The impact of adopting EHRs: how losing connectivity affects clinical reasoning.

CONTEXT: As electronic health records (EHRs) are adopted by teaching hospitals, educators must examine how this change impacts trainee development. OBJECTIVES: We investigate this influence by studying clinician experiences of a hospital's move from paper charts to an EHR. We ask: how does each chart modality present conceptions of time and data interconnections? How do these conceptions affect clinical reasoning? METHODS: This two-phase, longitudinal study employed constructivist grounded theory. Data were collected at a paediatric teaching hospital before (Phase 1), during and after (Phase 2) the transition from a paper chart to an EHR system. Data collection consisted of field observations (146 hours involving 300 health care providers, 22 patients and 32 patient family members), think-aloud (n = 13) and think-after (n = 11) sessions, interviews (n = 39) and document retrieval (n = 392). Theories of rhetorical genre studies and visual rhetoric informed analysis. RESULTS: In the paper flowsheet, clinicians recorded and viewed patient data in chronologically organised displays that emphasised data interconnections. In the EHR flowsheet, clinicians viewed and recorded individual data points that were largely chronologically and contextually isolated. Clinicians reported that this change resulted in: (i) not knowing the patient's evolving status; (ii) increased cognitive workload, and (iii) loss of clinical reasoning support mechanisms. CONCLUSIONS: Understanding how patient data are interconnected is essential to clinical reasoning. The use of EHRs supports this goal because the EHR is a tool for collecting dispersed data; however, these collections often deconstruct data interconnections. Where the paper flowsheet emphasises chronology and interconnectedness, the EHR flowsheet emphasises individual data values that are largely independent of time and other patient data. To prepare trainees to work with EHRs, the ways of thinking and acting that were implicitly learned through the use of paper charts must be made explicit. To support clinical reasoning, medical educators should provide lessons in connectivity ­ the chronologically framed data interconnections upon which clinicians rely to provide patient care.

Measuring psychological outcomes following pediatric intensive care unit hospitalization: psychometric analysis of the Children's Critical Illness Impact Scale.

OBJECTIVE: Critically ill children are at risk for psychological sequelae following pediatric intensive care unit hospitalization. This article reports on the psychometric testing of the first self-report measure of psychological distress for 6-12-yr-old children post-pediatric intensive care unit hospitalization: The Children's Critical Illness Impact Scale. This 23-item scale takes approximately 15 mins for children to complete. DESIGN: Psychometric testing based on Classic Test Theory and guidelines for health measurement scale development. SETTING: The pediatric intensive care units of four Canadian pediatric hospitals and the ear, nose, and throat clinic of one participating hospital. PATIENTS: A total of 172 children (pediatric intensive care unit group, n = 84; ear, nose, and throat group, n = 88) aged 6-12 yrs and their parents. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We assessed the factor structure, internal consistency, and test-retest reliability of the Children's Critical Illness Impact Scale and conducted contrasted group comparisons and convergent and concurrent validation testing. Fit indices and internal consistency were best for a three-factor solution, suggesting three dimensions of psychological distress: 1) worries about getting sick again, 2) feeling things have changed, and 3) feeling anxious and fearful about hospitalization. As expected, Children's Critical Illness Impact Scale scores were positively correlated with child anxiety and medical fear scores. The ear, nose, and throat group scores were higher than expected. Higher Children's Critical Illness Impact Scale scores in older children may reflect a better understanding of the situation and its complexity and meaning, and younger children's tendency to provide more positive self-evaluation. CONCLUSIONS: The Children's Critical Illness Impact Scale is a promising new self-report measure of psychological distress with demonstrated reliability and validation testing in 6-12-yr-old children post-pediatric intensive care unit hospitalization. This new measure has potential to advance the evidence base for pediatric intensive care unit and post-pediatric intensive care unit health promotion interventions.

Nurses' moral experience of administering PRN anti-seizure medications in pediatric palliative care.

This article explores nurses' decision-making related to the administration of PRN anti-seizure medications to children with long-term seizure disorders in palliative care. Hermeneutic phenomenological inquiry guided by van Manen's approach was the method used. Six nurses participated in interviews. Data analysis revealed that not on my watch was the overarching theme in which nurses engaged in bearing witness, being attentive, creating connectedness, and finding the right thing to do. Four themes emerged: being in the know--what to know and ways of knowing; marking time--waiting and timekeeping; seeking a sense of personal comfort--developing a sense of comfort, experiencing distress, and responding to distress; and making the decision--recognizing a seizure, identifying options, weighing the options, and rethinking the decision. This study reveals the moral dilemmas and resulting moral distress that may be experienced in making this type of decision and advances our thinking about the corresponding tensions and rewards.

The transformational journey of nurse practitioners in acute-care settings.

This study explored the nature of the lived experience of being nurse practitioners (NPs) in acute-care settings in Canadian teaching hospitals using hermeneutic phenomenological inquiry guided by van Manen's approach. A total of 26 NPs were interviewed. Data analysis revealed that NPs experienced a transformational journey as they searched for being more, the overarching phenomenon that best characterizes their overall experience, which occurred in the context of being pioneers. Five themes emerged: being called to be more--being more connected, in control, visible, challenged, and able to make more of a difference; being adrift--being disconnected, uncertain, lost, and staying afloat; being an acute-care NP--being competent, confident, comfortable, committed, connected, and content; being pulled to be more--being a wearer of two hats; and being more--being an advanced practitioner. The NP journey reveals the complex, largely invisible experience of being an acute-care NP.

Connecting With Adolescent Mothers: Perspectives of Hospital-Based Perinatal Nurses.

Adolescent mothers are more likely to be dissatisfied with their perinatal nursing care than adult mothers. The purpose of this interpretive descriptive study was to explore adolescent-friendly care from the perspective of hospital-based perinatal nurses. Twenty-seven interviews were conducted with nurses with expertise caring for adolescent mothers. Open-ended questions were used to determine how they adapted their nursing practice when caring for adolescents, how they learned to provide adolescent-friendly care, and the facilitators and barriers to providing adolescent-friendly care. Nurses described two main goals: (a) delivering a positive experience and (b) ensuring mother and infant safety. They accomplished these goals by being nonjudgmental, forming a connection, and individualizing nursing care. The nurses described being mother-friendly, regardless of maternal age, and employing strategies to develop a nurse-adolescent mother therapeutic relationship. This research contributes to our understanding of how hospital-based perinatal nurses engage and support adolescent mothers.

Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research.

A systematic review of published research on children's psychological outcomes following Pediatric Intensive Care Unit (PICU) hospitalization was conducted. Of the 275 papers published between 1970 and April 2008 which were identified using keywords, reference lists and one author's collections, a total of 28 papers met the inclusion criteria for this review. The papers fell into four categories based on the focus of the research: (1) children's PICU perceptions and recall; (2) children's psychological outcomes, broadly defined; (3) post-traumatic stress responses; and (4) general health status and quality of life. The findings suggest that PICU hospitalization can result in negative psychological sequelae in children, which can manifest themselves up to one year post-discharge. While a small number of studies have attempted to identify predictors of psychological outcome, this work remains in its infancy. The importance of the child's interpretation of the illness experience in influencing subsequent behavioral and emotional responses is highlighted.

Implementation of a two-part unit-based multiple intervention: moving evidence-based practice into action.

This study examined the impact of a 2-part unit-based multiple intervention on the use by pediatric critical care nurses of best practice guidelines for pressure-ulcer prevention. A total of 23 nurses participated in a repeated-measures design pre- and post-intervention to address 2 questions: Is there a difference in nurses' evidence-based practices following implementation of an educational intervention only versus implementation of both an educational and an innovative intervention? Are the changes sustained 6 months after completion of the intervention? A significant change occurred in the implementation of 2 of 11 recommended practices following both interventions: assessment of risk of pressure ulcers using an age-appropriate tool (p < or = 0.001), and the documentation of same (p < or = 0.001). These changes may have been sustained. The findings bring to light the real challenges encountered when attempting to implement and evaluate multiple knowledge translation strategies associated with complex best practice guidelines in clinical practice.

Building to Make a Difference: Advanced Practice Nurses' Experience of Power.

Power is necessary for nurses to affect change in patient care and to move the nursing profession forward. Despite the evolving body of nursing research on power, there have been no studies that have investigated the nature of advanced practice nurses' (APNs') power. The purpose of this study was to explore the APNs' lived experience of power. Interpretive phenomenology guided the method and analysis. Eight APNs employed in a single Canadian tertiary care teaching health-care organization engaged in in-depth interviews. The overarching theme, building to make a difference, reflected the APNs' perception of power in their practice, which involved a passion to facilitate change in practice to improve patient care. Building to make a difference involved three themes: building on, building with, and building for. The APNs experienced more power-a process they described as power creep-when they used soft power that was shared with others to affect positive change in health care. These findings contribute to our understanding of how power is perceived and manifested in the APN role, thus further enabling organizations to create working conditions to support the APNs' endeavors to empower others.

Validity in hermeneutic phenomenological inquiry: towards an ethics of evaluation.

This article explores the relationship of ethics to validity in hermeneutic phenomenological inquiry. First, the authors present a brief overview of the various discourses on validity in qualitative research that have been variously applied to hermeneutic phenomenological inquiry. Next, they examine how relational ethics is a presence to bear within this form of inquiry. Finally, they offer a set of ethical reflections to help the researcher engage in a process of ethical questioning during each step of the research process.

Mapping communication spaces: The development and use of a tool for analyzing the impact of EHRs on interprofessional collaborative practice.

INTRODUCTION: Members of the healthcare team must access and share patient information to coordinate interprofessional collaborative practice (ICP). Although some evidence suggests that electronic health records (EHRs) contribute to in-team communication breakdowns, EHRs are still widely hailed as tools that support ICP. If EHRs are expected to promote ICP, researchers must be able to longitudinally study the impact of EHRs on ICP across communication types, users, and physical locations. OBJECTIVE: This paper presents a data collection and analysis tool, named the Map of the Clinical Interprofessional Communication Spaces (MCICS), which supports examining how EHRs impact ICP over time, and across communication types, users, and physical locations. METHODS: The tool's development evolved during a large prospective longitudinal study conducted at a Canadian pediatric academic tertiary-care hospital. This two-phased study [i.e., pre-implementation (phase 1) and post implementation (phase 2)] of an EHR employed a constructivist grounded theory approach and triangulated data collection strategies (i.e., non-participant observations, interviews, think-alouds, and document analysis). The MCICS was created through a five-step process: (i) preliminary structural development based on the use of the paper-based chart (phase 1); (ii) confirmatory review and modification process (phase 1); (iii) ongoing data collection and analysis facilitated by the map (phase 1); (iv) data collection and modification of map based on impact of EHR (phase 2); and (v) confirmatory review and modification process (phase 2). RESULTS: Creating and using the MCICS enabled our research team to locate, observe, and analyze the impact of the EHR on ICP, (a) across oral, electronic, and paper communications, (b) through a patient's passage across different units in the hospital, (c) across the duration of the patient's stay in hospital, and (d) across multiple healthcare providers. By using the MCICS, we captured a comprehensive, detailed picture of the clinical milieu in which the EHR was implemented, and of the intended and unintended consequences of the EHR's deployment. The map supported our observations and analysis of ICP communication spaces, and of the role of the patient chart in these spaces. CONCLUSIONS: If EHRs are expected to help resolve ICP challenges, it is important that researchers be able to longitudinally assess the impact of EHRs on ICP across multiple modes of communication, users, and physical locations. Mapping the clinical communication spaces can help EHR designers, clinicians, educators and researchers understand these spaces, appreciate their complexity, and navigate their way towards effective use of EHRs as means for supporting ICP. We propose that the MCICS can be used "as is" in other academic tertiary-care pediatric hospitals, and can be tailored for use in other healthcare institutions.

Information structure and organisation in change of shift reports: An observational study of nursing hand-offs in a Paediatric Intensive Care Unit.

Patient hand-offs involve the exchange of critical information. Ineffective hand-offs can result in reduced patient safety by leading to wrong treatment, delayed diagnoses or other outcomes that can negatively affect the healthcare system. The objectives of this study were to uncover the structure of the information conveyed during patient hand-offs and look for principles characterising the organisation of the information. With an observational study approach, data was gathered during the morning and evening nursing change of shift hand-offs in a Paediatric Intensive Care Unit. Content analysis identified a common meta-structure used for information transfer that contained categories with varying degrees of information integration and the repetition of high consequence information. Differences were found in the organisation of the hand-off structures, and these varied as a function of nursing experience. The findings are discussed in terms of the potential benefits of computerised tools which utilise standardised structure for information transfer and the implications for future education and critical care skill acquisition.

The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity.

BACKGROUND: Recent research has suggested that using electronic health records (EHRs) can negatively impact clinical reasoning (CR) and interprofessional collaborative practices (ICPs). Understanding the benefits and obstacles that EHR use introduces into clinical activities is essential for improving medical documentation, while also supporting CR and ICP. METHODS: This qualitative study was a longitudinal pre/post investigation of the impact of EHR implementation on CR and ICP at a large pediatric hospital. We collected data via observations, interviews, document analysis, and think-aloud/-after sessions. Using constructivist Grounded Theory's iterative cycles of data collection and analysis, we identified and explored an emerging theme that clinicians described as central to their CR and ICP activities: building the patient's story. We studied how building the patient's story was impacted by the introduction and implementation of an EHR. RESULTS: Clinicians described the patient's story as a cognitive awareness and overview understanding of the patient's (1) current status, (2) relevant history, (3) data patterns that emerged during care, and (4) the future-oriented care plan. Constructed by consolidating and interpreting a wide array of patient data, building the patient's story was described as a vitally important skill that was required to provide patient-centered care, within an interprofessional team, that safeguards patient safety and clinicians' professional credibility. Our data revealed that EHR use obstructed clinicians' ability to build the patient's story by fragmenting data interconnections. Further, the EHR limited the number and size of free-text spaces available for narrative notes. This constraint inhibited clinicians' ability to read the why and how interpretations of clinical activities from other team members. This resulted in the loss of shared interprofessional understanding of the patient's story, and the increased time required to build the patient's story. CONCLUSIONS: We discuss these findings in relation to research on the role of narratives for enabling CR and ICP. We conclude that EHRs have yet to truly fulfill their promise to support clinicians in their patient care activities, including the essential work of building the patient's story.

Incorporating educational theory into critical care orientation.

This article describes the development and implementation of a critical care total education system, which includes an orientation program. The educational process in this unit reflects Benner's model of novice to expert integrated with Schon's theory of reflective practice and Cranton's transformational learning theory. This program reflects an educational philosophy that facilitates learning on entry into the new workplace, and an established continuum of expected acquisition of knowledge, practice skills, attitudes, and critical thinking abilities promoting the transition from novice to expert.

The experience of being a trauma nurse: a phenomenological study.

The lived experience of being a trauma nurse was explored using a phenomenological qualitative research approach. Seven registered nurses employed in a trauma unit from one large metropolitan Canadian teaching hospital participated in in-depth conversational interviews. Data analysis revealed four sub theme clusters embedded within the overarching theme of Seeing Through Cloudy Situations: being on guard all the time, being caught up short, facing the challenge and sharing the journey. Even though trauma nurses are able to find meaning and satisfaction in their work, the findings of this research reveal the need for support and the assurance of safe work environments as trauma nurses can live with violence and aggression in their daily nursing practice.

Living with sensor-augmented pump therapy in type 1 diabetes: adolescents' and parents' search for harmony.

OBJECTIVE: Adolescents have difficulty successfully sustaining use of continuous glucose monitoring even when it is introduced to experienced pump users. However, little is known about how adolescents and parents perceive and manage sensor-augmented pump therapy (SAPT) in daily life. The purpose of this study was to explore adolescents' and parents' daily experience of living with SAPT. METHODS: We used an interpretive phenomenological study design. We conducted in-depth, digitally recorded interviews with 7 adolescents and 9 parents recruited through 1 Canadian pediatric diabetes program. Adolescents who participated were 13 to 17 years of age with type 1 diabetes mellitus and had experience (current or past) living with SAPT. Transcripts of the interviews were subjected to a thematic analysis guided by the procedure outlined by Colaizzi. RESULTS: The overarching theme, seeking harmony, reflected adolescents' and parents' daily struggles with balancing multiple tensions that arose from managing SAPT and harmonizing seemingly opposing choices that were brought to the fore, while also struggling to live with both wellness and chronic illness. Four themes constituted the struggle to find harmony living with diabetes managed with SAPT: struggling with hopes and expectations for SAPT, being ready for SAPT, living the burdens of continuous glucose monitoring and creating partnerships. CONCLUSIONS: Healthcare providers can facilitate adolescent and parental decision-making about the optimal timing for SAPT introduction. Success with SAPT requires exploration of adolescent and parental expectations for SAPT as well as the degree to which parents have previously fostered their adolescent's involvement in and responsibility for diabetes management.

Health care professionals' pain narratives in hospitalized children's medical records. Part 1: pain descriptors.

BACKGROUND: Although documentation of children's pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children. OBJECTIVES: To describe health care professionals' use of written language related to the quality and quantity of pain experienced by hospitalized children. METHODS: Free-text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used. RESULTS: Pain narratives were documented a total of 5390 times in 1518 of the 3822 children's medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (e.g., vocal, motor, facial and activities cues), affective and physiological cues, and children's descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers. CONCLUSIONS: The richness and complexity of vocabulary used by clinicians to document children's pain lend support to the concept that the word 'pain' is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children's pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.

Health care professionals' pain narratives in hospitalized children's medical records. Part 2: structure and content.

BACKGROUND: Although clinical narratives - described as free-text notations--have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children's medical records. OBJECTIVES: To describe the structure and content of health care professionals' narratives related to hospitalized children's acute pain. METHODS: All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed. RESULTS: Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care. CONCLUSIONS: The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children's acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives' composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals' pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.

Hospital-based perinatal nurses identify the need to improve nursing care of adolescent mothers.

OBJECTIVE: To determine whether hospital-based perinatal nurses with expertise in adolescent mother-friendly care identify a need to improve inpatient nursing care of adolescent mothers and how well perinatal units support nurses' capacity to provide adolescent mother-friendly care. DESIGN/SETTING/PARTICIPANTS: A key informant survey of nurses from eight perinatal units at three hospitals (four separate sites) in a Canadian city. METHODS: Perinatal nurses expert in the care of adolescent mothers were identified by their managers and colleagues. These nurses and all perinatal clinical educators were invited to participate. Twenty-seven of 34 potential key informants completed the survey. RESULTS: Key informants rated their own skill in caring for adolescent mothers higher (median 8.0) than they rated the skill of other nurses (median 6.0) on their units. They attributed their expertise working with adolescent mothers to their clinical and life experiences and their ability to develop rapport with adolescents. A common reason for the assigned lower peer-group ratings was the judgmental manner in which some nurses care for adolescent mothers. Key informants also identified that hospital-based perinatal nurses lack adequate knowledge of community-based resources for adolescent mothers, educational programs related to adolescent mother-friendly care were insufficient, and policies to inform the nursing care of adolescent mothers were not available or known to them. CONCLUSION: A minority of perinatal nurses have expertise in adolescent mother-friendly care. There is a need for perinatal unit-level interventions to support the development of nurses' skills in caring for adolescent mothers and their knowledge of community-based resources. Peer mentoring and self-reflective practice are promising strategies.