Knowing What To Do

What gives guidance for patient care decisions? Clinical practice guidelines and patient preferences provide two complementary sources of guidance for clinicians and patients alike. Clinical practice guidelines bring the best scientific and clinical advice to bear on specific patient situations. Patient preferences temper clinical guidelines. The papers from the Nursing Informatics 1997 conference in Stockholm, Sweden, that are included in this issue provide a rich array of perspectives on the roles of informatics in eliciting and communicating guidelines and patient preferences and in ensuring strong infrastructures for practice.

Duff¹ offers the perspective of a health services researcher, looking to the informatics community to both provide the evidence necessary to build solid guidelines and also to build the tools necessary to deliver guidelines at the point of care. Zielstorff² and Henry et al.³ answer Duff's call by outlining strategies and illustrating prototypic systems for delivering guidelines at the point of care.

Ensuring that patients truly understand the complexity of choices for which they assent presents a challenge that many times exceeds the talent and time available to clinicians. Jimison et al.⁴ describe the use of multimedia programs to guide patients through the process of giving informed consent. Targeted at the moment for research participation, this application could also be extended to help patients think through many of the complex choices they face in contemporary health care. Brennan and Strombom⁵ explore the use of computer programs to elicit patient preferences necessary to make clear clinical choices.

Gassert⁶ and Hovenga et al.⁷ provide a broad perspective on some of the infrastructure resources needed to make guidelines and patient preferences accessible in clinical practice. Gassert presents the agenda established for the United States by the National Nursing Informatics Working Group, calling for test beds and model systems that train clinicians to use guidelines and preferences in clinical practice. Hovenga addresses the special needs of rural areas, illustrating how telecommunications networks support outreach and communication to remote clinical care facilities.

These papers represent the second report of an IMIA Nursing Special Interest Group Working Group, building on and expanding the first report “Informatics: the Infrastructure for Quality Assessment and Quality Improvement in Nursing.”⁸ Each presenter at the Nursing Informatics 1997 Conference was given the opportunity to recast his or her material in a manuscript for review and revision through the JAMIA editorial process. The papers in this issue therefore represent a subset of the ideas discussed at the conference. The complete proceedings of the conference are being released by the Swedish Nurses Association simultaneously with this issue of JAMIA.

Where is the nursing in these papers? one may ask. Most, but not all, authors were nurses. Therefore, it is likely that one should discern a common theme or perspective through the papers, and it is in fact detectable in the attention to the person in context. However, the papers themselves represent a subtle but important step in the growth of the informatics field as a truly interdisciplinary effort. Neither guidelines nor patient preferences are the exclusive purview of any single clinical discipline. The lessons from these papers apply equally well to all health clinicians concerned about quality decision-making and quality care. Yet, could these papers have arisen any where but in a nursing conference?

Probably not—because of nursings' special focus on the diagnosis and treatment of human responses⁹, nurse authors target as the focus of their attention the ability of an individual to cope with health challenges and health care choices. Additionally, guidelines and patient preferences take on special meaning in the practice of nursing, which is characterized by an enduring, intimate knowing of an individual. Nurses, perhaps more than all other health professionals, are best situated to learn of patients' most private desires and values and have a unique opportunity to tailor the scientific recommendations of clinical guidelines in a manner that best fits within the lifestyle of the person. It remains a challenge for the next triennial IMIA Nursing Special Interest Group conference to introduce new informatics applications to further extend our abilities to deliver quality of care.