstations that connect to the network with wireless technology. The nurse or other care provider could move a workstation to the bedside, conference room or other location and have the ability to access the complete client record. The wireless device can have many forms as well. The most common may be a notebook computer with a wireless network card installed. This would run on battery and be recharged when it is returned to the nursing station. Other wireless devices may include traditional desktop computers. These would need to be shut down and moved to a new location and re-started after it is connected to the network again. Finally, new handheld computers are being developed today that will allow the nurse to carry a subset of the patient's record and to either work on the wireless network or be linked and the data synchronized. The last device is also excellent for nurses who practice in the community as data can be collected and the chart updated either instantly on the wireless network or through a physical link. The physical link may be by modem or connection to a PC.
Extend this view to a physician in the community who needs to review lab results or enter new orders. While the ability to complete these tasks exists from a technical point of view, we need to be sure we create the system to support these new methods of processing the data without interrupting the function at hand—providing quality care.
All professions have established scientific processes. For health records, the steps of assessment, planning, implementation and evaluation are the steps of the scientific process. These principles must be incorporated into the design of all systems designed for use in health care. All components of the systems must lead to this outcome. The list below outlines points to consider when determining the value and/or effectiveness of any tool offered by technology (primarily health care systems) as a solution for health care providers.
- In order for technology to support sound nursing practice it must, first of all, incorporate all aspects of the nursing process.
Ask: Does it allow me to enter an assessment, create a care plan and record supplementary information? - The nursing process is based on a scientific thought process (assessment through evaluation) and not on nursing actions. The system should demonstrate this process and show the links between one another.
Ask: Does the system allow you to show a flow of thought? - Implementing a computerized documentation system is not something that will occur overnight, nor will it occur all at once. After determining that the system provides the complexities of the nursing process and displays flow of thought, evaluate its flexibility. Thus, while a system must be based on the nursing process, users have to be able to access and update a health record, care plan or progress note without having to re-do the entire process.
Ask: Can each element of the system operate as a stand-alone module? - A large percentage of health care providers are not trained in advanced electronic health record management software. Learning how to use technology is part of a commitment to life-long learning and the pursuit of quality and efficiency in job tasks.
Ask: Is this tool user-friendly? 'User-friendly' may include consistency of screen design, ease of information entry, what is necessary to support the system inhouse, required training time and anything else you can think of that will effect the interaction between your staff and the tool. - Part of sound nursing practice is contributing to research at both the facility and global levels. In order to contribute to research, one must be able to retrieve accurate information.
Ask: How is information stored? Is it easy to get at? How much time is involved in its retrieval? Do I have flexibility in what I retrieve & how I display it? - Public and professional accountability must also be addressed when considering any form of technology. Identify potential issues at hand and determine how the tool or system accounts for such issues; for example, consider issues of privacy and security—not only in terms of access to health records, but the safe storage and backup of the data.
Ask: Who has access to what? How can the information be tracked in terms of who, what and when? - Since nursing is not the only health care discipline to document, it is necessary to ask who else could potentially use the system and determine if the technology accurately meets the needs of multi-disciplinary teams. For example, physiotherapy and Social Work departments also have care providers who should have access to the system to promote information sharing and increase efficiencies by reducing duplication.
Ask: Does the technology lend itself to disciplines other than nursing? - As an evidence-based discipline, nursing must be flexible as knowledge changes and as clients change.
Ask: Is it easy to change/add information both within the health record and the way things are set up? How will I know that things have been changed?
Historically, health care has expressed great interest and expected great things from the software industry. Many of the promises of technology have not been delivered either because the technology was not ready or the basic design of the technology ignored the underlying scientific process the health professionals worked by. Some of the first systems implemented in health care provided only basic functionality and may have increased staff workloads through inefficient implementations and design.
Today, a new range of systems are coming to the market that allow the health care provider to function using a complimenting blend of technology and scientific process. In the right balance, technology cannot only support the nursing practice, but can augment it. It can structure data in such a way that reflects thought patterns and provides the ability to organize, retrieve and display data quickly. While it is important that we keep our eyes on the horizon with technology and the advancements it may bring, we must remember that the foundations of the nursing process must be adhered to.