Prior to technology adoption, nurses would pass down information to each other verbally. Most documentation was defensive; it focused on protected the nurse or care institution from litigation, slow and difficult to access. However, with the use of computerized systems to record nursing information, it is now possible for nurses to personalize care processes. Technology has caused them to become more patient-centered and thus more effective.
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The relevance of technology in nursing documentation
Application of information systems in documentation assists in increasing visibility during care provision. Technology in documentation assists in the measurement of quality of care. If data on different nursing interventions is available on information systems, then national bodies can use these repositories as standards for assessment of performance. The information eases benchmarking and thus enables health institutions to improve service outcomes.
Quality assurance cannot take place without proper methods for data collection and analysis; technology provides a solution to both these problems. In line with the above argument is the assessment of caregiver competency. Technology allows supervisors to have a basis upon which to assess nurses during care provision. They can use information systems and best practice to analyze whether a nurse is doing the right thing.
Perhaps one of the most relevant benefits of technology in documentation is time-saving. During the 1980s, most nursing professionals created work charts and sheets, in which they spent a large portion of their time recording the events of their shift. Not only was this a tedious process, which was prone to numerous errors, it was also time-wasting. Manual nursing documentation takes time away from the patient and focuses it on the documentation process.
Therefore, nurses are prevented from improving the quality of care. However, the advent of nursing informatics and digital documentation of information minimized this problem (Fuller 2). While nurses spent almost 80% of their time on documentation processes in the past, technology has substantially reduced the amount of time that they spend on this activity today. Essentially, the nursing profession has become more efficient due to this approach.
Nursing errors can have detrimental effects on all stakeholders involved. Mistakes can worsen a patient’s medical condition or even lead to death. Alternatively, they can cause litigation from affected relatives. Hospitals would have to contend with tarnished images and loss of clients. They would also have to lose a lot of income on legal fees or fines. On the other hand, nurses’ competencies would be on the line. Proper documentation is one of the solutions to nursing error.
Technology-enhanced processes are more effective in the prevention of error. Documentation processes that rely on IT would not have to depend entirely on human judgment, which is susceptible to error. Technology provides a platform for detecting errors and thus protects patients, nurses and health institutions from the challenges associated with inaccuracies (Lyden 14). It achieves this by facilitating efficient communication between healthcare professionals in the institution. It also enables them to make a plan for patient care.
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Documentation of nursing processes using technology also assists in analyzing the healthcare industry. It allows nurses from different hospitals to communicate with each other and thus establish best practice. Caregivers are able to know about the status of certain nursing interventions. New methods and practices are often made available to those who need them. Medical knowledge is now easily available to nurses from around the world because different professionals are documenting their processes (Fuller 8).
The ease with which nurses can access relevant patient information is another reason why technology is imperative in nursing documentation. Staff can easily retrieve data about a certain patient or situation and thus respond appropriately. In the past, manual systems would cause nurses to waste valuable patient time in retrieving their medical records. The technology eliminates the need for such an approach and thus enables efficient data collection.
Documentation processes that rely on technology are more accessible than manual processes. Staff members can easily find what they are looking for in different locations simultaneously. In the past, file systems could only be accessed by one entity, but technology has changed this (Lyden 14).
Technology is quite useful in the development of standardized language for nursing documentation. Standardized language is a universal code that consists of common terminology for interventions, outcomes and other aspects of care provision (Rutherford 8). Having a standardized language in nursing documentation assists nurses in communicating with one another. It also leads to better visibility of the care process, comparison of care processes in different settings as well as a better measurement of outcomes.
Technology is critical in the development of standard processes because it is the platform against which standardization takes place. Here, developers volunteer to offer information to a nursing committee. The submission process takes place using known software programs. After receiving the application, the committee checks for compatibility with certain criteria. This analytical process also takes place through a database that is available to the group. Usually, they update criteria from time to time.
Thereafter, the submission will be tested for reliability and validity through the use of technology. Once again, a group of people is responsible for updating this information through the use of nursing information software. Before final approval of the submission, experts need to ascertain that terms in the application are connectable. Additionally, the ease with which they are retrieved and stored is also examined. All this information depends on computerized information systems for nurses as well as the Commission’s information systems. In this regard, it is essential to acknowledge that all the aspects of nursing language standardization depend on technology. The platform makes approval of new criteria, seamless, fast and transparent (Rutherford 22).
Care providers can communicate with each other on the national and international level seamlessly through technology because they have standardized language on which to rely. Nurses can receive alerts concerning new interventions that are relevant to their area of study. For instance, standardized language assisted nurses in Brazil to develop protocols on caring for sexual violence victims. Other nurses learned from their experience and applied it in their own care regimens. Such information would not have been accessible to persons in different parts of the world, at a speedy rate, without technology (Rutherford 39).
Factors that undermine the effect of technology in nursing documentation
Staudinger et. al. (5) explain that most nurses understand the importance of technology in nursing performance assessment. However, few of them think of it as a tool for the enhancement of quality of care. This perception stems from the assumption that nursing is a profession that relies on close personal contact between patients and nurses. Therefore, some nurses feel that technology impedes this connection instead of enhancing it. When an institution does not address such misgivings about technology, nurses will only pay lip service to computerized documentation systems but they will not be committed to the outcomes. Institutions ought to address these reservations before they can realize any positive outcomes from technology.
The lack of skills required to use documentation technologies may also impede the positive effects of the approach. Not only do nurses require the IT skills needed to cope with nursing documentation, but they also require scientific knowledge in research and application of various models or theories of nursing. If nurses lack any of these skills, then they are likely to underutilize the potential of technology in the documentation.
Health institutions must take them through training in order to enable them to keep up with new developments. The problem of skill deficiency does not just affect individual caregivers; it also applies to entire organizations. Nursing administrators ought to select models of care that will govern practice in their institution. They must base their information technology system on this model. Administrators need to have the right technical background needed to merge nursing practice with ICT. In addition, they must know how to integrate quality assurance programs into their computerized documentation system. Deciding on the right benchmarks will be imperative in making technology work for an institution.
Some challenges in finance may also impede effective use of technology in nursing documentation. Many health institutions have rigorous cost management processes. Their administrators need to assess new projects thoroughly before they can approve of them. Most times, they examine how effectively a new initiative will contribute to better healthcare. Therefore, technology advocates must convince health administrators that computerized documentation will lead to an improvement in quality. Failure to demonstrate this trait could stifle funding and thus undermine the success of the strategy (Staudinger et. al. 17).
Poor consideration of legal issues could also come in the way of proper use of technology in nursing documentation. Institutions can face legal challenges if they do not have a proper way of documenting nursing processes. Once a computerized system has been chosen by an organization, the firm must then come up with various processes that incorporate all legal standards. A new IT documentation scheme must consider risk assessment as well as the comprehensiveness of care interventions. If these issues have not been included in the technology, then chances are that organizations will expose themselves to risk.
Organizational development issues may also become a matter of concern in the implementation of technology-assisted nursing documentation. During the beginning of the project, nurses will have to familiarize themselves with the new infrastructure. This might manifest in the form of additional workload as well as work disruptions. Daily planning must incorporate the new documentation system. Sometimes, the consecutive nature of documentation and nursing interventions may cause disruption. If an organization is quite large, then information transfer may be a complex process and could take a toll on nurses’ care processes.
They must invent a new workflow management system at the beginning of the technology process. Most companies respond to this problem by reminding nurses that the interruptions will only be temporary. They let them know that the problem will end when they fully understand the workings of the system. Administrators or IT advocates need to remind them that technology improves service provision, so any glitches they experience should be regarded as teething problems. Aside from the latter, most institutions detect potential challenges in organizational development and address them as soon as they arise.
Rutherford, Marjorie. “Standardized nursing language: What does it mean for nursing practice?” Online Journal of Issues in Nursing 13.1(2008): 1-15. Web.
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The article focuses on the usefulness of the standardized nursing language. It identifies aspects such as improved communication and greater visibility as the key advantages of standardized nursing language. The information in the discussion is relevant to a discussion on nursing documentation because standardized nursing language relies almost exclusively on technology for implementation. Therefore advantages in standardized language also apply to the use of technology in nursing.
Staudinger, Bettina, Oskar Staudinger, Christa Them & Herwig Ostermann. “Successful implementation of electronic nursing documentation into practice.” Canadian Nursing Informatics Journal 2.2(2007): 7-19. Web.
The authors focus on matters of organizational change that arise during the implementation of electronic nursing documentation. They identify several human resources as well as technical aspects that may arise during implementation. They also give suggestions on how these challenges can be solved. This article is quite useful in the current discussion because it addresses obstacles to effective use of technology in nursing documentation.
Lyden, Cathy. “From paper to computer documentation: One easy step?” Online Journal of Nursing Informatics 12.3(2008): 1-10. Web.
The author talks about a case study in which the institution transitioned from paper documentation to computer documentation. She addresses key challenges in the process especially in light of the selected software. The paper is relevant to the discussion because Lyden tackles the importance of technology in her institution.
Fuller, Crystal. “Challenges in nursing informatics.” Journal of Nursing 21(2013): 1-15. Web.
This article focuses on the case of nursing informatics. It looks at statistics in the nursing profession and why people may choose the approach. The piece is quite useful in showing why technology is indispensable in nursing documentation.