By Kathleen G. J. Charters, Naval Regional Medical Center Bremerton, Washington 98314
Proceedings of the Second Annual Conference, American Association for Medical Systems & Informatics, Bethesda, MD: AAMSI, 1983, pp. 725-727.
Abstract
A review of the capabilities of “home” computers (e.g.: Apple III or TRS-80 Model III) indicates these inexpensive machines could automate as much as 80% of nursing service paperwork. With software currently available, a complete novice could run such a system after just a few hours of training. Challenges to be met in establishing a nursing information management system include staff reactions of fear, distrust, resentment, disbelief, and skepticism, and occasional feelings of professional inferiority.
Introduction
Many hospitals have been unable to fully utilize available beds due to shortages of nursing staff. One aspect of this problem is that nurses are spending 25% (or more) of their time on non-patient care tasks. Most of this time is involved in clerical work — paperwork — which could be performed by non-nurses. Automation of this clerical load would free nurses for direct patient care.
Most nursing services generate innumerable reports, minutes, and memoranda. All nursing services keep records of their staff members. In order to maintain hospital accreditation, certain information must be statistically analyzed. Scheduling staff members to cover 24 hours a day, seven days a week, as patient loads fluctuate, is complex and time-consuming. These burdens have all been addressed, in other settings, through automation, and solved through word processing, database management, and statistical analysis.
Many nursing services, (especially those within smaller acute care facilities) do not have funds for the development of unique nursing information systems or to purchase high-cost systems currently on the market. Yet they clearly could benefit from a low-cost system {with low maintenance requirements) that could be developed and supported by nursing service personnel. Traditional business computers are designed to be versatile, but this requires skilled programmers and operators. Home computers are designed to be easy to use, which is more important in the nursing service setting. Nurses are trained, skilled professionals who have completed several years of education. They do not want to complete a
A review of the capabilities of “home” computers indicates these inexpensive machines could provide extensive nursing service support using readily available generic software tailored to meet the specific needs of nursing. A TRS-80 Model III computer, with floppy disk-based mass storage, a letter-quality printer, and software for word processing, spelling checking, database management, statistical analysis, and mathematical modeling, can be readily purchased for around $5100, and a similar system based on the Apple III would run around $9100.
Method
The introduction of a computer as a nursing management tool requires the involvement of hospital staff at all levels. A three-fold strategy is useful. First, administrators within the nursing department must be approached about their perception of short staffing and of the time demands of paperwork upon nurses. Then the information can be offered about hospitals that have turned to automation as a way of decreasing demands upon the staff. A formal study should be undertaken to document the amount of time and number of personnel involved in those tasks not unique to nursing. From this, nursing administrators can identify potential applications for an automated nursing information system and list these applications according to priority. The machine(s) best suited in terms of expense, maintenance, software availability, memory capacity, expansion capacity, and ease of use by novice operators can then be identified.
Once nursing administrators are comfortable with the concept of automation and have made a preliminary decision on what kind of system is desired, a formal presentation can be made to the administrative/executive officers of the hospital. A demonstration of the computer(s) under consideration should be included in the presentation. Research defining the impact of automation should be cited to establish the cost-effectiveness of the proposal. This approach should foster backing by hospital administrators.
While gathering administrative support for a nursing information system, a concurrent effort must be made to create a grass-roots demand by staff nurses for a way to decrease paperwork. Charge nurses should be individually approached and asked for their views on staffing shortages and the impact of paperwork. The concept of an automated nursing information system should be presented and any suggestions for paperwork which would lend itself to automation collected. After the charge nurses are approached, the staff nurses should be made aware of the potential for an automated nursing information system. Possible uses for the system should be explored with the nursing staff. Also, the staff’s experiences with computers and their knowledge of other hospitals with automated information systems should be explored.
Challenges and Strategies
Properly handled, the result of this three-fold approach will be both nursing and hospital management backing for a nursing information system, as well as general staff acceptance of (if not a demand for) automation. Still, there are several challenges yet to be met in bringing about an automated nursing management system. Most of the challenges arise from nursing staff reactions of fear, distrust, resentment, disbelief, skepticism, and feelings of professional inferiority.
Most people who are computer ignorant are greatly intimidated by the very idea of a computer. When a computer is an unknown, people assume it must be highly complex and requires understanding beyond their capability or need. One useful strategy is to present computers in a non-threatening manner. The potential users should be assured that while it is true that computers are complex, the use of computers requires only a desire to do so and programs (software) written specifically for non-specialists. The level of understanding need not be greater than the ability to read and follow directions. An analogy to computer arcade games is a powerful example of this.
For someone who has never been exposed to a personal computer, the thought of trying to use a computer is presumptuous at best, and extremely intimidating even to the adventurous. Therefore, in setting up the criteria for choosing a computer for nursing service, the appearance of the computer must be a major consideration. The computer must not be overwhelming in appearance. It should bear resemblance to some other common piece of equipment, take up a minimum amount of room, and have few separate parts. The staff can be introduced to the computer by making comparisons, e.g., “the screen is similar to a television set, the keyboard is similar to that on a typewriter, and then
Nursing staff can be exposed to computers in positive ways. Computer printed pictures and computer-generated mazes are examples of non-specialized applications. Ward minutes composed on and printed by a computer can be compared with the more difficult problem of typing the minutes on a typewriter. Interested staff members should be encouraged to run a demonstration program on a computer. The program should provide interactive instructions that allow the user to influence the course of events. Giving the staff the experience of performing simple but meaningful tasks should result in the discovery that it is not difficult to use the computer. Often, computer novices respond with “Look what I can do!”
One area which readily lends itself to this approach is the programmed study format for decision-making. A nurse can be presented with a situation requiring a series of decisions about which course of action to take. The nurse can make a decision and see the consequences of that action. Then the nurse can return to the original question and try out alternatives, and see the new set of consequences. Thus, the nurse can experience several hypothetical scenarios and choose the best course of action.
One of the fears raised by the words “automation” and “computerization” is the fear of unemployment due to the replacement of a human being by a machine. This fear is especially unfounded in the health care setting. As health care becomes increasingly complex, more and better-trained individuals are needed. Machines do not replace nursing staff; they free staff from the burden of tasks not unique to nursing. Machines are tools. Nursing is both a science and an art. No tool can perform without someone to wield it, and tools can not supplant the art of
The fear of being replaced or of being left without adequate staff to provide the care required by the patients is fanned by rumors. Speculation about what administrators plan to do, especially in those areas the staff perceives as directly affecting them, is not uncommon. In order to allay such fears, there must be an effective communication network to keep the staff informed as to how projects are going, and what the future plans are. Lack of such information leads to distrust by the staff and poor acceptance (possibly to the point of total rejection) of any material produced by the computer. If the staff feel they are involved in and understand how the automation of information management tasks is progressing, unfounded fears will be laid to rest and legitimate fears can be explored and resolved. A formal newsletter can supplement an informal communication network very effectively. An attitude of “What’s happening is –” will create an atmosphere of creativity and growth.
In order to avoid the feeling that a computer is being imposed upon the nursing staff, great care must be taken to involve staff nurses with every step of the problem-solving process. Information about the potential tasks should be presented in a manner that allows nurses to make their own assessment of how this would fit into their daily routine. Their ideas on how to make use of such a tool, and about the pitfalls they foresee should be actively sought. The outcome of such an approach should be the feeling by the staff that they have acquired a new tool rather than the feeling of the imposition of another unwanted burden.
Part of this strategy is to portray the computer as a nursing tool, and not as competition. The potential for freedom from undesirable information management tasks should be stressed. One example is that of scheduling. A computer would not mind trying any number of schedule combinations in order to find a schedule that best meets individual and hospital needs. A realistic hope for improvement in work conditions should be fostered by this approach.
One issue evident in the implementation of a nursing based information management system is the issue of the nursing profession’s inferiority complex. There are individuals – nurses among them — who do not perceive nursing as a service “worthy” of automation. The question to be addressed is not whether a given profession is “worthy of automation.” The question to be addressed is whether automation is the most effective and efficient approach to a problem.
Results
By identifying potential negative reactions of nursing staff to the introduction of an automated nursing information system, one can develop strategies that will foster acceptance of the system by nursing personnel. The following strategies can decrease reactions of fear, distrust, resentment, disbelief, skepticism, and feelings of “unworthiness:” 1) presentation of the computer in a non-threatening manner, through analogies to familiar objects and events, and through nursing staff “hands-on” experience; 2) emphasizing the role of a computer as a tool; 3) use of both formal and informal communication channels to gather ideas and to keep the staff informed on the progress of the nursing information system; 4) education of nursing staff as to the potential for automation, so that nurses are able to draw conclusions as to how automation would affect nursing activities.
Using these strategies, potential negative staff reactions can be converted to acceptance of or even a demand for an automated nursing information management system. Fears can be overcome through education and experience, leading to discovery by the nursing staff of a new tool and their ability to make use of it. The nursing staff can take an active role in the automation process, creating improved work conditions. Using these strategies, nurses can bring about an effective and efficient solution to the problem of too few nurses for too many non-patient care tasks.
Discussion
Limited documentation exists concerning the implementation of nursing information management systems. In order to make automation possible for all nursing services, the problems and successes in nursing information systems must be collected and evaluated. This information must be widely shared. Each institution undertaking the automation of management tasks will encounter and create unique solutions. Sharing this information will allow other institutions to avoid known pitfalls, and to build upon the work already completed. Such exchanges will facilitate the spread of automation throughout all nursing services, bringing the nursing profession’s management tools into the realm of the 21st century. Nursing information systems research can bring about tremendous growth within the nursing profession.
This material represents the author’s views and not necessarily those of the publisher or the U.S. Navy.