A Thesis of - Drexel University
Transcript of A Thesis of - Drexel University
Healthcare Information Technology and Medical Surgical Nurses: The Emergence
of a New Care Partnership
A Thesis
Submitted to the Faculty
of
Drexel University
by
An'Nita C. Moore
in partial fulfillment of the
requirements for the degree
of
Doctor of Nursing Practice
May 2010
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Dedications
I would first like to dedicate this thesis to my parents for their relentless confidence and
support in my educational endeavors. They‟ve always been my largest supporters
throughout my academic matriculation and without a doubt, this success is just as much
theirs as it is mine. Congratulations! Secondly, I‟d like to dedicate this thesis to all of the
children in my life – Calvin, Kanell, KaNya, Kayla, Christian, Kirsten, Deja, Daria, &
Daliyah. Never doubt your ability to excel and succeed. It is possible to maintain a
balance between hard work and hard play! If you push yourself beyond the realm of
comfort, you‟ll be surprised at how much you can achieve. However, if you aren‟t able to
push yourself, don‟t worry; I don‟t mind giving you a healthy nudge. Lastly, I would like
to dedicate this thesis to my family, friends, colleagues, and associates who have a desire
to embark upon and/or complete academic pursuits but have been unable to do so. Know
that I carry the torch for you as well as myself as I recognize that I am not an isolated
being, but rather a representative of my community.
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Acknowledgements
There have been so many who have contributed to my degree completion in one way or
another I hope I am able to do justice in acknowledging their involvement. First and
foremost, I must thank God who is the head of my life. I know the terminology is very
cliché, but I mean it with all sincerity. So many times I‟ve asked “Father, why me? –
Why did you pick me at such a young age to achieve the successes I‟ve been able to
achieve? Why have you allowed me to progress in a season when so many others have
experienced set-backs? How have I been able to matriculate through ten years of college
without any student loans or debt? How did I manage to complete my degree
requirements early and be the first African-American to graduate from this program?”
While there are many things I do know, I don‟t have a sensible answer to any of these
questions so with meekness and sincerity all I can say is “Father, thank you!” I would be
remiss to if I did not acknowledge the guidance I received from my supervising
professor, Dr. Kathleen Fisher, as well as my other committee members, Dr. Fran
Cornelius, Dr. Prudence Dalrymple, and Dr. Jean Giddens. They served as a perfectly
blended group with unique contributions all aimed toward helping me succeed. I must
extend an additional note of gratitude to Dr. Fisher for her flexibility in working with me.
I appreciate you making yourself available to me and being sensitive to my proposed
timeline. To my classmates who were a part of the Drexel dozen, I must say I greatly
benefited from each of your unique perspectives, our collegial debates, and the healthy
competition experienced. Rita thank you again for opening your doors to me the times I
needed to stay in Philadelphia. It meant a great deal to me. Becky, Deanne, Stephanie,
and Lisa, you don‟t know how great it felt to have you share in my special day with me.
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The comradery shown was genuine and I was comforted by it. I must extend a very
special thank you to my other half Darnell. I‟m quite sure I metmorphosed into a
minimum of 12 personalities over the past three years - thank you for your patience!
LaKeisha, thank you for working with me as my focus group moderator. I know it wasn‟t
the easiest task to fit into your busy schedule but you found a way. Joy I appreciate the
opportunity to bounce information around with you regarding the use of data analysis
packages. That‟s not a topic most people want to talk about but you were just excited
about it as I. Tamika thank you for your genuine excitement and zeal for my success. Last
but not least, Pam thank you for your quiet support during this process. I know that many
times you extended latitude and understanding as I shifted priorities – you are
appreciated.
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Table of Contents
LIST OF TABLES .......................................................................................................... vii
LIST OF FIGURES ........................................................................................................ viii
ABSTRACT ....................................................................................................................... ix
CHAPTER 1: INTRODUCTION AND OVERVIEW .................................................. 1
1.1. Introduction ........................................................................................................1
1.2. Background ........................................................................................................2
1.3. Purpose................................................................................................................3
1.4. Research Questions ............................................................................................3
1.5. Significance .........................................................................................................4
1.6. Limitations ..........................................................................................................5
1.7. Delimitations .......................................................................................................6
1.8. Summary .............................................................................................................6
CHAPTER 2: REVIEW OF THE LITERATURE........................................................ 8
2.1. Introduction ........................................................................................................8
2.2. Concept One: The Nurse-Technology Dyad ....................................................8
2.3. Concept Two: Healthcare Information Technology ..................................... 10
2.4. Concept Three: Clinical Decision Making ..................................................... 14
2.5. Summary ........................................................................................................... 17
CHAPTER 3: DESIGN AND METHODOLOGY....................................................... 19
3.1. Overall Approach and Rationale .................................................................... 19
3.2. Trustworthiness................................................................................................ 21
3.3. Methods ............................................................................................................. 22
3.4. Focus Groups .................................................................................................... 24
3.5. Site Selection ..................................................................................................... 26
3.6. Population Sample ........................................................................................... 28
3.7. Protection of Human Subjects ........................................................................ 29
3.8. Data Collection ................................................................................................. 30
3.9. Data Analysis .................................................................................................... 31
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3.10. Epoche ............................................................................................................... 33
CHAPTER 4: RESULTS ............................................................................................... 35
4.1. Introduction ...................................................................................................... 35
4.2. Overview of the Study ..................................................................................... 35
4.3. Subject Demographics ..................................................................................... 36
4.4. Themes .............................................................................................................. 38
4.5. Novice and Experienced Nurses: Perceptual Similarities and Differences 44
CHAPTER 5: SUMMARY & IMPLICATIONS FOR FUTURE RESEARCH ....... 54
5.1. Overview of Study ............................................................................................ 54
5.2. Conclusions ....................................................................................................... 54
5.3. Limitations of Study ........................................................................................ 62
5.4. Recommendations for Future Research ........................................................ 62
LIST OF REFERENCES ............................................................................................... 64
APPENDIX A: LIFEBRIDGE HEALTH IRB APPROVAL ...................................... 70
APPENDIX B DREXEL UNIVERSITY IRB APPROVAL ........................................ 71
APPENDIX C: INFORMED CONSENT DOCUMENT ............................................. 73
APPENDIX D: FOCUS GROUP INTERVIEW GUIDE ............................................. 83
APPENDIX E: DEMOGRAPHIC DATA COLLECTION FORM ............................ 84
APPENDIX F: CATEGORICAL ANALYSIS OF FINDINGS .................................. 88
APPENDIX G: VENN DIAGRAM COMPARISON OF DATA CATEGORIES ..... 92
APPENDIX H: DEMOGRAPHIC DATA SUMMARY .............................................. 93
VITA ............................................................................................................................ 94
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Abstract Healthcare Information Technology and Medical Surgical Nurses: The Emergence of a
New Care Partnership
An‟Nita C. Moore, DrNP
Kathleen Fisher, PhD – Supervising Professor
Currently, increasing numbers of hospitals and ambulatory care institutions in the United
States are experiencing expanding use and diffusion of healthcare information technology
(HIT), including more expansion toward the electronic health record (EHR). Considering
nurses are responsible for documenting, interpreting, and acting upon the voluminous
amount of data maintained by information systems, it is imperative that they efficiently
utilize HIT by effectively analyzing the data it yields to aid in their clinical decision
making. A few studies have addressed the relationship between nurses and information
technology in practice, unfortunately the body of literature relative to the topic is narrow
and was primarily explored prior to the proliferate implementation of EHRs. This study
sought to explore two focal points with regards to the interaction between healthcare
information technology and nurses, the first being how medical surgical nurses are
utilizing HIT in their current clinical practice. The second aim was to examine the
influence of HIT on nurses‟ clinical decision making. Utilizing qualitative content
analysis, data from two homogeneous focus groups of novice and experienced nurses was
analyzed to evaluate the identified research questions. Findings from data collected from
both groups suggest that nurses‟ clinical decision making is not overtly influenced by the
use of healthcare information technology. Five themes emerged that described nurses‟
experiences with the information technology. The following were identified as theme
labels: (a) healthcare information technology as a care coordination partner, (b)
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healthcare information technology as a change agent in the care delivery environment, (c)
healthcare information technology – unable to meet all the needs, of all the people, all the
time, (d) curiosity about healthcare information technology – what other bells and
whistles exist, and (e) big brother is watching. Nurses‟ use of new information
technology is more reliant on its‟ ability to organize and coordinate care for assigned
patient groups as opposed to guiding decision making. Results of this study suggests that
a new care partnership has emerged as the provision of nursing care is no longer supplied
by a single practitioner but rather by a paired team, consisting of nurses and technology.
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CHAPTER 1: INTRODUCTION AND OVERVIEW
1.1. Introduction
Currently, increasing numbers of hospitals and ambulatory care institutions in the
United States are experiencing expanding use and diffusion of healthcare information
technology (HIT), including more expansion toward the electronic health record (EHR)
(Taylor, et al., 2005). Survey estimates suggest approximately 27% of acute care
hospitals and 12% of ambulatory care settings have adopted various forms of electronic
health records (Bower, 2005). This progressive shift toward electronic health records has
begun to augment the delivery of patient care thus resulting in a dramatic transformation
in the care giving paradigm. Representing the largest portion of direct caregivers,
registered nurses have been labeled the largest consumers of HIT (Deese & Stein, 2004).
Because of their continuously interdependent working relationship, healthcare technology
has become an integral component of contemporary workflow practices for nurses.
Despite the safety and efficacy benefits provided by HIT, it has not been clearly
substantiated that the presence of highly advanced healthcare information technology in
the workplace truly influences a nurse‟s clinical decision making, thus potentially
improving health outcomes (Weber, 2007).
Considering nurses are responsible for documenting, interpreting, and acting upon
the voluminous amount of data maintained by clinical information systems (CIS), it is
imperative that they efficiently utilize HIT by effectively analyzing the data it yields to
aid in their clinical decision making (Kleiman & Kleiman, 2007). The majority of clinical
information systems literature focuses on practitioners‟ acceptance and use, factors
influencing successful system implementation, workflow considerations, as well as
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perceived and actual benefits (Davis, 1989; McGrath, 2008; Prince & Herrin, 2007;
Zuzelo, Gettis, Hansell, & Thomas, 2008). What remains to be further examined
however, is the interaction between nurses and technology since the infusion of more
technology in the nursing workplace is likely to continue. However, the expense of
purchasing, training, and updating healthcare technology is immense, and even more so
in a less than robust economic climate. A typical nurse‟s 24/7 use of technology to
support and deliver care must be maximized to be cost effective.
1.2. Background
The nursing literature has largely focused on the complexities experienced by
nurses in their increased roles and responsibilities to manage healthcare technologies
(Almerud, Alapack, Fridlund, & Ekebergh, 2008; Henderson & Henderson, 2006;
Zuzelo, Gettis, Hansell, & Thomas, 2008). Considering the necessity to manage clinical
and technical knowledge, it is not surprising that the consequences of the interaction
remain unknown. Research suggests that experienced nurses are better equipped to
optimally incorporate technology into their practice as opposed to their less-experienced
counterparts (Tabak, Bar-Tal, & Cohen-Mansfield, 1996). Experienced nurses have also
been found to possess refined clinical decision making skills thus enhancing their patient
care abilities (Banning, 2008). Clinical Decision Support Systems (CDSS) have been
introduced to aid in clinicians‟ decision making although questions have been raised
regarding its effect on health outcomes. In other words, is there really a true payoff or
benefit to the technology? A few studies have addressed the relationship between nurses
and technology in practice and have similarly concluded that the value of technology is
not determined by the technology itself, but rather by the user‟s appraisal of it (Holroyd,
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et al., 2007; Weber, 2007). Unfortunately the body of literature relative to the topic is
narrow and was primarily explored prior to the proliferate implementation of EHRs.
However, literature does provide descriptive templates for institutional administrators
implementing CDSS. Considerations include obtaining early user participation by
allowing end-users an opportunity to engage in needs assessments prior to the selection
of a system, allowing clinical staff an opportunity to test applications in a simulation or
pilot setting prior to widespread use, extending invitations to nurse experts to work with
system designers in individualizing system settings to reflect practical clinical scenarios,
and increasing the availability of resource staff when new CIS‟s are first introduced.
Despite the presence of suggested integration strategies to optimize acceptance and
success, institutions have liberty in determining what elements they choose to include in
implementation tactics.
1.3. Purpose
The objective of this study was to address the gap in current literature relative to
the relationship between nurses and technology in practice. Thus, the primary intent of
this project was to explore nurses‟ experiences with HIT and to better discern if the new
clinical decision support systems enhanced nurse‟s clinical decision making (CDM). The
long term goal of this project was to establish a foundation for programs that can be
developed to help novice nurses effectively and appropriately integrate HIT into their
practice.
1.4. Research Questions
The specific questions of this study were to evaluate:
1.4.1. Question One
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How are medical surgical nurses utilizing healthcare information technology in their
current clinical practice?
1.4.2. Question Two
Is nurse‟s clinical decision making influenced by healthcare information technology?
1.5. Significance
As the prevalence of HIT continues to rise, it will be critical to ensure that nurses
continue to develop and maintain the cognitive skills necessary to practice as efficient
clinicians. Unfortunately, cognitive competence in the area of clinical decision making is
potentially compromised when clinicians excessively rely on external forms of support
such as clinical decision support systems. This study is paramount in examining how
nurses currently interact with HIT so that as healthcare environments continue to flourish
with advanced forms of technology, appropriate consideration is also given to the
development of nurses responsible for the effective and efficient use of clinical
information systems.
Additionally, it is essential that those involved in CIS implementation efforts
evaluate and address practical integration in addition to logistical considerations. The
American Association of Colleges of Nurses recently deemed the management and
application of information and patient care technology an essential element to be taught
to baccalaureate nursing students (2009). Effective integration for the nurse clinician
necessitates the development and maintenance of well-developed clinical decision
making skills to prioritize the role of HIT in patient care. As the largest consumers of
healthcare information technology, the nursing profession is best suited to lead an
evaluation of how nurses are integrating HIT into their practice. This work facilitates a
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better understanding of how nurses are using CIS and its impact on CDM. The resulting
knowledge will help structure HIT implementation and evaluation efforts to ensure
optimal benefits for patients, nurses, and society.
1.6. Limitations
Limitations of the study were relative to recruitment strategies, investigator
influence, data collection method, and applicability to other settings. The participants
were recruited through purposive sampling which does not allow for the adequate
probability that the sample will be representative of the population as a whole.
Additionally, the nurse researcher worked in the research setting with direct interaction
with most members of the targeted population and as such may have influenced
participant responses. Although open-ended questions were asked, the presence of the
nurse investigator as the interviewer could have persuaded participants to respond in a
manner they perceived as favored versus truthful. Therefore, a facilitator conducted the
focus groups to avoid undue influence. Literature has reported that one of the downfalls
of group interviews is that one to two members generally dominate the discussion which
may interfere with the participation of more passive members (Stewart & Shamdasani,
1990a). Lastly, the researches applicability to other settings is of concern. Qualitative
research is often critiqued regarding the usefulness of its‟ findings beyond the sample
population of interest. The cooperating facility has its own set of cultures and norms that
may influence user interactions which may not be shared with other healthcare
institutions.
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1.7. Delimitations
Several measures were taken to mitigate the study‟s limitations and increase
trustworthiness of the work. To eliminate investigator influence of participant responses,
a moderator was utilized to conduct the focus group sessions. The moderator has
experience with leading focus groups as she has previously functioned in that capacity as
part of a multi-site National Institute of Mental Health funded study. Additionally the
moderator‟s direction of questions to participants helped to facilitate a balanced group
interview and allowed both introvert and extrovert participants an opportunity to share
their experiences. Albeit that qualitative research is criticized for the applicability of
generated knowledge to other settings, generalizability is not a primary goal of qualitative
research. It is important however that consumers of the work gain knowledge that is
useable and transferable into practice. The methods of the research process for this study
have been meticulously described so that based upon the design and sample population
consumers can adequately appraise the usefulness of research findings to their current
practice environment.
1.8. Summary
Nurses providing patient care in current technologically enhanced environments face
a level of complexity not previously encountered by veteran clinicians. HIT literature has
demonstrated the efficacy of its‟ systems relative to clinician workflow, improved
efficiency in care delivery, as well as enhancing patient safety. Despite possible benefits,
researchers have demonstrated that successful outcomes cannot be attained without early
end-user involvement, thoughtful system integration, and seamless organizational and
process considerations. The progressive emergence of healthcare information technology
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has expanded the role of nurses from care coordinators to also functioning as information
processors. Effectively blending responsibilities requires knowledgeable professionals
who are well prepared to balance care demands with technology influences.
Although existing literature has evaluated the mitigating effects of technology on
workflow, medical errors, and patient outcomes, a very narrow body of literature has
raised concern with nurses‟ integration of technology into their practice in an effort to
achieve proposed beneficial outcomes. Considering contraindication exists regarding the
benefits of clinician use of HIT, additional exploration is indicated. Existing literature has
taken into consideration user interactions with Healthcare Information Systems which are
influenced by factors such as perceived ease of use, perceived usefulness, and prior
exposure to technology (Davis, 1989). Further investigation is necessary centered upon
the narrow focus of how clinicians integrate the components of HIT into their practice
that aid in cognitive performance, such as clinical decision making, without
compromising the development of analytical and logical thought processes that are
essential for nursing functions. The nurse educator and scholar have an opportunity to fill
the gap in HIT literature relative to technology use, thus impacting HIT implementation
considerations.
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CHAPTER 2: REVIEW OF THE LITERATURE
2.1. Introduction
The progression of healthcare delivery has been augmented not only by changes
in practice but also by assistive resources utilized for the enhancement of patient care,
resulting in a dramatic change in the care giving paradigm. Similar to other professions,
the healthcare industry has incorporated the use of varying forms of technology to help
streamline care delivery, secure patient confidentiality, and improve patient safety as well
as health outcomes (Almerud, et al., 2008; Ammenwerth, Iller, & Mahler, 2006; Barnard,
1999; Barnard & Sandelowski, 2001; Henderson & Henderson, 2006; Simpson, 2004;
Summers, 2007). Accordingly, nurses as care providers are challenged with balancing
artful care delivery with technology navigation while maintaining a positive nurse-patient
relationship. The introduction of HIT and clinical information systems has expanded the
realm of nursing to integrate technology as an element as important in nursing practice as
the patient or population being served (Huffman & Sandelowski, 1997).
2.2. Concept One: The Nurse-Technology Dyad
Many nurses have embraced technology as a part of their care delivery model. As
a result, the provision of nursing care is no longer supplied by a single practitioner but
rather by a paired team, consisting of nurses and technology, working collaboratively in
an interdependent relationship to achieve established goals. A combination of two
separate terms, the concept of the nurse-technology dyad may be further understood by
defining its components. As depicted in the Miriam-Webster dictionary the term nurse
refers to an individual who cares for others who are ill or are in poor health. The source
further describes a nurse as a person who looks after, promotes and/or directs ("Nurse,"
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2008). In their Occupational Outlook Handbook, the Bureau of Labor Statistics (2008)
describes a nurse relative to functions of the nursing profession. According to the agency,
a nurse is responsible for treating and educating patients, as well as the community, about
multiple medical conditions. They further describe the role of the medical surgical nurse
as one who offers health promotion and fundamental medical care to clients presenting
with a myriad of medical and surgical diagnosis. The concept of technology can convey a
multitude of connotations depending upon the context in which it is utilized. In her
review of technology in nursing, Sandelowski (1999a) proposes that technology can be
described as either an object, a representation of a secondary concept, or as an
interpretant that helps to understand another phenomena. Barnard (1996) discusses the
three ways technology can be considered. Technology can be defined by the use of
machinery, tools, or instruments, the essence of technological advancement, or its‟
existence as a science. Dominating literature relative to technology in healthcare is the
broad classifications of technology emergence in information processing and the
mechanization of skill or labor (Almerud, et al., 2008; Barnard, 1996; Deese & Stein,
2004; McGillivray, Yates, & McLister, 2007; Zuzelo, et al., 2008).
Human computer interaction (HCI) literature presents several models that attempt
to evaluate or explain end-user interaction with information technology (IT) (Au, Ngai, &
Cheng, 2002; Davis, 1989; Goodhue & Thompson, 1995). However, recent literature
critiques that prior HCI models were not best suited to evaluate clinical information
systems (CIS). Despont-Gros, Mueller, and Lovis (2005) developed a model to evaluate
user interactions with clinical information systems that gives consideration to the
complexities associated with healthcare information technology (HIT). The model
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proposes six dimensions critical to the evaluation of CIS. A brief review of the variables
as evidenced in HIT literature will be discussed. User and system characteristics were
both identified as two separate components of the model. In his presentation of the
technology acceptance model, Davis (1989) proposed that perceived usefulness and
perceived ease of use are essential system characteristics affecting successful system
implementation. Additionally user characteristics such as years of experience and
professional training were described by Huffman & Sandelowski (1997), Aspiuynall
(1979), O‟Neil (2005), and Manias et al. (2004) as factors influencing user interaction
with CIS components. Impacts to individuals and organizations are also described as a
dimension of the model. Zuzelo and colleagues (2008) have identified that although
technologies improve the efficiency and efficacy of care delivery, they also increase the
likelihood of error and potentiate clinician dissatisfaction when system gaps are present.
Simpson (2007) further addresses the organizational and process related influences on
system implementation efforts as political forces requiring synergy for successful
outcomes. His description closely correlates with the use/context/environment aspect of
the HCI model. The process characteristic of the model is addressed in literature
discussing methods to achieve a successful system implementation. Hannah, Ball, &
Edwards (2005) provide a synopsis of informatics literature suggesting that nursing and
other end users are involved early in the planning phase of CIS implementation and that
adequate resource personnel are made available during the transition.
2.3. Concept Two: Healthcare Information Technology
Healthcare information technology is not a new concept for care environments
although it has assumed new dimensions within recent years. Computers emerged into
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the healthcare environment in the 1950‟s and evolved throughout the remainder of the
20th
century for functions relative to payroll, patient charges, inventory, research,
education, and generating statistical data (Hannah, et al., 2005). However, healthcare
computing and technology made a drastic change in the 21st century after the release of
To Err is Human by the Institute of Medicine, which called for improved safety and
efficacy in healthcare delivery (To err is human, 1999). Currently, the term healthcare
information technology refers to systems that serve as a repository for healthcare data
that can be accessed by care providers for purposes of retrieval, transfer, communication,
and/or analysis (Barnard & Gerber, 1999; Deese & Stein, 2004; Medpac, 2004; Zuzelo, et
al., 2008). The term has been used synonymously with other concepts such as clinical
information system (CIS) since a precise definition does not exist.
In a congressional report submitted by the Medicare Payment Advisory
Commission (2004), three types of information technology are evident in hospital
settings: administrative and financial, clinical, and infrastructure. Considering ambiguity
that may exist in delineating healthcare information technology from clinical information
systems, further clarification will be provided. Healthcare information technology is a
broad terminology that is inclusive of systems that can be utilized for a multitude of
healthcare related functions including scheduling, maintaining inventory, personnel
record keeping, tracking performance improvement data, and billing purposes. Clinical
information systems are a subset of HIT as these systems have a more narrowed focus
toward providing support at the point of patient care. They gather, store, analyze, and
make available clinical data for use by various members of the healthcare team. There are
multiple components of clinical systems that exist although each system is not inclusive
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of all components. Common applications of clinical information systems include
electronic health records/electronic medical records (EHR/EMR), clinical decision
support systems (CDSS), computerized provider/physician order entry (CPOE), results
reporting, and picture archiving (Medpac, 2004). Literature addressing healthcare
information technology has often focused on select CIS applications within their work as
opposed to HIT as a whole. A description of each of these CIS components will be
provided.
In their column assessing how nurses utilize HIT for improved care, Deese and
Stein (2004) describe EMR‟s as a resource that collects and stores lifelong patient care
data which can be synchronously accessed and viewed by various members of the
healthcare team. The electronic repository for patient data can be utilized to store some or
all aspects of a client‟s paper chart including provider orders, consult reports, test results,
the medication administration record (MAR) and progress notes. They further describe
the EHR as foundational for CIS. Ambiguity persists in nursing literature regarding a
concise definition for CDSS as various conceptualizations exist. Weber (2007) presents
six different characteristic descriptions of CDSS while more exist in other informatics
and information technology (IT) research. Most readily applicable is the description of
CDSS as heuristic-based computer software systems that are designed for clinician use to
aid in clinical decision making (Hannah, et al., 2005). Utilizing embedded rules and
decision-tree algorithms, this CIS element evaluates stored patient data to generate
suggestions for clinician actions (Holroyd, et al., 2007). Considering the proposed
function of CDSS, it is essential for the nursing profession to evaluate the influence of
CDSS on practice. Weber (2007) attempted to evaluate critical care nurse specialists‟
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interaction with CDSS, however no identifiable patterns of use could be identified that
describe how the systems impacted their practice.
Yet another component of HIT is the ability for CPOE. This functionality allows
providers the ability to electronically prescribe medications, lab tests, and/or procedures
both from within a care institution as well as from remote locations such as provider
offices, home, or from mobile handheld devices (Hannah, et al., 2005; Medpac, 2004).
The impact of a computerized provider order entry system was evaluated in surgical
patients by Stone et al. (2009). The findings suggested increased efficacy was realized
relative to decreased time between order entry and nurse receipt, however the percentage
of medication errors remained comparably equivalent to those experienced prior to
system implementation. This may be explained by the continued need for clinician
evaluation of provider orders, despite their electronic format, to determine
appropriateness for the patient considering the context of the clinical situation. The
remaining components of HIT offer less complexity and ambiguity in scope versus those
previously discussed. Results reporting is a method by which laboratory or diagnostic
results are electronically stored and later retrieved by clinicians while picture archiving
refers to the electronic communication of filmless images, such as x-rays, that can be
conveniently viewed on a computer. Providers can access image results through the EHR,
negating the need to locate films from various imaging departments (Medpac, 2004).
There is a great deal of variability regarding whether or not a newly hired nurse or
nursing student entering a CIS environment would have prior exposure to the varying
CIS elements. Regional or institutional characteristics could however serve as a predictor
considering the most proliferative use of EHR‟s is evident in urban areas and in teaching
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institutions (Jha, et al., 2009). Inconsistency in exposure is also influenced by the
flexibility exercised by facilities in implementing a CIS. Some institutions may choose to
maintain a hybrid electronic and paper environment by implementing isolated CIS
elements such as results reporting while other functions such as writing provider orders
remains paper based. Other institutions may create a clinical environment that is 100%
electronic requiring computerized devices to access any patient information necessary for
point of care activities. For the purposes of this research, the clinical decision support
element of CIS is the focus of consideration when evaluating nurses‟ interaction with
HIT.
Also variable in healthcare is the method by which CIS elements are introduced
into an environment. No single template exists for technology integration that is widely
accepted and utilized. As a result, end-users perception and use of the technology can be
greatly impacted by their initial exposure. Literature has however detailed factors
influencing positive introduction and adoption of HIT including the establishment of a
dedicated transition team, allowing an opportunity for early end-user involvement,
piloting the proposed system with a small user group, and providing ongoing training and
support (Hannah, et al., 2005).
2.4. Concept Three: Clinical Decision Making
Clinical decision making (CDM) is an essential aspect of nursing activity as
nurses are often responsible for interpreting and responding to a large volume of data.
The concept has been theoretically defined as making judgments about and consequently
choosing amongst options (Thompson & Dowding, 2002). Weber further describes the
process by which effective decision making is achieved to be inclusive of problem
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detection, alternatives consideration, outcomes prediction, and finally a choice selection
(Weber, 2007). Two major models exist relative to clinical decision making practices
amongst nurses, the information processing model and the intuitive humanist model
(Banning, 2008; ONeill, et al., 2005; Weber, 2007). The information processing model
emphasizes a hypothetico-deductive approach suggesting that decision making is a
rationale process following sequential algorithmic-type thinking. CDM based in this
approach has been most dominant in healthcare literature (Banning, 2008).
In early CDM work, Aspiuynall (1979) noted that nurses had improved decision
making abilities with the use of decision trees. Additionally, O‟Neil and colleagues were
in agreement that algorithms can prove beneficial in achieving optimal outcomes
considering they‟ve identified the decision making process as complex and dependent
upon internal and external clinician characteristics (ONeill, et al., 2005). The information
processing approach has been observed in the practices of novice nurses as the most
prevalent model used. In a mixed methods study conducted by Manias, Aitken, &
Dunning (2004), 25 out of 37 nurse-client interactions displayed evidence of hypothetico-
deductive reasoning. The decision making method has not only proven useful for care
delivery but also to help build nurse-patient relationships. In a 2005 publication, Wu and
colleagues described their use of a decision tree to analyze how women concluded
whether or not to have a hysterectomy. As a result of the work, nurses were able to better
understand the thought processes of their patients as well as the need for appropriate
psychological and emotional support. Despite the beneficial outcomes that have been
achieved through application of the method, it must be noted that limitations may exist
relative to the algorithm‟s structure, decision points, or incorporation of current
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knowledge (Banning, 2008). Considering the heuristic nature of clinical decision support
systems, it can be determined that their development is most closely aligned with the
hypothetico-deductive approach to decision making.
The humanist-inductive model has underpinnings in Patricia Benner‟s novice to
expert theory of clinical competence (Benner, 1984). The basis for decision making
utilizing this model is intuition and the knowledge gained through nursing experience
(Banning, 2008). In their exploratory study of CDM practices of 459 nurses in five
different countries, Lauri et al. (2001) identified a correlation between demographic
variables and decision making styles. Workers in acute care settings, with professional
education and clinical experience were most associated with intuitive CDM while those
with lower levels of education, in long-term settings, and utilizing theoretical knowledge
were more likely to subscribe to CDM practices within the realm of the information
processing model. Tabak and colleagues (1996) had similar outcomes in their evaluation
of the cognitive processes involved in decision making. They identified that experienced
nurses utilized their past experiences as a knowledge base to aid in decision making. The
intuitive aspect of the humanist-inductive model is closely linked with experience as it
relies upon pattern recognition as a CDM tool. A deficit of the approach is that the
prompting initiated by pattern recognition may be linked with incorrect decisions and the
memory of the clinician becomes integral in categorizing cues (Banning, 2008).
The two described approaches for clinical decision making in healthcare highlight
the different cognitive styles that clinicians utilize in making choices for their patients.
Use of the information processing model versus that of the humanist-inductive model is
largely influenced by user characteristics including professional experience. As a result,
17
novice nurses are most likely to make decisions using sequential algorithmic-type
thinking that is more closely aligned with the information processing model. On the other
hand, nurses with additional clinical experience will likely consider previous professional
exposure and emerging patterns in drawing conclusions that are more intuitively rooted.
2.5. Summary
Since the proliferation of healthcare information technology, various authors have
assessed its‟ effect on nursing workflow, patient outcomes, as well as the nurse-patient
relationship. Despite established benefits, ambiguous perceptions about HIT have been
reported. In a phenomenological investigation, nurses in intensive care environments
reported a polarization between technologies and caring (Almerud, et al., 2008).
Similarly, decision support technologies were acknowledged as tools useful in knowledge
translation, although system process and interface concerns affect successful clinician
adoption (Holroyd, et al., 2007). From a more favorable perspective, Dykes et al. (2007)
discussed the promotion of evidenced based practice as a benefit of nurses‟ use of HIT.
They further examined the influence of CIS on communication and workflow patterns
acknowledging that technology based communication is a transition from the
synchronous communication generally preferred by healthcare providers. Yet another
aspect of nurses‟ interaction with HIT is the effect it has on aspects of metacognition.
Considering protocols and algorithms are embedded in HIT, the question has been raised
as to what form of knowledge dominates in the healthcare environment, that of the nurse
or the information system (Hanlon, et al., 2005; Kleiman & Kleiman, 2007; Sandelowski,
1999b). A directed examination of nurses‟ experiences working with HIT will provide
18
valuable insight into the evolving care dynamics present in current healthcare settings and
resulting trends in information management.
19
CHAPTER 3: DESIGN AND METHODOLOGY
3.1. Overall Approach and Rationale
Existing nursing literature fails to adequately describe how nurses interact with
HIT and its‟ subsequent effect on decision making patterns. Considering the true
relationship between nurses and technology cannot be exclusively captured through
quantitative measures, a qualitative description is essential in performing an adequate
evaluation of their subjective experiences. The use of focus group interviews of both
novice and experienced nurses provided an optimal platform for caregivers to share their
experiences, while also allowing for exploration of the research questions. While content
analysis is traditionally considered merely a qualitative data analysis method, it is
actually a fairly standard qualitative method, although less frequently identified in the
nursing literature as a method than a form of data analysis. Use of this method in the
current study allowed for the thematic description of subjective behaviors and
experiences of nurses interacting with HIT by categorizing textual data and identifying
patterns elucidated from participant narratives. This form of inquiry proved extremely
beneficial for the study as the practical integration of technology in practice and its
perceived impact on day to day clinical decision making was explicated through
descriptions of use by end-users themselves.
Existing as one of the multiple research methods available to analyze textual data,
researchers have employed the use of Content Analysis (CA) since the 18th
century. The
first message forms analyzed with this method included hymns, media articles,
advertisements, and political speeches (Elo & Kyngas, 2008). Initially appearing in
United States literature in the mid 20th
century, CA was originally used as either a
20
quantitative or qualitative method but later became more paralleled with quantitative
research as textual data was coded and categorized (Hsieh & Shannon, 2005; Mayring,
2000). Despite its long standing history in communication, journalism, sociology,
psychology, and business, CA has gained popularity amongst qualitative researchers and
has shown steady growth in nursing and other health care professions (Ernesater,
Holmstrom, & Engstrom, 2009; Graneheim & Lundman, 2004). Recent nursing literature
has included research utilizing qualitative content analysis to analyze telenurses‟
experiences working with computerized decision support (Ernesater, et al., 2009). The
study evaluated the subjective experiences of eight telenurses utilizing a telephone
network decision support system in Sweden. Utilizing content analysis of participant
responses, researchers found that the decision support technology was supportive and
improved the quality of their work. Conversely, nurses described use of the system to be
simultaneously inhibiting as they experienced discrepancies in their interpretation of data
versus that of the system. Content analysis is a beneficial method for qualitative nursing
research because of the design flexibility afforded to the investigator. The approach
allows researchers to engage in an expansive investigation of participant experiences
considering data analysis involves much more than a simplistic description of data
(Cavanagh, 1997; Elo & Kyngas, 2008).
As a research method, content analysis permits researchers the opportunity to
follow either a deductive or inductive approach to evaluate data. The selection of analysis
techniques depends upon the research question. A deductive analysis is best suited when
there are existing categories, concepts, models, or hypothesis to be tested. Conversely, an
inductive approach is preferred when there is insufficient or fragmented knowledge
21
available about the phenomena. Despite the selection of a deductive versus an inductive
approach, the researcher has a responsibility in establishing soundness in the analytic
process to ensure a clear understanding of how analysis ensued as well as existing
limitations. Termed trustworthiness, means of determining soundness in qualitative
content analysis are similar to those techniques necessary to demonstrate validity in any
qualitative work. This process often involves dissecting the research procedures and
providing detailed descriptions of the analytic design (Elo & Kyngas, 2008).
3.2. Trustworthiness
Methods for establishing the rigor of qualitative work differ from those that are
typically utilized in the conventional quantitative realm. Traditional means of evaluating
results of research conducted in the positivist paradigm are not appropriate for qualitative
content analysis considering it differs in its research purpose and interpretive processes.
In judging research originating from the naturalistic or constructivist paradigm, the term
trustworthiness is often applied to an evaluation of the quality of the work. When
evaluating the trustworthiness of qualitative research key concepts emerge. The notion of
credibility replaces internal validity, dependability replaces reliability, transferability
replaces applicability, and confirmability replaces objectivity (Munhall, 2007).
As it pertains to qualitative research, credibility involves ensuring that the raw
data was adequately and logically constructed into the derived categories and themes.
This was established through the group moderator‟s engagement in concurrent member
checking during the group session as well as allowing respondents to view and confirm
analysis results following interpretation of data. Additionally peer debriefing contributed
to establishing credibility in that two nurse researchers, myself as the principal
22
investigator and the supervising professor overseeing this study, reviewed and coded
group data and continually met until consensus was reached. Dependability in qualitative
research denotes the process and degree to which the researcher accounts for the
evolution of the phenomenon while confirmability refers to the extent to which elements
of the data can be corroborated by those who review the results (Zhang & Wildemuth,
2009, p. 313). Both dependability and confirmability are generally established through
evaluation of the research methods and findings. Dependabiltiy can be judged by
appraising adherence to the determined process as described in the research report.
Research consumers can assess confirmability by considering the process of peer
debriefing utilized by the nurse researcher as well as auditing relevant research data
including notes, memos, transcripts, and derived categories. Lastly, a measure of a
study‟s trustworthiness is the degree to which derived interpretations can be applied to
other settings, contexts, or populations. This is also referred to as transferability. While it
is not the researchers responsibility to establish applicability of outcomes in other
contexts, this element can be enhanced by the provision of comprehensive detailed
information about components of the study process and by following established criteria
for reporting qualitative research (Zhang & Wildemuth, 2009). Both elements for
improving transferability have been detailed in this research report.
3.3. Methods
Initial planning of the study began with development and refinement of the
research plan. Additionally, written approval was obtained from the Vice President of
Patient Care Services to utilize Northwest Hospital as the research site and its‟ nurses as
potential participants. To ensure compliance with institutional regulations as well as
23
participant protection, institutional review board (IRB) approval was sought and obtained
from both LifeBridge Health and Drexel University prior to the initiation of any research
activities (appendices A & B). After receiving IRB approval, recruitment notices
highlighting the proposed study were placed throughout the facility in areas frequently
accessed by registered nurses. Additionally, the nurse researcher attended staff meetings
to announce recruitment efforts for the proposed study. Interested employees were
provided with a telephone number dedicated to the research study as a means to contact
the researcher. The same contact information was included on the advertising material for
potential respondents. At the time of respondent contact, the nurse researcher reviewed
inclusion and exclusion criteria to determine if the potential participant was eligible for
study participation. Once eligibility was established, an offer was extended for
participation in the corresponding focus group on a pre-determined date and time.
Registered nurses were stratified into either the novice or experienced group depending
upon their years of experience.
To ensure participants were well informed of their role and options relevant to the
study, the nurse researcher made arrangements with the registered nurse to provide
him/her with a copy of the consent form prior to the focus group date (appendix C).
Participants were encouraged to take the consent form home to review and contact the
researcher should they have any additional questions. Written informed consent was
obtained from participants on the date of the group interview immediately preceding the
commencement of data collection. Each participating nurse was provided with a signed
copy of the written consent prior to the conclusion of the focus group interview.
24
Prior to the initiation of data collection activities, several meetings were held with
the focus group moderator to review the objective of the research as well as her role as
the facilitator. The nurse researcher reviewed the CDSS technology with the moderator
by accessing the system during one of the preparatory meetings to enhance awareness of
the participants‟ experiences. The moderator was provided with relevant literature
detailing practical methods for focus group moderation to strengthen the quality and
blend of data received from participants. Additionally, a copy of the focus group question
guide was provided prior to the focus group date. The nurse researcher and the facilitator
reviewed the focus group guide to ensure understanding of each question and its
relationship to the overall research intent. Supplemental questions were provided that
could have been used for probing should the moderator have experienced a lull in
participant discussion. On the day of data collection, the nurse researcher met with the
moderator immediately preceding each group interview to assess if any outstanding
issues needed to be addressed and to assure appropriate functioning of the digital audio
recorder. The nurse researcher met each participant at the beginning of the scheduled
group interview to obtain informed consent and to introduce the moderator, but left the
meeting room prior to the initiation of each group session.
3.4. Focus Groups
As previously stated, a focus group strategy was selected in order to engage
nurses who were interacting with information technology at various experience levels.
Focus groups can be described as group interviews undertaken “…with the ultimate goal
of observing the interactions among focus group members and detecting their attitudes,
opinions, and solutions to specific topics posed by the facilitator” (Fain, 2004, p. 160).
25
Originally utilized in marketing research, the data collection method has become
increasingly popular in social science as well as nursing work (McLafferty, 2004). Use of
this strategy not only allowed for the exchange of ideas, but also provided an opportunity
for in-group validation of experiences.
Varying literature has described groups sizes that include as few as four and as
many as 15 participants (Krueger & Casey, 2009; Marshall & Rossman, 2006;
McLafferty, 2004). Although there is no ubiquitous consensus on focus group sizes, most
are composed of 6 to 12 members (Fain, 2004; McLafferty, 2004; Stewart & Shamdasani,
1990b). Larger groups of 10 to 12 members are commonplace for marketing and
commercial research purposes. The larger size is most appropriate for discussing topics
not well explored or experienced by participants. Differing from that which is
traditionally recommended, the use of a smaller assembly of four to six members, also
referred to as a mini-focus group, has become increasingly popular. In determining a
suitable sample size for focus group construction, consideration should be given to the
purpose of the research as well as participant characteristics. Despite their infrequent use,
smaller mini-focus groups are appropriate when: (a) the intent of the research is to
understand a phenomena or behavior, (b) the issue is complex, (c) groups members have
a substantial degree of experience or expertise with the subject matter, (d) participants are
passionate about the topic, or (e) there are an extensive amount of questions to be
presented (Krueger & Casey, 2009). While not ideal, the use of mini focus groups for this
work was adequate considering the explorative intent of the research as well as the
participants‟ continuous interaction with the subject matter, healthcare information
technology. Knowledge gained from the small group provided compelling insight into the
26
shift in care processes for the nurse clinicians. Considering the group members expertise
with utilizing the healthcare information system, they were able to provide detailed
feedback about the effect of its use on their workflow and other patient care activities.
This study met many of the criteria for acceptably utilizing a mini-group in that the intent
of the research was to understand clinician behaviors, the nurses had a substantial degree
of experience with the topic, and they were passionate in their subjective depictions.
3.5. Site Selection
Participants were recruited from the Acute Care Services Division of Northwest
Hospital (NWH) in Randallstown, Maryland. A part of the LifeBridge Health System, the
institution is a 242 bed, not-for-profit community acute care hospital providing services
for medical, surgical, behavioral health, rehabilitative and hospice patients (LifeBridge
Health, 2010). The hospital employees approximately 213 registered nurses possessing
varying levels of nursing skill ("Northwest Hospital Center - Randallstown, MD," 2010).
During the spring of 2006, NWH began to phase out portions of its‟ paper health record
by gradually introducing elements of the Cerner clinical decision support system
including electronic health records, computerized provider order entry, results retrieval,
and an electronic medication administration record. The systems implementation
involved the administrative selection of a CIS and pilot introduction amongst small user
groups. The facility has currently adopted several aspects of the CIS including use of an
electronic medical record, computerized provider order entry, clinical decision support
elements, results reporting, and picture archiving. Discussion relative to Cerner system
use by research participants largely focused on the results reporting element as well as the
clinical decision support component. As previously described, the results reporting
27
element allows nurses to quickly retrieve various types of patient information at the point
of care. The clinical decision support component is most evident in the form of patient
care alerts. The Cerner system analyzes stored patient data utilizing embedded heuristics
and recommends subsequent clinician actions. One such example is a sepsis alert that
suggests clinicians evaluate a patient for sepsis based upon an electronic evaluation of a
patient‟s vital signs.
Despite the comprehensive nature of the current system, CIS components have
been incrementally introduced in stages since the systems adoption four years ago. Prior
to each new stage of the Cerner system implementation, staff were required to attend
classes regarding use of the new system component. Additionally, during periods of
hospital-wide Cerner implementation initiatives, designated staff were made available for
HIT concerns as a resource to bedside clinicians at the point of care. The organization
continues to employ a small e-learning department tasked with providing ongoing system
support for clinicians, as well as training newly hired nursing staff and student nurses.
Phased-in transition from paper to electronic documentation continues as the
environment is currently hybrid with records of various care elements still located in
patient‟s paper charts. For those employees entering the hospital since the 2006
introduction of Cerner, standardized classroom-based computer training is provided as a
part of clinical orientation. Regardless of skill level and experience, all nurses receive
approximately nine hours of Cerner training prior to entering the care environment. For
nurses new to the hospital, this training is reinforced in the clinical setting as staff work
with their unit based preceptor.
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3.6. Population Sample
A purposive sample was utilized for this study in an effort to elicit rich
meaningful data. This method of sampling involves the deliberate selection of
participants who have experience with the phenomena of interest and also possess traits
of a contributable informant (Munhall, 2007). The targeted populations were novice and
experienced nurses regularly utilizing the Cerner clinical decision support system in their
clinician workflow practices. As described by Benner (1982), novice or beginner nurses
have no experience in the areas they are expected to perform while professional
competency is likely achieved after two to three years of practice when the nurse is able
to see their actions as a part of long-term goals. Considering the previous work of Benner
in developing this study, 10 years has been identified as the minimal practice timeframe
for experienced nurse as the veteran nurse will have passed the two-three year threshold
associated with the beginning nurse and also will have gained additional clinical exposure
adding to their background of experience.
Potential participants were unable to participate if they met any of the following
exclusion parameters: (a) younger than 21 years old or older than 75 years old, (b)
working in the hospital as a temporary or agency employee, (c) educationally prepared
with a Master‟s Degree in Nursing, (d) unable to read, speak, or understand English, (e)
have a self reported learning disability that interferes with the receipt or interpretation of
information, or (e) currently a novice registered nurse previously employed as a practical
nurse. An invitation to join the study was extended to potential participants who: (a)
possess a current active license as a Registered Nurse in the state of Maryland, (b) read,
speak, and understand English, (c) were employed a minimum of 16 hours per week by
29
the cooperating facility as a staff nurse on a medical/surgical unit, (d) were legally and
cognitively competent of signing their own consent to participate in a research study, and
(e) have been employed either two years or less or 10 years or more as a Registered nurse
in an inpatient hospital setting.
3.7. Protection of Human Subjects
Although medical surgical nurses interacting with healthcare information
technology in an acute care setting are not considered a vulnerable population, measures
were taken to ensure their protection in this study. As candidates volunteered to be
included in the study the nurse researcher, in accordance with the institutional review
board (IRB), obtained written informed consent from each potential participant, which
conveyed the intent to maintain confidentiality. Upon initial determination of study
eligibility, a review of the consent was provided to participants, as well as an explanation
of the purpose, risks, and benefits of the study. Candidates were then provided with an
opportunity to ask questions and clarify any unresolved concerns. The participants were
provided with a copy of the consent form prior to the focus group date to allow
participants sufficient time for review. The researcher obtained written consent from each
participant on the date of the focus group before any data collection began. Immediately
prior to obtaining written consent, participants were asked to accurately restate the
purpose of the study in addition to expectations of persons involved. Participants were
clearly informed that their involvement in the project was purely voluntary and that they
reserved the right to withdraw from participation at any time.
All data collected and analyzed as part of this study were protected from
disclosure outside the research team, thus minimizing the risk to individual participants.
30
Communication with both candidates and established participants was kept private. Initial
screening communications were conducted over the telephone from a telephone number
and line designated for the research project and only accessible by the PI. The focus
groups were held in a private locked room that once locked could only be opened by
maintenance employees and those inside the room. Additionally, no personal identifiers
were connected with the data. A unique identification number was assigned to each
participant and a log generated that was only accessible to the investigators. The PI
managed and stored all data and only shared that which was necessary with the co-
investigator. Electronic data as well as audio recordings were stored in the PI‟s locked
office. Participant demographic sheets were also securely located and double locked to
protect participant privacy. Electronic transcriptions of the audio data were maintained on
LifeBridge Health‟s secured network which is password protected and inclusive of
firewall technologies that prevent access from unauthorized users.
3.8. Data Collection
During the focus group interview, participants were asked investigator developed
questions relative to their use of and interaction with technology. The interview guide and
demographic data form were reviewed for face validity. In conjunction with the research
team/advisory committee, the nurse researcher refined the data collection instruments to
ensure targeted pieces of demographic data were collected and to facilitate a rich
discussion about the phenomena of interest. Both the interview guide and demographic
data tool are included with the final report as appendices D and E respectively. Open
ended questions were utilized to solicit participant perceptions relative to the influence of
healthcare information technology on their clinical decision making and resulting patient
31
care. Questions included “Has the clinical decision support system ever helped you to
make patient care decisions?” and “What do you think is the role of the clinical decision
support system in analyzing or interpreting patient data?” The novice group interview
lasted approximately one hour while the experienced group interview was approximately
one and one half hours in length. Both focus group interviews were audio recorded and
subsequently sent for professional transcription. Additionally, demographic data was
collected from each participant using an investigator-developed form. The form queried
participants for information such as age, gender, educational level, months and/or years
of experience as a registered nurse, perception of Cerner training, and use of technology
for purposes other than nursing care. Demographic data provided a descriptor of the study
participants in each group, their professional nursing experience, and prior exposure to
varying forms of technology.
3.9. Data Analysis
Hsieh and Shannon (2005) describe three approaches to qualitative content
analysis, conventional, directed, and summative. A conventional analysis is often
employed when there is scarce literature available about the phenomena of interest. This
approach avoids preconceived categories when analyzing the data, but rather allows
insights to emerge from the data. Directed analysis utilizes a more structured approach to
analyze data as existing research of theories are often utilized to predict or further explain
the relationship amongst variables. Lastly, summative analysis in qualitative work
involves the identification and subsequent counting of particular words or content with
the resulting purpose of exploring usage and latent meaning.
32
Considering the limited amount of research available discussing the relationship
between nursing and technology in clinical practice, a conventional analysis was utilized
which allowed for a thematic interpretation of participant responses to emerge from the
data. Zhang and Wildemuth (2009) present a structured and systematic way to process
data for qualitative content analysis. This includes the following nine steps: (a) data
preparation, (b) determining the unit of analysis, (c) development of categories/coding
scheme, (d) testing the coding scheme, (e) coding the remaining data, (f) assessing for
coding consistency, (g) interpretation of coded data, and (h) drafting the final report of
methods and findings.
Demographic data was maintained and analyzed with a SPSS statistical package
while transcribed data was managed with ATLAS.ti qualitative data analysis software.
The researcher was adequately prepared to utilize SPSS software through formalized
training received in the academic setting, while attendance at a two-day dedicated
training session served as the preparatory method for use of ATLAS.ti. The analysis
process began with transcription of the data by a professional transcription service. The
resulting records were compared against the focus group audio recordings to confirm
accuracy and inclusiveness of all participant data. The participant data was independently
reviewed and assigned preliminary codes by two nurse researchers. Utilizing electronic
and telecommunication platforms, the two researchers met weekly until consensus about
the coding schematic was achieved. Codes were subsequently grouped into categories
and later counted for frequency of occurrence in each group (appendix F). Dominant
categories were grouped and pictorially recorded in a venn diagram (appendix G) to
identify ideas that were unique to novice or experienced nurses as well as those that were
33
shared by both. Categories were later shared with a member of each of the focus groups
to confirm interpretations and contribute to the authenticity of the data.
3.10. Epoche
Considering my professional relationship with the cooperating institution as well
as the sample population, I may have biases that could potentially interfere with an
impartial evaluation of the data. For purposes of analysis, it is important that I identify
my position as the researcher as well as how I dealt with professional prejudice to
maximize objectivity in this study. While conducting this research, I functioned as an
Education Specialist with LifeBridge Health. In this role I shared responsibility for the
development and progression of new graduate nurses as well as recently hired clinical
staff. In addition to working with new staff, I provided educational support for existing
nursing personnel working in acute care areas for an array of topics including Cerner.
Oftentimes, gaining familiarity with use of the Cerner CDSS system was an area
of contention for new staff and so I‟ve frequently provided or arranged for additional
support in this area. During the initial system implementation in 2006, I functioned as a
member of the super user team teaching several of the inaugural courses and providing
after hours support. Since the implementation of the Cerner clinical decision support
system, I‟ve witnessed the change in nursing care patterns. I found the decision making
patterns of new graduate novice nurses working together with this new form of healthcare
information technology to be very intriguing. Although novice nurses are inherently in a
developmental phase, I questioned whether or not some of their faulty decision making
was a result of lack of experience or from blindly following heuristic-based computerized
directives.
34
In acknowledging my inherent biases, I engaged in bracketing throughout the
research process in an effort to minimize personal influence and express validity of the
data collection and analytic methods (Ahern, 1999). Bracketing has been described as an
active process whereby researchers identify pre-existing experience, ideas, beliefs, and/or
judgments about a phenomena and make concerted efforts toward separating them from
the research process (Ahern, 1999; Fain, 2004; Gearing, 2004). Prior to the initiation of
research activities, I shared my theoretical position with the research team as well as my
subjective experiences with the phenomena of interest. To eliminate bias during the data
collection process, an experienced group moderator was hired to conduct both focus
group sessions. This not only eliminated investigator influence, but also helped to create
an atmosphere where participants were able to freely share their experiences.
Additionally, audio recordings of the sessions were sent for professional transcription
prior to initiating the analysis process. During the data analysis phase of this study, two
nurse researchers met via teleconferencing after independently reviewing the focus group
data. Each separately assigned codes to the data and continued to meet until inter-coder
agreement was achieved. Following investigator analysis, select participants were
engaged in member checking to validate conclusions reached by the researchers. Munhall
(2007) described member checking as a process during which narrative results are shared
with research informants prior to public presentation or publication. Findings from the
data were presented to representative members of each group to verify correct
interpretation of participant responses and allow for clarity of ideas not appropriately
captured.
35
CHAPTER 4: RESULTS
4.1. Introduction
The results of this study are described and organized into three main sections.
Following a brief overview of the study, the first section describes the demographics of
study participants. The second section includes the study themes and findings with
excerpts from the two focus group interviews. A conventional analysis was utilized
which allowed for a thematic interpretation of participant data and the five main themes
that emerged from this data is presented. The third section describes support for study
findings with existing studies in nursing literature.
4.2. Overview of the Study
This study sought to examine the relationship between medical surgical nurses
and healthcare information technology in the acute care setting, and the subsequent effect
of this relationship on nurses‟ clinical decision making. The two research questions were:
Question one: How are medical surgical nurses utilizing healthcare information
technology in their current clinical practice?
Question two: Is nurses‟ clinical decision making influenced by healthcare
information technology?
A qualitative approach was essential for this research considering the limited availability
of literature describing the interaction between nurses and clinical decision support
systems in the hospital setting. To conduct an adequate exploration of nurses‟
experiences with HIT, it was necessary to allow nurses, as end users, an opportunity to
openly describe their experience with CDSS, as well as their perception of its role in the
provision of patient care. The use of focus group interviews provided a platform for
36
novice and experienced nurses to share their opinions about use of new Cerner
technology. Additionally, the group setting allowed for the exchange and validation of
ideas amongst participants having experience with the topic of interest. Considering the
explorative intent of the study, content analysis served as a suitable research and analysis
method in evaluating participant responses. Insights regarding the role of HIT in the
provision of patient care emerged from the methodological review of transcribed
participant data and subsequent themes were able to be identified.
4.3. Subject Demographics
A total of eight medical surgical nurses participated in the study, four novice and
four experienced. Considering nursing is a female dominated profession with only 5.8%
of RN‟s being male, the gender mix mirrored that which is evident in current nursing
trends as there was only one male participant within the sample (HRSA, 2004). The mean
age of the novice nurse was 37.5 years of age while that of the experienced nurse was
43.5 years. The average age of both groups is still less than the mean age of 46.8 reported
in the last National Sample Survey of Registered Nurses (RN) (Health Resources and
Services Administration, 2004). Also differing from national statistics of registered
nurses is the ethnic mix of research participants. Nationally, approximately 80% of
registered nurses are white while RN‟s of African American and Asian descent account
for a combined 7% of the nursing population. A more diverse group was represented in
the sample considering only 38% of participants were White and the remaining 62% self
identified as African American or Asian. The ethnic mix may partially be explained by
the progressive recruitment of internationally educated nurses to meet demands for a
larger nursing workforce. Additionally, the institution is located in close proximity to the
37
city of Baltimore, which is a predominately African-American community. Six of the
eight participants were academically prepared with an Associate‟s degree in nursing
representing 75% of the study sample. All of the respondents reported utilizing computer
technology for personal functions other than those associated with work requirements.
Additionally, all of the participants denied ever attending classes or receiving instruction
in nursing informatics. Only one of the eight respondents, an experienced nurse, reported
using clinical applications on a personal digital assistant (PDA) to aid in making patient
care decisions. A further description of participant responses to demographic data
collection follows and is also summarized in appendix H.
4.3.1. Novice Nurse Demographic Responses
The novice group was comprised of one male and three female participants, all of
whom were Associate prepared registered nurses, ranging in age from 28 to 47. Although
screening was performed for all study candidates, one respondent reported having
practiced two and a half years as a registered nurse while the nurse with the least amount
of experience reported only six months in practice. Contributions from the novice
participant with two and a half years experience were considered equally valuable
considering the lengthy amount of time required to gain the skill and experience
necessary for expert practice. Two of the nurses identified themselves as Black or African
American while the remaining two identified themselves as White. None of the novice
participants had experience working with a HIT system other than the Cerner system
utilized at the cooperating facility. Three of the four novice participants reported being
very comfortable with utilizing the Cerner technology and perceived that the initial
training received as a new hire was adequate for efficient use.
38
4.3.2. Experience Nurse Demographic Responses
All four of the experienced nurses were female and ranged from 38 to 51 years of
age with a span of 13 to 30 years of experience reported. Two group members self
identified as Asian, one as Black or African American and one as White. A mix of
educational preparation was evident in the experienced group as two of the nurses were
Bachelor‟s prepared and two were prepared at the Associate level. Additionally, one of
the Associate prepared nurses also reported having a Bachelor‟s degree with an education
concentration. Different from the novice group, only one of the experienced nurses
received their initial registered nurse training in the United States. Also different from the
novice group, two of the experienced nurses had experience utilizing another HIT system
other than Cerner. Similar to novice responses, three of the four participants perceived
the initial Cerner training to be adequate and were comfortable with utilizing it in the
clinical setting.
4.4. Themes
In subscribing to the conventional inductive approach to qualitative content
analysis, an exploration of specific responses revealed five main themes that emerged
from participant data. These ideas embody the numerous categories developed from
transcript codes and provide descriptive quality to the interaction between nurses and
healthcare information technology in the medical surgical care environment. While three
overarching themes were identified with applicability to both novice and experienced
nurses, two additional ones surfaced, one specific to the novice group and the other to
experience.
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4.4.1. Theme One: Healthcare Information Technology as a Care Coordination Partner
Highly evident from participant data is the presumption that the integration of
healthcare information technology in the medical-surgical care setting has led to the
partnering of nurses and technology in the provision of patient care. This dynamic is
evidenced by the following categorization of coded data: presence of the nurse-
technology dyad, Cerner‟s function as a convenient depot for patient information,
Cerner‟s provision of clues or prompts to further investigate patient data, and the
increased vulnerability of nurses when the clinical information system is not available.
Whether nurses have an affinity or disdain for the clinical decision support system and its
accompanying electronic health record, an impermeable relationship exists between the
two. Both novice and experienced nurses described functions of the Cerner system
relative to the retrieval of patient information, care orders, and scheduled tasks. Their
reliance on Cerner for elements of care coordination is further supported by descriptions
of care interruptions and task uncertainty when the system is not available.
N1 –One of the best advantages of the Cerner is that it sort of schedules your day
for you because you know what you have to look ahead to, what you have to plan
for.
E1 – If this computer suddenly lost, out of the blue, you are going to get lost too.
E2 – You are dependent on the computer.
The presence of Cerner as a care coordinator partner is a manifestation of the previously
described nurse-technology dyad that is increasing evident in technology-enhanced
environments.
40
4.4.2. Theme Two: Healthcare Information Technology as a Change Agent in the Care
Delivery Environment
In discussing care patterns with use of the Cerner technology, nurses were able to
describe a palpable conversion in the patient care environment. Many of these changes
related to the transparency of user access, actions, and documentation that resulted in
functional or workflow changes amongst members of the care team.
N1 – Save time for me because it‟s fast.
Prior to the introduction of EHR‟s, no definitive methods existed to assess what
clinicians accessed health records to document care, revise forms, or place and update
patient orders. As a result of the increased transparency provided by the Cerner system,
users are more meticulous when accessing and documenting in electronic charts.
E1 - You cannot actually just open any patient because it will tell you opened
it…it will actually guide you to just mind your own business.
Additional code categories supporting Cerner‟s influence in changing the care
environment were the increased safety classification as well as the description of Cerner
as both comprehensive and restrictive.
E2 – It provides a safer environment for the nurses, especially the MAR. When it
used to be in the paper, there were more mistakes, more likely to have mistakes
because the penmanship is not too legible when they describe it – more mistakes.
4.4.3. Theme Three: Health Care Information Technology – Unable to Meet all the
Needs, of all the People, all the Time
Despite the numerous positive elements identified by nurse users, there were a
great deal of system limitations that subsequently necessitated creative thinking from the
41
staff to achieve desired outcomes. When discussing Cerner‟s deficiency in meeting some
clinical user needs, participants specifically referenced limited areas available for
individualized documentation, template-based orders that did not entirely reflect the
primary care provider‟s intent, as well as electronically scheduled medications resulting
in schedules that are heuristically based as opposed to contextually driven.
E3 – The MAR, you cannot put there, those are not given because pharmacy has
not delivered.
E4 – The time comes again,10:00 pm you give it, it is overloading the patient. Not
only that it is going to charge the patient….it is not good for the system or the
patient.
N2 – Would appreciate if we have more areas to type in a comment.
N4 - Nowhere you can write your own little note to something.
In these instances, the use of Cerner created a gap in the continuity of care.
Subsequently, both experienced and novice nurses assumed responsibility for initiating
system work-arounds to repair fissures created by mandated use of the system.
Caregivers‟ perception of CIS deficiencies can potentially have detrimental effects on
future acceptance and use. As previously alluded to, the value of clinical information
systems cannot solely be evaluated by outcome measures, end-user appraisal must also be
taken into consideration. Should users perceive the technology as incapable of meeting
essential care-functions, an impermeable lack of acceptance may arise, resulting in a
fixed dissociation from integrated use. Participants in this study were able to devise
methods to obtain pre-determined outcomes when system limitations persisted. For
example, nurses described occasions when it was contextually fitting to rearrange
42
medication administration times that were originally scheduled in the electronic MAR for
a different time. Nurse users navigated system options to reschedule or omit a medication
dose when they deemed it clinically appropriate, as opposed to adhering to timeframes
originally reflected in the CIS.
E2 - When it [medication] is not due, sometimes it does not come up…I say okay
no problem, I know what to do, you click on additional, you reschedule.
E1 - I reschedule the second dose of the medication and then I return the
medication but I write on the medication already given
N4 – I recently had a situation where the patient had the same medication ordered
in different doses for the same time to be given. And I thought something couldn‟t
be right.
4.4.4. Theme Four: Curiosity about Healthcare Information Technology – What other
Bells and Whistles Exist
While not an idea shared by both groups, curiosity about various system elements
was undoubtedly evident during the novice nurse interview. Throughout the discussion,
the inexperienced nurses inquisitively commented on the multifaceted nature of the
Cerner system. Users acknowledged that there were several system functions that aren‟t
utilized as well as documentation areas where they‟ve not been exposed.
N3 – Everyday I‟m seeing something new that I didn‟t know was there before.
N4 – Probably a thousand more things it would do that we don‟t do everyday.
Additionally, the group gave feedback about what features they‟d welcome that would
aid in their patient care activities. When considering contrasting perceptions of
experienced nurses, their interest in working with more elements of the clinical decision
43
support system may result from their initial development in a technologically enhanced
atmosphere as opposed to having previous experience with a paper-based environment.
4.4.5. Theme Five: Big Brother is Watching
Peculiar to the experienced nurses was their uneasiness with the increased
transparency provided by use of electronic health records and the clinical decision
support technology. Participants were comfortable and confident in their patient care
responsibilities and conveyed a disdain for having to intricately balance meeting
predetermined demands for computer documentation that impeded their ability to
prioritize patient care.
E3 – Sometimes it is the people around it. Sometimes, these people around it, like
the performance evaluator or anything that looks into your work, sometimes it
adds stress to yourself because they want us to put the assessment by this certain
time. Of course you cannot really do that one because you have to take care of
your patient.
Experienced nurses expressed irritation with retribution received by administrative
nursing staff tracking documentation trends not consistently in compliance with
institutional policies and procedures.
E4 – Our names are going to be printed on the billboard if we do not do our
patient response.
The perceived divide in priorities for clinical versus administrative staff has resulted in
the experienced nurses‟ view of performance improvement staff as oppositional team
members who are not abreast with the realities of direct care and subsequently most
concerned about documentation completion.
44
E1 – They do not know what is going on, you are the one who knows what is
going on although they want to check.
Experienced nurses seemingly respond to administrative pressures by continually
asserting their autonomy as care providers who are best able to determine what nursing
actions should take precedence over others.
4.5. Novice and Experienced Nurses: Perceptual Similarities and Differences
Despite differences in levels of experience, members from both the novice and
experienced nurse groups shared various perceptions about aspects of the Cerner system
and its subsequent influence on their workflow. Reported data also revealed polarized
observations that were more insular to one group versus the other. Analysis of the
transcribed data is reflected in the subsequent categorization of participant responses.
4.5.1. Shared Novice and Experience Nurse Perceptions
Initial reactions to the Cerner system were constructive and reflected the
advantageous components of the technology. Participants from both the novice and
experienced group shared positive impressions about the convenience of the program as
evident in descriptions of it making things quicker and faster as well as its ease of use.
Particular discussion regarding convenience of the system centered on easy accessibility
to patient information at the point of care, in addition to its function as a resource for
medication, diagnostic, and disease related data. Zuzelo and colleagues (2008) reported
similar time conserving efforts in their study evaluating the influence of technology on
registered nurses‟ work. Technologies were perceived as productive in eliminating the
necessity for staff to complete tasks able to be met through other technological means.
When asked about the importance of clinical decision support cues that direct
45
practitioners to consider particular etiologies for various clinical manifestations including
vital signs and/or laboratory results, two collective ideas were expressed. The first being
that the summary patient data provided to clinician users in the form of „clinical alerts‟
was perceived as a beneficial prompt to further investigate the patient‟s current health
state.
N2 – It does at least make you stop for a second and usually right away I‟ll go
verify the vitals and the labs to see if I agree that the alert is telling me something;
to see if there‟s an infection or a temperature or vitals out of line, so it does help
in that sense
E1 – I think that is one way to remind the nurses that they initially assess a septic
[patient] and if you think they are not septic anymore you still have to look after
that patient…you still have to look for those signs and symptoms; you still have to
check if they are septic.
Novice nurse users did however express that repetition of such alerts could be
desensitizing. Secondly, both groups maintained that the decision making practices of the
nurse superseded that of the clinical decision support system as evident in one experience
nurses‟ response, “…do not rely on the computer itself.” Yet another observation shared
about interaction with the program during patient care activities is its propensity to
restrict individualized documentation despite the vast and comprehensive documentation
abilities available. Users expressed that Cerner provides them with flexibility in their
documentation options but that fixed categorical selections may not fully capture the
intent of the care provider.
46
E2 – That selection is fixed already but sometimes other doctors want something
else. But even if they modify, you cannot really find it on the computer what they
want to order. So sometimes they put it as a miscellaneous order.
Several studies evaluating nursing and technology have also reported dichotomous
perceptions of the beneficial yet restrictive properties of healthcare information
technology. Swedish telenurses working with a telephone based clinical decision support
system conveyed that system elements complemented their existing knowledge but
simultaneously reported use of the system could be inhibiting if they disagreed with the
technological guidance (Ernesater, et al., 2009). Wikstrom, Cederborg, & Johanson
(2007) provide a summarized report of earlier research proposing that the actions of RN‟s
are restricted by various forms of technology. When describing their use of and
interaction with the new clinical decision support technology, nurses indirectly described
their dependence on the system and increased vulnerability without it. This dependence
was not conveyed with regards to physically providing patient care, but rather the need of
the HIT system to provide essential information stored within that directs patient care
activities. Compounding the issue of dependence, novice and experienced nurses alike
described feeling lost when the system was unavailable due to periods of downtime
because of their reliance on it to organize care activities.
N3 – I think it would be very difficult if it goes down to know everything you
have to do for all of your patients.
N4 - It keeps you reminded so to speak. You know, as to what to do at different
times, which is very good.
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E1 – If this computer is suddenly lost, out of the blue, you are going to get lost
too.
E2 - So your computer always needs to be like always on. It needs to be hung
around my neck.
Considering the proliferative nature of healthcare information technology, it is not
surprising that numerous articles report the emerging care partnership evident between
nurses and forms of information technology, namely clinical information systems. In
evaluating the results of an international survey of 933 nurses use of technology in 14
countries, researchers approached the study with the supposition that nurses and
computerized technology have become inseparable and as such should be considered a
partnership if beneficial, safe, and effective outcomes are to be achieved (McGillivray, et
al., 2007). A qualitative evaluation of the meaning of technology to 12 healthcare
workers in an intensive care unit revealed clinicians reliance on technology for functions
relative to care coordination considering users description of “…technology as a support
they trusted in their everyday practice” (Wikstrom, et al., 2007, p. 190). Their reliance
was more specifically described relative to the direction and organization of medical
interventions.
4.5.2. Novice Nurse Perceptions
Most of the ideas expressed by the novice group were not isolated to nurses with
minimal experience, but rather shared amongst participants from both groups. As a result,
the majority of the findings from the novice group are expressed in the results segment
describing collective novice and experienced perceptions. In addition to ideas previously
conveyed, one additional observation emerged. Novice nurses expressed an interest in the
48
multifaceted nature of the system. Transcript comments reflected inquisitive inquiry into
what other program features may exist as well as functionalities yet to be explored.
N2 – Probably another hundred applications that it‟ll do that I‟m not aware of.
N4 - Everyday I‟m seeing something new that I didn‟t know was there before.
Nursing literature does validate that nurses welcome new and innovative technologies
providing they are efficient and user-friendly. If not, clinicians will implore the use of
work-arounds to achieve outcomes and bypass more complex and time consuming
technological resources (Zuzelo, et al., 2008). In evaluating the ideas expressed by the
novice nurse, it is interesting to note their lack of independent views as evident in the
experienced interview.
4.5.3. Experience Nurse Perceptions
While nurses in the experienced group shared many overlapping ideas with their
novice colleagues, analysis of their transcript data revealed many passionately conveyed
views not previously presented. A positive system element not identified by novice
nurses but recognized by the experienced group was the enhanced patient safety achieved
through integration with the HIT system as they reported a decreased likelihood of error.
A facet of the system identified as increasing safety included the transparency of clinician
actions considering Cerner maintains electronic fingerprints of actions performed.
Additionally, elimination of ineligible handwriting was identified a positive factor
resulting in increased protection considering plausible mistakes resulting from
inaccurately interpreted written communication.
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E1 - It provides a safer environment for the nurses, especially the MAR. When it
used to be in the paper, there were more mistakes, more likely to have mistakes
because the penmanship is not too legible when they describe it, more mistakes.
Their perceptions are closely aligned with various studies detailing the numerous
beneficial outcomes of healthcare information technology including enhanced safety
(Ball & Lillis, 2000; Bower, 2005; Courtney, Demiris, & Alexander, 2005; To err is
human, 1999).
Despite presenting numerous positive aspects of the system, experienced users
communicated that the presence of the Cerner system could also easily serve as
interference to the nurse‟s care routine. Various factors contributed to this viewpoint
including the speed of the system, which was described by experienced users as slow
when considering the time consuming nature of entering patient data and retrieving data
from a large database.
E2 - Because of a lot of information that has been input in the computer and like say
all of us are using the computer, it slows the computer down. It slows the pace of
your work because of that.
Yet another factor contributing to the perception of Cerner as an impediment to care is its
role in communication between care providers. Nurses reported that a side effect of
allowing multiple users to access patient information from various locations is decreased
communication and collaboration between clinicians. Experienced nurses described that
less real communication exists considering many relevant pieces of patient data can be
retrieved and appraised through use of the computer technology without contacting other
members of the healthcare team. Logistical considerations around use were also a source
50
of frustration and presented as a barrier to patient care. Issues included finding an
accessible computer and battery sustainability of the computers on wheels.
E3 - As soon as you unplug it, plunk, it is not working. It takes time to reboot
again…When you want to do your bedside care, it takes a lot of time wasted when
you want to do the computer stuff and the patient care.
E4 - You have to go to the other computer, look for another computer, that is a lot
of time wasted already. Sometimes there are a lot of students coming on the unit.
No computer that you can use.
E1 - I am waiting on the hourglass for it to load up and it is just time, and time…I
feel like I am being pulled away from bedside nursing to do the computer,
computer, computer, and computer…that is not why I got into nursing for.
Such frustrations surrounding logistical use, fragmented care because of interruptions in
the exchange of clinician communication, and the time-consuming nature of
electronically entering patient data into clinical information systems have been cited as
reasons supporting the perception of clinical information systems as potential
impediments to patient care activities(Almerud, et al., 2008; McGillivray, et al., 2007;
Wikstrom, et al., 2007; Zuzelo, et al., 2008). The required use of Cerner was described as
a frustrating impediment to care not only because of time and access considerations, but
also due to institutional requirements about the timeliness of documentation. Clinicians
are required to complete computerized forms within pre-determined timeframes to be
considered in compliance with established policies and procedures. Per participant
responses, attempting to meet time requirements for documentation posed difficulty in
balancing patient needs versus expectations of the facilities.
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E2 - We are compliant anyway, it is just that the four hour timeframe or whatever,
it is not enough for us because there are a lot of things that are going to go on
around us, a lot of things happening on the floor.
E4 - We know how to document the things that we need to document properly,
but they do not really need to rush us, rush us or stress us because the more they
are going to do that kind of thing we are going to make mistakes.
Experienced participants reported an oppositional view of non-clinical nursing staff as a
result of their persistent struggles with responding to patient care needs and also adhering
to expectations enforced by administrative staff. During the group interview, members
conveyed that unrealistic documentation expectations exist and that administrative staff is
out of touch with the realities surrounding providing patient care.
E1 - People in the office that are always chasing us around need to be on the floor
one day out of the month.
E3 - They do not know what is going on, you are the one who knows what is
going on although they want to check.
A phenomenological assessment of ten healthcare providers caring for patients in a
technologically intense environment also reported the tension that exist between
balancing the art of nursing with meeting an apparent shift in nursing priorities. Authors
reported that respondents conveyed “It is more prestigious to document technological
procedures than, for instance, to write that you comforted the patient with talk”
(Almerud, et al., 2008). As a result of differences in the value of care priorities for
clinical versus that of administrative staff, there is an emerging polarization of care team
members, thus straining essential clinical relationships. Despite workflow changes
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influencing care provision in their technologically enhanced environment, the group
vehemently asserted their autonomy as primary decision makers and care providers.
Nursing literature describes the importance of mastering technology or else risk being
subjected to servitude under it. It is proposed however that mastery of mechanized
support is not inherent for all nurses but rather achieved by obtaining a blend of clinical
experience and theoretical competence (Almerud, et al., 2008). The assertion of an
authentic clinical presence by experienced nurses can be explained by their degree of
exposure to varying clinical scenarios resulting in their enhance ability to contextually
evaluate the meaning and value of technology in their environment. Experienced nurses
reported knowing what care decisions needed to be made dependent upon individual
patient characteristics and outcome expectations.
E1 – Nurse runs the show and makes decisions.
E2 – It does not have any brain. It does not tell you wrong order, wrong order. It
will not tell. If you keep on following what is there, you have to think too, you
have to think and you have to be vigilant.
Zuzelo et al. (2008) describe nurses as experts in achieving work-arounds by
circumventing technology system elements. Their apparent navigation around problems
may successfully them to achieve an outcome but does little to resolve the initial
presenting problem. In using the clinical decision support system, the nurses took
different measures to achieve goals they independently established without assistance
from the HIT system.
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E3 - The computer does not have a mind, it does not have intellect. It only follows
what you and me enter there. So you as a nurse, you are the one, making
decisions. You run the computer, the computer should not run you.
E1 - I know what I want to do with my patient first before I go to the computer
thing.
E4 - When it [medication] is not due, sometimes it does not come up…I say okay
no problem, I know what to do, you click on additional, you reschedule.
In discussing the impact of the Cerner system on their workflow, nurses communicated
an appreciation for less technologically enhanced care environments. Specific attention
was directed toward mechanical flagging systems that were used by physicians to serve
as a visual indication of newly placed patient care orders. Nurses reported in the current
computerized order entry setting, orders could easily be missed if the electronic chart is
not frequently accessed. Additionally, the experienced group took liberty in sharing their
belief that older nurses having been introduced to Cerner maintain a preference for paper-
based documentation. However, what must be considered is that nurses‟ evasion of
system processes and reversion to „old‟ routines likely results from the perceived
complexity and interference of new technologically enhanced methods of providing
patient care.
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CHAPTER 5: SUMMARY & IMPLICATIONS FOR FUTURE RESEARCH
5.1. Overview of Study
This study sought to explore two focal points with regards to the interaction
between healthcare information technology and nurses, the first being how medical
surgical nurses are utilizing HIT in their current clinical practice. The second aim was to
examine the influence of HIT on nurses‟ clinical decision making. Utilizing qualitative
content analysis, data from two homogeneous focus groups of novice and experienced
nurses was analyzed to evaluate the identified research questions. During the focus group
interviews, respondents expressed many overlapping views of the Cerner system and its
effect on their patient care activities. Additionally, polarized perceptions were expressed
with some ideas isolated to the experienced group while others were particular to the
novice group. Nurses participating in the group interviews primarily conveyed
information relative to the impact of Cerner HIT on their workflow practices as well as
contextual experiences when interacting with the system.
5.2. Conclusions
The initial aims of this study were twofold: (a) evaluate whether or not nurses‟
clinical decision making was influenced by healthcare information technology and (b)
evaluate how medical-surgical nurses are utilizing HIT in their current clinical practice.
Previous research examining nurses‟ use of CDSS has similarly reported both positive
and negative perceptions of new information technology and its subsequent effect on
workflow considerations. In their evaluation of telenurses‟ experiences working with
computerized decision support technology, Ernesater, Holmstrom, & Engstrom (2009)
found similar findings to those presented in the current study. Data received utilizing
55
semi-structured interviews and analyzed using qualitative content analysis
correspondingly revealed what the authors referred to as a duality of perceptions in
working with computerized decision support. Authors found that the telenurses gave
negative feedback about the system likely because of its rigidity, but simultaneously
valued the structure, information, and prompts it provided. These beneficial care
coordination functions were useful to both novice and experienced nurses in the current
study as they aided in organizing care for assigned patient groups.
Considering findings from data collected from both groups, nurses clinical
decision making is not overtly influenced by the use of healthcare information
technology. Nurses interacting with the Cerner system in the cooperating facility utilized
clinical decision support prompts as a signal to further evaluate and appraise patient
needs and progress. Irrespective to the level of experience, consensus was reach in
confirming that the ultimate responsibility for making patient care decisions was that of
the nurse due to limited individualization of CDSS and their inability to critically judge
evolving clinical dynamics. Despite working collaboratively together, the domineering
relationship established amongst clinicians working with clinical decision support
systems validates that nurses maintain a hierarchical connection with their technologic
care coordination partners. The nurses‟ perceived that decision elements of HIT play a
supportive role to clinician knowledge and judgment and is incapable of replacing it.
The systems‟ limitations in meeting all the needs of all the people all the time
likely prohibits a complete reliance on its‟ clinical decision support components resulting
in clinician‟s re-appraisal of computerized decision points. Both novice and experienced
users were able to articulate their role in information management. However, what must
56
remain a primary focus for administrators, educators, and healthcare informaticists is
whether or not users with minimal experience will know when the CIS falls short of
considering contextual clinical data, thus necessitating their responsible subversion
(Hutchinson, 1990). This concern is relevant as the novice nurses in this study were not
as passionate as their experienced counterparts in asserting their intuitive knowledge of
patient care practices independent of information technology likely because of their
limited professional patient care practice.
Cerner users having practiced as a RN for ten or more years undoubtedly
displayed characteristics of decision-making closely aligned with that of the humanist-
inductive model. The model proposes inductive decision-making emerges from intuition
and experience-based knowledge. Nurses described an innate familiarity with what care
practices were necessary for their patients. This study suggests that CIS will never be
able to account for the tacit knowledge gained through experience and clinical exposure.
Their embedded heuristics are rightfully based-upon evidenced based practice (EBP);
however they are limited to only one element of evidence-based practice, an integration
of appraised clinical evidence. The nursing literature describes two additional
components of EBP to include patient‟s values and professional clinical experience
(Melnyk & Fineout-Overholt, 2005). The continued growth of registered nurses able to
ascertain an authentic professional self is predicated on their ability to remain perceptive
to the subjective variable aspects of EBP, the patient and the clinician.
Establishing a continued authentic professional presence was an effort for some
participants as evident by their compelled need to assert their autonomy in functioning as
the care provider able to effectively determine what patient care priorities were of most
57
importance to the patient. The tension felt by nurses attempting to establish and maintain
autonomy in technological enhanced environments will likely remain commonplace in
nursing as the proliferation of CIS continues. Despite some of the struggles and
frustrations communicated by participants, there was an overall appreciation for various
elements of the system. Nurses welcomed the easier accessibility to patient information, a
concise location for summary clinical data, as well as the clinical decision support cues
that prompted more focused investigation of the patient‟s health state.
In describing interactions with the Cerner system, a clear correlation with the
humanist-inductive model of decision making was evident in the decision making
patterns of experienced nurses. They utilized knowledge gained through experience to
guide their patient care practices. However, novice users surprisingly did not clearly
validate or dispel the association of the information processing model with novice
decision making. When interacting with the Cerner system novice nurses conveyed that
their decision making superseded that of information technology in relation to patient
care matters. Nonetheless, they did verbalize knowledge of and adherence to algorithmic
type functions during periods of system downtime that their experienced counterparts
were unable to articulate.
E2 – I do not even know if I can fill out that MAR, or if I forget it. You go to this
one, initial that one, that time that you have to do. I do not even know how to do
that one. There is a form, a checklist like, buddy system. There are a lot of things
you have to do, if it is downtime I think.
Novice nurses‟ blurred use of decision making practices is not distinct in this study likely
due to the focused examination of one environmental interaction. A more broad
58
evaluation of the practice patterns of novice nurses is necessary to further identify their
decision making style.
The emergence of the care-coordination partnership answers the second research
question relative to how medical-surgical nurses are utilizing HIT in their practice. The
clinical decision support technology purports to aid clinicians in their decision making.
Both novice and experienced users described interaction with the technology consistent
with its use as an assistive resource as opposed to that of a fixed rule. This finding is
comforting when considering previous research has raised concern with whether or not
essential clinical cognitive processes would be affected by advanced forms of technology
(Kleiman & Kleiman, 2007; Zuzelo, et al., 2008).
Although there were passionately conveyed arguments about negative aspects of
the system, users conveyed a general acceptance of the HIT. Davis (1989) illustrates that
user acceptance of information technology can be assessed by evaluating two main end-
users perceptions: perceived usefulness & perceived ease of use. Users from the novice
group described the system as user friendly and were able to identify various useful
elements. Albeit that experienced nurses expressed an obvious love-hate relationship with
the Cerner technology‟s impact on workflow considerations, they too shared subjective
impressions that supported their opinion of perceived usefulness and perceived ease of
use.
A likely consideration for the differences in passionately expressed views by the
experienced group describing many negative impacts on workflow considerations versus
the usage discussion amongst the novice nurses is the degree of nursing exposure.
Participants with less than two years of experience entered the care setting as a registered
59
nurse after the implementation of the Cerner system. As a result, their initial exposure to
professional nursing, clinical documentation, and development of a care routine began in
a technologically enhanced environment. Novice participants, without previous exposure
to working in a paper-based institution as a professional nurse, have no basis for
comparison of how the Cerner system impacts their care routine – that is they don’t know
what they don’t know. On the other hand, their experienced counterparts had to adapt to
providing and documenting care in a manner different from that which they‟d grown
familiarity. This shift can be regarded as both positive and negative for different reasons.
The knowledge and skill learned without technological support is essential in making
patient-centered decisions that reflect prioritized care needs. These traits assist clinicians
to regroup and rebound during periods of Cerner unavailability. Conversely, veteran
nurses with engrained workflow patterns primarily conducive to paper-based systems,
may resist progressive changes in the care environment. Such resistance could
inadvertently result in compromises with quality of care considering the evidenced based
shift to electronic health records (To err is human, 1999).
5.2.1 Significance to Nursing
The increased prevalence of clinical information systems in healthcare has aided
in increasing various quality outcomes relative to safety and continuity of care. However
favorable benefits cannot be achieved without appropriate technology integration in
academic and practice settings. Optimizing the relationship between nurses and
technology requires attention and forethought regarding all entry points into the
technologically evolving healthcare arena. This study has significant implications when
considering the development of undergraduate nursing students, the training of new
60
graduate nurses entering the care setting, and the preparation of existing nursing
professionals who transition into technologically enhanced environments.
The 2009 Essentials of Baccalaureate Education for Professional Nursing Practice
Faculty Tool Kit (American Association of Colleges of Nursing) details as its fourth
essential the need to prepare graduate nurses to effectively manage information and
patient care technology. Educators are specifically directed to “Provide
opportunities/assignments for students to: Use simulation and electronic medical records
to access and analyze data relevant to the patient situation” (American Association of
Colleges of Nursing, 2009, p. 6). Skills relative to the management of patient care
technology are not merely suggested, but rather considered critical in providing quality
care. Results of this study contribute to the narrow body of literature addressing how
nurses integrate the use of healthcare information technology in their care practices. By
accessing these findings, nurse educators will have increased insight when developing
curricula that stresses the importance of navigating HIT systems and managing the
patient information derived from them.
Those participating in the development of new graduate nurses in the clinical
setting can also benefit from the current exploration of nurse-technology interactions. The
introduction of CDSS into a healthcare environment have been purported to aid in
knowledge translation by filling gaps created by clinician underuse of information
generated by research (Holroyd, et al., 2007). However nursing literature has identified
that clinical decision support systems have assumed a role more closely aligned with
information management as opposed to having a pronounced presence in knowledge
translation. That is, clinicians utilize the resource to access stored patient information and
61
perform subsequent independent analysis as opposed to relying upon knowledge gained
from algorithmic based logic (Courtney, et al., 2005). Appropriate nursing adoption of
CDSS involves a blend of “…technical skills, social acceptance, and workplace culture “
(Courtney, et al., 2005, p. 317). Additional literature further describes the risk for
mechanized nurse functions possibly resulting in diminished professional competence
(Ernesater, et al., 2009). Staff development nurses as well as preceptors of new graduate
nurses are ideally best situated to ensure novice professional s are groomed to exude self-
reliance in prioritization and maintain autonomy in decision making while utilizing
information yielded from CIS as supportive aids. In evaluating the interaction between
technology and novice and experienced nurses as presented in this study, staff
responsible for the development of new nursing professionals can structure orientation
plans to reflect efforts geared toward mastering appropriate use of HIT as well as
corresponding evaluation measures.
Lastly, findings from the study have significance when considering the
transformed care environment experienced nurses encounter when transitioning to the use
of CIS. These nurses have established care routines and practices that are certainly
impacted by the use of electronic health records and computerized documentation. Such a
shift in care practices can ultimately result in nurses‟ rejection of the system, problematic
and inconsistent use, and subsequently compromised quality of care. By considering the
passionately expressed views of nurses who‟ve experienced an evolution of care
environments, institutions integrating technology elements can consider and attempt to
minimize sources of frustration and discontent in an effort to achieve seamless CDSS
implementation and established quality outcomes.
62
5.3. Limitations of Study
While this research significantly contributes to the body of healthcare information
technology literature, the study had limitations that should be considered by consumers
when reviewing derived data. These limitations were mainly relevant to the qualitative
research design, the sample size, and the contextually based analysis. A relatively small
sample size was utilized to collect data and subsequently may not have been
representative of the larger population of interest. Additionally the contextual and
qualitative nature of this research could possible limit the applicability of findings to
other settings. Variable interpretations of participant data are possible considering the
subjective influence of qualitative analysis. However, the researcher has met the
responsibility of detailing research and analytic methods to aid in transferring knowledge
derived from this study into appropriate settings.
5.4. Recommendations for Future Research
This research adds to the narrow body of literature addressing the intricate
relationship between nurses and healthcare information technology in current clinical
settings. Additional work is needed that explores the subjective experiences of end-users
responsible for achieving enhanced quality outcomes possible with use of CDSS. Nurses,
as the largest proportion of healthcare workers, are the ideal population to provide this
insight considering their innate responsibility for care coordination and information
appraisal. Further research is also needed to assess the cohesiveness of care teams
working in environments utilizing CDSS. An apparent divide between clinical and
administrative staff should be further evaluated for its presence and impact on care
quality. Assessment of cohesiveness should also consider communication patterns of staff
63
working in computer based environments as opposed to those who do not. Finally, a
continued palpable determination of the ability of nurses with varying levels of
experience to individually establish and maintain professional confidence and
competence is essential. Registered nurses must retain their clinical reasoning abilities
and changes in the environment of care necessitate periodic evaluations.
64
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Appendix D: Focus Group Interview Guide
1. Tell me about your experiences utilizing the Cerner clinical documentation
system in the clinical environment.
2. Can you describe how using the Cerner clinical decision support system has
affected or impacted your care?
3. Can you give specific examples of when the decision support system was
helpful and when it was not helpful.
4. Can you talk about specific occurrences when the system has helped you in
making a decision for your patients.
5. Describe for me times when it was not appropriate to follow the direction of
the Cerner clinical documentation system?
6. What do you think is the role of the clinical decision support system in
analyzing or interpreting patient data?
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Appendix E: Demographic Data Collection Form
Demographic Data Form
Thank you for agreeing to participate in this study. The demographic data here is being
collected as part of a research study titled “Is Nurses‟ Clinical Decision Making
Influenced by Healthcare Information Technology: A Qualitative Content Analysis”.
Please complete all portions of the instrument. Your comments are very important. In the
form, please select or enter the response that bests describe your choice of the answer(s).
1. Age: Please enter your age in years.
2. Gender (select one)
Male
Female
3. Please enter the amount of time in years you have been practicing as a Registered
Nurse
4. Indicate your level of preparation to function as a Registered Nurse. Identify all
educational levels that apply.
Diploma
Associates Degree
Bachelor‟s Degree
Other:
Specify
5. If currently enrolled in a nursing program, please indicate the level of your studies.
BSN
MSN
DNP/PhD
6. Please indicate any additional credentials you currently possess and specify the
discipline
Associate‟s Degree
Bachelors Degree
Master‟s Degree
Doctorate
85
Certification
7. Please indicate specific area(s) of practice where you have worked. Specify if not
listed.
Medical/Surgical
Operating Room
Oncology
Staff Development/Educator
College Professor/Instructor
Radiation Oncology
Surgical Intensive Care
Pediatric
Pediatric Intensive Care
Clinical Coordinator
Nurse Manager
Gastroenterology
Cardiac Cath Laboratory
Obstetrics / Gynecology
Informatics
Quality Management
Ambulatory Care
Outpatient Surgery
Emergency Room
Urgent Care
Home Care
Radiology
Medical Intensive Care
Neonatal Intensive Care
Post Anesthesia Care Unit
Administrator
Hospice
Research
Chemotherapy Infusion
Clinic
Risk Management
Hemodialysis
Rehabilitation
Other:
Specify
8. Please specify your race and ethnicity.
Race
Ethnicity
Hispanic or Latino
Not Hispanic
American Indian/Alaskan
Native
Asian
Black or African American
Native Hawaiian/Pacific
Islander
86
White
9. Do you utilize a personal computer for purposes other than LifeBridge work
requirements?
Yes – Please specify purpose
Banking
School Work
Searching/Entertainm
ent
No
Other
10. Have you had instructions/classes in any nursing program in informatics?
No
Yes: Specify program type
How long ago did instruction take place?
Less than 2 years ago
Between 2 to 5 years
N/A
Between 5 to 10 years
Over 10 years ago
87
11. Have you ever worked with another electronic clinical documentation system other
than the Cerner clinical documentation system?
No
Yes: Specify system
12. Which Statement best describes your comfort level with utilizing the Cerner system?
I am very comfortable
I am somewhat comfortable
I am neither comfortable or uncomfortable
I am somewhat uncomfortable
I am very uncomfortable
13. Do you believe that the initial instruction you received about using the Cerner clinical
documentation system was adequate for you to effectively utilize it in your current
practice?
Yes
No
14. Was your initial RN training received in the United States?
Yes
No
15. Do you utilize clinically-based applications on a PDA device to help you make
patient care decisions?
Yes – Specify
No
88
Appendix F: Categorical Analysis of Findings
FINDINGS DISCUSSION (THEMES)
Advantages
Convenient
It‟s a good program (N2)
Makes things quicker/faster (N2, E1)
More convenient than using the paper
chart (N2, E2)
User friendly
It‟s a good program (N2)
User friendly (E3, N2)
Disadvantages
Hinders communication
Less real communication (E1)
Use of computerized documentation
by different departments decreases
collaborative clinician-to-clinician
communication (E5)
Time consuming because of slow
system
Entering clinical documentation time
consuming for users (E1)
Frustration exists because the system
is slow from so much information
contained in it (E4)
Logistical problems affect use
COWS should be regularly serviced
and maintained
Flaws in the system exist (E1)
Frustrations with Cerner system
prompted by logistical considerations
of access and availability (E1)
Negative interaction concerns
between system and user not
necessarily related to Cerner system
but general computer functionality
(E4)
(HIT & Clinical decision making)
Provides puzzle clues - Cerner promotes
user investigation
Cerner forces clinicians to take their time
in documenting care (E1)
Cerner promotes critical thinking for the
nurse (E1)
False alerts remain throughout the
admission seen as both positive and
negative (E2)
System alerts prompt clinician actions even
before patient interaction (E1)
System pop-ups remind clinicians about
patient care considerations (E1)
System promotes user investigation
(E4,N6)
Clinician reasoning supersedes Cerner
directives & analysis / Nurse Hierarchy
Clinical reasoning utilized to initiate
interventions that may be appropriate but
perhaps aren‟t official orders (E1)
Clinician assessment valued over CDSS
interpretation of clinical data (E2,N5)
Computer does not have intellect, nurse
runs the show and makes decisions (E3)
Need for further clinician evaluation of
Cerner medication orders (E1, N2)
Nurse clinician enters documentation to
reflect when medication is not appropriate
to be given (E1)
Nurse must implement system
workarounds to achieve outcomes not
supported by the system (E1)
(How nurses are utilizing HIT)
Nurse-technology dyad Care
coordination partner
Care elements may be missed due to
89
Cerner-User Interactions
Transparency
Cerner maintains an electronic
fingerprint of user activity that guides
clinicians to mind their own business
(E1)
Cerner provides evidence of rationales
for care delays (E1)
Cerner provides transparent,
consistent detailed information
without user interpretation (E2)
Increases safety
Accessing patient information
maintained in Cerner helps to alleviate
errors in care (E1)
Safer documentation environment that
decreases likelihood of error (E3)
System promotes safer environment
for the hospital and patient (E1)
Both comprehensive and restrictive
Cerner offers flexibility in
documentation options (E3)
Clinician response to CDSS analysis
of data influenced by institutional
rules regarding CDSS interpretation
of data (E2N1)
Comprehensive documentation
abilities (E1, N2)
Documentation options may be too
exhaustive (N2)
Fixed categorical selection of patient
care orders does not always include
what the provider really wants to
order (E1)
Limited ability to individualize
documentation (E1, N4)
Orders that are not appropriately
entered into the system will not be as
readily available for system user
because they will appear in
unexpected sections (E1)
Multifaceted system
Numerous system functions available
downtime (E2)
CDSS maintains schedule of patient care
activities for clinicians to perform (E1,N2)
Miscategorization of orders may not be
carried out as ordered thus relying on
verbal communication of provider intent
(E1)
Not on the right track without Cerner (E3)
Periods of Cerner downtime interrupts
workflow (E2)
Possibility of missed orders if computer is
not frequently accessed (E3)
Reliance on CDSS components to aid in
organizing patient care activities (E1, N3)
Cerner serves as a convenient depot for
patient information
Allows for quicker access to patient
diagnostic tests (E1)
CDSS used as a resource for information
(E3, N3)
System provides some helpful patient
summary information (E3, N2)
Useful research functions available at the
point of care for clinicians (E2)
Resource in provision of patient care
Emergence of oppositional team members/
Big brother is watching
Administrative staff more task centered as
opposed to care centered (E1)
Administrative staff have unrealistic
documentation expectations compared to
the reality of providing direct patient care
(E3)
Administrative staff out of touch with
realities of providing bedside care (E3)
Negative remediation from performance
improvement staff for untimely
documentation (E1)
Pressure exists from documentation
performance improvement department that
conflicts with patient care routine (E5)
Pressure/struggle exists between having
90
that aren‟t utilized (N5)
Unfamiliarity with all documentation
areas (N1)
Promotes communication
Interdisciplinary collaboration
prompted by Cerner beneficial (E2,
N1)
Process of providing patient care
quicker because of results that are
communicated more efficiently (E1)
Added stressor
Clinical documentation poses added
stress (E1)
Frustrated staff may kick cows (E1)
Sense of loss without Cerner during
downtime
Unfamiliar with what to do during
downtime (E2)
Pre-existing ideas/approach to patient
care
Push-pull struggle between balancing
patient care and administrative
restraints for clinical documentation
Time struggles exists relative to
timely documentation and provision
of patient care (E1)
Being pulled away for care interferes
with Cerner documentation efforts
(E1)
Computer documentation completed
for administrative purposes of
performance improvement (E1)
It is not possible to meet all the
documentation expectations and
provide patient care (E1)
Individual user characteristics affect
interaction with the system
Fears / Potential Disadvantages
time to provide patient care and accessing
e-mail to receive system update
information (E2)
Struggle to maintain autonomy
Nurse can program themself to care for
patient without computer interference (E1)
Nurse knows what they‟d like to do before
interacting with the computer (E1)
HIT as an impediment/interference to
patient care
Added a hundred pounds on my back (E1)
Cerner system takes users away from
patient care (E2)
Interacting with Cerner can slow down
patient care (E1)
Less human contact with patients (E2)
Patient care provided prior to Cerner
clinical documentation to minimize
interruptions in care routine (E1)
Slow speed of system pulls users away
from the bedside, interfering with nursing
care (E4)
Integration has resulted in vulnerability of
nurses
Feel lost without Cerner as a reference
when system is unavailable (E2, N4)
Integration and reliance on HIT causes
nurses to forget what they are suppose to
do during their care day (E2)
Loss of control during downtime (E1)
Independent clinician assessment,
reasoning, & interpretation remains
critical despite CDSS
Common sense required in using the
Cerner system (E1)
Computer does not have intellect, nurse
runs the show and makes decisions (E3)
Computerized documentation still requires
nurse to pause and think about what they
are documenting despite availability of
forms (E1)
91
Weary of ‘Too much’ clinical
technology in the future consents,
nursing notes, excessive alerts
Weary of electronic consents in the
future (E2)
Weary of nursing notes being entered
– switch from paper to electronic (E1)
Weary of too many decision support
cues from Cerner (N1)
Necessary to be a prudent nurse in
evaluating system orders (E1)
Necessary to look at provider orders not
just directives about when to give
medications (E1)
Nurses may question duplicate orders
appearing in Cerner (E1)
Nurses using Cerner system in providing
patient care is not a task centered, but
rather involves levels of cognitive
processing (E1)
Providers contacted regarding orders in
Cerner system that don‟t seem to be
appropriate (N2)
Success of Cerner dependent on users, not
system itself (E1)
System does not discriminate user scope of
practice (N4)
HIT is not ‘all knowing’ – not fully
reflective of entire clinical picture
Clinical documentation may not fully
capture what is going on in the clinical
environment (E2)
System interprets patient data & sometimes
generates false alerts (E1, N4)
Back to the Basics???
Appreciation for basic flagging systems
that visually alerted nurse to updated
patient information (E2)
Necessary to know how to function and
perform basic nursing without the Cerner
system (E1)
Sometimes preference exists for basics of
paper documentation (E3)
92
Good program that
adds convenience
Comprehensive in
options but equally
restrictive for users
Provides puzzles clues
that ultimately promote
user investigation
Nurse hierarchy over
HIT system (weighted
toward experienced)
Nurse-technology Dyad
Increased vulnerability
of nurses
Appendix G: Venn Diagram Comparison of Data Categories
Experienced
Cerner easily an interference
Time
Consideration
Hinders Communication
Logistical problems
Added Stressor
Interferes with care
Increased Safety
Transparency /
Big Brother
Struggle to balance patient
Care & meet administrative
Demands regarding
Documentation
Assertion of nurse autonomy
Appreciation for
‘basics’ of nursing
Novice
Multifaceted System
93
Appendix H: Demographic Data Summary
Sample Characteristic Experience Level
Novice N=4
Experienced N=4
N=8 %
Personal
Demographics
Mean Age
Novice
Experienced
37.5
43.5
-
-
Race
White
African American
Asian
Novice
Experienced
Novice
Experienced
Novice
Experienced
N=2
N=1
N=2
N=1
N=0
N=2
25%
12.5%
25%
12.5%
0%
25%
Mean Practice Years
as a RN
Novice
Experienced
1.38
19
-
-
Initial RN training
Associate Degree
Baccalaureate Degree
Novice
Experienced
Novice
Experienced
N=4
N=2
N=0
N=2
50%
25%
0%
25%
Gender
Male
Female
Novice
Experienced
Novice
Experienced
N=1
N=0
N=3
N=4
12.5%
0%
37.5%
50%
94
Vita
An‟Nita C. Moore is a native of the United States of America, born and raised in the
suburbs surrounding Baltimore, Maryland. She obtained her undergraduate nursing
degree from Coppin State University in 2001 and her Master of Public Health degree in
2004 from Morgan State University. Dr. Moore completed her doctoral nursing studies in
2010 from Drexel University with nursing education being her primary concentration.
Considering her commitment to nursing education, Dr. Moore has begun to develop a
progressively evolving career in the field as she has teaching experience with nursing
students, as well as both experienced and novice nursing professionals. She has served as
a clinical nursing instructor for three nursing schools as well as an inpatient educator for
experienced nursing staff in the hospital setting. Her most recent teaching position is as
an Assistant Professor of Nursing with Morgan State University teaching principles of
medical/surgical nursing and health assessment. Dr. Moore has received several academic
awards and honors for her successes and is published in the Journal of National Black
Nurses‟ Association as part of a team of researchers evaluating cardiovascular disease in
African American women.