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Mastering Skills that Support Nursing Practice

Melissa Barthold^†

ABSTRACT

The world of healthcare information technology (HIT) is changing very quickly and the change that is driving healthcare today is the focus on patient outcomes. Patients’ outcomes can only be determined by analyzing data. Nurses are often the clinicians that enter that data, but querying, managing, and reporting that data is not often used by or understood by nursing. In order to improve patient outcomes, nursing needs to learn to not only collect data, but to analyze it, report it, and use it to improve patient care and the nursing process.

HISTORY

The first documented use of data in nursing practice was by Florence Nightingale when she collected and analyzed data about soldiers in the Crimean war (Brennan & Baken, 2015).

She said, “[I]f wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present. They would enable us, besides, to ascertain the influence of the hospital . . . upon the general course of operations and diseases passing through its wards; and the truth thus ascertained would enable us to save life and suffering, and to improve the treatment and management of the sick” (Nightingale, 1863, pp. 75–176)

She used that data to change how nurses provided care to those soldiers (Westra et al., 2015). That was the beginning of nursing’s commitment to evaluating patient care and then using that evaluation to improve patient care and outcomes. It became a part of nursing’s professional practice to evaluate and then provide improved care.

As explained in the ANA Ethical Statement, it is the responsibility of nursing to evaluate its own practice (American Nurses Association [ANA], 2010). ANA’s work on healthcare quality was the foundation of the quality work in place today. Since that time, nurses have continued to collect data and apply it to effect practice change. Information that was obtained from patients’ care was used to improve patient care. Nursing leadership became concerned that nursing care was invisible in patients’ outcomes. Most of the nursing data collection has been done manually, by auditing paper patient charts post discharge (Montalvo, 2007). There was no clear connection to patient outcomes from nursing documentation.

When computers were hard at work in the business world, they had just barely been introduced into healthcare. Initially, healthcare IT (HIT) consisted of patient registration, order entry, and billing. Software that had been developed for businesses was adapted to those functions in healthcare and required only minor changes. Since orders and patient billing involved diagnosisrelated group (DRG) codes, it was possible to get patient data (based on billing codes). That data wasn’t detailed and didn’t involve any actual clinical data. As can be imagined, the data was usually in provider or nursing notes, which meant that each note had to be read to find the necessary data.

Few nursing programs included the use of computers or software in nursing classes or nursing practice. Faculty couldn’t teach what they hadn’t learned. The process to collect clinical data continued to be a laborious, timeconsuming manual process. Clinical data was collected from paper charts and often transferred manually into spreadsheets or sent to statisticians. Nurses—even nurses in leadership positions—knew little about how to select the data to be collected, how to find the data, especially if it was in a text file, how to store it, or how to query and report it. Pravikoff, Tanner, and Pierce (2005) reported in their study that nurses didn’t have the computer skills necessary to find the evidence needed for practice. While technology was helping business to grow, and beginning to work in healthcare, nurses didn’t learn about the “tools of business” when they learned about caring for patients.

NURSING INFORMATICS AS A ROLE

Nursing informatics began as a specialty in an informal manner in the 1970s and grew quickly over the next thirty years. Nursing informaticists (NIs) began their informatics learning in schools of business or computer science, after earning either an associate degree, baccalaureate, or diploma in nursing. Once they began practice, other nurses—from staff nurses who had returned to school to Chief Nursing Officers preparing presentations or analyzing data—would call them for help with software applications from spreadsheets to presentation software.

The Technology Informatics Guiding Education Reform (TIGER) was founded by a group of educators in 2006 who had identified the lack of skills and the need for informatics competencies in nursing (Technology Informatics Guiding Education Reform [TIGER], 2016). In 2006, the Quality and Education Safety for Nurses program began with funding from the Robert Wood Johnson Foundation and began at the School of Nursing at Chapel Hill (Quality and Education Safety for Nurses [QSEN], 2019). Both these programs developed competencies for all levels and roles in nursing practice.

In addition, the ANA, the National League for Nursing (NLN), and the American Association of Colleges of Nursing (AACN) all developed standards that included informatics competencies at all levels of nursing practice. The Bachelor’s, Master’s, and Doctoral Essentials from AACN all include informatics practice. Despite this requirement, many nurses don’t know how to use the “tools of business.” This deficit becomes apparent during their education, when the students struggle to use presentation, writing, spreadsheets, or database software. In many cases, doctoral students do not know to insert a picture into a document and maintain the picture’s correct aspect ratio. There are sources available from SimonSezIT (SimonSezIT, n.d.). Microsoft also provides help in using their applications. The Help can be accessed by typing a question into the window in the application titled “Help.” There is help available on Microsoft’s Web page at https://support.microsoft.com/en-us.

DATA’S INFLUENCE ON NURSING PRACTICE

As Florence Nightingale demonstrated that data can be used to change practice, nurses have continued to collect, analyze, and apply data to nursing practice. The collection of this data has led to the growth of healthcare quality. Over the last forty years, healthcare data collection by professional organizations, such as the American Heart Association as well as governmental agencies, such as the Center for Disease Control (CDC) has increased the growth of healthcare quality.

The Minimum Data Set (MDS) creation was encouraged by the Department of Health and Human Services (HHS). The set that was developed in the 1970s was based on financial data collected from billing and did not include any clinical data, and specifically, no nursing data. A group of nurse leaders worked together to identify 16 elements particular to nursing, and they created the Nursing Minimum Data Set (NMDS) in 1987.

The American Nurses Association (ANA) led the development of the “outcomes movement” in 1994 with the Nurse Safety and Quality Initiative. The list of the nurse-sensitive indicators grew over the next twenty years, but many of the indicators were hospital-based and weren’t able to demonstrate outcomes based on nursing care. The California Nursing Outcomes Coalition, the Military Nursing Outcomes Database, and the Veteran’s Administration Nursing Outcomes Database all contributed nursing indicators to the National Quality Forum review process, but only 15 indicators were judged to have met the requirements for endorsement (Jones, 2016).

ANA sponsored the development of the National Database of Nursing Quality Indicators in 1998 (Montalvo, 2007). The database stores and provides reports on the data that is provided by the subscribing nursing departments in hospitals across the country. This was the first collection of nursing data created by and managed by nurses. This is information about nursing care and the outcomes of that care identified, collected, stored, and reported by nurses.

Current Status

With the advent of the Accountable Care Act (ACA) in 2014 and the beginning of the movement toward “Pay for Performance,” healthcare began to consider that rather than practicing “the way we’ve always done it,” practice should be driven by evidence. According to Jones:

The lack of evidence to delineate the nurse’s contributions to care is problematic. In response to declining reimbursement and escalating quality and safety problems, stakeholders in the healthcare industry now challenge traditional assumptions across the delivery system and seek empirical evidence to guide system redesign. The goal of system redesign is encapsulated in the Institute of Medicine (IOM) six aims for care: safe, effective, timely, equitable, patient-centered, and efficient (IOM, 2001). Continued support is unlikely for care providers and processes that lack evidence of a meaningful contribution to these aims. (Jones, 2016, para. 2)

This push to proving that healthcare providers are giving care that makes a difference in patient outcomes supported the work to clearly link nursing care to patient outcomes. While other providers, such as physical therapists, social workers, and surgeons were able to demonstrate that a particular care episode was providing care and then affecting the patient’s outcomes, nursing wasn’t able to provide that type of evidence. A physical therapy visit is one event, while “close monitoring” of a patient may be done by more than one nurse and may cover a period of hours, making clear demonstration of the linkage difficult. Most of the care that is measured is actually negative, such as the patient doesn’t develop a decubitus ulcer, or the patient doesn’t develop a postoperative infection. Care that is equally important to nursing includes preventing illness, reducing suffering, and supporting health. To ensure the inclusion of nursing care in the patients’ outcomes, the data collected must represent what nursing does. In order to make that change, nursing leaders began the development of nursing terminologies. There are seven terminologies that have been approved by ANA, but their implementation in nursing practice has been slow. Nurses that provide direct care are reluctant to adopt terminologies (Jones, 2016), but since nurses are the coordinators for healthcare, almost all health interventions are touched by nurses.

Documentation that is correctly designed can be used to obtain data to support nursing’s contribution to healthcare improvement. Despite efforts, there is still no standardized taxonomy in place, and nursing data is still underrepresented in data collection. Nurse leaders need to require systems that not only monitor patients but also contribute to helping measure patient outcomes and nursing interventions.

Personal Health Records and Wearable Technology

While the electronic health record has been designed for acute medical care, personal health records (PHR) are electronic records that are controlled by the patient or caregiver. It allows the patient to enter and change information, as well as provide access to selected people (“PHR’s,” 2008). In addition to permitting the manual entry of patient information, these PHRs often permit the importation of data collected by wearable devices. Devices such as Fitbit, Samsung, or Apple watches collect patient data such as heart rate or the number of calories burned during exercise. The PHRs were originally designed only for manual data entry. With the increase in wearable devices, the PHR designers have added the ability to import data from those devices into the PHR. The ANA has a position statement on PHRs and recommends their use by patients while also suggesting the different rules under which those PHRs are designed and maintained (American Nurses Association [ANA], 2012).

Insulin pumps that can be used for children and adults are available. These pumps can provide continuous shortacting insulin, as well as programmed bolus prior to meals. The pump’s design is being continuously improved but does require dedication to use correctly (“Insulin Pump,” 2019). Intrathecal pumps are becoming more common. A catheter connected to the pump is implanted under the skin and medication is delivered directly to the spinal cord, which requires a much smaller dose of medication (“Pain Pump,” 2019).

The designs and creation of different patient-wearable equipment continue to grow. With the improvement in technology, more and more devices that can help patients will be invented.

Data Presentation Using Dashboards

Nurses often manage data, whether in flowsheets, computer programs or data entry applications. This management of data makes nurses responsible for the accuracy of that data, for managing large Data Sets, or data analytics and presenting the information in an understandable format to stakeholders. One method of presentation is the use of a dashboard. Techopedia defines a “Digital Dashboard” as:

“A digital dashboard is an electronic interface used to acquire and consolidate data across an organization. A digital dashboard provides in-depth business analysis, while providing a real-time snapshot of department productivity, trends and activities and key performance indicators, etc. A digital dashboard is also known as a dashboard, traffic dashboard and traffic dash.”

Technopedia.com (June 16, 2020) What Does Digital Dashboard Mean?.

To learn more about dashboard development and use refer to: 10 Tips for Presenting Data by Michele Kiss. (January 18, 2018).

In 2019, Heath, et.al., described using a Telehealth dashboard to leverage reporting functionality. (BMJ, 2019). Telehealth’s adoption began slowly, but the recent pandemic demonstrated the usefulness and efficacy of telehealth. The limitation in tests limited the ways to prove that a particular patient is safe to see face-to-face. That limitation supported the growth of telehealth. The Centers for Medicare & Medicaid Services (CMS) released guidance on March 17, 2020 that permits Medicare to pay for telehealth across the country (Council of Economic Advisors, 2020).

According to an article in U.S.News, telehealth charges for individual procedures has increased 7.52% in a year ending in March 2020 (Gelburd, 2020). That same article discusses how medical care has been changed by the use of telehealth. Aetna, has created a video conferencing program that interfaces with its electronic health record, and it has increased telehealth’s use by 3400% (Jerich 2000).

Nursing’s position in telehealth is growing. “The telehealth nursing process evolves as nurses interact with patients over the phone to identify and prioritize their health needs through questioning, information interpretation, symptom review, and skillful assessment of the urgency and level of care necessary to safely and effectively meet the caller’s needs.” (Mataxen, P. & Webb, D. 2020).

Purdue nursing has a lengthy article on telehealth nursing and details the various ways that nurses deliver nursing care via telehealth. They list the ‘Continued Growth of Telehealth’ in the “Top 10 Nursing Trends for 2020 (Purdue Global 2020). With the of growth of telehealth, nurses are learning either on the job or by taking a course in telehealth. Nurses interact with patients via remote monitors, asynchronous recording/analysis by the RN, remote monitoring and mobile health. Telehealth has grown due to increased reimbursement from CMS and private insurers as well as request from consumers (79% of patients said a telehealth follow up visit would be more convenient). (Purdueglobal.edu 2020).

The Coronovirus-19 (COVID-19) pandemic has also increased the use of telehealth. Very quickly, both the smaller as well as the large hospital systems wanted to minimize their staff’s and their patients’ COVID-19 exposure. They found that telehealth does that. Aetna interfaced a video conferencing software. Lee Health, in the Southwestern Florida region, implemented telehealth as the pandemic began impacting the area and didn’t charge for a telehealth visit (Lee Health 2020).

While the University of Southern California has been using telehealth in their Community-based Nursing Department and Stroke protocols, as well as other parts of their system, it was encouraged during the pandemic for those quarantining in place as well as those admitted to the hospital (University of California in Los Angeles, 2020). According to the Health Information Management & System Society (HIMSS 2020, June 1), telehealth expansion is one of COVID-19’s sliver-linings.

The manager of the database for the state of Florida was fired after she refused to, she stated, manipulate data to match statistics that the then Governor, Ron DeSantis, wanted changed. (Iati, M. 2020). Maintaining the integrity of health-care data is imperative in anyone that works with that data. Not every state creates graphics reflective of its data, but the CDC does post a graphic of the number of COVID-19 cases reported by each state and territory.

Nurses: The Data Lifeguards

Data drives all that is done in nursing; however, nurses may not always think of it that way. Data can be as simple as a heart rate recorded in the EMR, or as complex as a registry of patients based on a chronic condition. Data is everywhere in nursing, and there has never been a better time for nursing to take the lead in using the fruits of their labor to validate the key role that they play as one of the largest groups of health providers.

How do they know that their practice works? How do they learn from opportunities when things may not have gone as planned? Quality improvement allows us to do these things and continue the evolution of nursing practice. Since Florence Nightingale, nurses have always been looking for ways to improve the care that they provide to their patients. In order to do this effectively, they must find ways to count and measure the interventions that they perform. Using data as the foundation of this, they can often trace their practices using the Data, Information, Knowledge, and Wisdom framework.

With the rise of the EMR, there has been an increased focus on the large pools of data that nurses have created both locally in their organizations and globally as they use standardized terminologies to combine and analyze their data. Within these data pools, nurses are often using many of the traditional patient scoring tools and automating them in order to help guide the practice of clinicians and plan a course of action for the interventions a patient may need. Within the past few years, nurses have used advanced analytics tools to look at these large pools of data and make predictions on outcomes that their patients may be likely to experience. This is commonly known as predictive analytics.

The thought of trying to make sense out of the large volumes of data that they have created in recent years is daunting. Fortunately, dashboards are a great tool to help bring together various pools of data in a graphical manner so that end-users are able to easily digest the story we are telling. Dashboards are a great tool for nurses from the bedside to the boardroom. Some great examples of these could be the following:

Nurse Manager Dashboard: To show an overview of the patients on the unit, with quality metrics identifying any deficiencies. Nurse Administrator Dashboards: can show things such as performance with regards to financial, quality, or clinical outcome goals.

The United States Department of Health and Human Resources has created a great set of dashboards based upon publicly reported data from organizations that allows the user to start from a high-level view and then filter down to a specific provider or organization in their area. An example from the Office of the National Coordinator’s Health IT Web site can be seen in Fig. 24.1.

• FIGURE 24.1. Health IT Dashboard (HealthIT.gov, 2019).

Data Visualization

When we tell our story in healthcare, it’s vital to use the appropriate tools to ensure that we are representing our data in the best way possible. This is similar to selecting the blood pressure cuff for the correct patient, using a cuff that is too big or too small would not present an accurate picture, and the same is true with the tools we use to present our data.

Key Terms

These are key words needed to understand expressing data.

See Table 24.1 for a list of the common types of charts used to display data.

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