Second Life in Nursing

Welcome to the virtual world where we are part of a 3D virtual reality world. When many think of a 3D virtual world they think of futuristic movies like Tron or maybe even video games like The Sims. Believe it or not that virtual world is beginning to become reality in the world of nursing. Virtual 3D simulations are now being used to teach nursing skills and allow nurses to see in 3D simulations how to complete procedures and simulate real life health emergency care.

Second Life is a virtual simulated game developed by Linden Lab where users can create alternate personas called avatars and is an advanced level of social networking, where virtual residents explore, meet other residents, socialize and participate in individual or group activities. It was created as a social media application but is now moving into nursing education.

The health care world has started to take hold of this alternate universe by incorporating it into the education of health care workers. For example, Duke University has incorporated Second Life as part of its nursing curriculum. It seems like an odd thing to use for higher education but it is said to work while making the classroom much more engaging. According to Noteborn, Hebert, Carbonell & Gijseaers (2013) it allows students to freely interact in the classroom with the teacher and other students while class is going on, students from around the world can meet in a single classroom without having to travel away from their home, it provides simulation in a safe environment, and allows nursing students to practice skills, try new ideas and learn from their mistakes without having to use a real patient.

There is some disagreement about the use of a virtual classroom. Basically, some feel a real situation supplies a much better learning environment than a virtual simulation. However, in nursing there may be skills that students will not encounter during a hands on session and so a virtual simulation seems like it would be better than not being able to practice at all.

In 2014 Jone & Hoglund completed a study where she sought information about the use of Second Life for nurse educators and how that was transferable into the real world of nursing practice. She actually asked students to complete surveys related to using Second Life as a tool for learning. At the end of this study most of the students surveyed reported a meaningful learning experience with Second Life. While there were some barriers to the use of the technology the conclusions of the study showed that this type of virtual learning as a valid tool.

This technology is fairly new as far as being used for nursing education, however it does show some promise. Most nursing educators agree this cannot be used alone in teaching nurses the skills they need to know but it can be an effective tool to practice skills. It cannot take the place of clinical rotations but it can allow students to visualize clinical situations in a 3D simulated world. Second Life holds promise in the world of education and it will be interesting to see where this technology takes us in the world of nursing education.

References

Jone, T. & Hoglund, B. (2014). Teaching/learning in second life: Perspectives of future nurse     educators. Clinical Simulation in Nursing. Retrieved from nursingsimulation.org

Noteborn, G., Hebert, A., Carbonell, K., & Gijselaers, W. (2013). Essential knowledge for academic performance: Educating in the virtual world to promote active learning. ScienceDirect. Retrieved from sciencedirect.com

A Change for Doctors and Nurses

There was an urgent need for a new paging system. Nurses were miserable because nobody was answering them in a timely fashion. Doctors were annoyed because when they received a page they never knew if it was something that could wait or something that needed urgent attention. There was a need for change but quite simply nobody seemed to have time to figure out a solution.  Tensions seemed to be rising as the nurses and doctors seemed to be creating this unspoken war with each other.

Then one day like magic the doctors and nurses started to talk, yes talk! They formed a little coalition that decided enough was enough and a new system needed to be put in place. It seemed like the perfect time for a change since both groups wanted something new so everyone seemed to be on board. 

A few months ago a group of nurses came together over lunch and talked about a new vision for paging. They discussed terms that would make it easy for doctors to figure out what was needed and how quickly they needed to respond. There were also rules developed about what would happen if there was no response and a three strikes you’re out consequence if there was no response after a second attempt. The plan was given to the doctors and the nurses held their breath.

After several days of playing the waiting game the doctors returned their feedback. They wanted the nurses to use the terms stat, urgent and routine to indicate the time frame in which they needed to respond.  Stat indicates an immediate response is needed, urgent means fifteen minutes or less and routine gives the doctor the entire shift to respond. The nurses would need to decide if something could wait or if it couldn’t. In addition to the terminology, pages needed to include the patient last name, room number, issue and the nurse name and a contact phone number. If by chance a physician did not respond in the given time frame a second page was allowed and needed to be sent stat and second attempt. This would tell the physician, “Hey, we sent you a page and have not heard back.” If the physician still did not respond in the time frame after a second attempt, a supervisor could be notified.

The nurses communicated that they were ecstatic about this new plan and told the physicians that they were very happy with the new plan.  They proposed a trial run to see how the new paging system would go. Only one floor participated and it was a huge success. Once the trial period was over the new paging system was released to all floors. The system is now policy and both doctors and nurses are very happy with the implemented change. The doctors even chipped in and offered a pizza party to the floor with the most correct pages sent in a month. (Of course my floor won that party.)

The system has been in place now for about six months and everyone is happy and satisfied. The nurses are getting page responses quickly and efficiently and the doctors can now rest easy that they have a time frame to answer non urgent pages. It could be said that they lived happily ever after but that would be too cliché. There will always be things that need fixing or updating but for now the doctors and nurses are coexisting in a positive work culture. As Kotter (2014) explains in his book Leading Change, constantly seek opportunities, identify initiatives to capitalize upon, and complete them quickly.

 Reference

Kotter, J. (2014). Leading change. Watertown, Mass.: Harvard Business Review Press.

 

 

 

 

 

We Need A Better EHR

Electronic health records are all the rage. As a nurse, they make documenting easier, faster, safer and more reliable....but do they really?  According to the Report of the AMIA EHR-2020 Task Force on the status and future direction of EHRs (2015) many clinicians are voicing concerns that EHR use has had unintended clinical consequences, including reduced time for patient-clinician interaction, new and burdensome data entry tasks being transferred to front-line clinicians, and lengthened clinician workdays. Additionally, interoperability between different EHR systems has languished despite large efforts towards that goal. These challenges are contributing to physicians’ decreased satisfaction with their work lives.

How do we fix these inconsistencies? How do we make a system that is supposed to make our lives easier better? There is a plan to make the EHR better for those that use it most, the health care worker. Monegain (2015) breaks down several steps developed by an IT task force that will take the EHR into the next century. This is a breakdown of the ways in which the EHR can be streamlined and improved.

            First, the process of documentation needs to be streamlined and simplified. In many cases it seems that members of every discipline enter the same information over and over again. There is repetition that takes each person valuable time. This ends up being time that could be better spent with the patient. Most of the documentation comes down to the physician being the main responsible party but other members of the care team should share in the documentation and should be just as valued as the physician. Even the patient could input some of the data themselves, especially regarding their own history.

Documentation is not just about writing notes like it used to be in the past. The EHR required us to input encoded data that often causes issues based on the fact that there is no standardization.  Unfortunately the EHR does not have a standardized interface, so this often causes glitches in the system and problems as codes are not recognized. There really needs to be standardization of this process.

The EHR is looked upon as being such a miracle system that there are not a whole lot of resources set aside for research and improvement. According to Monegain (2015) we need similar studies to understand the cost and benefits of proposed data items to be recorded in the EHR. We need researchers looking at the EHR long term and continually finding areas where improvements can be made.

The restriction of informatics research is being caused by commercial monopoly. The EHR has been hijacked by commercial companies that are edging out the smaller competition. This is making the EHR suffer because the research is not being done in order to look at safer, more efficient and perhaps more cost efficient options. Big business is truly stifling the innovation in this area. We need to prevent this type of monopoly from happening so we can continue to expand and improve.

            The EHR is an amazing system but it is not without its problems. The very thing we found to make out job easier is creating other problems that need solving. It is only with continual research and innovation that we can solve some of the problems the EHR has created. This way we can get back to what matters most, the patient.

References

Monegain, B. (2015). What will EHR’s look like in 2020?. HealthcareITNews, 
                Retrieved from http://www.healthcareitnews.com/news/what-will-ehrs-look-
                2020

Payne, T., Corley, S., Cullen, T., Ghandi, T., Harrington, L., Kuperman, G., 
                Zaroukian, M. (2015).Report of the AMIA EHR-2020 task force on the status 
                and future direction of EHRs. Journal of the American Medical Informatics 
                Association. 22(5), 1102-1110.

The Electronic Health Record Risk

The copy and pasting feature on most computer applications can be a serious risk in regards to the electronic health record. While we in our personal lives find this feature to be something that makes our lives easier, the act of copying or cloning text from locations in a health record raises a whole other sort of problem.

According to Bowman (2013), copying and pasting an electronic health record pose risks to documentation integrity resulting from incorrect use of the copy and pasting functionality. This can raise issues on many levels, but most importantly the probability of errors within the record. As nurses some of the problems that can arise include copying old and outdated information, repeating information that was already wrong to begin with, the inability to indentify the true author, the inability to accurately identify time, and the repetition of information that is unnecessary.

I have witnessed nurses use the copy and paste feature in the electronic health records in my practice on many occasions. In most cases, it is used as a way to save time. This can be understood as nurses want to spend less time documenting and more time with their patients. In most cases, the nurse still reviews the information and makes changes to include current information but this is not always the case. For example, Bowman (2013) describes a case study published in the Agency for Healthcare Research and Quality where copied and pasted text led to a failure to administer medication, resulting in the patient being readmitted for a serious medical condition. In another reported case, copying and pasting the same note for several days in a row nearly resulted in a patient’s treatment being changed because the note had not been updated to reflect the true state of the patient’s condition. In both of these cases there were serious consequences related to the copying and pasting of information.

The reasons nurses use the copy and paste feature is understandable. Documentation takes an enormous amount of time and in many cases the information you are charting seems redundant. For example, if I am charting on a patient every two hours and nothing changes related to a wound, it seems understandable that copy and pasting would be quicker than continually saying the same thing over and over. However, then redundancy becomes apparent. According to Bowman (2013), the ease with which documentation can be copied and pasted has resulted in clinician complaints that electronic health records are cluttered with unnecessary information making it difficult to read the record and to locate important details. You can see how this can have implications for clinical decision-making as well as medical malpractice litigation.

Recent studies on the prevalence of copying and pasting in the electronic health record indicate that the practice is very common among health care workers. If this is being seen as such an issue is regards to integrity and safety, it seems to make sense that the electronic health record would eliminate the copy and paste feature in order to prevent health care workers from using it. While this may not make life easier for those of us having to document, there are perhaps ways we can streamline the documentation in order to make it easier but prevent actual copying. For example, it would be nice when doing checks every two hours to be able to easily say there has been no change since the previous check without having to repeat everything that was described two hours ago. The electronic health record does include repetitious information that perhaps can be streamlines so health care workers are not so tempted to copy and paste to save time.

In my institution, it would be very interesting to do a survey of health care workers to find out how many are actually using the copy and pasting feature. The survey could also identify anonymously if those that use are checking their documentation carefully to ensure its accuracy. In addition, if there has ever been a time where documentation or treatment were compromised or even if it could have been compromised related to this practice. This could be a very eye opening study to determine the prevalence, risk and outcomes related to this documentation feature.

                                                            References

Bowman, S. (2013). Impact of electronic health record systems on information integrity:  Quality and safety implications, 1-19.