Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

Assessing confidence in triage decision making: evaluation of an inventory in a sample of navy and civilian nurses.

Triage decision making and prioritizing nursing care are essential nursing skills in all clinical settings. The purpose of this study was to evaluate the psychometric properties of the Triage Decision Making Inventory in a sample of Navy and civilian nurses with diverse clinical specialties and years of clinical experience. Establishing reliability and validity allows staff development educators to evaluate training strategies that promote confidence in decision making among nurses of all specialty practices.

Use of intuition by nursing students: instrument development and testing.

BACKGROUND: Intuition has been described as an important type of nursing knowledge and has gained acceptance as a valid way of knowing in clinical nursing. Use of intuition has become one way of explaining professional expertise. Measures of the use of intuition have been developed primarily for experienced nurses, but few measures of intuition use among nursing students exist. AIM: The aim of this paper is to describe the development and psychometric testing of an instrument to measure use of intuition by nursing students. METHODS: Instrument development consisted of concept clarification, item development, and psychometric testing. Intuition was defined as a non-linear process of knowing perceived through physical awareness, emotional awareness, and/or through physical or spiritual connections. Initial measurement items were derived inductively from the literature and informal interviews with senior nursing students. Seven content experts established a content validity index of 0.86 for the initial 33-item measure. It was pretested with a sample of 20 senior nursing students prior to its nationwide validation with a random sample of 1000 senior bachelor of science and associate degree nursing students. RESULTS: Postal mail data collection resulted in 349 responses (35% response rate). Principal component analysis with orthogonal varimax rotation resulted in seven factors accounting for 66.2% of the variance: physical sensations (28.4%); premonitions (9.7%); spiritual connections (7.7%); reading of cues (6.1%); sensing energy (5.7%); apprehension (4.3%); and reassuring feelings (4%). Eigenvalues ranged from 1 to 7.1 and factor loadings ranged from 0.534 to 0.858. The validation resulted in a revised 25-item measure that demonstrated an overall Cronbach's alpha of 0.89 and a range of 0.69-0.84 for each factor. The study is limited by the use of a self-report measure and the attrition in the randomized sample. CONCLUSIONS: The intuition measure for use with students showed evidence of construct validity and reliability. With further testing, the measure could serve as a stimulus to foster students' intuitive abilities.