Fig. 17.1
NHS Wales Local Health Boards. Contains Ordnance Survey data © Crown copyright and database right 2014 (Reproduced with permission)
The Welsh Government’s Departments are headed by senior civil servants; the Director General for Health and Social Services is also Chief Executive of NHS Wales. As Chief Executive, NHS Wales, the Director is accountable to the Minister for Health and Social Services, and is responsible for providing policy advice and exercising strategic leadership and management of the NHS.
The Director General receives professional nursing advice from the Chief Nursing Officer (CNO) for Wales, who is the head of the Nursing and Midwifery Professions in NHS Wales (the largest single group of health professionals within the NHS in Wales) and is responsible for the professional performance and development of Nurse Directors and the nursing profession. The CNO provides expert professional advice on nursing, midwifery and specialist community public health matters to Welsh Government.
The description of some of the key nursing informatics strategic decisions within Wales is intended to illustrate the importance of professional collaboration at national and international levels in order to reduce duplication of effort and to efficiently share good practice. It is hoped that the lessons from Wales will signpost readers to other local Welsh informatics initiatives that have not been explicitly described in this chapter, a number of which are sponsored by Welsh Universities, Local Health Boards, Welsh Trusts, the Royal College of Nursing1 and local nursing and Allied Health Professional informatics interest groups.
Welsh National Health Services in Context
Enabling Improved Healthcare Delivery in Wales – Utilizing Information Communication Technology (ICT)
In order to improve health care delivery supported by ICT, the Welsh Government sponsored a key strategic document titled Informing Healthcare a National IT Programme for Wales [1] in 2004. The Informing Healthcare Programme (IHC) was established to progress this agenda.
The remit of IHC, subsequently the NHS Wales Informatics Service (NWIS), is to enable service improvement. Welsh policy directives have underpinned the direction of all Wales ICT developments, the most recent being Together for Health [2]. The content of this chapter considers the impact of health informatics in Wales on Welsh Nurses.
The Use of ICT to Enable Improved Care Delivery
The strategic objectives of the Welsh Government in relation to healthcare services are to position patients and citizens at the centre of modern, efficient and high quality services [1, 2] and to ensure that individuals have greater access to information about their health and the ability to provide feedback on the quality of services they receive. One of the organizations committed to enabling this approach is NHS Wales Informatics Service (NWIS), the national IT programme for Wales, formed in April 2010, which was previously known as Informing Healthcare [1]. NWIS is concerned with the development of new methods, tools and technologies to transform NHS Wales for the benefit of the people of Wales. Modernizing eHealth service delivery and promoting new ways of working through better access to information and knowledge is a key aim of the national IT Programme. Recognition within the current health and social care environment regarding the range of constraints to the effective use of information communication technology supporting the delivery of care has been a critical step in the transformational process. Constraints identified include:
Poor preparation of users of ICT;
Poor access to information technology systems;
A limited range of systems to address the effective management of patient/client information;
Variability in staff skills and experience in the use of technology; and
Inadequate education and training of system users.
Involving nurses in developments utilizing ICT to deliver improved clinical care in Wales is fully supported by the country’s senior nurses.
Some of the prerequisites of effective delivery of technology supported by nurses have been identified as understanding;
the clinical and business requirements, including the design of the planned service,
the process for the delivery of the service,
utilization and/ or defining technical and information standards; and
the preparation of the users of the new technologies.
The importance of involving nurses in ICT developments has been described by Thomas and Warm [3]. Survey reports by the Royal College of Nursing [4] indicated that nurses have clear opinions on the ways in which information technology can help to deliver care to patients. Early studies undertaken by the Nomina Group [5] highlighted developments in nursing, health informatics, and the management and use of nursing information. The recommendations contained in this report are still relevant; in particular the recommendation that the nursing profession should be actively involved in all programs leading to the development of electronic health records.
Oroviogoicoechea et al. [6] suggests that for effective implementation of information and communication technology (ICT) systems, that are to be used by nurses, critical issues such as attitude and culture as well as broader technological solutions need to be addressed. This notion is supported by Hannah et al. [7] and Clark [8] who suggest that nurses need to be at the forefront of informatics development, to achieve this aspiration; nurses should be actively included in informatics developments and have opportunities to develop their understanding of the benefits of clinical informatics. Nurses competent in change management can lead transformation in the use of ICT [9].
Surveys from several countries, show that front line nurses are not necessarily confident or have the necessary skills to use ICT effectively [10, 11]. The DKIW Framework, discussed in chapter one emphasizes the importance of nursing informatics education and the importance of good data to create a strong knowledge framework for the profession.
Overview of Welsh Nursing Informatics 2007–2013
The Welsh national IT Programme, Informing Healthcare (subsequently NHS Wales Informatics Service) supported the introduction of new processes through incremental service improvement projects. These projects ensured that new ICT and information services, based on sound evidence, delivered real benefits to patients and the public. The organization’s founding principle was continuous consultation and engagement with clinicians and key stakeholders to drive service development.
In 2007, the Informing Healthcare programme appointed a National Nurse Lead to support the development of clinical informatics and to establish effective engagement with the nursing profession in Wales. During 2007/2008 senior nurses in Wales were consulted about a framework (the framework) for engaging nurses, midwives and specialist public health nurses in the Informing Healthcare change management agenda.
The aim of the framework was to work in partnership with nurses and other healthcare professionals in Wales to identify, develop, test and evaluate the benefits of potential electronic solutions to assist and improve the outcomes of care for patients, carers and service users.
The objectives of the framework included:
Creating a useful and manageable method of two way communication and dissemination of information within and between key stakeholder groups;
Contributing to testing new technological methods from a nursing and clinical perspective; and
Evaluating the contribution of the framework in relation to influencing the ICT agenda in Wales.
The key principles underpinning the framework were listening, influencing and evaluating. Table 17.1 provides more detail.
Table 17.1
The key principles underpinning the Informing Healthcare framework in Wales
Listening – The view of nurses and midwives about the potential benefits and application of information communication technology (ICT) to enhance the provision of care by defining the most appropriate way of capturing the clinical expertise of nurses from all disciplines and at all levels within organizations, formed a key component of the implementation of the framework |
Influencing – Ensuring that the nursing and midwifery profession in Wales has the opportunity to shape the design and testing of new technological methods early in the process. This requires engagement at both a national and local level |
Evaluation – Measuring the effectiveness of the engagement process and subsequently applying the lessons learned from the process |
To enact the aims and objectives, as agreed by senior nurses in Wales, a National Nursing and Midwifery Advisory Group (the advisory group) was established. Outputs from the advisory group included; contributing to the development of IHC products and services including associated clinical risk management/ patient safety activities, and influencing the e-health agenda associated with the Welsh Government initiatives in particular the Community Nursing Strategy for Wales (2009) [12].
To provide a context for the advisory group, a draft set of eight principles were developed in order to guide the group’s activities. These principles were subsequently endorsed by senior nurses in Wales and included in the Community Nursing Strategy for Wales. Figure 17.2 offers a conceptual overview of the eight principles and a summary Table 17.2, which provides an illustration of the eight principles.
Fig. 17.2
Conceptual overview of the eight Principles in Community Nursing Strategy in support of emerging nursing eHealth agenda in Wales
Table 17.2
Principles eHealth Agenda
Access to up to date, evidence based knowledge to support the delivery of modern health and social care services: |
The efficient and effective collection, retrieval, analysis and communication of information enables informed decisions to support treatment and care planning options that can provide the data necessary to support service planning and resource management. Knowledge management and the subsequent development of knowledge management tools will provide: |
the evidence upon which the provision of health care can be informed; |
support for clinical audit; |
the evidence to support service planning and resource management, and assistance with research and development activities |
Access to information about an individual persons care (contained in an individual’s health record): |
Supporting staff to undertake their day to day activities through the capture of real time standardized patient/ client information, should be the ultimate goal. Clinical staff need to be able to receive and record information at the point of care using appropriate devices such as laptops, mobile computers with touch screens/graphic tablet screens, or Personal Digital Assistants (PDAs) |
Access to information about specific groups of the population: |
The ability to access accurate information about specific groups within the population and subsequently to introduce a more community focused service for patients/ clients is a challenge for health and social care service providers. The ability to identify people at risk of, either unplanned admission to hospital services or those in need of additional packages of care, has the potential to inform proactive care management |
The development of efficient and effective communication channels between patients/ clients and care givers and between professional groups that provide care: |
New and emerging plans for the redesign of services need to consider the linkages and impact of information technology to these services. Managing the information available within and between health, social care, independent and voluntary sector organizations and other public sector organizations is fundamental to the creation of improved service design. Digital communications, use of e –mail, conference call facilities and call centers as communications as a means of communication have become an essential part of working practice for many employed in the NHS in Wales |
The provision of technological systems and tools that help the health professional perform routine tasks: |
There are a number of system options that could be used to support the delivery of health care, as a minimum the system should provide functionality that allows effective and efficient recoding of information to support; the record of assessment of care need, development of care plans and monitoring of care delivered |
The availability of functions within technical applications to support professional decision making: |
Supporting professional decision making with technical applications has been proven to be efficient and effective. Functions that are available to improve safety include; alerts and warnings for example, relating to administration of medications. As more complex care is delivered in community settings, including people’s homes this functionality will be extremely important |
Appropriate levels of training and education: |
The training and education of clinical staff is critically important, preparation for clinical practice in an electronic world is should be embedded in all clinical education learning programs. The challenge is to embed within all educational learning programs an understanding of information management, information governance requirements and the underlying principles upon which information systems and the proper use of IT in healthcare depend |
Methodologies for measuring the effect of interventions supported by technology: |
Audit packages, scheduling systems and the development of intelligent performance indicators are potential methods for measuring the effectiveness of interventions supported by technology |
Eight Principles to Support the Emerging Nursing E-Health Agenda In Wales
Welsh Nurses opinions about ICT supporting community nursing services informed a Community Nursing Strategy which was launched in September 2009 by the Welsh Government. The strategy contains a range of chapters that cover the areas of particular relevance to community nurses. Chapter eight of the strategy discusses the impact of the e-health agenda on the nursing profession in Wales. The development of the e-health chapter was led by Informing Healthcares National Nurse Lead with input from the advisory group and others, for example the Royal College of Nursing in Wales.
The core set of principles relating to Information Communication Technology enabled healthcare delivery in this eHealth chapter are of particular importance, as set out in Table 17.2. These principles continue to be relevant for nurses in Wales as the e-health agenda progresses.
Following the launch of the Community Nursing Strategy, during 2009, a survey that utilized the principles outlined in the strategy, was undertaken by IHCs Clinical Informaticist (Nursing). The survey involved 144 district nurses and health visitors; the themes identified by those responding to the survey questionnaire, with respect to the vision for a community nursing service supported by ICT, have been included in Table 17.3.
Table 17.3
ICT supporting community nursing services
There must be appropriate financial investment in the system and associated technical equipment (for example mobile devices); |
The design of ICT systems must be informed by nurses; |
Information systems need to satisfy clinical and managerial requirements; |
ICT solutions must enable seamless sharing of essential information to support service delivery; and |
All nurses should receive appropriate training and support in the use of technology solutions |
The results of the survey have been instrumental in informing the requirements of the emerging approach to the procurement of a community system for Wales and are equally relevant to acute and specialist care settings.
The National IT Programme – NHS Wales Informatics Service
On 1 October 2009, NHS Wales Informatics Service (NWIS) reaffirmed its commitment to developing clinical informatics skills to support the NHS in Wales. Large-scale NHS reforms took place in Wales, 22 Local Health Boards (LHBs) and seven NHS Trusts were replaced with seven integrated Local Health Boards, responsible for all health care services. In addition, three new Trusts were formed: Public Health Wales NHS Trust, Velindre NHS Trust, the specialist cancer Trust and Welsh Ambulance Services NHS Trust.
As part of the Welsh healthcare reform programme 2009, the NHS Wales Informatics Service (NWIS) was established on April, 1, 2010, replacing the Informing Healthcare programme. The new arrangements will allow ICT resources to work together more closely to support a consistent approach to health informatics and the implementation of common national systems. The new organization was formed by merging Informing Healthcare, Health Solutions Wales, the Business Services Centre (Information Management and Technology section), the Corporate Health Information Programme and the Primary Care informatics Programme. The new organization has a national remit to support the transformation of NHS Wales making better use of ICT skills and resources.
New technologies affect many aspects of care delivery, from patient administration and clinical documentation systems to decision support aids. Hersh [13] highlights the importance of involving the expertise and knowledge of healthcare professionals to ensure emerging technologies are appropriate for clinical use.
Ensuring clinicians are skilled in the use of new technologies is essential, particularly if they are to describe the clinical requirements to system developers, and help implement these new technologies. Huryk in 2010 [14] reported that nurses are more likely to be satisfied with a system if they have been involved in its design. Stevens in 2010 [15] suggested that nurse involvement in system design can yield positive results because they understand the context in which the system will be used and can link it with issues such as patient safety and user acceptance.
Warm and Thomas [16] reviewed the effectiveness of the clinical informaticist role and findings supported earlier studies [17–20] demonstrating that excluding healthcare professionals from the development of IM&T systems is likely to be detrimental to their design. Helping clinicians to understand the importance and benefit of technology, and including their input in the design process, can help ensure that patients receive the best possible care [21, 22].
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