Abstract
The results of an evaluation of a nurse care planning (NCP) system that is based on the use of evidence-based order sets will be presented. The integration of the nurse care planning function into the clinical information system (CIS) at Nebraska Health System (NHS) was implemented in March, 2003. The evaluation addresses the usability and completeness of the order sets to plan and direct nursing care.
Background
Nebraska Health System (NHS) is moving toward an electronic multi-disciplinary plan of care (POC). The elements of the POC include patient problems, patient goals, and interventions from multiple disciplines that are necessary to achieve desired patient outcomes. The plan for multi-disciplinary order entry is envisioned to include problem-based order sets. The order sets formulate the intentions of the entire care team and specify goals, interventions, and monitoring necessary for optimal patient outcomes.
The initial step was to incorporate nursing order sets into the computerized patient record to facilitate nurse care planning. A nurse care planning (NCP) design team began meeting in January 2001 to devise an approach to integrate care planning into the CIS and simultaneously develop a cognitive infrastructure that would promote critical thinking. The limitations of the current care planning system identified by the staff nurses provided additional direction for the NCP design team. These limitations included redundancy of physician/nursing orders on the work list, and inclusion of all possible interventions rather than a customized list to direct patient care. The ultimate goal was the creation of a care planning system that would be valued by the bedside nurse as a tool to guide the provision of individualized nursing care.
Project Description
The NCP design team identified the standards of care as the foundation of the order sets for the new care planning system, since standards provide the basis for guiding nursing care. Each standard of care was reviewed and revised to 1) ensure a focus on one specific patient problem, 2) include measurable patient goals, and 3) establish evidence-based support for interventions. The literature was reviewed and evidence-based clinical guidelines were incorporated into the standards of care whenever available. The sources and strength of evidence for each intervention were recorded. The standards of care were placed on the intranet for access by staff.
Order sets were derived from the standards of care. The staff nurse users identified key interventions from the standards of care. The goals and key interventions are the order sets from which the patient’s POC is derived. The patient’s POC is developed by 1) selecting the order sets for all of the identified patient problems, 2) selecting those goals and interventions from the order sets which apply to the specific patient, and 3) adding any additional goals and interventions that are needed to individualize the POC. The staff was oriented to the new care planning system that was implemented in the spring of 2003.
Evaluation
The purpose of the evaluation is to determine the usefulness and completeness of the NCP system and whether the limitations of the former care planning system have been overcome. The evaluation includes user reactions to the 1) overall system, 2) standards of care, 3) nursing order sets, and 4) goals on the computer. Approaches for data collection include focus groups for super users, paper and pencil evaluation forms for all users of the NCP and structured interviews of staff by their managers. Focus groups will solicit feedback regarding usefulness and completeness of the components of the NCP system. The paper and pencil questionnaire consists of rating scales to evaluate the components of the NCP system. The unit managers’ interviews of staff will be conducted with reference to worklists currently being used by staff to provide care. Structured questions to be asked of staff are designed to determine whether the limitations of the previous worklists from previous care planning system have been eliminated. The evaluation process will begin the week following go-live and include multiple waves of data collection.
Conclusions
Based on the conclusions of the NCP evaluation, recommendations and implications for incorporating evidence-based nursing order sets into clinical information systems will be presented.