Nursing’s electronic transition

Technology looks set to blitz time-honoured Australian nursing procedures. 

Paper records are taking a back seat to e-health and e-learning, and clinical informatics is making inroads on Australian nursing practices.

Schemes already in place include electronic admission risk screening tools in acute wards at Geelong’s Barwon Health. In NSW, it’s a 23 per cent reduction in the incidence of patient deterioration in the past two years is reported by NSW Health’s Clinical Excellence Commission (CEC) as a result of e-learning systems contributing to newly introduced e-charting in northern and mid-north coast region hospitals.

Highlighting such trends, a national conference in Adelaide in mid-July will feature nationwide discussion on informatics, the term described by health cognoscenti as ‘science for processing data for storage and retrieval’, or ‘betterment for patient outcomes’.

The Australian Nursing Federation, while conceding electronic transition is overwhelming for many employees, is embracing change on behalf of its 200,000-plus nursing members.

The federation’s secretary, Lee Thomas, said she believes e-health will enhance the ability of nurses, midwives and assistants to deliver safe patient care across all health sectors and aged-care systems.

Technical education and tertiary nursing schools contacted reported undergraduates, including mature-age students, must have basic computer skills, use a laptop or PC to access course material, as well as YouTube and other programs, often on their own systems.

But instructors say a gap exists between digital usage in simulated college tuition practices and on-the-job computer usage, with access to hardware a missing element, and data capture electronic skills among nurses a key concern.

Registered nurse informatician and a lecturer at Queensland University of Technology’s school of nursing, Joanne Foster, said she is concerned at lack of awareness of electronic health and e-record keeping. She said paper-based records are still being taught in employer settings, including patient record charts and progress reports. “We are trying to implement e-health, but it is slow going,” Foster added.

While students in three-year undergraduate courses may not learn every aspect of record keeping during training, the trend to supervised online record keeping is gathering strength. Registered nurse and chief information officer and director information services of Barwon Health, Ann Larkin, confirmed the group’s latest moves. She described them as assisting greatly in the communication of information across the care continuum.

“[We] are working towards the development of an integrated electronic patient management system, and are ensuring that our staff have the right hardware and training for the transition to take technology to the bedside which ensures a greater partnership with staff and our patients,” Larkin said.

Some professionals describe attitudes in many wards as outdated, and under pressure to make the switch to electronic document delivery, while too busy and short of funds to provide sufficient hardware to meet the needs of every staffer on every floor.

“It’s got a long way to go,” says lead clinician in IT at Gold Coast Hospital, Dr Nick Buckmaster. He described present information systems, including paper-based systems, as unsustainable. “The newer electronic methods are different but are smarter, more efficient and potentially safer,” he said.

Buckmaster also said he sees nurses in the future having to be assisted with technology.

But some senior professionals see a worrying gap between supply of equipment and of nurses trained to use the systems effectively, while others perceive change to increased IT usage by nurses as a longer-term objective.

Confirming developments in the NSW CEC’s patient observation system, Dr Charles Pain, a CEC director, said accessing computer hardware was a key component for statewide e-chart use in hospital wards. “It’s a gradual process,” Dr Pain said. “All nurses and MOs require e-training in this program.”

Registered nurse and e-health project officer, General Practice Gold Coast, Lis Herbert, told Nursing Review she sees more action urgently needed that link widened IT usage with clinicians and informaticians. “An Australia-wide push for increased digital training is needed,” she said.

Nurse informatician Foster said adaptation is needed beyond existing digital entry uses in emergency departments and ICUs to e-health education of employees. “Computers also need to be located near nurse point of care areas for entering patient data on a daily work round.”

She said handheld mobile or computers on wheels (COWs), already in use in some Queensland hospitals, may prove a solution to the spectre of multiple terminals on a desk. “The employer is responsible,” Foster said. “Few nurses were having input in IT developments,” she added. But much would depend on access staffers have to computers.

Privacy also looms as a concern, with the prevalence of smartphones under-equipping graduates, and to what extent explicit duty-of-care training principles may prove vulnerable.

The University of Sydney’s nursing school associate professor, clinical nursing, Sandra West, registered nurse, said she sees smartphone image-taking capability creating concerns among some clinical supervisors.

Official guidelines on computer user privacy points positively to security solutions for employers.

But questions remain, specifically in clinical situations, West said. She has concerns about operational aspects of how system constructs of privacy can sometimes be used to limit access to computer terminals or mobile devices in clinical environments.

“There have always been gaps in management of personal information in health care,” she said.

“For example, accessing medical records traditionally functions on trust and the accountability of individuals. “With electronic transition many of these unformulated approaches are being translated into logins and passwords,” she said.

“There is possibly still some way to go with getting it sorted. The advent and rapid uptake of mobile devices was adding complexity, West said.

Sue McIndoe, registered nurse, senior project officer, e-health, and treasurer, Nursing Informatics Australia, said she sees gradual evolution to digital record keeping for all nurses in the care team in the medium term, using computers nationally for viewing health records, and specifically for personally controlled electronic health records (PCEHR).

“Big bang implementations in health traditionally have a poor success record,” said McIndoe, a speaker at the forthcoming Informatics Conference. “Its early days, but the PCEHR will be advantageous for patients being admitted, as well as for medical discharge,” she said. “They don’t replace hospital systems.

“The PCEHR is just one component of e-health. Secure message delivery and individual healthcare identifiers are also vital so patient information can be shared safely. This was in place for district nurses in selected regions in telehealth across Australia and in daily use.”

McIndoe said she sees most hospitals, and nurses as the corollary, at present moving towards electronic records. “Some hospitals still work entirely with paper, with many hospitals using both paper and e-records, and over time, hopes are high for transition,” McIndoe said. But challenges for nurses remain.

“Nurses really need to have clear what their requirements are in the implementation of any electronic system. If not, it is not likely to succeed,” McIndoe cautioned.

She said she can see a day when the term ‘e-health’ is disbanded.

Sandra West said clinical nursing laboratories are providing student access to software packages in clinical data recording and monitoring of simulated critically-ill patients. “But the most problematic issue for most new graduates in acute care wards is not their ability or skill in using the software but their access to a computer to complete tasks required,” West said

“Hardware availability is not matching demand for use by nurses and therefore limiting local analyses that can be made of the data entered,” West said.

There was little evidence as yet of nurses being facilitated in the use of mobile technologies, such as tablets and notebooks which have obvious benefits for bedside documentation, although other health professions were moving this way.

The ANF’s Lee Thomas said e-health records would over time, give healthcare professionals access to a summary of patient information including medicines, imaging reports, test results, discharge summaries, allergies and immunisations.

“We’re confident that both the e-health record system and telehealth have the potential to deliver better person-centred care for health consumers and make the health system more efficient across the country,” Thomas said.

“Australia’s nursing and midwifery workforce is, and will continue to be, essential to the successful rollout of e-health. Thomas expressed concerns for mature aged nurses unused to computer usage. “As with any profession, learning new skills, for some older employees will be at times be overwhelming,” she said.

“That’s one of the reasons why the federation is playing a key role in the development and implementation of PCEHR,” Thomas said. “We’ve already taken part in numerous forums in conjunction with the National E-Health Transition Authority (NEHTA) and have also taken opportunities to contribute to the development of electronic health records, namely, the PCEHR. (We) are also part of a Nursing and Midwifery Telehealth Consortia, along with the Australian Practice Nurses Association, the Australian College of Midwives, the Australian College of Nurse Practitioners and CRANAplus, funded by the Department of Health and Ageing, to provide telehealth education and support, specifically for nurses and midwives.”

Thomas said the consortia was working on the development of a four-hour online learning package and national Telehealth Professional Standards and Practice Guidelines for nurses and midwives.

“The ANF has taken carriage of the Telehealth standards and guidelines component of the project,” Thomas said. She said since the project began in mid-2012, the federation had convened, managed and actively taken part in the Standards Advisory Group, known as the TeleSAG, to advise on the development of the standards and guidelines which will assist nurses, nurse practitioners and midwives.

“The draft standards, which are based on the national competency standards for both the registered nurse and the registered midwife, have been circulated for comment to the nursing and midwifery professions,” Thomas said.

She said practice guidelines designed to complement a range of resources available for health professionals undertaking telehealth, were still in development and would focus on advice to nurses and midwives on specific clinical practice issues relating to the use of telehealth for online video consultations.

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