Items 23 - 34 - computer may produce a standardized care plan based on little more than the medical diagnosis. It is up to the nurse to review the data mentally,.
A PROTOTYPE INFORMATION SYSTEM TO AID NURSING DECISIONS
Judy G. Ozbolt, Ph.D., R.N. Center for Nursing Research The University of Michigan Ann Arbor, Michigan 48109 Abstract A prototype is being developed for a computerized nursing information system that will not only record, transmit, and retrieve information but also aid clinical decision-making and facilitate research and evaluation. A model of the nursing process has been drawn up, with the content of each stage of the process defined from the perspective of Orem's3*4 concept of nursing. Algorithms have been developed to derive individualized nursing diagnoses from the patient data, and a program has been written in PASCAL for the Apple II microcomputer. The program will be extended through all stages of the nursing process, with decision-making operations at each stage being driven by patient data. The complete system will be structured as a relational data base management system to facilitate retrieval and use of data for multiple purposes, including research and evaluation. A fully-developed system modeled on this prototype would improve decision-making in day-to-day practice and increase knowledge of the relative effectiveness of nursing interventions, leading to better outcomes and lower costs.
collect a great deal of data that they never use to formulate a diagnosis because they lack the confidence to commit themselves. This is bad for both the efficacy and the cost-effectiveness of the nursing process. What is needed is an information system that allows its human and machine components to do what each does best. Nurses are essential for making the kinds of observations, inquiries, and judgments that produce valid and reliable data. The computer, which excels at recognizing patterns and computing probabilities, can help to aggregate and analyze that information to formulate diagnoses and select an appropriate care plan.
Theoretical nursing knowledge and computing technology are now both sufficiently sophisticated to create a second generation of nursing information systems that go beyond electronic charting to assist clinical decision making. To demonstrate this potential, we are developing a prototype that could become a component of a comprehensive nursing information system. For convenience in demonstration, we are developing our program on the Apple II microcomputer. We are using the PASCAL language because its structure is well-suited to the kind of system we are developing, because its readability is advantageous when several persons are working together on the project, and because the P-CODE it produces makes the program adaptable to a variety of hardware.
Background In a variety of applications, computerized information systems are facilitating the recording, transmission, and retrieval of nursing information. Although these systems help to organize and systematize information for planning and documenting nursing care, they generally do not take advantage of the computer's evolving capacity to aid clinical decision-making. The nursing data base is stored in the computer, but the computer does not use it to guide care planning. At most, the computer may produce a standardized care plan based on little more than the medical diagnosis. It is up to the nurse to review the data mentally, identify the nursing problems, and individualize the plan of care.
Defining the Process to be Computerized The Model
An information system to assist the nursing process must begin with a model of that process. Figure 1 depicts the model we are using. (See
following page.)
Romano' has noted that many nurses find this difficult. Her empirical observation is supported by Edwards'2 review of the research on human information processing, which shows that people do an excellent job of collecting data, but they tend to wait for more information than they actually need before making decisions. Thus, nurses will collect more data than necessary before committing themselves to a nursing diagnosis, or, worse yet,
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0195-4210/82/0000/0653$00.75 i 1982 IEEE
with self-care, either because his or her own self-care capacities are limited or because the necessary self-care calls for specialized knowledge and skills. In our nursing process model the stage of Entry is therefore defined as follows:
ance
ENTRY I
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THE PERSON LACKS THE ABILITY TO MAINTAIN CONTINUOUSLY THAT AMOUNT AND QUALITY OF SELF-CARE WHICH IS THERAPEUTIC IN SUSTAINING LIFE AND HEALTH, IN PROMOTING PERSONAL DEVELOPMENT AND MATURING, IN RECOVERING FROM DISEASE OR INJURY, OR IN COPING WITH THEIR EFFECTS.
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This state of affairs represents the condition immediately preceding the application of the nursing process and the associated information system, and it is not directly represented by a component of the system. It does, however, define the basis for all the nursing action and all the nursing information to follow.
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Collecting Data
Figure 1.
General model of the nursing
If the purpose of nursing is to provide assistance as needed with self-care, then the data to be collected must be those that will help us to determine the nature and extent of this need. Consequently, we define the stage of Collecting Data as follows:
process.
The Conceptual Content
COLLECTING [ATA
We also find it necessary to define the content of each stage of the process--or each box in the model--from some consistent perspective.
COLLECTING EVIDENCE OF THE CURRENT DEGREE OF SATISFACTION OF EA9H SELF-CARE OF THE PATIENT S CAPACITY REQUISITE ANDPERFORMANCE ABILITIES, MOTIVA(KNOWLEDGE, TION) TO CONTINUE TO SATISFY THE REQUISITE.
Otherwise, the patient's problems and other data may be defined in such diverse ways that relationships among problems and between problems and other information become chaotic and impossible to trace. It is essential, therefore, to determine at the outset how we will define the patient problems for which the nurse bears primary responsibility. Shall we see them, for example, as deficits in self-care? Or shall we consider them to be instances of maladaptation? From that determination will follow the kinds of data that will be collected to diagnose the individual's difficulties and the direction of the care that will be provided (e.g., to augment self-care agency or to facilitate adaptation). Although any of a variety of conceptual frameworks might provide a useful perspective for defining nursing content, we have chosen to use Orem's3'4.
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Orem' describes 16 self-care requisites and ascribes them to universal, developmental, or health-deviation categories. A comprehensive nursing information system would follow all 16 requisites through all stages of the nursing process. Our prototype program currently focuses on only one requisite from the universal category, the requisite for maintaining a sufficient intake of air. To insure that the data collected are valid and reliable, we are using the procedures of the Horn-Swain5 assessment instrument. This instrument, based on Orem' S3 conceptual framework, includes instructions for collecting and coding data on the extent to which self-care requisites are met and on the patient's capacity to continue meeting the requisite. Instrument development procedures included extensive testing of validity and reliability.
Computerizing the Steps of the Process Entry
According to Orem34, every person requires self-care, which includes care of the self (by others) as well as care by the sief. A nurse and a patient may legitimateTy enter into a professional relationship when the person requires assist-
To assist with data collection, the computer presents a series of screens. The screens print brief instructions on data collection procedures
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and allow the nurse to enter data, usually by touching a light pen to the screen but occasionally by typing a short response on the keyboard. The program is thus designed to be used at the bedside or in an examining room while the nurse is actually collecting data. This averts the need to record information manually and transcribe it, thereby saving time and avoiding transcription errors. By prompting the nurse to collect data and by branching to follow up on certain responses only if they appear to be problematic, the program helps to produce a concise but comprehensive data base.
SYNTHESIZING NURSING DIAGNOSES WITHIN EACH CATEGORY OF SELF-CARE
REQ-
UISITES, RECOGNIZING PATTERNS AND COMPUTING PROBABILITIES FOR THE FOLLOWING EVENTUALI-
TIES;
TYPE 4 TYPE 1 TYPE 2 TYPE 3 REQUISITE REQUISITE REQUISITE REQUISITE MET, PAT- MET, PAT- NOT MET, NOT MET, IENT CAN CONTINUE TO MEET
Analyzing Data Data collection is organized so that, in general, related items appear in proximity to one another. For example, on our instrument, items 6, 7, and 8 measure dyspnea, shortness of breath, and forced expiratory time, all indicators of airflow resistance. Sometimes, however, for convenience in data collection, it is necessary to separate related items. Thus, patency of airways is determined by items 4 and 5, which measure audible wheeze and stridor, and also by items 23-34, which measure adventitious lung sounds by auscultation. The separation occurs because it is more convenient for nurse and patient if auscultation is performed later in the examination. When related items are separated like this in a large data set, however, it is difficult for a human being to seek out all the items that relate to a particular question, with no omissions or faulty inclusions. By contrast, the computer can perform this kind of analysis rapidly and accurately. In our prototype, therefore, data analysis is defined as follows:
IENT CANNOT CONTINUE TO MEET
PATIENT PATIENT CAN MEET UNABLE TO TO DEGREE MEET FEASIBLE
In our conceptual framework, moving from the to the nursing diagnosis is a two-step First, the algorithm groups relevant items selected in the step of Analyzing Data, and produces intermediate interpretive statements.
raw data process.
For example, If no wheeze (item 4) and if no stridor (item 5) and if no adventitious sounds (items 23-34) then airways are patent (intermediate interpretive statement). The computer then evaluates all the related intermediate interpretive statements to produce a diagnosis. For example, If respirations are regular and if respiratory rate is normal and if airways are patent and if airflow resistance is normal and if ventilation is normal and if the lungs and airways are free of infection or irritation, then the requisite for maintaining a sufficient intake of air is met (nursing diagnosis).
ANALYZING DATA SCANNING THE ENTIRE DATA BASE TO IDENTIFY THOSE FACTS THAT PROVIDE EVIDENCE OF THE DEGREE OF SATISFACTI9N OF EACH REQUISITE AND OF THE PATIENT S CAPACITY TO CONTINUE TO SATISFY THAT REQUI-
On the other hand, if one or more of the intermediate interpretive statements indicated an abnormality, the computer would print a diagnosis of the following type:
SITE.
Maintaining a sufficient intake of air is impaired by a. infection or irritation in the lungs or airways b. increased airflow resistance.
Synthesizing Nursing Diagnoses Once the relevant data items are identified, the program uses them to formulate diagnoses. If nursing's concerns are defined in terms of whether or not a self-care requisite is met and whether or not the patient is able to continue meeting that requisite, four logical possibilities for diagnoses occur. These possibilities determine the way we have defined the action of synthesizing nursing diagnoses:
Such statements refer to the first part of the nursing diagnosis, whether or not the requisite is currently being met. This is as far as our program currently goes. In the future, we will extend our program to include the second part, whether or not the patient is able to continue meeting the requisite. These diagnostic statements will take the following form: Self-care agency for maintaining a sufficient intake of air is impaired by a. inadequate knowledge related to
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alterations in respiratory function appropriate actions to take when alterations occur b. inability to adapt activity so that oxygen supply is equal to demand c. embarrassment re clearing secretions in social situations.
b. ability to gen supply c. resolution secretions
The program will prompt the nurse to establish
priorities and target dates for interventions and then will help the nurse to select interventions. Corresponding to the diagnoses and the objectives, the interventions are also of four types:
Formulating Objectives and Selecting Interventions A major advantage of expressing diagnoses in terms of whether self-care requisites are currently met and whether the patient can continue to meet them is that objectives and interventions follow naturally from the diagnoses. The four types of objectives are as follows:
SELECTING NURSING IN[ERVffIONS EACH CATEGORY SF SELF-CARE REQUISITES, .ELECTINGTOINTERVENTIONS CORRESPONDING EACH OBJECTIVE: TYPE I TYPE 2 CONTINUING OBSERVATION A. CONTINUING
WITH£N
FORMLATING O&ECTIVES EACH CATEGORY OF SELF-CARE REQUISITES, WITHINrROPO ING OBJECTIVES CORRESPONDING 10 THE NJRSING DIAGNOSES:
TYPE 1 A. REQUISITE WILL B.
CONTINUE TO BE MET; SELF-CARE ABILITIES WILL BE
OR TERMINATING
B.
EDUCATION AND SUPPORT TO ALUGMENT SELFCARE ABILI-
TYPE 3 A. MONITORING
FEASIBLE.
TYPE 4 A. REQUISITE WILL
B.
B.
OBSERVATION; PROVIDING SELF-CARE THE PATIENT CANNOT DO ALONE;
B. PROVIDING
CONTINUE TO BE MET; PATIENT WILL AUGMENT SELFCARE ABILITIES TO DEGREE
TYPE 3 A. REQUISITE
MAINTAINED.
NURSING.
TYPE 2 A. REQUISITE WILL
MAINTAINED.
WILL BE MET TO DEGREE FEASIBLE; SELF-CARE ABILITIES WILL BE
adapt activity so that oxyis equal to demand of embarrassment re clearing in social situations.
TIES. TYPE 4 PROGRESS
TOWARD MEETING REQUISITE; B. PROVIDING SUPPORT
BE MET TO DEGREE FEASIBLE; PATIENT WILL AUGMENT SELFCARE ABILITIES TO DEGREE
AS NEEDED TO MAINTAIN SELFCARE ABILITIES.
A. MoNIToRING PROGRESS TOWARD MEETING REQUISITE; PROVIDING SELF-CARE THE PATIENT CANNOT DO ALONE;
B. PROVIDING EI-
FEASIBLE.
CATION AND SUPPORT TO AUGMENT SELFCARE ABILI-
Just as the program uses patient data to individualize diagnoses, so will it individualize objectives. For example, for the diagnoses presented earlier, the following objectives might be proposed: Patient will maintain a sufficient intake of air, with no further evidence of a. infection or irritation in lungs or airways b. increased airflow resistance.
TIES.
We would expect that in an initial implementation, the program would prompt the nurse to type in interventions of the appropriate type. With experience, however, it would be possible to study the relative success rates of alternative interventions in meeting particular objectives, given particular patterns of patient data. The program could then be designed to propose interventions with their statistical probabilities of success, so that the nurse could make an informed choice.
Patient's self-care agency for maintaining
a sufficient intake of air will be augmented to include: a. adequate knowledge related to
Implementing and Evaluating Interventions
alterations in respiratory function appropriate actions to take when alterations occur
The program has the potential to assist nurses to implement and document interventions much as other nursing information systems do, by producing
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reminders of what is to be done for each patient and by facilitating recording. It will be structured, however, to provide significant assistance with evaluation. As a relational data base management system, it will offer easy retrieval of information related to diagnoses, objectives, interventions, and subsequent diagnoses (or outcomes). This information can be used for concurrent evaluation of one patient's care, for more generalized evaluations according to identified criteria, or for research on the effectiveness of specific interventions. By making data from practice accessible both for day-to-day nursing care and for research and evaluation, this system will give nurses the information they need to practice and to know the results of their practice. Moreover, it will provide the generalizable knowledge needed to maximize the use of effective interventions and to minimize the use of ineffective interventions, thereby improving outcomes and controlling costs. Conclusions
Existing nursing information systems have shown that computerization is a cost-effective way to improve information management. Now it is time to develop the next generation of applications. These new systems will not only record, transmit, and retrieve clinical data, but also perform operations to aid clinical decision-making, to provide feedback on practice, and to generate knowledge for improving nursing care. References 1.
Documentation of nursing practice using a computerized medical information
Romano, C.
system. In H.G. Heffernan (Ed.), Proceedings of the fifth annual symPosium on computer applications in medical care. Los Angeles: IEEE Computer Society, 1981.
2.
Edwards, W. Conservatism in human information processing. In B. Kleinmutz (Ed.), Formal presentation of human judgment. New-York: Wiley, 1968.
3. Orem, D.E. Nursing: concepts of practice. New York: McGraw-Hill Book Company, 1971. 4. Orem, D.E. Nursing: concepts of practice (2nd ed.). New York: McGraw-Hill Book Company, 1980. 5. Horn, B.J., & Swain, M.A. Criterion measures of nursing care quality: a health'status instrument (PHS Pub. No. 78-3187). Bethesda, MD: National Center for Health Services Research, U.S. Department of Health, Education, and Welfare, 1978.
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