By Filipe Pereira, MSN, RN
Citation: Pereira, F. (October, 2005). Information relevance for continuity of nursing care. Online Journal of Nursing Informatics (OJNI), 9, (3) [Online]. Available at http://ojni.org/9_3/pereira.htm
The present report refers to action research carried out at an Internal Medicine unit, which uses a paper supported, Nursing Information System (NIS). An ethnographic approach was developed in order to understand the role that NIS, with International Classification for Nursing Practice (ICNPâ) incorporated, plays in promoting continuity of nursing care. The importance assumed by information related to patient problematic condition is outlined as well as the finding that the nursing care plan is the preferred repository of the relevant documented information, while nurses are assumed as privileged repositories of non-documented information. Additionally, a significant amount of non-documented information may be included in nursing documentation. We concluded that the relevance or value of information is not a constant, but a dynamic reality, resulting from the influence of different factors and different contexts that characterize nursing practice.
Keywords: nursing information systems, continuity of care, nursing documentation and nursing records, International Classification for Nursing Practice (ICNPâ).
In the context of modern societies, information plays a very important role, and in the health domain, the development of efficient information systems, which improve unit management and the quality of health care, is expected. For the past two decades the Nursing Scientific Community has become increasingly aware of the need for nurses to assume the responsibility for the development of Nursing Information Systems (NIS). For this reason, the active participation of nurses in the development of NIS is highly relevant to the NIS structure and contents.
In the 19th century, Florence Nightingale raised the issues of “how” and “why” to collect and document health care data systematically. The content and quality of nursing care have changed drastically since Florence Nightingale, which strengthens the need and relevance for the development of NIS that facilitate the collection, processing and use of information in a systematic way.
A Nursing Information System can be defined as “... a part of the health care information system that deals with some aspects of nursing specially the maintenance of nursing records” (CEN/TC 251 Pt 001 Medical informatics vocabulary first Draft Working Document, cit. by Goossen, 2000 b. p. 9).
The first-generation NIS was designed primarily with the aim of decreasing the time nurses spent in documentation. Expectations have since grown. Now, when we think of NIS we expect the following features (Ehrenberg & Ehenfors, 1999; Marin et al, 2001):
The promotion of continuity of care has become one of the main goals for a NIS. In this context, the information processed by the NIS should gather the needed attributes to guarantee that the continuity of care becomes a reality. On the other hand, when the issue is health care quality, one of the factors that must always be considered is the continuity of care. It is easy to see the importance that this aspect assumes in health care in general and particularly in nursing.
When we intend to develop a research study on NIS domain, it is important to examine questions related to the continuity of care and its relationship to the information processed and documented in the NIS. In this scenario, research centred on the information content and how this information is used in health care is necessary to evaluate the effect of the NIS on nursing practices.
The aim of this study was to understand the role of NIS in the promotion of continuity of nursing care. This research aims to contribute to the improvement of information systems by promoting information management as a resource, in a strategic context in order to improve the quality of nursing care.
We defined the following set of research guiding questions:
For the purpose of this study we defined three main concepts: information, nursing information systems and classified language, and continuity of care. Taking these concepts as a starting point, we also approached other associated concepts we found relevant to clarify.
When we sought to clarify the concept of information, we come across a real tautology because nowadays everything is information and information is everywhere (Lussato, 1995).
No doubt “information is the most spread out and the least defined thing in the world.” (Lussato, 1995, p. 35). Relative to the inability to clearly say what information means, Lussato referred to “multiple points of view”. From this perspective, when we talk about information we are referring to three closely related, but different concepts: data, information and knowledge. According to Blum (1986, cit. by NCNR) and Graves and Corcoran (1989), data is something that is described objectively without any sort of interpretation; information concerns the facts that have already been interpreted, organised and structured; and knowledge refers to information that has been summarised, related to other subjects and formalised. When the word information is used generically it represents, in fact, the three concepts.
Now that the concept of information has been clarified, the concept of information stock or repository must be addressed. It is important to know where information needed to promote the continuity of care is available for nurses.
Our theoretical concept of information allows us to understand that we cannot reduce the concept of an information repository only to objective and physical structures, but we should broaden it to a dimension that includes memory structures and the individual perceptive fields. Therefore, the information repositories that concern this study are understood as: entities or/and basis where the information is available to be used.
There is some consensus about the main requirements for NIS. These include, but are not necessarily limited to the following requirements (Goossen, Epping and Dassen, 1997):
Keeping the NIS conceptual goals in mind, we should consider that the utilization of classified language in the diagnosis, interventions and nursing outcomes nomination consist in one of the elements included in the NIS that leads to the continuity of care promotion. The expression Continuity of Care as currently used in the literature, is multidimensional (Starfield, 1980; Walls, 1981; Fletcher at al., 1984; Ruane and Brody, 1987). It has been used to describe a large amount of relationships between patients and the health care professionals;the information availability between the different health professionals (Ellsbury et al., 1987; Feltovich at al., 1989; Rivo at al., 1994); the assistance level after the patient has been discharged and his level of accessibility to health services (Hargraves et al., 1993; Kiefe and Harrinson, 1993).
Banahan and Banahan (1981) suggest another perspective of continuity of care. These authors argue that the continuity of care should be seen as an “attitudinal contract”, meaning an aspect of the tacit agreement of assistance established the moment a person is admitted to a health institution. Thinking of Continuity of Care in the hospital context, we realise the stress is placed in the co-ordination between the several people who intervene in the assistance process and are involved in the information exchange related to the patient’s condition. This information exchange between healthcare professionals is paramount to facilitate the patient’s health care.
Fletcher, et al. (1984) make the distinction between co-ordination, the degree to which various components of care bear a useful relation to each other, and continuity, the existence of some thread, individual, practitioner, group or medical records, that bind together episodes of care, admitting that in most cases it is difficult to separate both concepts and one is used to define the other. Regardless, using both concepts - co-ordination and continuity – we consider the continuity of care as an attribute to the assistance process, whose multiple behaviours, in the case of nurses, keep a straight tendency that aims to reach the nursing care goals, both implicit or declared, while the patient is in hospital.
Therefore, the continuity of care is associated with the quality of information presented about patients; to the availability and the possibility of it being re-used and, moreover, being used to provide a better assistance (Brunt et al., 1999; Anderson and Helms, 2000). At this level the NIS plays a very important role (Mainous and Gill, 1998; Brunt et al., 1999; Anderson and Helms, 2000; Cook et al., 2000), because the biggest gaps in the continuity of care are due to quality and/or quantity of information needs or the absence of able information systems (Cook et al., 2000).
Although we place stress on the information role in promoting the continuity of care, it is important to explain that this problem may be seen as an exchange of multi-professional information, between professionals of the same area working in the same unit, but also between different units or institutions. In this study, we refer to the information exchanged between nurses working in the same unit.
Considering the study purpose, it was appropriate to select a study design fitting the qualitative research paradigm. The design had to facilitate the need to catch, analyse and interpret the deeper elements (not yet explored), which cannot be statistically manipulated of the phenomenon in an environment of informality or naturally in its “own habitat”. The objective was always: “What is the method to reach the phenomenon?” and not “How to bring the phenomenon to the grounds of any method”. In addition, we recognise the “... intimate relationship between the researcher and what is studied...” (Denzin and Lincoln, 1994, p. 4) and that we do not have a theoretical background that allows us to explain the nursing phenomena, since “... there is little known about a phenomenon...” (Morse and Field, 1998, p. 8).
An ethnographic profile study allowed us to understand the essential elements of the problem, as well as distinguish patterns and relations based on the unit singular features of the study setting (Hammersley and Atkinson, 1994). It was an ethnographic profile study and not a true ethnography because although our approach is mainly ethnographic the interpretative study is not. The nature of this study is more generic, without the approach proposed by Spradley (1979).
The research techniques used were affiliated in ethnography. We carried out participant observation during 220 hours, between August 2000 and February 2001, using Lenninger’s (1991) model and producing Field Notes (Maanen, 1988). In this period, we realised 12 individual interviews with key–informants, according Spradley orientations (1979). All of the information produced by nurses, was submitted to content analysis (Goetz and Lecompte, 1988; Hammersley and Atkinson, 1994). We used several strategies while collecting the data to afford flexibility in gathering the information that would allow us to see “the whole of the phenomenon study”. It was important not to reduce the information relevance to the continuity of care to exclusively what nurses told us or even what was documented on the NIS they used. Only gleaning this limited information could be reducing and unsuitable to the framework we have adopted.
This study took place in a medical unit of a district hospital in the Oporto area, in the North of Portugal over an eight-month period. This unit was chosen for two reasons. In first place, this unit had been developing its NIS having its basis in the NIS criteria (Silva, 2001). Secondly, it was easier to develop the study in an already known context (the author has worked as a nurse for approximately five years in this unit).
Relative to NIS use on this unit, it is important to stress that during our fieldwork, this unit had already performed the present requisites of the NIS (Goossen, Epping and Dassen, 1997), although all data was documented only on paper. One of the most important aspects refers to the use of ICNPâ (ICN, 1999) as the nursing terminology for the nomination of diagnosis, interventions and nursing sensitivity outcomes (Henry et al., 1999; Nielsen, 1999; Silva 2000).
The data analyses and interpretation evolved from three central questions: the assigned information value, its content and its repositories.
Basing our research on the question of information relevance, we found that its value was circumstantial and contextual. The information relevance for the continuity of care is the result of the crossing and balance established through different factors, some of them related to the profession context, some related to the action context and even others directly connected to nurses themselves (LeBoterf, 1994; 1998; Rebelo, 1996). This set of factors function as the foundations for the information relevance according to the value nurses assign to it and this influence is characterised by simultaneity.
Concerning the profession context factors, which seem to have a significant influence on the information value, different concepts of nursing come out as well as the care related values (Fitzpatrick & Whall, 1989). Therefore, we can talk about two different concepts or orientations, one close to the “to treat” values “ …Some times its difficult for us to plan nursing care, without the medical diagnose … it’s a long since way of thinking…” (Interview IV) and another close to the “caring” values (Kérouac, et al., 1994; Ribeiro, 1995) “ Two patients with the some disease, for example, …Heart Failure… but the nursing diagnoses are different one from another…its not the medical diagnose that matters…” (Interview VI). Professional tradition based on established routines over the years, has been associated to nursing practices (Basto, 1998) and come out in a remarkable way as another factor of the profession context that influences the value nurses assign to information.
We realise that in the action context that seems to influence the information value, we should point out the unit tradition (Basto, 1998) “In the morning shift when we say we finish the routines, what we mean is that all the patients hygiene’s are done, they are out of the bed and all have taken breakfast … every thing is ready for physicians pass by …” (Interview X) its implicit rules (Thibaut and Kelly, 1959, cit by Jesuíno, 1999), the implicit care patterns and the NIS in use itself. In many circumstances we realize that frequently the information needs are not meaningful because all the interventions that have to be implemented are part of a set of tasks or routines that are pre-determined. On the other hand, the existence of informal group constructs where one knows the normal set of nursing interventions to be implemented towards certain usual medical conditions – Implicit Care Patterns – seem to be another factor that leads to an information value that is as the participants in the study said“beyond the usual and what is normally done in the unit”.
In what concerns the individual context factors that influence the information assigned value, we realise that the opinions each nurse has about its interlocutor seem to influence strongly the information value, “ … Some nurses catch my attention much more than others …like everybody we have previous ideas about the others …” (Interview X), what some authors entitle informative and social influence (Hewstone, Stephenson and Stroeb, 1996; Hogg and Tindale, 2001; Hogg and Vaughan, 1998; Turner, 1991). Here the interlocutor recognized skill manifests as promoting the assigned value of received information. The data we have available allows us to reach the conclusion that the receptor opinion about the sender skills is a key element to the value given to information. We also realise that the information is more or less relevant concerning what each nurse, at every moment, knows of her/his patients (Carnevali and Thomas, 1993; Ford and Walsh, 1995). When the nurse already “knows the patient” the information which is most valued is the one that allows “.... Mentioning any change...” trying to avoid the dangers of an “overloaded information” (Lussato, 1995). Still, in the individual context one factor that influences the information value, is that when nurses have any doubts about the diagnostic reasoning, they release the content uncertainty of related data in order to be anchored in the group diagnostic decision, probably as a self defence behaviour “When I’m not sure about some nursing diagnose … I have doubts … I mention the data to other nurses… and then we decide … and we document the nursing diagnose we achieve …” (Interview VII). Therefore, we can say the information value in what concerns the continuity of care is not constant, it is really a dynamic reality, resulting of the simultaneous and permanent influences of different factors, of different contexts that characterise and are presented in all nursing practices.
We analysed the content of relevant information to the continuity of care without an explicative model. As the field work progressed and the material was collected and organised, it became clear that the content of relevant information to the continuity of care was directly linked to its level of formalisation (Hoy, 1997), whether that content was documented or not. From these elements, level of formalisation and the presence or absence of documented information, a model of analyses developed that allowed us to organise and interpret data related to the information content. In this analyses model, we have considered formal information, all the information processed by a classification system as, for example, the ICNPâ (nursing classification used in the unit) or on the International Classification of Diseases (ICD – 10) (WHO, 1992). All the information that could not be categorised as formal was, naturally, considered informal information as Hoy suggests. Documentation here is understood generically, that is, in the logic of information reproduction or representation related to nursing care.
The content of relevant information to the continuity of nursing care was another key element of this study. We pointed out two essential ideas. First, the relevance that the information related to problematic patient condition assumed to promote the continuity of care. Second, the meaningfulness of the information related to nursing intervention to reach the same aim.
When we looked at the set of sub-categories that came out from our analyses of the information content after gathering both the information documented and not documented, we delineated ten sub-categories. Seven refer to the problematic patient condition, two refer to the nursing interventions and one refers to logistical and organising information. We will focus on each of the sub-categories. But it is important to say what we mean by problematic patient condition: it is the result of several health situations experienced by the patient that demand assistance.
In what concerns documented and formal information, the sub-categories nursing phenomena and medical diagnosis and prescriptions refers to what we considered, problematic patient condition. When we refer to nursing phenomena we are talking about relevant health aspects to nursing practice such as: expectoration, ineffective airway clearance, risk of dehydration, dependency for self-care: hygiene.... The special interventions and the surveillance, seems to be the only nursing interventions valued to the continuity of care promotion because they are in Folk terms: “... the interventions that are beyond what is normal and usual...” (Interview I). So, “performing the first getting up technique tomorrow; avoiding the trendelenburg positioning or monitoring the consciousness through the Glasgow coma scale”, are interventions which are “beyond what is normal and usual in the unit” (Field Notes).
About the category of documented and informal information, we consider that the “patient problems” recorded in natural language are also included in the problematic patient condition. The excerpt we reproduced from our field notes made it evident that one of the aspects of relevance to nursing practice – Care giver role – was documented in natural language, like this: “ The wife of our patient has difficulties dealing with her husband’s hygienic treatments, she doesn’t feel at ease, she still doesn’t know very well.” (Field Notes). The remarks, the other sub-category of documented and informal information, obviously represent logistic information that is, in our context, traditionally a responsibility of nurses (Basto, 1998).
About not documented and formal information, two of the sub-categories included are part of what we name problematic patient condition, since it refers information related to the nursing phenomena. We can include here the unusual nursing phenomena as, for example, anxiety, which is not documented because it is “beyond what is usual in the unit” (Field Notes). It becomes clear the influence, for example, of the action context factors, like unit tradition and its implicit rules, have on the process of documenting information. We also found the usual but absent nursing phenomena, which can be shown by our field notes: “It is a patient with pneumonia, we should only take the safety precautions... he doesn’t feel hypothermia, there is no expectoration, no cough, nothing else... none of the phenomena normally associated with respiratory infections.” (Field Notes).
The not documented and informal information interestingly refers to two sub-categories we have included. The Synthetic “Chunks” (Lussato, 1995) composed of items of information highly significant in the context in which we have developed this study. They are used as strategies to summarise very complex conditions of the patients, which we can notice in expressions such as: “... Although there are no expectoration... his looks... it seems he’s nothing well at all.... I don’t like the way he looks... as we normally say, you know.... He’s not well” (Field Notes).
We named the other sub-category as “added information” referring to descriptive and analytic data. We realise that, in many circumstances, it is used to refer to some problematic aspects of the patient’s situation, but without the sufficient clarification of the diagnostic reasoning and data formalisation. As we have said, we have included these two sub-categories of information within our concept of problematic patient condition.
In addition, is important to point out that hhe “added information” used was intended to describe some kind of “do-it-yourself” aspects of the unit, for example, the activities description that led to a certain nursing intervention. Additionally, “added information” assumes some relevance to describe some essential aspects of nursing practices, which are related to the ethic, aesthetics and relational domains. In effect: “There are things about the patient’s behaviour, the way he reacts with the nurses... etc. These things are important but it is not necessary to write about them (...) because it is difficult... with the ICNP... do you understand? They are important things and why do we say them? Because they may influence the way we act with the relatives, for example.” (Interview III). These findings are according to what Abraham & Fitzpatrick (1987; cit. by Goossen, 2000 a) found in a study about the way different types of knowledge can be formalised and included in clinical records, particularly the electronic records. These authors have concluded that only a small part of the knowledge can be formalised, which helps us to understand why this kind of data is not, normally, documented or represented in the NIS.
In the identification of relevant information repositories to the continuity of nursing care it is important to note that the nursing care plan and the nursing notes are the most important repositories for the relevant documented information. Nurses are the privileged repositories of not documented information.
The nursing care plan, due to its structure and systematisation contains the most documented and formal relevant information to the continuity of nursing care. We believe that some of other sub-categories that use other repositories besides the nursing care plan can also be documented in this repository, once the conditions for its non-documentation have been overcome. Some examples are: in what concerns the informal and not documented information; the “patient’s problems” recorded in natural language and, in the case of formal and not documented information the unusual nursing phenomena. In relation to the sub-category -Usual but absent nursing phenomena - we can say that this type of information is presumed from what is documented in the nursing care plan, strengthening the value of this repository in our study context.
The synthetic “chunks, information not documented and informal, due to its nature and characteristics can not be formalised and documented. As this study progressed, we often came to the conclusion that “silence” and “dots” are also relevant information. It was interesting to realise that there are things that cannot be expressed by words. This kind of information, which has proven important in patient problems description, has the nurses as the most privileged repositories. This raises important questions about how this kind of information can be articulated with the NIS.
In what concerns the “added information”, we realise that nurses use it to describe situations where they express doubts about the diagnostic reasoning. However, once the reasons that justify why it is not documented have been overcome, this kind of information can be documented. It would most probably be documented at the level of the nursing care plan. It is important to remember that the added information is also used in some situations to describe aspects of the “do-it-yourself” of the unit and in these conditions, this information cannot be formalised and the nurses are its repositories.
It is clear from all the data available that there is relevant information for the continuity of nursing care which is not documented and that cannot be documented. The privileged repositories of this not documented relevant information are nurse’s memory structures.
The nursing shift change has revealed itself the most important moment when the relevant information is changed in order to assure the continuity of care. The nursing shift change is important for two reasons. First, it is the moment when not documented information is transmitted, for example, the synthetic “chunks”. Second, it is during the nursing shift change that the selection of the relevant information for the continuity of care is done. The information that is exchanged at this moment is part of the documented information, associated to the sub-categories, which are part of the not documented information. Therefore, in order to promote the continuity of nursing care, in this study context, the nursing shift change cannot be replaced only by nursing documentation. This moment that characterises nursing practices assumes an extreme significance.
In this study, it became clear that the nursing shift change should be prospective rather than retrospective. While the retrospective nursing shift change is centred on the exhaustive narration of what happened during the shift that now ends, in the context of the service where we developed this study, we realise that the main aim is put in the characterisation of the patient problematic situation and in the set of special cares that should be held in the shift that now begins.
We can conclude, about the role of the NIS in the promotion of the continuity of care, that most of the relevant information is within the NIS, a significant part of the not documented information can be included in nursing documentation, when the factors for its non-documentation have been overcome, and that part of the relevant information is inferred from the NIS. Therefore, the information and nursing documentation system is an element that plays an important role in the continuity of nursing care, because it is, no doubt, the repository of most of the relevant information.
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Filipe Pereira, MSN, RN
Filipe Pereira is currently a Doctoral Student at the Oporto University, Portugal and has a Master in Nursing Science. Filipe has eight years of professional experience in the clinical setting, five years of experience as a teacher in Nursing College and is a member of the Nursing College research team in “Nursing Informatics”. Filipe’s professional interests are Nursing Informatics, Nursing Languages and Nursing Minimum Data Set.