Registered nurses' reasoning process during care planning and documentation in the electronic health records: A concurrent think-aloud study.

AIMS AND OBJECTIVES: To explore the clinical reasoning process of experienced registered nurses during care planning and documentation of nursing in the electronic health records of residents in long-term dementia care. BACKGROUND: Clinical reasoning is an essential element in nursing practice. Registered nurses' clinical reasoning process during the documentation of nursing care in electronic health records has received little attention in nursing literature. Further research is needed to understand registered nurses' clinical reasoning, especially for care planning and documentation of dementia care due to its complexity and a large amount of information collected. DESIGN: A qualitative explorative design was used with a concurrent think-aloud technique. METHODS: The transcribed verbalisations were analysed using protocol analysis with referring phrase, assertional and script analyses. Data were collected over ten months in 2019-2020 from 12 registered nurses in three nursing homes offering special dementia care. The COREQ checklist for qualitative studies was used. RESULTS: The nurses primarily focused on assessments and interventions during documentation. Most registered nurses used their experience and heuristics when reasoning about the residents' current health and well-being. They also used logical thinking or followed local practice rules when reasoning about planned or implemented interventions. CONCLUSION: The registered nurses moved back and forth among all the elements in the nursing process. They used a variety of clinical reasoning attributes during care planning and nursing documentation. The most used clinical reasoning attributes were information processing, cognition and inference. The most focused information was planned and implemented interventions. RELEVANCE TO CLINICAL PRACTICE: Knowledge of the clinical reasoning process of registered nurses during care planning and documentation should be used in developing electronic health record systems that support the workflow of registered nurses and enhance their ability to disseminate relevant information.

Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review.

BACKGROUND: Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. The accuracy of nursing documentation is vital in areas where residents have difficulties in communicating needs and preferences. This study described the content and comprehensiveness of nursing documentation for residents living with dementia in nursing homes. METHODS: We used a retrospective chart review to describe content and comprehensiveness in the nursing documentation. Person-centered content related to identity, comfort, inclusion, attachment, and occupation was identified, using an extraction tool derived from person-centered care literature. The five-point Comprehensiveness in the Nursing Documentation scale was used to describe the comprehensiveness of the nursing documentation in relation to the nursing process. RESULTS: The residents' life stories were identified in 16% of the reviewed records. There were variations in the identified nursing diagnoses related to person-centered information, across all the five categories. There were variations in comprehensiveness within all five categories, and inclusion and occupation had the least comprehensive information. CONCLUSION: Findings from this study highlights challenges in documenting person-centered information in a comprehensive way. To improve nursing documentation of residents living with dementia in nursing homes, nurses need to include residents' perspectives and experiences in their planning and evaluation of care.

Utilizing nursing standards in electronic health records: A descriptive qualitative study.

BACKGROUND: The electronic health record (EHR), including standardized structures and languages, represents an important data source for nurses, to continually update their individual and shared perceptual understanding of clinical situations. Registered nurses' utilization of nursing standards, such as standardized nursing care plans and language in EHRs, has received little attention in the literature. Further research is needed to understand nurses' care planning and documentation practice. AIMS: This study aimed to describe the experiences and perceptions of nurses' EHR documentation practices utilizing standardized nursing care plans including standardized nursing language, in the daily documentation of nursing care for patients living in special dementia-care units in nursing homes in Norway. METHODS: A descriptive qualitative study was conducted between April and November 2021 among registered nurses working in special dementia care units in Norwegian nursing homes. In-depth interviews were conducted, and data was analyzed utilizing reflexive thematic analysis with a deductive orientation. Findings Four themes were generated from the analysis. First, the knowledge, skills, and attitude of system users were perceived to influence daily documentation practice. Second, management and organization of documentation work, internally and externally, influenced motivation and engagement in daily documentation processes. Third, usability issues of the EHR were perceived to limit the daily workflow and the nurses' information-needs. Last, nursing standards in the EHR were perceived to contribute to the development of documentation practices, supporting and stimulating ethical awareness, cognitive processes, and knowledge development. CONCLUSION: Nurses and nursing leaders need to be continuously involved and engaged in EHR documentation to safeguard development and implementation of relevant nursing standards.

What Determines the Use of Clinical Decision Support Systems in Nursing? Results of a Multiple Regression Analysis.

INTRODUCTION: In nursing, professionals are expected to base their practice on evidence-based knowledge, however the successful implementation of this knowledge into nursing practice is not always assured. Clinical Decision Support Systems (CDSS) are considered to bridge this evidence-practice gap. METHODS: This study examines the extent to which evidence-based nursing (EBN) practices influence the use of CDSS and identifies what additional factors from acceptance theories such as UTAUT play a role. RESULTS AND DISCUSSION: Our findings from three regression models revealed that nursing professionals and nursing students who employ evidence-based practices are not more likely to use an evidence-based CDSS. The relationship between an EBN composite score (model 1) or is individual dimensions (model 2) and CDSS use was not significant. However, a more comprehensive model (model 3), incorporating items from the UTAUT such as Social Influences, Facilitating Conditions, Performance Expectancy, and Effort Expectancy, supplemented by Satisfaction demonstrated a significant variance explained (R2 = 0.279). Performance Expectancy and Satisfaction were found to be significantly associated with CDSS utilization. CONCLUSION: This underscores the importance of user-friendliness and practical utility of a CDSS. Despite potential limitations in generalizability and a limited sample size, the results provide insights into that CDSS first and foremost underly the same mechanisms of use as other health IT systems.

Dimensions of Evidence-Based Practice in Nursing: Results of a Factor Analysis.

Clinical decision support systems (CDSS) are capable of bridging evidence and practice. However, it is unclear what dimensions determine evidence-based practice under real world conditions. To answer this question, 126 registered nurses and nursing students from the Munich municipal hospital group filled in a systematically developed and validated questionnaire with 26 items. An exploratory factor analysis revealed the three dimensions "Knowledge", "Trust" and "Practice" which explain 56.5% of the total variance. They are corroborated by the literature and match findings about evidence-based practice in medicine. These results not only provide insights into the construct evidence-based practice but also give practical hints how to foster evidence-based daily work in nursing. A supportive clinical environment seems to be paramount to achieve this goal: access to evidence-based resources, team meetings to reflect the experience and the inclusion of the patients' needs.

Clinical Decision Support: Evaluating the Development of a Tool for Nurses.

VAR Healthcare is a clinical decision support system for nurses that aspires to become even more advanced. By applying The Five Rights model, we have evaluated the status and direction of its development to bring potential lacks or barriers into the fore. The evaluation shows that ensuring APIs that will allow the nurses to combine the assets of VAR Healthcare with information on individual patients from EPRs would bring advanced decision support to nurses. This would adhere to all the principles of the five rights model.

Nursing Informatics' Contribution to One Health.

OBJECTIVES: To summarise contemporary knowledge in nursing informatics related to education, practice, governance and research in advancing One Health. METHODS: This descriptive study combined a theoretical and an empirical approach. Published literature on recent advancements and areas of interest in nursing informatics was explored. In addition, empirical data from International Medical Informatics Association (IMIA) Nursing Informatics (NI) society reports were extracted and categorised into key areas regarding needs, established activities, issues under development and items not current. RESULTS: A total of 1,772 references were identified through bibliographic database searches. After screening and assessment for eligibility, 146 articles were included in the review. Three topics were identified for each key area: 1) education: "building basic nursing informatics competence", "interdisciplinary and interprofessional competence" and "supporting educators competence"; 2) practice: "digital nursing and patient care", "evidence for timely issues in practice" and "patient-centred safe care"; 3) governance: "information systems in healthcare", "standardised documentation in clinical context" and "concepts and interoperability", and 4) research: "informatics literacy and competence", "leadership and management", and "electronic documentation of care". 17 reports from society members were included. The data showed overlap with the literature, but also highlighted needs for further work, including more strategies, methods and competence in nursing informatics to support One Health. CONCLUSIONS: Considering the results of this study, from the literature nursing informatics would appear to have a significant contribution to make to One Health across settings. Future work is needed for international guidelines on roles and policies as well as knowledge sharing.

Mapping nurses' natural language to oncology patients' symptom expressions.

Systems that integrate information from both the patients and health professionals require bi-directional term translation. We manually extracted nursing terms from 25 randomly selected cancer patients' charts that expressed symptoms and mapped these to a set of patient-oriented symptoms from a cancer support system. We found that 40% of the nursing terms were synonyms of patient expressions that could be mapped directly; however 38% of the nursing terms required a map to more than one patient expression. In this study, we gained an understanding of the link between nursing and patient language that is needed for future system development.

Mapping VIPS concepts for nursing interventions to the ISO reference terminology model for nursing actions: A collaborative Scandinavian analysis.

The aims of this study were to analyze the coherence between the concepts for nursing interventions in the Swedish VIPS model for nursing recording and the ISO Reference Terminology Model for Nursing Actions and to identify areas in the two models for further development. Seven Scandinavian experts analyzed the VIPS model's concepts for nursing interventions using prototypical examples of nursing actions, involving 233 units of analyses, and collaborated in mapping the two models. All nursing interventions in the VIPS model comprise actions and targets, but a few lack explicit expressions of means. In most cases, the recipient of care is implicit. Expressions for the aim of an action are absent from the ISO model. By this mapping we identified areas for future development of the VIPS model and the experience from nursing terminology work in Scandinavia can contribute to the international standardization efforts.

Documentation and Reporting of Nutrition - Interoperability, Standards, Practice and Procedures.

Interoperability, fragmentation, standardization and data integrity are key challenges in efforts to improve documentation, streamline reporting and ensure quality of care. This workshop aims at demonstrating and discussing health politics and solutions aimed to improve nutritional status in elderly.

Health assets in nursing documentation of cancer care.

Patients' experiences, knowledge and preferences, as well as more person-centered care need to be implemented in clinical support systems and are central values and outcomes of eHealth. Health assets represent such information. The concept of health assets was explored and described based on analysis of nursing documentation in cancer patients' records. A convenience sample from 100 records, available from a larger study, resulted in 43 records that met the inclusion criteria. These were analyzed using content analysis methods. A mean of 3.2 health assets was documented in these records, and 61% of the descriptions of assets quoted patients. Assets were found most often in the admission notes (49%), but no information was found that described or indicated an intended use or follow up in the nursing documentation.

Cancer patients' experiences of their personal strengths through illness and recovery.

BACKGROUND: Cancer patients' strengths and capabilities have received little attention from healthcare providers whose primary focus is on patients' problems. Thus, providers miss an important opportunity to build on cancer patients' strengths. New care approaches are needed that nourish patients' strengths and encourage them to take an active role in their care. Focusing on health assets is 1 such approach. However, so far, little is known about the strengths cancer patients use and experience during their illness and recovery. OBJECTIVE: The objective of the study was to explore and describe cancer patients' experiences and perception of their strengths, needed or used by themselves or supported by their care providers. METHODS: In this qualitative, exploratory study, we collected data from 26 participants in 4 focus group interviews. We conducted a qualitative, thematic analysis with an inductive approach to analyze the interview transcripts. RESULTS: Cancer patients described a large repertoire of strengths they used or wished for during illness and recovery including good mood, mindfulness, willpower, positive relationships, hopes and beliefs, protection, and taking action and control. Patients also reported that healthcare providers rarely focused on patients' strengths, something they fervently wished for. CONCLUSION: Patients want their strengths to be more appreciated and encouraged by care providers, to become active partners in care and feeling in control. IMPLICATIONS FOR PRACTICE: Our findings support that patients' own strengths are a crucial factor to get through their illness. Nurses should therefore have a greater focus on eliciting and nourishing patients' personal strengths in their care.

Nurse perceptions and experiences of patient health assets in oncology care: a qualitative study.

Health assets, a term that refers to patients' strengths and potentials, has emerged as an important aspect of health care. A conceptual analysis of health assets revealed five core dimensions: mobilization, motivational, relational, volitional, and protective strengths. How nurses experience and use patients' health assets, however, is unknown. In this qualitative study, 26 expert nurses in cancer care participated in focus group interviews. The nurses had a large repertoire of experiences with cancer patients' health assets. When the data were subjected to thematic analysis, three new core dimensions were revealed: cognitive, emotional, and physical strengths. Balancing processes within and among health assets--identified as an overriding theme--appeared to be affected by individual and contextual variations. The nurses realized that patients' health assets could be better used and voiced a need for the clinical and organizational support to do so. New issues about health assets raised in this study may be caused by its novel context (e.g., expert nurses in oncology care). More research is needed on health assets in other contexts, such as patients with different health problems, and of possible strategies to support nurses' use of health assets.

Health assets: a concept analysis.

PURPOSE: Traditionally, nursing care has focused primarily on patients' problems and to solve these problems on behalf of the patient. However, with the growing focus in health care on patient-centered care, self-management of illness, and patient empowerment, the problem-oriented approach to nursing care is no longer sufficient. Assessing and strengthening patients' health assets has evolved into a complementary approach to problem-focused care, helping patients achieve and maintain their health and wellness. This requires a clear definition of the concept of health assets and a better understanding of their role in overall health and wellness. The purpose of this paper was to examine the concept of health assets, including its attributes, associated concepts, and application in a health care context. METHODS: We systematically reviewed 60 journal articles and Web documents dated from 1966 through March 2007. Data were then analyzed using Rodger's evolutionary method of concept analysis. RESULTS: The health assets concept has not been widely used in health care. However, use has increased during recent years within multiple disciplines, including psychology, psychiatry, nursing, medicine, social sciences, and public health. This concept analysis identified core attributes of health assets to be potentials in the individuals' possession. The core attributes embraces relational, motivational, protective, and volitional strengths, which are internal; and support, expectations of others, and physical and environmental elements, which are external. The antecedents of health assets are genes, values, beliefs, and life experiences. Health assets mobilize an individual to engage in deliberation, decision making, and change. Consequences of health assets are positive health behaviors that can lead to mastery, self-actualization, and improved health outcomes. We propose both a definition of health assets and a descriptive model of its components and relationships. CONCLUSION: Focusing nursing care on a person's health assets, as a complement to the traditional approach of addressing a person's health problems, may contribute to improved health behavior and outcomes. Health assets should, therefore, receive greater attention in nursing practice, education, and research.

Mapping cancer patients' symptoms to UMLS concepts.

A prerequisite for patient-friendly personal health records (PHR) is their ability to allow seamless integration of patient terminology with professional terminologies. In this work, we mapped a set of symptoms/ problems from the self-assessment component of a cancer patient support system to concepts in the Unified Medical Language System (UMLS) Metathesaurus. Our objective was to learn how the UMLS can be used as a tool to connect patient terminology with professional vocabularies. The mapping to UMLS was done with the help of ten expert cancer nurses who evaluated concepts, their synonyms and placement in the source vocabulary hierarchical structure. The UMLS concepts were also compared with terms and phrases found in patient medical records that addressed the same set of symptoms. In this study we observed several problems related to the use of the UMLS Metathesaurus as a tool to connect from patient-level expressions to professional-level classification systems. More work is needed to increase interoperability between layperson health applications and clinical systems.