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Computerized decision support system in nursing homes
Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to study the thinking strategies and clinical reasoning processes of registered nurses (RNs) and to implement and test a computerized decision support system (CDSS) integrated into the electronic health care record (EHR) to improve patient outcomes, i.e. to prevent pressure ulcers (PUs) and malnutrition among residents in nursing homes. 

A think-aloud (TA) study with a purposeful sample of RNs (n=30) was conducted to explore their thinking strategies and clinical reasoning (Paper I). A quasi-experimental study with a convenience sample of residents (at baseline, n=491 and at follow-up, n=480) from nursing homes (n=15) allocated into two intervention groups and one control group was carried out in 2007 and 2009 (Paper II). In Paper III residents’ records were reviewed with three instruments. Nursing personnel (n=25) from four nursing homes that had used the CDSS for eight months were interviewed and the CDSS was tested by nursing personnel (n=5) in two usability evaluations (Paper IV).

The results showed that the RNs used a variety of thinking strategies and a lack of systematic risk assessment was identified (Paper I). The proportion of malnourished residents decreased significantly in one of the intervention groups after implementing the CDSS, however there were no differences between the groups (Paper II). The CDSS resulted in more complete and comprehensive documentation of PUs and malnutrition (Paper III). The nursing personnel considered ease of use, usefulness and a supportive work environment as the main facilitators of CDSS use in nursing homes. Barriers were lack of training, resistance to using computers and limited integration of the CDSS within the EHR system (Paper IV). In conclusion, the findings support integrating CDSSs into the EHR in nursing homes to support the nursing personnel.

Place, publisher, year, edition, pages
Örebro: Örebro universitet , 2012. , 95 p.
Series
Örebro Studies in Care Sciences, ISSN 1652-1153 ; 36
Keyword [en]
Computerized decision support, intervention study, malnutrition, nursing documentation, pressure ulcer, qualitative content analysis, think-aloud interviews, usability evaluation
National Category
Medical and Health Sciences Nursing Information Systems
Research subject
Nursing Science
Identifiers
URN: urn:nbn:se:oru:diva-21673ISBN: 978-91-7668-857-1 (print)OAI: oai:DiVA.org:oru-21673DiVA: diva2:503705
Public defence
2012-04-20, Hörsal P2, Prismahuset, Örebro universitet, Fakultetsgatan 1, Örebro, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2012-02-16 Created: 2012-02-16 Last updated: 2017-10-17Bibliographically approved
List of papers
1. Registered nurses' thinking strategies on malnutrition and pressure ulcers in nursing homes: a scenario-based think-aloud study
Open this publication in new window or tab >>Registered nurses' thinking strategies on malnutrition and pressure ulcers in nursing homes: a scenario-based think-aloud study
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2011 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 20, no 17-18, 2425-2435 p.Article in journal (Refereed) Published
Abstract [en]

Aim: The aim of this study was to explore the thinking strategies and clinical reasoning processes registered nurses use during simulated care planning for malnutrition and pressure ulcers in nursing home care.

Background: Clinical reasoning is an essential component of nursing practice. Registered nurses’ thinking strategies and clinical reasoning have received limited attention in nursing science. Further research is needed to understand registered nurses’ clinical reasoning, especially for prevention of malnutrition and pressure ulcers as they are important quality indicators of resident care in nursing homes.

Design: A qualitative explorative design was used with a think-aloud interview technique.

Methods: The transcribed verbalisations were analysed with qualitative deductive content analysis. Data were collected during six months in 2007-2008 from 30 registered nurses at nine nursing homes in Norway.

Results: The registered nurses used a variety of thinking strategies, but there were differences in the frequency of use of the different strategies. The three most commonly used thinking strategies were ‘making choices’, ‘forming relationships’ and ‘drawing conclusions’. None of the nurses performed a structured risk assessment of malnutrition or pressure ulcers. Registered nurses started with assessing data from the scenarios, but after a short and elementary assessment they moved directly to planning.

Conclusion: Many different thinking strategies were used in registered nurses’ clinical reasoning for prevention of malnutrition and pressure ulcers. The thinking strategy ‘making choices’ was most commonly used and registered nurses’ main focus in their reasoning was on planning nursing interventions. Relevance to clinical practice. This study showed that most of the registered nurses go directly to planning when reasoning clinically about residents in nursing homes. A lack of systematic risk assessments was identified. The insight gained from this study can be used to recommend improvements in tools designed for nursing homes to support the registered nurses.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2011
Keyword
clinical reasoning, content analysis, pressure ulcers, registered nurses, think-aloud method, thinking strategies
National Category
Nursing
Research subject
Nursing Science
Identifiers
urn:nbn:se:oru:diva-17022 (URN)10.1111/j.1365-2702.2010.03578.x (DOI)000293748900005 ()21689181 (PubMedID)2-s2.0-80051573153 (Scopus ID)
Available from: 2011-09-07 Created: 2011-09-02 Last updated: 2017-12-08Bibliographically approved
2. Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly
Open this publication in new window or tab >>Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly
2011 (English)In: International Journal of Medical Informatics, ISSN 1386-5056, E-ISSN 1872-8243, Vol. 80, no 9, 607-617 p.Article in journal (Refereed) Published
Abstract [en]

Background: Computerized decision support systems (CDSSs) have been shown to help health care professionals to avoid errors and improve clinical practice and efficiency in health care. Little is known about its influence on nursing practice and outcomes for residents in nursing homes.

Aim: The aim of this study was to evaluate the effects on the risk for and prevalence of pressure ulcers (PUs) and malnutrition of implementing a CDSS to improve prevention and care of PUs and also to improve nutrition in the elderly in nursing homes.

Design setting and participants: The study used a quasi-experimental design with two intervention groups and one control group. A convenience sample of residents from 46 units in 15 nursing homes in rural areas in Norway was included. A total of 491 residents participated at baseline in 2007 and 480 residents at follow-up in 2009. Methods: The intervention included educational sessions in prevention of PUs and malnutrition for registered nurses (RNs) and nursing aides (NAs) in the two intervention groups. In addition, one intervention group (intervention group 1) had a CDSS integrated into the electronic healthcare record (EHR) based on two research-based risk assessment instruments: the Risk Assessment Pressure Scale (RAPS) for PU risk screening and the Mini Nutritional Assessment (MNA (R)) scale for screening nutritional status. In each participating nursing home trained RNs and NAs examined all residents who consented to participate on the RAPS and the MNA (R) scale. This examination included a skin assessment and details about PUs were collected.

Results: The proportion of malnourished residents decreased significantly in intervention group 1 between the two data collection periods (2007 and 2009). No other significant effects of the CDSS on resident outcomes based on the RAPS and MNA (R) scores were found.

Conclusion: CDSSs used by RNs and NAs in nursing homes are still largely unexplored. A CDSS can be incorporated into the EHR to increase the meaningful use of these computerized systems in nursing home care. The effects of CDSS on healthcare provider workflow, clinical decision making and communication about preventive measures in nursing home practice still need further exploration. Based on results from our study, recommendations would be to increase both sample size and the number of RNs and NAs who participate in CDSS education programs.

Place, publisher, year, edition, pages
Elsevier, 2011
Keyword
Computerized, Decision support system, Electronic health record, Intervention, Malnutrition, Nursing home, Pressure ulcer, Risk assessment
National Category
Nursing
Research subject
Nursing Science
Identifiers
urn:nbn:se:oru:diva-17019 (URN)10.1016/j.ijmedinf.2011.06.009 (DOI)000293729900001 ()21783409 (PubMedID)2-s2.0-79961210693 (Scopus ID)
Available from: 2011-09-07 Created: 2011-09-02 Last updated: 2017-12-08Bibliographically approved
3. Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes
Open this publication in new window or tab >>Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Nursing
Research subject
Nursing Science
Identifiers
urn:nbn:se:oru:diva-22539 (URN)
Available from: 2012-04-13 Created: 2012-04-13 Last updated: 2017-10-17Bibliographically approved
4. An evaluation of the usability of a computerized decision support system for nursing homes
Open this publication in new window or tab >>An evaluation of the usability of a computerized decision support system for nursing homes
2011 (English)In: Applied Clinical Informatics, ISSN 1869-0327, Vol. 2, no 4, 420-436 p.Article in journal (Refereed) Published
Abstract [en]

Background: Computerized decision support systems (CDSSs) have the potential to significantly improve the quality of nursing care of older people by enhancing the decision making of nursing personnel. Despite this potential, health care organizations have been slow to incorporate CDSSs into nursing home practices.

Objective: This study describes facilitators and barriers that impact the ability of nursing personnel to effectively use a clinical CDSS for planning and treating pressure ulcers (PUs) and malnutrition and for following the suggested risk assessment guidelines for the care of nursing home residents.

Methods: We employed a qualitative descriptive design using varied methods, including structured group interviews, cognitive walkthrough observations and a graphical user interface (GUI) usability evaluation. Group interviews were conducted with 25 nursing personnel from four nursing homes in southern Norway. Five nursing personnel participated in cognitive walkthrough observations and the GUI usability evaluation. Text transcripts were analyzed using qualitative content analysis.

Results: Group interview participants reported that ease of use, usefulness and a supportive work environment were key facilitators of CDSS use. The barriers identified were lack of training, resistance to using computers and limited integration of the CDSS with the facility’s electronic health record (EHR) system. Key findings from the usability evaluation also identified the difficulty of using the CDSS within the EHR and the poorly designed GUI integration as barriers.

Conclusion: Overall, we found disconnect between two types of nursing personnel. Those who were comfortable with computer technology reported positive feedback about the CDSS, while others expressed resistance to using the CDSS for various reasons. This study revealed that organizations must invest more resources in educating nursing personnel on the seriousness of PUs and poor nutrition in the elderly, providing specialized CDSS training and ensuring that nursing personnel have time in the workday to use the CDSS.

Place, publisher, year, edition, pages
Schattauer Gmbh, 2011
Keyword
Decision Support System, computerized, graphical user interface evaluation, nursing homes, qualitative content analysis
National Category
Information Systems Nursing
Research subject
Nursing Science
Identifiers
urn:nbn:se:oru:diva-21753 (URN)10.4338/ACI-2011-07-RA-0043 (DOI)000208686800003 ()23616886 (PubMedID)2-s2.0-84884484684 (Scopus ID)
Note

Mariann Fossum is also affiliated to Centre for Caring Research – Southern Norway, Department of Health and Nursing Sciences, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway

Available from: 2012-02-22 Created: 2012-02-22 Last updated: 2017-12-07Bibliographically approved

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