Posted: March 13th, 2024

Nursing Informaticists interacting with staff nursesNurse Informaticists Collaboration

Module 3: Discussion

Initial Post

Personal Experience: Nursing Informaticists interacting with staff nurses

During my tenure in an inpatient child and adolescent behavioral health unit, a significant portion of my duties revolved around ensuring accurate and comprehensive documentation in the electronic medical record (EMR). This practice is crucial for achieving quality assurance standards, safeguarding against liability issues, and ensuring the identification and resolution of patient health concerns (Griffith, 2004; Upadhyay & Hu, 2022). The EMR also facilitates evidence-based decision-making, enhances patient outcomes, supports research, improves patient safety, and helps in reducing healthcare system costs (Upadhyay & Hu, 2022). In my final year, I transitioned from a daytime schedule (7am to 7pm) to a nighttime schedule (7pm to 7am), continuing to provide patient care, document in the EMR, administer medications, and address behavioral and health issues, along with additional nighttime responsibilities. One of my primary nighttime tasks was conducting chart audits, where I followed an audit checklist and audited every chart daily. As a dayshift nurse, I had heard my colleagues express dissatisfaction with the night shifts’ audits, describing them as overly meticulous or overly strict. Our unit lacked a specialized nurse informaticist, leading me to believe that the work of night nurses’ audits qualifies them as nurse informaticists interacting with their peers.

Chart auditing is intended to ensure that care providers accurately and fully document patient data required by the facility, insurers, and JACHO. It serves as a means to enhance accountability and improve quality (Hut-Mossel et al., 2021). However, it is often perceived as burdensome, unnecessary, and bureaucratic (Wolfe et al., 2018; Hut-Mossel et al., 2021). On my unit, dayshift nurses frequently expressed frustration with corrections or suggestions made by the auditing nurses. The EMR is a powerful tool with numerous benefits and applications for improving care, health costs, and patient satisfaction (Kreidler, 2021; Hut-Mossel et al., 2021). Regrettably, the use of EMRs has also led to nurses and other providers employing workarounds, such as using paper as a cognitive tool, scanning patient identifiers not linked to the patient, entering free text documentation instead of in structured fields, producing batched documentation, administering medications or treatments before orders are in or vice versa documenting treatment before actually providing it, bypassing safety measures, scanning medications for multiple patients at once, and more (Fraczkowski et al., 2020; Stevenson et al., 2018). These workarounds can be hazardous and are often the result of several key factors: nurses’ reluctance to inconvenience the patient, environmental constraints (like space), organizational issues where policy doesn’t align with procedure, task issues (emergencies, insufficient time, previous tasks not documented), and technology and usability issues (functional and understanding problems) (Fraczkowski et al., 2020). Identifying and addressing these workarounds can lead to tension between staff nurses and nurse informaticists.

Initially, I viewed auditing as somewhat unnecessary and a distraction from my primary duties. However, this perspective shifted when I observed the gaps or inaccuracies in patient charts. After reviewing documentation for a few weeks, I noticed improvements in my own charting due to familiarity with the required documentation. I was able to identify and notify my colleagues about incorrect charting entries, and they were sometimes able to rectify the issue. Additionally, I discovered instances of batch charting and addressed this with the staff to enhance the quality of charting. I found that the most significant issues on my unit were related to time, understanding of the system or actual documentation procedures, and perception of necessity.

Improvement Strategy

To enhance the quality of nursing documentation and improve the relationship between staff nurses and nurse informaticists, I propose two strategies. The first is that all nurses should be trained to audit their peers’ charts. In many hospitals, nurses volunteer or are assigned to an audit committee to prepare for JACHO visits, but I suggest this be an ongoing rotating task. This approach is because familiarity with the system and the requirements comes from spending time with them. Increasing experience with an electronic medical record system enhances satisfaction with using the system (Wolfe et al., 2018). Additionally, most staff learn to use the EMR primarily on the job, and three days of training is insufficient. Most staff acquire tips and tricks from senior staff who may or may not have ever learned how to correctly use the systems in the first place, leading to the spread of EMR workarounds (Fraczkowski et al., 2020). The main complaints about using EMRs are technical difficulties and the increase in workload related to clinical documentation (Fraczkowski, 2020; De Groot et al., 2022). While the former is sometimes a systems problem, both can be improved by increasing the understanding of the system and protocols (Wolfe et al., 2018; De Groot et al., 2022). I believe this strategy would foster collective responsibility for documentation quality (ending the us vs them mentality by giving all nurses a little more of a nurse informaticist role) and promote peer learning.

If having nurses increase their workload by auditing seems too burdensome, my second suggestion would be the employment of a nurse informatics specialist for on-unit training and troubleshooting. This solution aligns with the guiding principles described in Mosier et al.’s systems-level method for nursing informatics solutions development, but in a slightly different way in a day-to-day clinical setting instead of specific solution development (2019). Firstly, it would establish clear lines of responsibility by creating a dedicated position (Mosier et al., 2019). The utilization of a nurse informaticist to literally follow people around and assist them in learning and understanding the best way to use the system and what they actually need to be doing would also work. Having this type of collaboration between a specialized nurse informaticist and the unit nurses would decrease barriers and make the nurse informaticist more personable, as well as providing a known and comfortable resource for troubleshooting. Providing a dedicated staff member who understands the burdens of nurses and the system and policies necessary for proper documentation would allow the staff to feel more comfortable and supported while allowing for respect for different types of expertise, removing tensions (Mosier et al. 2019). Having them available during work hours instead of just reporting issues in documentation would allow for learning instead of frustration at being critiqued. I hypothesize that this would increase the likelihood of unit nurses asking for help, taking an interest in better understanding the systems, and self-monitoring for workarounds. Working as a unit towards the goal of better documentation, increased work satisfaction, and increased patient outcomes by removing some of the burden on staff nurses and providing support through an IT nurse specialist speaks to the guiding principle of Commitment to the vision (Mosier et al., 2019). In addition, having a specialist nurse informaticist on the units could help identify and address changes to the EMR systems to better meet the needs of nurse workflow, which has been cited as an issue with using the EMR (Moy et al., 2023; Fraczkowski et al., 2020).

Impact of Nursing Informatics Evolution

With the evolution of nursing informatics, we have a unique opportunity to create a connection between the IT world and the in-person nursing world. Nursing informatics, like nursing itself, has many far-reaching branches and opportunities. For this discussion, I want to explore the in-person role of a specialized nurse informaticist to foster a sense of connectedness and collaboration on individual units. The world of IT has been far removed and elusive for many over the years. On many nursing units, if you had an IT problem, you would need to make a call or send an email request for tech assistance, which would be answered by some unidentifiable ‘IT guy.’ As a result, you would only call these IT workers for something functional that you could not figure out, not for improved understanding of the system. Recognition is an important tool to promote engagement (George & Massey, 2020). Leaders use recognition to increase organizational excellence through improved staff engagement and a perceived supportive culture (George & Massey, 2020). Visibility and accessibility have been shown to increase utilization of resources in many fields from electronic resources to healthcare for vulnerable populations (Bhatt & Bathija, 2018; Zuniga, 2022). I hypothesize this principle can be adapted to positive nursing engagement with informatics, such as the EMR on the unit, to increase quality and promote adherence to organization protocols and best practices. Having visible, available, and relatable IT nurses on units to train staff and troubleshoot system problems would be a functional and beneficial evolution of nursing informatics.

Impact of New Technologies

New technologies can also help bridge the gap between staff nurses and nursing informatics. Many staff nurses resent the burden of increased clinical documentation in the EMRs, partly due to insufficient understanding of the systems and protocols (Fraczkowski et al., 2020; De Groot et al., 2022). New AI technologies could provide support, guidance, and other assistance to nurses in the near future. AI-based education and training modules could provide similar assistance as an on-staff IT nurse, minus relatability. Leveraging AI algorithms to analysis and address individual gaps in knowledge or practice could enhance engagement and comprehension of nurses with the EMR software. The most common type of EMR workaround identified is the use of paper as a cognitive tool; to remember vitals to put into the system later, to organize tasks, track medication, and plan patient care (Fraczkowski et al., 2020). To address this issue, the use of AI virtual assistant technologies could provide real-time feedback and assist in organizing data via voice commands or chat interfaces. AI virtual assistants could also offer clarification on protocols, tech troubleshooting, and documentation requirements.
Conclusion

The interaction between Nursing staff and nurse informatics specialists can be distant and might contain tension, as in the case between the staff nurses on my unit and those providing auditing. The role of nursing informatics is pivotal to addressing challenges within the healthcare world, in particular in relation to electronic medical record documentation. Strategies such as peer chart auditing and the integration of on unit specialized nurse informaticists could be a positive evolution of the nurse informaticist/staff nurse collaborative relationship. The continued evolution of nursing informatics coupled with the emergence of new technology, like AI, offers promising avenues to bridge the gaps between staff nurses and informatics nurses, ultimately leading to improved patient outcomes.

References

Bhatt, J., & Bathija, P. (2018). Ensuring access to quality health care in vulnerable communities. Academic medicine: Journal of the Association of American Medical Colleges, 93(9), 1271–1275. https://doi.org/10.1097/ACM.0000000000002254

De Groot, K., De Veer, A. J. E., Munster, A. M., Francke, A. L., & Paans, W. (2022). Nursing documentation and its relationship with perceived nursing workload: A mixed-methods study among community nurses. BMC nursing, 21(1), 34. https://doi.org/10.1186/s12912-022-00811-7

Fraczkowski, D., Matson, J., & Lopez, K. D. (2020). Nurse workarounds in the electronic health record: An integrative review. Journal of the American Medical Informatics Association: JAMIA, 27(7), 1149–1165. https://doi.org/10.1093/jamia/ocaa050Links to an external site.

George, V., & Massey, L. (2020). Proactive strategy to improve staff engagement. Nurse leader, 18(6), 532–535. https://doi.org/10.1016/j.mnl.2020.08.008Links to an external site.

Griffith R. (2004). Putting the record straight: the importance of documentation. British Journal of Community Nursing, 9(3), 122–125. https://doi.org/10.12968/bjcn.2004.9.3.12436

Hut-Mossel, L., Ahaus, K., Welker, G., & Gans, R. (2021). Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. PloS one, 16(3), e0248677. https://doi.org/10.1371/journal.pone.0248677Links to an external site.

Kreidler, M. L. (2021). Quality improvement in health care. Salem Press Encyclopedia. Quality Improvement in Health Care: @ Walden University Library (ebscohost.com)Links to an external site.

Mosier, S., Roberts, W. D., & Englebright, J. (2019). A systems-level method for developing nursing informatics solutions: The role of executive leadership. JONA: The Journal of Nursing Administration, 49(11), 543-548. A Systems-Level Method for Developing Nursing Informatics Solutions: The Role of Executive Leadership (ovid.com)Links to an external site.

Moy, A. J., Hobensack, M., Marshall, K., Vawdrey, D. K., Kim, E. Y., Cato, K. D., & Rossetti, S. C. (2023). Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments. Journal of the American Medical Informatics Association, 30(5), 797–808. https://doi.org/10.1093/jamia/ocad038Links to an external site.

Stevenson, J. E., Israelsson, J., Nilsson, G., Petersson, G., & Bath, P. A. (2018). Vital sign documentation in electronic records: The development of workarounds. Health Informatics Journal, 24(2), 206–215. https://doi.org/10.1177/1460458216663024Links to an external site.

Upadhyay, S., & Hu, H. F. (2022). A qualitative analysis of the impact of electronic health records (EHR) on healthcare quality and safety: Clinicians\’ lived experiences. Health services insights, 15, 11786329211070722. https://doi.org/10.1177/11786329211070722

Wolfe, L., Chisolm, M. S., & Bohsali, F. (2018). Clinically excellent use of the electronic health record: Review. JMIR human factors, 5(4), e10426. https://doi.org/10.2196/10426Links to an external site.

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Nurse Informatics Partnership

The paramount issue in nursing is patient safety. Nursing informatics has facilitated various technological breakthroughs in nursing, enhancing patient care safety and fostering innovation in nursing practices. “Despite the introduction of technologies like smart pumps, bar-code medication administration systems, electronic health records (EHRs), wearables, and smartphones, designed to boost efficiency, ensure safety, and simplify nursing tasks, it’s crucial to inquire about the extent to which these technologies alter the nurse-patient interaction” (McGonigle & Mastrian, 2022). The safety enhancements technology has offered to nurses are significant. Despite the availability of technology, nurses must meticulously verify variables in the field to prevent errors. In the maternity unit, nurse informaticists visit our unit to update us on changes to our daily charting, often making it safer for patients and more efficient for nurses. Should any errors occur, the nurse informaticist corrects them, conducts research to address the issue, and ensures it’s less likely to happen again.

Approach for Enhancement

“Nurse executives and nurse informaticists are collaborating to devise new solutions for improving nursing processes and patient care. The challenge lies in determining the best way to coordinate the efforts of subject matter experts from nursing, informatics, and information technology to design, develop, and implement solutions to complex problems. Nursing leadership is well-equipped to influence these processes through their comprehensive understanding and oversight of nursing care. Although executive leadership is not typically involved in developing nursing informatics solutions, we argue that it is essential to this process” (Mosier et al., 2019). Collaboration and change are essential to ensure improvements in the field. Nursing informatics must work closely with nurses engaged in daily nursing activities. The necessity for improvement in the medical field necessitates collaboration across the healthcare sector. Integrating informatics into nursing is crucial for new nurses to understand the importance of the field. “The framework was grounded in three guiding principles: clear delineation of responsibilities and authority, respect for each type of expertise required for the project, and a clear commitment to the project’s objectives” (Mosier et al., 2019).

Progression of Nursing Informatics

Technology has revolutionized healthcare in ways we could never have imagined. Consider the absence of technology in diagnosing internal bleeding or damage in patients, or the management of broken bones. Without access to current technology, healthcare providers would be at a loss. Before technology, numerous errors occurred in healthcare, leading to fatalities from a single mistake. With the advent of technology, we now have tools like force stops and flags for healthcare providers to identify potential incompatibilities and medication administration issues. Our most secure method of medication administration is the MAR and the eight rights of medical administration. “The advent of new technologies brings endless possibilities and potential benefits in delivering high-quality, cost-effective patient care. The key to sustainability for mHealth technologies lies in the appropriate use of the right tool, at the right time, for the right patient. Gathering relevant data is also essential to support patient use and in clinical workflow. With their blend of clinical and technological expertise, nurse informaticists are well-positioned to integrate mHealth applications into clinical practice and connect patients and healthcare providers in ways that are compatible with life, work, and population health” (Ng et al., 2018).

References

McGonigle, D., & Mastrian, K. G. (2022). Nursing Informatics and the foundation of knowledge. Jones & Bartlett Learning.

Mosier, S., Roberts, D. Wm., & Englebright, J. (2019, November). A Systems-Level Method for Developing Nursing Informatics Solutions: The Role of Executive Leadership. OVID. https://oce.ovid.com/article/00005110-201911000-00008/HTML

Ng, Y. C., Alexander, S., & Frith, K. H. (2018). Integration of mobile health applications in Health Information Technology Initiatives. CIN: Computers, Informatics, Nursing, 36(5), 209–213. https://doi.org/10.1097/cin.0000000000000445

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