The Omaha System: Bridging Nursing Education and Information Technology
by Vicky Elfrink RNC, PhD
INTRODUCTIONDramatic changes in health care have led to a major restructuring of clinical nursing practice. There is a greater emphasis on prevention, hospitalization stays are shorter with an accompanying need for acute follow-up care, more chronic illness care is provided in the community, and major health care decisions once made almost exclusively in the hospital are increasingly taking place in patient's homes. As clinical practice evolves to include a greater emphasis on community-focused care, nursing faculty must in turn make a shift in how and where they provide clinical education experiences. Today, educators are increasingly seeking community-focused clinical experiences for their students.
Community learning environments pose tremendous obstacles in the supervision of students. Often, students are geographically dispersed at multiple distant sites such as patient's homes, clinics or other outreach centers. Instructors, used to supervising students immediately on-site, can not do so in the community and are finding it challenging to promote a valid learning experience while ensuring patient safety. Added to these difficulties, is the reality of practicing in today's data-driven health care environment (Zielstorff, R., Hudgings C. & Grobe, S.,1993). Because health care decisions are increasingly dependent on timely and relevant clinical data, there is an additional burden for students and faculty to maintain clinical communication that is timely, relevant and consistent with practice-based documentation standards. Clearly, faculty must consider alternatives to traditional on-site observation, to supervise and maintain communication with their students at distant clinical sites. One such strategy involves the greater use of information technology between faculty and students.
NIGHTINGALE TRACKER PROJECT
In response to the changing needs of nursing education, FITNE, Inc. (formerly the Fuld Institute for Technology in Nursing) developed a computerized communication system designed to: (1) enable timely voice and data communication between students and faculty during the student-patient encounter and (2) process (gather, store, retrieve and aggregate) clinical data related to the community clinical assignment using electronic communication (Elfrink, 1996a, 1996b). Named the Nightingale Tracker, the project was conceived during a planning retreat in 1993, funded by the Helene Fuld Health Trust in 1994, researched and developed from 1994 -1998, and released in May, 1998.
The detailed research and development efforts were geared toward (1) investigating the communication needs that occur as faculty supervise clinical students in community settings, (2) determining the types of clinical information processing skills needed by nurses in the future, and (3) translating findings from points 1 and 2 into a user-friendly, portable and automated computer-based communication system to be used by students and faculty in community-focused clinical experiences. Research and Development activities were broken down into three broad initiatives: (a) needs analysis and technology requirements gathering, (b) first clinical field test and (c) second clinical field test.
THE NEED FOR A STANDARDIZED CLINICAL VOCABULARY
It was during the needs analysis and technology requirements gathering portion of the project, that it became clear that using a standardized vocabulary would be essential to meeting the communication needs of mobile faculty and students. Although early interviews with educators indicated that they desired a technology that would allow them to visually observe and hear their students on a one-to-one basis in real-time, regardless of where the student was conducting the visit, the telecommunications infrastructure simply could not (and most likely will not for at least another 5-10 years) reliably support this type of linkage.
Translating this requirement into technical terms, faculty wanted technology that was capable of providing full color fluid motion, high resolution images, clear and synchronized sound and rapid switching from student to student at their various remote sites. While there is developing technology available to support these requirements, it is expensive and requires a telecommunications infrastructure more commonly found in sophisticated broad band-width transmissions such as those using multiple T1 connections. Narrow bandwidth infrastructures such as those occurring with "Plain Old Telephone Service" or POTS, the common telecommunications links available in most community settings, including patient's homes, is capable of handling voice, text and some still images transmissions.
Because faculty cannot monitor their students in the community as they have in hospitals, it became evident that instead of using direct observational methods, faculty would need to depend on other systematic procedures which are reliably supported by the current and emerging telecommunication infrastructure. Therefore, combining technology that could consistently communicate using voice, e-mail, and facsimile transmissions with commonly understood terms of a reliable and valid clinical vocabulary became the foundation for the clinical communication in the Nightingale Tracker.
RATIONALE FOR CHOOSING THE OMAHA SYSTEM
As previously noted, an essential component to the success of the Tracker system is its' use of a reliable and valid standardized clinical vocabulary. To some readers, it still may be unclear as to how a standardized vocabulary becomes the "facultys' [sic: faculty's] eyes and ears" for validating the practice and decision-making of students. Using a standardized vocabulary facilitates the validation of learning opportunities through applying the vocabulary's commonly agreed upon rules and criteria for decision-making. These rules in turn help students to focus and document their care based on actual patients' needs. This focus, however, also represents a shift in current nursing practice communication from one which is process-oriented to data-driven interactions (Zielstorff et.al, 1993).
In a data-driven documentation system, decisions about patient care are made based on the data available to support one decision over another. A patient-centered focus (rather than a transactional episode, or specific discipline focus) allows the patient data to be used across time to support multiple patient care functions. For example, collected patient data can be abstracted, summarized and aggregated to benefit the patient, the health care agency, the community, the nation and health care world at large. In turn, a data-driven approach to clinical communication not only helps students and faculty to focus students' delivery of care, but can also lead to broader learning activities dealing with research about communities and populations.
As decisions were being made about choosing a vocabulary for use in the Tracker, the team took into account findings from the research and other supportive literature available in early 1995. At the time, there were four vocabularies recognized by the American Nurses Association and given reference in the International Medical Thesaurus. Those four vocabularies were: North America Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), The Home Health Classification (HHC), and the Omaha System (ANA, 1995). Today two additional clinical vocabularies have been recognized by the ANA, the Nursing Sensitive Patient Outcome Classification (NOC) and the Ozbolt Patient Care Data Set (Elfrink, 1998; Thede, 1998). The Tracker team has continued to closely monitor the development activities related to all of the nursing vocabularies, however we perceived that it was incumbent to choose a single vocabulary to integrate fully into the Tracker System.
The Omaha System was selected for use because of its extensive research base and its practical use in community-focused practice. More specifically, the System was evaluated comprehensively and found to have: (1) reliability and validity studies for the integrity of the System, (2) utility over its more than 20 years of research in multiple community-focused settings, (3) simple (common) terms, recognizable and useable by non-nurse health professionals as well as nurses, (4) a complete vocabulary with schemata for reliably documenting problems, interventions and outcomes, (5) the essential requirements of the nursing minimum data, (6) an organizational framework that lends it to be "teachable" to nursing students of all levels, (7) public domain availability for comprehensive and widely distributed use, (8) an actual user-base of over 200 clinical practice agencies and numerous academic nurse-managed centers throughout the United States. In summary, of the six ANA accepted languages, the Omaha System was evaluated to be the oldest, the most freely available, the most fully developed, most researched and the most appropriate fit for use with a computerized communication system in community-focused nursing education.
USING THE OMAHA SYSTEM IN THE NIGHTINGALE TRACKER
The Omaha System comprises the foundation for the Tracker's clinical documentation system in two ways. An electronic version of the System resides on the Tracker Client hardware which is carried by students during their assignments (this hardware is also called a hand-held client or clinical field device). A second Omaha System application known as the clinical data repository resides on the Tracker Server. In technical terms, this communications framework is called a client/server architecture. To date most students have only used the electronic version of the Omaha System operating on the Tracker client.
The Omaha System as integrated into the handheld field device is used to organize the way in which students: (1) create pre-plans of care for upcoming patient encounters, (2) enter patient care visit data (name nursing problems, identify appropriate nursing interventions, rate the intensity of patient problems, and describe relevant follow-up to care) in the Tracker client user-interface, (3) verbally communicate clinical findings to their instructors, (4) aggregate clinical data for use in further research including program planning, measuring standards of care over time and predicting resource allocation.
An example of how the Tracker is used for planning and communicating about clinical practice is found at the following URL: http://www.fitne.net/tracker/trackermain_nonjava.html then click on Tracker in Nursing. Yet another example of how the Tracker interface integrates the use the Omaha System is found in a case study format and is provided at the following URL: http://www.fitne.net/tracker/casestudy_nonjava.html. Finally, more specific information can be found about how the Omaha System is organized within the Tracker client/server architecture works by accessing the following URL: http://www.fitne.net/tracker/trackermain_nonjava.html then click on Tracker in Nursing and then click on Use of Standardized Language.
Because the Tracker technology is so new, nursing programs to date have only a few case records stored, that are thusly organized around a relational database using the Omaha System. However, as schools' clinical data repositories grow in their amount of collected data, educators and students will be able to export the data organized in these tables for use with statistical packages, databases and spreadsheets, thus, being able to facilitate research-related learning activities.
STUDENT REACTIONS TO THE OMAHA SYSTEM
During the two clinical field tests, students used prototype versions of the Nightingale Tracker including early versions of the Tracker adapted Omaha System. The first study focused on subjects from a single nursing program, while the second test involved students from five programs nationwide. In both studies, students were required to use the 'Tracker with at least one patient per week to communicate their care plans and document their visits with their instructors. The length of the field tests varied according to the program's academic calendar, however, subjects from each site used the Nightingale Tracker for a minimum of six weeks.
The overall feedback from both studies indicated that the student subjects felt that the Omaha System was "simple to learn", "efficient to use" and "kept them focused in their planning and delivery of care". Feedback from faculty was positive with regard to how the Omaha System facilitated clinical communication. Other formative feedback from student and faculty subjects resulted in adding to the Nightingale Tracker's objective standardized assessment fields as organized around the 44 problems of the Omaha System. For example, based on the feedback from one program, many additional danger signs for pregnancy monitoring were added to Omaha System Problem # 33 Antepartum/postpartum. Finally, some findings focused on the best strategies for including standardized vocabularies and information technology in the curriculum. It was concluded that providing concentrated time in practicing with the Omaha System using relevant case studies prior to using the computerized version is important as a foundation to learning.
Today, there are over 25 nursing programs who have adopted the Nightingale Tracker for use in community clinical education. Seven Centers of Excellence in Community Healthcare and Nursing Technology ( note the following URL for more information http://www.fitne.net/tracker/trackermain_nonjava.html ) were established as Tracker demonstration sites by FITNE in January, 1998. As part of the Tracker's ongoing research mission, FITNE has partnered with these seven schools and other volunteer early adopters of the Tracker to continue to gather feedback regarding the ways in which the Omaha System is useful as a foundation for community-focused clinical education.
There are numerous benefits related to integrating the Omaha System into the Tracker. First, because the System was developed to be used with non-nursing as well as nursing health care practitioners, the Schemes for describing problems and interventions and the scale used for rating problem intensity are easily recognized and descriptive of the needs of various health care disciplines. Students in the future will have an even greater need to coordinate and communicate their care with inter-disciplinary health care teams.
Additionally, because students are using the Omaha System, they will have a common framework and set of terms for efficiently and effectively communicating their clinical findings with their faculty. Such an approach will facilitate structure and organization to the hazards associated with the mobile community clinical environment. Not only can clinical communication be more timely and focused, the delivery of care can be more defined and the learning environment better supported. Finally, information gathered and recorded by those learners using the Omaha System can be part of a common language to be used in a full range of related practice and documentation research.
As nursing evolves to face the demands of a changing health care world, educators and students will continue to face the challenges of distance communication. Student/faculty use of information technology has the potential to promote a safer practice environment, save time and provide the means to efficiently manage clinical data in multiple ways. The effective integration of information technology and standardized vocabularies can help to prepare nurses for the challenges of the future and for leadership roles in health care information management.