Computers, Informatics, Clinical Information,
and the Professional Nurse
NURSING INFORMATICS
Although all
nurses are involved with computers to some degree, there are nurses who have
chosen to specialize in the area of nursing practice that relates to computers.
This field is known as nursing informatics. This is a new specialty within the
profession of nursing. It is only within the past 10 years that it has been
named, recognized as a specialty, and defined by the nursing profession.
Academic programs to prepare nurses with expertise in informatics have been
established; the American Nurses Credentialing Center (ANCC) has developed a
certification examination to allow nurses who demonstrate beginning levels of
competency to be certified as an informatics nurse (IN) (Gassert,
2000; Newbold, 1996). There is tremendous potential
for nurses within this specialty to have a major impact on the way care is
planned and delivered in the current tumultuous health care environment.
What Is Nursing Informatics?
Informatics was coined from
the French word informatique. It was
first defined by Gorn (1983) as computer science plus
information science. Informatics is more than just computers—it includes all
aspects of technology and science, from the theoretic to the applied. Learning
how to use new tools and building on capabilities provided by computers and
related information technologies also are important parts of the field of
informatics (Ball, Hannah, and Douglas, 2000).
Nursing informatics refers
to that component of informatics designed for and relevant to nurses. Several
definitions of nursing informatics have been developed since 1984, but the one
that generally is accepted has been set forth by the American Nurses
Association (ANA), which states:
Embedded in this definition
are the many components of nursing informatics: information processing,
language development, applications of the system's life cycle, and human
computer interface issues. In addition, the definition provides guidance for
content that is relevant to curricula for nurses studying to become informatics
specialists (Gassert, 2000).
The Specialty of
Nursing Informatics
There are many specialties
in nursing that cover a range of interests and clinical domains, such as
perioperative nursing, community health nursing, and administration. What makes
a practice area a specialty? According to Styles (1989) the following
attributes are necessary.
• Differentiated practice
• A research program
• Representation of the
specialty by at least one organized body
• A mechanism for
credentialing nurses in the specialty
• Educational programs for
preparing nurses to practice in the specialty In 1992 the ANA acknowledged that
nursing informatics possessed these attributes and designated nursing
informatics as an area of specialty practice.
Differentiated
Practice.
For more than
two decades nurses have been working in hospitals and other settings to help
with the selection, development, installation, and evaluation of information
systems. This early role function of the IN continues to be important, but with
the constant changes in health care, the scope of practice has expanded, and
job opportunities are increasing rapidly. Hersher
(2000) describes several current and future roles for nurses in informatics,
both traditional and nontraditional. Some of these include:
• User liaison: A nurse in
this role is involved in the installation of a CIS and interfaces with the
system vendors, the users, and management of the health care institution.
Generally the nurse working in this role is employed by the health care
institution.
• Clinical systems
installation: In this role the nurse works for the vendor who has developed and
sold the CIS to a health care institution. The nurse-installer helps train the
users of the system and troubleshoots problems during the conversion to the new
system. The nurse-installer often serves as the liaison between the health care
institution and the vendor and in most cases works closely with the system
coordinator for the health care institution, who may very well be a nurse.
• Product manager: A nurse
in this role is responsible for constantly updating a current product and
keeping abreast of new developments in the field. Product managers interface
with marketing staff, clients, technical staff, and management. Applications
that nurse product managers have developed include decision-support systems,
nurse staffing systems, scheduling systems, acuity systems, and bedside and
handheld terminals. Although product managers typically have been employed by
vendors, many health care institutions are starting to develop this role.
• Systems analyst/programmer: In this role the nurse
works in the information systems department, helping analyze and maintain the
system or programming. To be effective in this role, the nurse needs a strong
working knowledge of the CIS. In many cases the nurse will work on all aspects
of the CIS, not just the nursing applications.
These are just a few examples of the types of roles
nurses in informatics are filling. Other examples that Hersher
(2000) describes include chief information officer, consultant, network
administrator, data repository specialist, and clinical information liaison.
Settings also vary, as nurses move from the
hospital-based acute care sites to community-based sites that include insurance
companies, utilization review organizations, integrated health networks, and
health care associations. Clearly nurses working in informatics have met the
criterion of differentiated practice.
Research
Program.
In 1986 Schwirian proposed a framework for research in nursing
informatics. At that time research in the field was practically nonexistent.
Since then, however, there has been rapid development; researchers have
reported their studies at national and international conferences and published
in a variety of peer-reviewed journals. In nursing the peer-reviewed journal Computers
in Nursing serves as the premier source of published research in nursing
informatics, as it has since its inception in 1984.
The National Institute of
Nursing Research (NINR) has provided direction for much of the research that is
ongoing in nursing; informatics is no exception. In
1. Establish nursing
languages, including lexicons, classification systems and taxonomies, and
standards for nursing data.
2. Develop methods to build
databases of clinical information (including clinical data, diagnoses,
objectives, interventions, and outcomes) and management information (including
staffing, charge capture, turnover, and vacancy rates) and analyze
relationships among them.
3. Determine how nurses use
data, information, and knowledge to give patient care and how care is affected
by differing levels of expertise and by organizational factors and working
conditions. Determine how to design information systems accordingly.
4. Develop and test patient
care decision support systems and knowledge delivery systems that are
appropriate for nurses' needs, with consideration for expertise, organizational
factors, and working conditions.
5. Develop prototypes and
eventually working models of nurse workstations equipped with tools to provide
nurses with all the information needed for patient care, research, and
education at the point of use and linked to an integrated information system.
6. Develop and implement
appropriate methods to evaluate nursing information systems and applications,
particularly as to their effects on patient care (NINR, 1993).
Research is ongoing in each
of these priority areas. In particular, great strides have been made in the
area of developing and testing standardized languages. Both the ANA and the
National League for Nursing (NLN) have provided leadership and support for
these efforts. In addition, the ANA has established criteria for recognizing
nursing classifications and standardized nursing languages. These criteria are
promulgated through the ANA Committee for Nursing Practice Information
Infrastructure, which recognizes languages that have met the criteria.
Currently there are 12 standardized languages that have been recognized by the
ANA, including:
·
North American Nursing Diagnosis
Association (NANDA) Taxonomy
·
·
Home Health
Care Classification
·
Nursing Interventions Classification
(NIC)
·
Nursing Outcomes Classification (NOC)
·
Patient Care Data Set (PCDS)
·
Perioperative Nursing Data Set (PNDS)
·
Nursing Management Minimum Data Set
(NMMDS)
·
SNOMED RT
·
Nursing Minimum Data Set (NMDS)
·
International Classification for
Nursing Practice (ICNP)
·
Alternative Link
These 12
languages were uniquely developed to document nursing care. They were designed
to record and track the clinical care process for an entire episode of care for
patients in the acute, home, and/or ambulatory care settings (ANA, 2000).
Research is underway to continue to test and refine the languages so that they
fulfill their stated goal of capturing nursing practice to promote positive
patient outcomes.
Communication Skills
Negative
Listening/Communication Skills – The following behaviors interfere with
listening and communication. Try to avoid these behaviors.
1. Interrupting
the person who is speaking to you.
2. Rehearsing
or planning what you’re going to say instead of actually listening to the other
person.
3. Second
guessing or showing doubt towards what the other person is saying.
4. Day dreaming
or not paying attention to the speaker.
5. Mind reading
or predicting what the other person is going to say instead of listening to them.
6. Realize that
there are many more negative listening/communication skills that people use on a daily
basis. Can you think of more?
Positive Listening/Communication Skills – The
following behaviors improve listening and communication. Try to practice and
implement these behaviors.
1. Set the stage by finding a proper time and place to talk.
2. Express
positive non-verbal body language, such as making eye contact and using
positive facial expressions (e.g. nodding and other gestures that express that
you are listening).
3. Express
verbal cues that illustrate you are listening.
4. Paraphrase
or summarize what has been said to you to ensure your understanding.
5. Ask
clarifying questions if you are unsure of what the person is saying to you.
6. Realize that
there are many more positive listening/communication skills that people use on a daily
basis. Can you think of more?
Representation
of the Specialty by an Organized Body. There are many organizations devoted to nursing informatics at the
local, regional, national, international, and even virtual level. These range
from small, grassroots efforts in local communities to large, formal
organizations with thousands of members. No matter what the size or geographic
location, these groups provide education, networking, and support for nurses
interested in informatics. Annual conferences provide the opportunity for
members to share their research and innovations and to meet with informatics
colleagues from around the world (Newbold, 1997; Newbold, 2000).
The American Nurses
Informatics Association (ANIA) was established in 1992 to serve the needs of
informatics nurses in southern
Several nursing
organizations, such as the Council on Nursing Services and Informatics of the
ANA and the Council on Nursing Informatics of the NLN, have established
informatics work groups. In addition, nonnursing
associations such as the American Medical Informatics Association (AMIA) have
nursing informatics work groups. In many of these organizations, INs have taken a leadership role. For example, Dr. Patricia Flatley Brennan has served on the Board of Directors of the
AMIA and is currently serving as President. Nurses are also well represented on
all of the committees of the AMIA.
Credentialing
Nurses in the Specialty. When nursing informatics was recognized as a specialty by the ANA in
1992, work began to establish a process by which nurses could be credentialed
in informatics. The ANCC, which offers certification examinations for a variety
of specialties in nursing, describes certification as a formal, systematic
mechanism whereby nurses can voluntarily seek a credential that recognizes
their quality and excellence in professional practice and continuing education
(ANCC, 1993). For many nurses becoming certified is a professional milestone
and validation of their qualifications, knowledge, and skills in a defined area
of nursing practice.
To be eligible for the
nursing informatics examination, which was first offered in
• Possess an active
registered nursing license in the
• Have earned a
baccalaureate or higher nursing degree
• Practiced actively as a
registered nurse for at least 2 years
• Practiced at least 2000
hours in the field of nursing informatics within the past 5 years or completed
at least 12 semester hours of academic credits in informatics in a graduate
program in nursing and a minimum of 1000 hours in informatics within the past 5
years
• Earned 20 contact hours of
continuing education credit applicable to the specialty area within the past 2
years (ANCC, 2001)
The nurse who successfully
passes the examination is certified as a generalist in informatics nursing. The
ANCC is planning to offer an examination for a specialist in informatics
nursing in the future. Once certified, the nurse must be recertified every 5
years. In the first year the examination was offered, 83 nurses became
certified in informatics (Newbold, 1996). Since then,
more than 200 additional nurses have become certified in the specialty (ANCC,
2000).
Education in
Informatics.
There are both
formal and informal opportunities for education in informatics. The first
formal educational programs that offered specific degrees in nursing
informatics were established within the past decade, and the number of programs
has been increasing steadily. However, because educational options were
limited, many nurses are currently practicing in informatics that has been
prepared for their role through on-the-job training or by receiving education
for the role outside of nursing. For example, a nurse may have a Bachelor of
Science degree in nursing (BSN) plus a second degree in computer science or
information technology. Nurses have been successful in educating themselves
using formal and informal resources. Nurses considering a career in informatics
need to carefully consider options that are available and plan their educational
programs accordingly.
Nursing requires
computer competencies.
This study aimed at identifying those competencies required for the nursing
profession in
Formal
Programs.
The Nursing
Working Informatics Group of the AMIA (NWIG-AMIA) describes formal educational
programs in nursing informatics as Category I, Category II, and Category III.
Category I programs are those graduate programs with a specialist nursing
informatics focus. There are currently eight Category
I programs, based at the following institutions of higher learning:
Category II programs are
graduate and undergraduate programs and courses that allow a student to pursue
a concentration (or minor) in nursing informatics. In these programs students
take 6 to 12 credit hours of course work in informatics. Category II programs
are available at Case Western Reserve University; Duke School of Nursing;
Loyola of Chicago; Northeastern University; Slippery Rock University; and the
Universities of Arizona, Iowa, Pennsylvania, and Phoenix.
Category III programs offer
individual courses in nursing informatics at both the graduate and
undergraduate level. The NWIG-AMIA has identified eight such programs (
APPLYING OF
CRITICAL THINKING
FACT, OPINION AND INFERENCE
Being able to distinguish between a statement of fact,
an opinion or an inference is an important skill to critical thinking. It
involves knowing what can be proven directly, what is a legitimate implication
derived from the facts, and what is fair to conclude from the historical
record.
Historians
typically interweave statements of fact, inferences they derive from the facts,
and statements of their own opinion into a seamless historical narrative.
Critical thinkers must be able to distinguish among these three types of
communication.
FACT: reports
information that can be directly observed or can be verified or checked for
accuracy.
OPINION: expresses
an evaluation based on a personal judgment or belief which may or may not be
verifiable.
INFERENCE: a logical
conclusion or a legitimate implication based on factual information.
Generally, facts are constants in historical study.
But a compendium of facts is inevitably incomplete and deathly dull to read.
Historians construct history by closing the gaps in their knowledge about the
past, enlarge our under- standing, and enliven their narrative by drawing
logical inferences from their assembled facts. Often, they then use their
expertise to arrive at a considered judgment about the wisdom or significance
of past decisions and events.
Distinguishing statements of fact, opinion, and
inference may at first seem difficult to do. That is because they are often
closely interwoven. Develop your own critical thinking abilities by placing an "F"
before each factual statement, an "O" before each opinion, and
an "I" before each inference in the practice exercise below.
This type of critical thinking exercise is
used often in quizzes and tests.
____1. The real rulers of the "black Republican"
governments of the South were white "scalawags" and "carbetbaggers."
____2. Scalawags were by far the more numerous of the two.
____3. Blacks lacked experience in politics and were mostly
poor and uneducated.
____4. That blacks should fail to dominate southern
governments is certainly understandable.
____5. Graft and callous disregard of the
public interest characterized government in all regions and at every level
during the decade after Appomattox.
____6. However, the corruption must be seen in perspective.
____7. The New York City Tweed Ring probably made off with
more money that all the southern thieves, black and white, combined.
____8. The evidence does not justify southern corruption.
____9. The evidence suggests that the unique features of
Reconstruction politics do not explain it either.
___10. In fact, Radical southern governments accomplished
much.
What
is Critical Thinking?
No one always
acts purely objectively and rationally. We connive for selfish interests.
We gossip, boast, exaggerate, and equivocate. It is "only human"
to wish to validate our prior knowledge, to vindicate our prior decisions, or
to sustain our earlier beliefs. In the process of satisfying our ego, however,
we can often deny ourselves intellectual growth and opportunity. We may not
always want to apply critical thinking skills, but we should have those skills
available to be employed when needed.
Critical
thinking includes a complex combination of skills. Among the main
characteristics are the following:
Rationality
We
are thinking critically when we
rely on reason rather than emotion, require evidence, ignore no known
evidence, and follow evidence where it leads, and are concerned more with
finding the best explanation than being right analyzing apparent confusion and
asking questions.
Self-awareness
We are thinking critically when we
· weigh
the influences of motives and bias, and recognize our own assumptions,
prejudices, biases, or point of view.
Honesty
We are thinking critically when we recognize emotional
impulses, selfish motives, nefarious purposes, or other modes of
self-deception.
Open-mindedness
We are thinking
critically when we
·
evaluate all reasonable
inferences
·
consider a variety of
possible viewpoints or perspectives,
·
remain open to alternative
interpretations
·
accept a new explanation,
model, or paradigm because it explains the evidence better, is simpler, or has
fewer inconsistencies or covers more data
·
accept new priorities in
response to a reevaluation of the evidence or reassessment of our real
interests, and
·
do not reject unpopular views
out of hand.
Discipline
We are thinking critically when we
are precise,
meticulous, comprehensive, and exhaustive
resist
manipulation and irrational appeals, and
avoid snap judgments.
Judgment
We are thinking
critically when we
recognize the relevance and/or merit of alternative assumptions
and perspectives
·recognize
the extent and weight of evidence
In sum,
·
Critical thinkers are by
nature skeptical. They approach texts with the same skepticism and
suspicion as they approach spoken remarks.
·
Critical thinkers are active,
not passive. They ask questions and analyze. They consciously apply
tactics and strategies to uncover meaning or assure their understanding.
·
Critical thinkers do not
take an egotistical view of the world. They are open to new ideas and
perspectives. They are willing to challenge their beliefs and investigate
competing evidence.
Critical thinking enables us to recognize a wide range
of subjective analyses of otherwise objective data, and to evaluate how well
each analysis might meet our needs. Facts may be facts, but how we interpret
them may vary.
By contrast, passive, non-critical thinkers take a
simplistic view of the world.
·
They see things in black and
white, as either-or, rather than recognizing a variety of possible
understanding.
·
They see questions as yes or
no with no subtleties.
·
They fail to see linkages
and complexities.
·
They fail to recognize
related elements.
Non-critical thinkers take an egotistical view of the
world
·
They take their facts
as the only relevant ones.
·
They take their own perspective
as the only sensible one.
·
They take their goal as
the only valid one.
This
educational web site provides over 100 free online tutorials on critical
thinking, logic, scientific reasoning, creativity, and other aspects of
thinking skills. Our online tutorials have been used by universities, community
colleges, and high schools across the world.
The online
tutorials are organized into over 10 modules listed on the left. You can also
check out the following:
·
Introduction
- What is critical thinking?
·
Sitemap
- A complete list of the online tutorials
·
Free download: Critical thinking mini-guide - a short
booklet (PDF) (via google
docs)
·
Free download: Class exercises - Critical thinking
exercises for teaching (PDF) (via google
docs)
·
Quiz - Test the consistency of your moral
beliefs
·
Puzzle - The hardest logic puzzle in the world!
·
101
philosophical questions to think about - one a day posting on
twitter!
This site is maintained by Dr. Joe
Lau at the Philosophy Department, The University of Hong
Kong.
Critical thinking studies a topic or
problem with open-mindedness.
This exercise outlines the first stage
of applying a critical thinking approach to developing and understanding a
topic. You will:
o
Develop a statement of the topic
o
List what you understand, what you've been told and what
opinions you hold about it
o
Identify resources available for research
o
Define timelines and due dates and how they affect the
development of your study
o
Print the list as your reference
Here is more on the first stage:
Define your destination, what you want to learn
Clarify or verify with your teacher or an
"expert" on your subject
Topics can be
simple phrases:
"The role of
gender in video game playing"
"Causes of the
war before 1939"
"Mahogany
trees in Central America"
"Plumbing
regulations in the suburbs"
"Regions of
the human brain"
o
Develop your frame of
reference, your starting point,
by
listing what you already know about the subject
o
What opinions and prejudices do
you already have about this?
What have you been told, or read about, this topic?
o
What resources
are
available to you for research
When gathering information, keep an open mind
Look for chance resources that pop up!
Play the "reporter" and follow leads
If you don't seem to find what you need, ask librarians
or your teacher.
o
How does your timeline and due
dates affect your research?
Keep in mind that you need to follow a schedule.
Work back from the due date and define stages of development,
not just with this first phase, but in completing the whole project.
Summary of critical thinking:
o
Determine the facts of a new situation or subject without
prejudice
o
Place these facts and information in a pattern so that
you can understand them
o
Accept or reject the source values and conclusions based
upon your experience, judgment, and beliefs
Critical thinking studies
a topic or problem with open-mindedness.
This exercise outlines the second stage
of applying a critical thinking approach to developing and understanding a
topic.
With the second stage:
o
Refine/revise the topic
either
narrowing or broadening it according to outcomes of research
o
Rank or indicate
the importance
of
three sources of research
o
Clarify any opinion, prejudice,
or bias their authors have
While an opinion is a belief or attitude toward someone
or some thing, a prejudice
is preconceived opinion without basis of fact while bias is an opinion based on
fact or research.
o
Identify key words and concepts that seem to repeat
Is there vocabulary you need to define?
Are there concepts you need to understand better?
o
In reviewing your research, are there
Sequences or patterns that emerge?
Opposing points of view, contradictions, or facts that
don't "fit?"
Summarize two points of view that you need to address
o
What questions remain to be answered?
Critical
thinking, first stage helped you to
o
Develop a statement of the topic
o
List what you understand, what you've been told and what
opinions you hold about it
o
Identify resources available for research
o
Define timelines and due dates and how they affect the
development of your study
·
Print
the list as your reference
·
Problem-Solving Strategies
Problem solving strategies are the steps that one would use to find the
problem(s) that in are in the way to getting to one’s own goal. Some would
refer to this as the ‘problem-solving cycle’. (Bransford
& Stein, 1993) In this cycle one will recognize the problem, define the
problem, develop a strategy to fix the problem, organize the knowledge of the
problem, figure-out the resources at the user's disposal, monitor one's
progress, and evaluate the solution for accuracy. Although called a cycle, one
does not have to do each step in order to fix the problem, in fact those who
don’t are usually better at problem solving.[citation
needed] The reason it is called a cycle is that once one
is completed with a problem another usually will pop up. Blanchard-Fields
(2007) looks at problem solving from one of two facets. The
first looking at those problems that only have one solution (like math
problems, or fact based questions) which are grounded in psychometric
intelligence. The other that is socioemotional
in nature and are unpredictable with answers that are constantly changing (like
what’s your favorite color or what you should get someone for Christmas).
The following techniques are usually called problem-solving strategies:
·
Abstraction: solving the problem in a
model of the system before applying it to the real system
·
Analogy:
using a solution that solves an analogous problem
·
Brainstorming: (especially among groups of
people) suggesting a large number of solutions or ideas and combining and
developing them until an optimum is found
·
Divide and conquer:
breaking down a large, complex problem into smaller, solvable problems
·
Hypothesis
testing: assuming a possible explanation to the problem and trying
to prove (or, in some contexts, disprove) the assumption
·
Lateral thinking: approaching solutions
indirectly and creatively
·
Means-ends
analysis: choosing an action at each step to move closer to the goal
·
Method
of focal objects: synthesizing seemingly non-matching
characteristics of different objects into something new
·
Morphological analysis: assessing the output and interactions
of an entire system
·
Proof: try to prove that the problem
cannot be solved. The point where the proof fails will be the starting point
for solving it
·
Reduction:
transforming the problem into another problem for which solutions exist
·
Research:
employing existing ideas or adapting existing solutions to similar problems
·
Root cause
analysis: identifying the cause of a problem
·
Trial-and-error: testing possible
solutions until the right one is found
Problem-Solving Methodologies
·
Eight
Disciplines Problem Solving
·
KEPNER and FOURIE Incident and Problem
Investigation
·
Kepner-Tregoe Problem Solving and Decision Making
·
PDCA (plan–do–check–act)
·
RPR
Problem Diagnosis (rapid problem resolution)
·
Thinking Dimensions - Problem Solving
·
TRIZ (in Russian: Teoriya
Resheniya Izobretatelskikh Zadatch, "theory of solving inventor's
problems")
Systems Thinking
Problem Solving is very important but problem solvers often misunderstand
it. This report proposes the definition of problems, terminology for Problem
Solving and useful Problem Solving patterns.
We should define what is the problem as the first step of
Problem Solving. Yet problem solvers often forget this first step.
Further, we should recognize common terminology such as Purpose, Situation,
Problem, Cause, Solvable Cause, Issue, and Solution. Even Consultants, who
should be professional problem solvers, are often confused with the terminology
of Problem Solving. For example, some consultants may think of issues as
problems, or some of them think of problems as causes. But issues must be the
proposal to solve problems and problems should be negative expressions while
issues should be a positive expression. Some consultants do not mind this type
of minute terminology, but clear terminology is helpful to increase the efficiency
of Problem Solving. Third, there are several useful thinking patterns such as
strategic thinking, emotional thinking, realistic thinking, empirical
thinking and so on. The thinking pattern means how we think. So far, I
recognized fourteen thinking patterns. If we choose an appropriate pattern at
each step in Problem Solving, we can improve the efficiency of Problem Solving.
This report will explain the above three points such as the definition of
problems, the terminology of Problem Solving, and useful thinking patterns.
Definition of problem
A problem is decided by purposes. If someone wants money and when he or she
has little money, he or she has a problem. But if someone does not want money,
little money is not a problem.
For example, manufacturing managers are usually evaluated with
line-operation rate, which is shown as a percentage of operated hours to
potential total operation hours. Therefore manufacturing managers sometimes
operate lines without orders from their sales division. This operation may
produce more than demand and make excessive inventories. The excessive
inventories may be a problem for general managers. But for the manufacturing
managers, the excessive inventories may not be a problem.
If a purpose is different between managers, they see the identical
situation in different ways. One may see a problem but the others may not see
the problem. Therefore, in order to identify a problem, problem solvers such as
consultants must clarify the differences of purposes. But oftentimes, problem solvers
frequently forget to clarify the differences of purposes and incur confusion
among their problem solving projects. Therefore problem solvers should start
their problem solving projects from the definition of purposes and problems
Terminology of Problem Solving
We should know the basic terminology for Problem Solving. This report
proposes seven terms such as Purpose, Situation, Problem, Cause, Solvable
Cause, Issue, and Solution.
Purpose
Purpose is what we want to do or what we want to be. Purpose is an easy
term to understand. But problem solvers frequently forget to confirm Purpose,
at the first step of Problem Solving. Without clear purposes, we can not think about problems.
Situation
Situation is just what a circumstance is. Situation is neither good nor
bad. We should recognize situations objectively as much as we can. Usually
almost all situations are not problems. But some problem solvers think of all
situations as problems. Before we recognize a problem, we should capture
situations clearly without recognizing them as problems or non-problems.
Without recognizing situations objectively, Problem Solving is likely to be
narrow sighted, because problem solvers recognize problems with their
prejudice.
Problem
Problem is some portions of a situation, which cannot realize purposes.
Since problem solvers often neglect the differences of purposes, they cannot
capture the true problems. If the purpose is different, the identical situation
may be a problem or may not be a problem.
Cause
Cause is what brings about a problem. Some problem solvers do not
distinguish causes from problems. But since problems are some portions of a
situation, problems are more general than causes are. In other words causes are
more specific facts, which bring about problems. Without distinguishing causes
from problems, Problem Solving can not be specific.
Finding specific facts which causes problems is the essential step in Problem
Solving.
Solvable Cause
Solvable cause is some portions of causes. When we solve a problem, we
should focus on solvable causes. Finding solvable causes is another essential
step in Problem Solving. But problem solvers frequently do not extract solvable
causes among causes. If we try to solve unsolvable causes, we waste time.
Extracting solvable causes is a useful step to make Problem Solving efficient.
Issue
Issue is the opposite expression of a problem. If a problem is that we do
not have money, the issue is that we get money. Some problem splvers do not know what Issue is. They may think of
"we do not have money" as an issue. At the worst case, they may mix
the problems, which should be negative expressions, and the issues, which
should be positive expressions.
Solution
Solution is a specific action to solve a problem, which is equal to a
specific action to realize an issue. Some problem solvers do not break down
issues into more specific actions. Issues are not solutions. Problem solvers
must break down issues into specific action.
Thinking patterns
Thinking patterns for judgements
In order to create a value through thinking we need to judge whether what
we think is right or wrong. This report lists four judging patterns such as
strategic thinking, emotional thinking, realistic thinking, and empirical
thinking.
Strategic thinking
Focus, or bias, is the criterion for strategic
thinking. If you judge whether a situation is right or wrong based on whether
the situation is focused or not, your judgement is
strategic. A strategy is not necessarily strategic. Historically, many
strategists such as Sonfucis in ancient
Emotional thinking
In organizations, an emotional aspect is essential.
Tactical leaders judge whether a situation is right or wrong based on the participantsf emotional commitment. They think that if
participants can be positive to a situation, the situation is right.
Realistic thinking
·
Start from what we can do
·
Fix the essential problem first
These two criteria are very useful. "Starting" is very important,
even if we do very little. We do not have to start from the essential part.
Even if we start from an easier part, starting is a better judgement
than a judgement of not-starting in terms of the
first part of realistic thinking. Further, after we start, we should search key
factors to make the Problem Solving more efficient. Usually, 80 % of the
problems are caused by only 20 % of the causes. If we can find the essential 20
% of the causes, we can fix 80 % of problems very efficiently. Then if we try
to find the essential problem, what we are doing is right in terms of the
second part of realistic thinking.
Empirical thinking
When we use empirical thinking, we judge whether the situation is right or
wrong based on our past experiences. Sometimes, this thinking pattern persists
on the past criteria too much, even if a situation has changed. But when it
comes to our daily lives, situations do not change frequently. Further, if we
have the experience of the identical situation before, we can utilize the
experience as a reliable knowledge data base.
Thinking patterns for thinking processes
If we can think systematically, we do not have to be frustrated when we think.
In contrast, if we have no systematic method, Problem Solving frustrate us. This reports lists five systematic thinking
processes such as rational thinking, systems thinking, cause & effect
thinking, contingent thinking, and the Toyotafs five
times WHYs method .
Rational thinking
Rational thinking is one of the most common
Problem Solving methods. This report will briefly show this Problem Solving
method.
1.
Set the ideal situation
2.
Identify a current situation
3.
Compare the ideal situation and the current
situation, and identify the problem situation
4.
Break down the problem to its causes
5.
Conceive the solution alternatives to the causes
6.
Evaluate and choose the reasonable solution
alternatives
7.
Implement the solutions
We can use rational thinking as a Problem
Solving method for almost all problems.
Systems thinking
Systems thinking is a more scientific Problem Solving approach than the rational thinking
approach. We set the system, which causes problems and analyze them based on systemsf functions. The following arre
the system and how the system works.
System
·
Purpose
·
Input
·
Output
·
Function
·
Inside cause (Solvable cause)
·
Outside cause (Unsolvable cause)
·
Result
In order to realize Purpose, we prepare Input and through Function we can
get Output. But Output does not necessarily realize Purpose. Result of the
Function may be different from Purpose. This difference is created by Outside
Cause and Inside Cause. We can not solve Outside
Cause but we can solve Inside Cause. For example, when we want to play golf,
Purpose is to play golf. If we can not play golf,
this situation is Output. If we can not play golf
because of a bad weather, the bad weather is Outside Cause, because we can not change the weather. In contrast, if we cannot play
golf because we left golf bags in our home, this cause is solvable. Then, that
we left bags in our home is an Inside Cause.
Systems thinking is a very clear and useful method to solve problems.
Cause & effect thinking
Traditionally, we like to clarify cause and
effect relations. We usually think of finding causes as solving problems.
Finding a cause and effect relation is a conventional basic Problem Solving
method.
Contingent thinking
Game Theory is a typical contingent thinking
method. If we think about as many situations as possible, which may happen, and
prepare solutions for each situation, this process is a contingent thinking
approach.
Thinking patterns for
efficient thinking
In order to think efficiently, there are several
useful thinking patterns. This report lists five patterns for efficient
thinking such as hypothesis thinking, conception thinking, structure thinking,
convergence & divergence thinking, and time order thinking.
Hypothesis thinking
If we can collect all information quickly and
easily, you can solve problems very efficiently. But actually, we can not collect every information.
If we try to collect all information, we need so long time. Hypothesis thinking
does not require collecting all information. We develop a hypothesis based on available
information. After we developed a hypothesis, we collect minimum information to
prove the hypothesis. If the first hypothesis is right, you do not have to
collect any more information. If the first hypothesis is wrong, we will develop
the next hypothesis based on available information. Hypothesis thinking is a
very efficient problem-solving method, because we do not have to waste time to
collect unnecessary information.
Conception thinking
Problem Solving is not necessarily logical or
rational. Creativity and flexibility are other important aspects for Problem
Solving. We can not recognize these aspects clearly.
This report shows only what kinds of tips are useful for creative and flexible
conception. Following are portions of tips.
·
To be visual.
·
To write down what we think.
·
Use cards to draw,
write and arrange ideas in many ways.
·
Change positions, forms, and viewpoints,
physically and mentally.
We can imagine without words and logic, but in order to communicate to
others, we must explain by words and logic. Therefore after we create ideas, we
must explain them literally. Creative conception must be translated into
reasonable explanations. Without explanations, conception does not make sense.
Structure thinking
If we make a structure like a tree to grasp a complex situation, we can
understand very clearly.
Upper level should be more abstract and lower level should be more
concrete. Dividing abstract situations from concrete situations is helpful to
clarify the complex situations. Very frequently, problem solvers cannot arrange
a situation clearly. A clear recognition of a complex situation increases
efficiency of Problem Solving.
Convergence & divergence thinking
When we should be creative we do not have to consider convergence of ideas.
In contrast, when we should summarize ideas we must focus on convergence. If we
do convergence and divergence simultaneously, Problem Solving becomes
inefficient.
Time order thinking
Thinking based on a time order is very convenient, when we are confused
with Problem Solving. We can think based on a time order from the past to the
future and make a complex situation clear.
Across the tiers, the problem-solving method is used to match instructional
resources to educational need. The problem-solving method is as follows:
1.
Define the problem by determining the discrepancy between what is expected and
what is occurring. Ask, “What’s the problem?”
2.
Analyze the problem using data to determine why the discrepancy is occurring. Ask,
“Why is it taking place?”
3.
Establish a student performance goal, develop an
intervention plan to address the goal, and delineate how the student’s progress
will be monitored and implementation integrity
will be ensured. Ask, “What are we going to do about it?”
4.
Use progress monitoring data to evaluate the effectiveness of the intervention plan based on the student’s response
to the intervention. Ask, “Is it working?” If not, how will the intervention
plan be adjusted to better support the student’s progress?
With this second exercise, think in
terms of how you would demonstrate your learning for your topic
How would you create a test on what you have learned?
How would you best explain or demonstrate your findings?
From simple to more complex (1-6) learning operations:
1.
List, label, identify: demonstrate
knowledge
2.
Define, explain, summarize in your own words:
Comprehend/understand
3.
Solve, apply to a new situation: Apply what you have learned
4.
Compare and contrast, differentiate between items: analyze
5.
Create, combine, invent: Synthesize
6.
Assess, recommend, value: Evaluate and explain why
Summary of
critical thinking:
o
Determine the facts of a new situation or subject without
prejudice
o
Place these facts and information in a pattern so that
you can understand and explain them
o
Accept or reject your resource values and conclusions
based upon your experience, judgment, and beliefs
With the increasing versatility and power of personal
computers, the use of information technology has a central role in all areas of
health care delivery. However, many staff dislike using computers and often it
is left to one or two people to use the machine (Hellan,
McGuire, & Cooper, 2008).
Therefore, every nurse needs
appropriate knowledge and skills about computers. Since new entrants to nursing
diploma programs often have varying degrees of competence and experience with
information technology (Sinclair & Gardner, 1999), some effort has to be
made to raise their information technology competence to an adequate level.
This paper describes a research project that was concerned with identifying important
computer competencies for nurses. The data were collected using the Delphi
technique, which has not been previously used in nursing informatics studies in
Although these are the only
formal programs available at this time, many universities have courses in
computer science and information technology. Interested students are able to
self-design programs that meet their individual learning needs. Programs at the
Nowadays,more
andmore computers are being used in health care
systems to store, organize, and transmit information. Although nurses do not
need a high degree of computer expertise, their performance will be much more
efficient if they have good computer skills. In other words, nurses who operate
computers proficiently can quickly access health care-related information using
computers. And they may be able to provide more appropriate and efficient care
to their patients.
Wilkinson (1996) predicted
that, in the near future, those who could not use computers would be as
disadvantaged as those who could not read andwrite.
The study by Ngin, Simms, and Erbin-Roesemann
(1993) suggested that the introduction of computers could not only improve unit
morale but could also stimulate the learning of new skills related to effective
and quality care delivery. An examination of the roles of nurses revealed that
nurses are high level information processors in all areas of nursing practice (Hovenga, 1998). Some hospitals even use computers to
provide Intranet-delivered training for nurses (Wolford & Hughes, 2001).
Informal
Education.
For many nurses
graduate education is not an option or personal choice, but they still desire
to become more knowledgeable about informatics. In this case many informal
opportunities exist, including networking through professional organizations,
keeping abreast of the literature by reading journals, and attending
professional conferences.
Organizations vary in their
scope, services offered to members, and the types of educational programs
offered. Nelson andjoos (1992) describe five types of
organizations.
1. Special interest groups
such as the councils of the ANA and NLN. Nonnursing
organizations that have special interest groups of interest to nurses include
the American Hospital Association and the Healthcare Financial Management
Association.
2. Information science and
computer organizations such as the Association for Computing Machinery. There
also are specialty organizations within this category, such as the Health
Science Communications Association.
3. Health computing organizations
such as the AMIA and the International Medical Informatics Association. Other
organizations in this category include the Medical Records Institute and the
Computer-Based Patient Record Institute (CPRI).
4. User groups, which
consist of individuals working with a specific language, software, or vendor.
One such group of interest to nurses is the Microsoft Healthcare Users Group
(MS-HUG), which focuses on applications of Microsoft products in health care
environments.
5. Local groups such as the
Capital Area Roundtable on Informatics in Nursing (CARING), located in
Anyone interested in learning more about informatics
should become active in at least one related organization. As a member a nurse
has access to the meetings, publications, and educational offerings that the
organization provides. Getting on mailing lists or visiting organizational
sites on the www also allows a nurse to keep abreast of different opportunities
available through each organization. provides a
listing of Internet addresses for some of the larger organizations.
This chart
gives us a better idea as to what type of job setting pay
the most. If we look at this chart we see that in an acute care setting the
salary is close to $60,000 dollars. However, you could be an experience
clinical analyst for example, and most likely your salary will be a lot higher
than that.
Therefore
this gives a rough overview as to the different salaries in different settings,
but again, these are not absolute numbers as a salary is always composed of
many factors. What’s known for a fact though, is that working for a consulting
employer will pay you the most, unless of course, you’re working in an
executive level position in any of these settings.
The Health Informatics field is a broad field which covers clinical
informatics and nursing informatics.
Trying to pinpoint a salary in this field, is
like trying to pinpoint the salary for an individual who says that he/she works
in the medical field. Obviously, this is a daunting task, because just like the
medical field could be anybody from a dentist to a doctor to a nurse to a
radiology tech, somebody working in the healthcare informatics field could be
an executive, an IT director, a clinical analyst or coding professional, and
many others.
Finally, according to this graphic, we see that jobs
in the southwest supposedly pay more than jobs in other regions, but from
personal experience, you can find good paying jobs in the north east, and in
states like
Reading journals and newsletters is another way to
become more knowledgeable about informatics. Offerings range from trade
magazines that are not related to health but are important sources of
information, such as PC Magazine or Byte, to specialized journals
in nursing such as Computers in Nursing.
Since 1995 Computers in Nursing has offered continuing education credit
for articles published in the journal. The AMIA publishes the Journal of the American Medical Informatics Association,
a publication source for much of the research that has been conducted
related to informatics. A nurse interested in informatics should become
familiar with the journals that are available, subscribe to those that are most
interesting, and read others in the library. Unfortunately more information is
published every month than anyone could possibly hope to keep abreast of—thus
the need for networking! Colleagues can alert others to articles of interest
that are in journals they might not regularly read.
Finally, conferences provide
an excellent source of education. At a conference the nurse is able to hear the
latest information directly from experts in the field. Larger conferences
usually have vendor exhibits that provide the opportunity for hands-on
demonstrations for a variety of commercial products. Conferences vary in size,
focus, location, and cost. For those interested in nursing informatics, nursing
conferences especially are helpful. Local organizations, such as CARING,
sponsor a variety of half-day or 1-day conferences.
CLINICAL INFORMATION
Clinical Information Systems
CISs are changing the way that health care is
delivered, whether in the hospital, the clinic, the provider's office, or the
patient's home. With capabilities ranging from advanced instrumentation to
high-level decision support, CISs offer nurses and other clinicians information
when, where, and how they need it. Increasingly CIS applications function as
the mechanisms for delivering patient-centered care and for supporting the move
toward the computer-based patient record (CPR).
What exactly is a CIS? Definitions vary, often from
organization to organization. Semancik (1997) describes
a CIS as a collection of software programs and associated hard ware that
supports the entry, retrieval, update, and analysis of patient care information
and associated clinical information related to patient care. The CIS is
primarily a computer system used to provide clinical information for the care
of a patient.
A CIS can be patient-focused
or departmental. In patient-focused systems, automation supports patient care
processes. Typical applications found in a patient-focused system include order
entry, results reporting, clinical documentation, care planning, and clinical
pathways. As data are entered into the system, data repositories are
established that can be accessed to look for trends in patient care.
Departmental systems evolved to meet the operational needs of a particular
department, such as the laboratory, radiology, pharmacy, medical records, or
billing. Early systems often were stand-alone systems designed for an
individual department. A major challenge facing CIS developers is to integrate
these stand-alone systems to work with each other and with the newer
patient-focused systems.
Computerized Patient Records
A CIS is not the same as a CPR or an electronic
patient record. Ideally the CPR will include all information about an individual's
lifetime health status and health care maintained electronically. The CPR is a
replacement for the paper medical record as the primary source of information
for health care, meeting all clinical, legal, and administrative requirements.
However, the CPR is more than today's medical record. Information technology
permits much more data to be captured, processed, and integrated, which results
in information that is broader than that found in a linear paper record.
The CPR is not a record in the traditional sense of
the term. "Record" connotes a repository with limitations of size,
content, and location. The term traditionally has suggested that the sole
purpose for maintaining health data is to document events. Although this is an
important purpose, the CPR permits health information to be used to support the
generation and communication of knowledge.
The health care delivery
system is dramatically changing, with a strong emphasis on improving outcomes
of care and maintaining health. The CPR needs to be considered in a broader
context and is not applicable only to patients (i.e., individuals with the
presence of an illness or disease). Rather in the CPR the focus is on the
individual's health, encompassing both wellness and illness.
As a result of this focus on
the individual, the CPR is a virtual compilation of nonredundant
health data about the person across his or her lifetime, including facts,
observations, interpretations, plans, actions, and outcomes. Health data
include information on allergies, history of illness and injury, functional
status, diagnostic studies, assessments, orders, consultation reports, and
treatment records. Health data also include wellness information such as
immunization history, behavioral data, environmental information, demographics,
health insurance, administrative data for care delivery processes, and legal
data such as informed consents. The who, what, when,
and where of data capture are also identified. The structure of the data
includes text, numbers, sounds, images, and full-motion video. These are
thoroughly integrated so that any given view of health data may incorporate one
or more structural elements.
Within a CPR, an
individual's health data are maintained and distributed over different systems
in different locations, such as a hospital, clinic, physician's office, and
pharmacy. Intelligent software agents with appropriate security measures are
necessary to access data across these distributed systems. The nurse or other
user who is retrieving these data must be able to assemble it in such a way as
to provide a chronology of health information about the individual.
The CPR is maintained in a system that captures,
processes, communicates, secures, and presents the data about the patient. This
system may include the CIS. Other components of the CPR system include clinical
rules, literature for patient education, expert opinions, and payer rules
related to reimbursement. When these elements work together in an integrated
fashion, the CPR becomes much more than a patient record—it becomes a knowledge
tool. The system is able to integrate information from multiple sources and
provides decision support; thus the CPR serves as the primary source of
information for patient care.
A fully functional CPR is a complex system. Consider a
single data element (datum), such as a person's weight. The system must be able
to capture, or record the weight; store it, process it, communicate it to
others, and present it in a different format such as a bar graph or chart. All
of this must be done in a secure environment that protects the patient's
confidentiality and privacy. The complexity of these issues and the development
of the necessary systems help to explain why few fully functional CPR systems
are in place today.
Data Capture. Data capture refers to the collection and entry of
data into a computer system. The origin of the data may be local or remote from
patient-monitoring devices, from telemedicine applications, directly from the
individual recipient of health care, and even from others who have information
about the recipient's health or environment, such as relatives and friends and
public health agencies. Data may be captured by multiple means, including key
entry, pattern recognition (voice, handwriting, or biologic characteristics),
and medical device transmission.
All data entered into a
computer are not necessarily structured for subsequent processing. For example,
document imaging systems provide for creation of electronically stored text but
have limitations on the ability to process that text. Data capture includes the
use of controlled vocabularies and code systems to ensure common meaning for
terminology and the ability to process units of information. As noted earlier,
great strides have been made in the development of standardized nursing
languages. These languages provide structured data entry and text processing,
which result in common meaning and processing.
Data capture also
encompasses authentication to identify the author of an entry and to ensure
that the author has been granted permission to access the system and change the
CPR
Storage. Storage refers to the physical location of data. In CPR systems health
data are distributed across multiple systems at different sites. For this
reason, common access protocols, retention schedules, and universal
identification are necessary.
Access protocols permit only
authorized users to obtain data for legitimate uses. The systems must have
backup and recovery mechanisms in the event of failure. Retention schedules
address the maintenance of the data in active and inactive form and the
permanence of the storage medium.
A person's identity can be
determined by many types of data in addition to common identifiers such as name
and number. Universal identifiers or other methods are required for integrating
health data of an individual distributed across multiple systems at different
sites.
Information
Processing.
Application
functions provide for effective retrieval and processing of data into useful
information. These include decision support tools such as alerts and alarms for
drug interactions, allergies, and abnormal laboratory results. Reminders can be
provided for appointments, critical path actions, medication administration,
and other activities. The systems also may provide access to consensus- and
evidence-driven diagnostic and treatment guidelines and protocols. The nurse
could integrate a standard guideline, protocol, or critical path into a
specific individual's CPR, modify it to meet unique circumstances, and use it
as a basis for managing and documenting care. Outcome data communicated from
various caregivers and health care recipients themselves also may be analyzed
and used for continual improvement of the guidelines and protocols.
Information
Communication. Information
communication refers to the interoperability of systems and linkages for
exchange of data across disparate systems. To integrate health data across
multiple systems at different sites, identifier systems (unique numbers or
other methodology) for health care recipients, caregivers, providers, payers,
and sites are essential. Local, regional, and national health information
infrastructures that tie all participants together using standard data
communication protocols are key to the linkage
function. There are hundreds of types of transactions or messages that must be
defined and agreed to by the participating stakeholders. Vocabulary and code
systems must permit the exchange and processing of data into meaningful
information. CPR systems must provide access to point-of-care information
databases and knowledge sources such as pharmaceutic
formularies, referral databases, and reference literature.
Security. Computer-based patient record systems provide better protection of
confidential health information than paper-based systems because such systems
support controls that ensure that only authorized users with legitimate uses
have access to health information. Security functions address the
confidentiality of private health information and the integrity of the data.
Security functions must be designed to ensure compliance with applicable laws,
regulations, and standards. Security systems must ensure that access to data is
provided only to those who are authorized and have a legitimate purpose for its
use. Security functions also must provide a means to audit for inappropriate
access.
Three important terms are
used when discussing security: privacy, confidentiality, and security. It is
important to understand the differences between these concepts.
• Privacy refers to the
right of an individual to keep information about himself
or herself from being disclosed to anyone. If a patient has had an abortion and
chose not to tell a health care provider this fact, the patient would be
keeping that information private.
• Confidentiality refers to
the act of limiting disclosure of private matters. Once a patient has disclosed
private information to a health care provider, that provider has a
responsibility to maintain the confidentiality of that information.
• Security refers to the
means to control access and protect information from accidental or intentional
disclosure to unauthorized persons and from alteration, destruction, or loss.
When private information is placed in a confidential CPR, the system must have
controls in place to maintain the security of the system and not allow
unauthorized persons access to the data (CPRI, 1995).
Information
Presentation. The wealth
of information available through CPR systems must be managed to ensure that
authorized caregivers, including nurses, and others with legitimate uses have
the information they need in their preferred presentation form. For example, a
nurse may want to see data organized by source, caregiver, encounter, problem,
or date. Data can be presented in detail or summary form. Tables, graphs,
narrative, and other forms of information presentation must be accommodated.
Some users may need only to know of the presence or absence of certain data,
not the nature of the data itself. For example, blood donation centers draw
blood for testing for human immunodeficiency virus, hepatitis, and other
conditions. If a donor has a positive test result, the center may not be given
the specific information regarding the test, but just general information that
a test result was abnormal and that the patient should be referred to an
appropriate health care provider.
Interface
Between the Informatics Nurse and the Clinical
Information System
Information demands in health care systems are pushing
the development of CISs and CPRs. The ongoing development of computer
technology—smaller, faster machines with extensive storage capabilities and the
ability for cross-platform communication—is making the goal of an integrated
electronic system a realistic option, not just a long-term dream. As these
systems evolve, INs will play an important role in their development,
implementation, and evaluation.
Because of their expertise, INs are
in an ideal position to assist with the development, implementation, and
evaluation of CISs. Their knowledge of policies, procedures, and clinical care
is essential as workflow systems are redesigned within a CIS. It is not unusual
for nurses within an institution to have more hands-on interaction with and
knowledge of different departments than any other group of employees in an
institution. Jenkins (2000) suggests that the process model of nursing
(assessment, planning, implementation, and evaluation) works well during a CIS
implementation; thus nurses have a familiar framework from which to understand
the complexity of a major system change.
TRENDS IN COMPUTING: PAST, PRESENT, AND
FUTURE
As noted earlier, computers have moved from the realm
of a "nice to know" luxury item to a "need to know"
essential resource for professional practice. Nurses are knowledge workers who
require accurate and up-to-date information for their professional work. The
explosion in information—some estimate that all information is replaced every 9
to 12 months—requires nurses to be on the cutting edge of knowledge to practice
ethically and safely. Trends in computing will also impact the work of
professional nurses and not just through the development of CISs and CPRs.
Research advances, new devices, monitoring equipment, sensors, and "smart
body parts" will all change the way that health care is conceptualized,
practiced, and delivered.
Within this context, not every nurse will need to be
an informatics specialist, but every nurse must be computer literate. Computer
literacy is defined as the knowledge and understanding of computers, combined
with the ability to use them effectively (Joos et al,
1996). Computer literacy may be interpreted as different levels of expertise
for different people in various roles. On the least specialized level, computer
literacy involves knowing how to turn on a computer, start and stop simple
application programs, and save and print information. For health care
professionals computer literacy requires having an understanding of systems
used in clinical practice, education, and research settings. For example, in
clinical practice electronic patient records and clinical information systems
are becoming more widely used.
The computer literate nurse
is able to use these systems effectively and can address issues discussed
earlier, such as confidentiality, security, and privacy. At the same time, the
nurse must be able to effectively use applications typically found on personal
computers (PCs), such as word pro cessing software,
spreadsheets, presentation graphics, and statistics for research. Finally, the
computer-literate nurse must know how to access information from a variety of
electronic sources and how to evaluate the appropriateness of the information
at both the professional and patient level. The remainder of this chapter is
designed to help you gain a broader understanding of computer literacy and the
computing environment of PCs and the online world, along with a discussion of
future trends.
The Past and Future
Weiser and Brown (1996) have
characterized the history and future of computing in three phases. The first
phase is known as the "mainframe era," in which many people share one
computer. Computers were found behind closed doors and run by experts with
specialized knowledge and skills. Although we have mostly moved beyond the
mainframe era, it still exists in CISs (hence some of the problems discussed
previously) or other situations with large mainframe systems, such as banking,
weather forecasting, and legacy systems in academic institutions.
The archetypal computer of
the mainframe era must be the Electronic Numerical Integrator and Computer
(ENIAC), developed at the
Phase II in modern computing
is the PC era, which is characterized by one person to one computer. In this
era the computing relationship is personal and intimate. Similar to a car, the
computer is seen as a special, relatively expensive item that requires
attention but provides a very valuable service in one's life.
The first harbinger of the
PC era was in 1948 with the development of the transistor at Bell Telephone
Laboratories. The transistor, which could act as an electric switch, replaced
the costly, energy-inefficient, and unreliable vacuum tubes in computers and
other devices, including televisions. By the late 1960s integrated circuits,
tiny transistors, and other electrical components arranged on a single chip of
silicon replaced individual transistors in computers. Integrated circuits
became miniaturized, enabling more components to be designed into a single
computer circuit. In the 1970s refinements in integrated circuit technology led
to the development of the modern microprocessor, integrated circuits that contained
thousands of transistors. Weiser and Brown (1996) date the true start of Phase
II as 1984, when the number of people using PCs surpassed the number of people
using shared computers.
Manufacturers used
integrated circuit technology to build smaller and cheaper computers. The first
PCs were sold by Instrumentation Telemetry Systems. The Altair 8800 appeared in
1975. Graphic user interfaces were first designed by the Xerox corporation in a prototype computer, the Alto, developed in
1974. The corporate decision to not pursue commercial development of the PC
(Xerox identified its core business strategy as copiers, not computers) has
become a bit of a computer history legend (Hiltzik,
2000; Smith and Alexander, 1988). Continuing development of sophisticated
operating systems and miniaturization of components (modern microprocessors
contain as many as 10 million transistors) have enabled computers to be
developed that can run programs and manipulate data in ways that were
unimaginable in the era of the ENIAC.
Phase III
has been dubbed the era of ubiquitous computing (UC), in which there will be
many computers to each person. Weiser and Brown (1996) estimate that the crossover with the PC era
will be between 2005 to
One only has to look around a typical house to see how
UC is becoming part of our lives. Microprocessors exist in every room:
appliances in the kitchen, remote controls for television and stereo in the
den, and clock radios and cordless phones in the bedroom. And
the bathroom? Matsushita of Japan has developed a prototype toilet (dubbed
the "smart toilet") that includes an online, real-time health
monitoring system. It measures the user's weight, fat content, and urine sugar
level; plots the recorded data on a graph; and sends it instantaneously to a
health care provider for monitoring (
Another dimension of UC is the Internet. Each time you
connect to the Internet, you are connecting with millions of information
resources and hundreds of information delivery systems. A person truly does
become one person to hundreds of computers. It is ironic that the interface to
the UC world of the Internet is still through a PC. But this is changing.
Wireless infrared connections will eliminate wires; handheld devices will
eliminate the bulky PC. Once we become wireless and mobile, UC will become a
reality.
The Present: PCs and the Internet
Although UC is exciting, the
current reality is we are firmly entrenched in the PC era. The Internet is
driving many changes, but the computer-literate nurse still needs a working
familiarity with the basics of a PC.
Hardware. The physical computer and its components are known as hardware. Computer
hardware includes the memory that stores data and instructions; the CPU that
carries out instructions; the bus that connects the various computer components;
the input devices such as a keyboard or mouse that allow the user to
communicate with the computer, and the output devices such as printers and
video display monitors that enable the computer to present information to the
user.
Software. Software contains the instructions that cause the hardware to work.
Software as a whole can be divided into categories based on the types of work
done by programs. The two primary software categories are operating systems,
which control the workings of the computer, and application software, which
controls the multitude of tasks for which people use computers. System software
thus handles such essential, but often invisible, chores as maintaining disk
files and managing the screen, whereas application software programs perform
tasks such as word processing and database management. Two additional
categories that are neither system nor application software, although they contain
elements of both, are network software, which enables groups of computers to
communicate, and language software, which provides programmers with the
necessary tools to write programs.
In addition to these
task-based categories, software may be described on the basis of the method of
distribution. These methods include packaged software, developed and sold
primarily through retail outlets; freeware and public-domain software, which is
made available without cost by its developer; and shareware, which is similar
to freeware but usually carries a small fee for those who like the program.
Some people also include vaporware in this classification, which is software
that either does not reach the market or appears much later than promised.
Nurses interact with and
primarily use application programs. Software in this category can be further
subdivided on the basis of its purpose and includes:
• General purpose programs,
which include communications, database, desktop publishing, graphics,
spreadsheets, statistics, and word processing applications.
• Educational programs,
which include CAI and computer-aided learning applications
• Utilities (i.e., programs
that help manage the functioning of the computers).
• Personal applications such
as calendars and appointment books.
• Entertainment and
simulations, such as games. Not all games are just for fun; sophisticated
simulations such as "SimCity" allow the user to run a small city and
deal with crises of weather, nature, and person-made disasters. This latter program
has been used in nursing programs to simulate environmental issues in the real
world (Bareford,2001).
The Internet. Applications such as word processing and database management typically
reside on a stand-alone PC and are under the purview of one user. However, this
is only one dimension of PC use. The other major component is the online world,
commonly called the Internet (with a capital I) and its graphic component, the www.
The exponential growth of the Internet makes it an essential item for the computer-literate
nurse to master. Information and professional resources that cannot be found
anywhere else are available on the Internet; this trend shows no sign of
slowing. Most people use the Internet for two broad purposes: to communicate
with others, either individually or in groups, and to find information. Nurses
are no exception, and as knowledge workers they must do both for their
professional work.
The Development Of the
Internet. Many
mistakenly believe that the Internet is a recent development. Rather, it has
been around for more than three decades. The modern Internet started out in
1969 as a U.S. Defense Department network called ARPAnet.
Scientists built ARPAnet with the intention of
creating a network that would still be able to function efficiently if part of
the network were damaged. This concept was important to military organizations,
which were studying ways to maintain a working communications network in the
event of nuclear war. Since then the Internet has grown, changed, matured, and
mutated, but the essential structure of interconnected domains randomly
distributed throughout the world has remained the same. ARPAnet
no longer exists, but many of the standards established for that first network
still govern the communication and structure of the modern Internet.
For many years the Internet was more or less the
private domain of scientists, researchers, and university professors who used
the Internet to communicate and exchange files and software. A number of events
transpired in the 1980s and early 1990s that resulted in the enormous growth of
the Internet and its ensuing popularity.
In 1989 English computer scientist Timothy Berners-Lee
introduced the www. Berners- Less initially designed the www to aid
communication between physicists who were working in different parts of the
world for the European Laboratory for Particle Physics (CERN). However, as it
grew, the www revolutionized the use of the Internet. During the early 1990s
increasingly large numbers of users who were not part of the scientific or
academic communities began to use the Internet, in large part because of the
ability of the www to easily handle multimedia documents. Other changes have
also influenced the growth of the Internet, such as the High-Performance
Computing Act of 1991, the decision to allow computers other than those used
for research and military purposes to connect to the network, and the
development of "user-friendly" software and tools that allowed less
experienced computer users to obtain information quickly and easily.
Going Online. To access the Internet, the user needs hardware, software, and a means
of access. Hardware includes the computer (such as a PC or Macintosh); and some
sort of device to make a connection such as a modem (which uses a phone line),
a cable modem (which connects through a cable television line), or a local area
network such as might be found in a workplace setting. Newer options include
handheld cellular phones with wireless modems, but the vast majority of those
online are still connecting with a wire-based computer system. Necessary
software includes a browser, which is used to view pages on the www, and an
e-mail program, which is necessary for sending and receiving mail. Finally, a
way to access the Internet, which is typically through an Internet Service
Provider (ISP) is needed to make the connection
between the hardware and online world. Again, there are several options,
including large commercial services such as America Online or online access
through a college or university. Detailed descriptions of all of these options
(hardware, software, and ISPs) are beyond the scope of this chapter; one useful
resource for more information is The Nurses' Guide to the Internet (NicoW., 2001).
Overview of Cultural Competence
Recent changes in the ethnic composition of the
population of the
According to an American
Nurses Association (ANA) report, nurses comprise the largest
segment of health care providers
in this country
(American Nurses Association, 2000). It is therefore essential
that they be prepared to
provide care that is culturally
competent. But, are nurses ready
to meet this
challenge? More importantly, are those charged with
theresponsibility of preparing nurses to care for
an increasingly diverse population in possession of
the skills, knowledge and experience
needed to fulfill this task?
In an attempt
to answer the latter question,
this research study examined the level of
cultural competence among faculty of
baccalaureate nursing programs in Louisiana.
Population Changes
According to Day (1996), United States census
data indicate that ethnic minorities
who in 1995 made up approximately
26% of the nation’s population are projected to
increase to 36% of the total
population by 2020. Diversity in the
population is not new to
the United States, given the
historical existence of diverse cultural
groups (e.g., African Americans,Appalachians, Navajos, Eskimos, Mexican Americans, etc.) in this country
(Giger & Davidhizar,
1995). What is new is the
increasing proportion of ethnic minorities
in relation to non-Hispanic Whites as indicated by
the above percentages. In addition, the composition
of the foreign
born population living in the
United States has changed. In
a U.S. Census Bureau report, Smidley and Gibson (1999) noted that the
number of immigrants from Europe has declined
from 62% in 1970 to 16% in 1999. On the other
hand, the proportion of immigrants
from Asia has tripled (9% to 27%) and the
proportion from Latin America has
risen from 19% to 51%, with Mexicans
making up two thirds of
the total.
Another population change is the influx
of recent immigrants to certain
regions of the U.S. (e.g. the South) that
have traditionally been very homogenous
(Salimbene, 1999). For example, in Robeson
County Georgia, it is estimated
that most of the 10,000 Latinos
living there arrived within the past five
years (LeDuff, 2000). This shift in
immigration patterns is also true
in Louisiana where the Asian
and Latino populations are projected to double
by the year
2025 (Louisiana’s population
projections, n.d.). Many of these
new immigrants speak little or
no English and have different
customs, values and beliefs about
health and illness. Thus, these changes have
contributed to greater population diversity in the
Southern United States and have
heightened the need for cultural
competency among nurses practicing in this region
(Salimbene, 1999).
Online Activities: Communicating With
Others
Individual
E-Mail.
By far the most
common use of the Internet is to send electronic mail (e-mail). It is also very
easy. The fact that it is so easy is a major driving force behind the
phenomenal growth of e-mail. In 1999 there were 569 million mailboxes, an
increase of 84% over 1998 (Year End, 1999). Analysts estimate that in less than
2 years there will be one billion online mailboxes, outnumbering both
televisions and phone lines. Even with this growth, every e-mail journey begins
with a single message. For many people, exchanging e-mail with col leagues is
their first introduction to the Internet. Since the interaction is limited and
often with someone who is known, it is usually a nonthreatening experience.
E-mail tends to be informal,
and most recipients are tolerant of "less-than-perfect"
communications. Even so, if your mail program includes features such as a
spellchecker, it is wise to use it. Another useful feature is to create a
signature file. With a signature file, certain information, such as your name,
e-mail address, and phone number will be appended to every message you send.
A few words of warning about
e-mail:
• TYPING IN CAPITALS IS NOT
A GOOD IDEA. In popular netiquette (etiquette for the Internet) terms, typing
exclusively in capital letters is considered shouting and very rude.
• Just because e-mail is
simple and informal, do not forget rules of common courtesy. If you are writing
to someone you don't know to request information, include a brief introduction
and explanation of why you need the material. Similarly, if you request
information, be reasonable in your request. A two-sentence e-mail message may
take the respondent an hour to answer. If you want someone to send you hard
copy of protocols, guidelines or procedures, offer to reimburse for mailing or
copying. Do not use e-mail as a substitute for doing your own work. I get a
surprising number of requests from people asking for literature searches on
nursing informatics, which I deal with quickly and completely by using the
delete key.
• Be careful with
attachments. Attachments are appended to e-mail messages and contain files or
pictures. Although attachments are a necessary way to send files, it is
possible to send a virus to someone via an attachment.
• Another problem is spam:
junk e-mail. Junk e-mail can fill up your electronic mailbox just as quickly as
traditional junk fills your home mailbox. There are many different types of
spam: messages selling goods and services, get-rich-quick schemes, chain letters,
and hoaxes. My advice for all of these is simple: HIT THE DELETE KEY. Many spam
messages include a line that says, "Reply to this message to be removed
from the mailing list." This is the worst thing you can do. By replying to
the message you confirm your e-mail address and in so doing, run the risk of
exponentially increasing the spam e-mail that you receive.
Group E-Mail: Mailing Lists. Another popular feature of the Internet is mailing
lists, which provide a forum for groups of people with similar interests to get
together and share their information through a mail-based discussion group.
These lists can range in size from a few dozen people to thousands, and they
can generate anywhere from a few messages a week to a hundred or more in a day.
Being on a mailing list can put information and resources literally at your
fingertips. Imagine asking 900 fellow students around the world a question
concerning a clinical problem and receiving multiple answers within minutes.
To find out about mailing lists, talk to others and
find out if they subscribe. Actual subscribers are the most reliable source of
information regarding a list (e.g., how active it is, whether the discussions
are valuable). Another option is to visit http://www.ualberta.ca/ ~jrnorris/nursenet/nurlists.html.
This is a "list of lists" specific to nursing and was created by Judy
Norris, who is a faculty member at the
Although there are hundreds of mailing lists on the
Internet, they all work in a similar fashion. As noted above, each list is
developed around a particular topic or interest area. One subscribes to a list,
but unlike subscribing to a magazine, there is no charge for the service. Once
you are subscribed to a list, you will receive messages that you can read,
reply to, or delete. The communications are asynchronous (i.e., the discussions
are not occurring in real time, such as you would have with a conversation).
Instead the discussions occur via e-mail, with one person asking a question or
posing a comment and other members on the list replying. Even though the
discussions are not synchronous, they are real discussions with sometimes
heated debates.
Although all mailing lists work in a similar fashion,
each list has its own quirks. Typically, when you successfully subscribe to a
mailing list, you will receive a welcome message from the list owner. Print
this message and save it, because it will contain useful information about how
to manage your subscription: how to unsubscribe, how to temporarily stop the
mail, and how to receive the list in different formats such as digest.
As with individual e-mail, there are some mailing list
courtesies to keep in mind. Mailing lists are not anonymous; there are real
people behind the messages. These people give the list its personality, and you
will get to know the other list members through their discussions and comments.
Many people choose to "lurk," that is, read messages but not post,
when they first subscribe to a list. This gives you a chance to get a feel for
the members of the community.
When you do decide to post a message, a short
introduction is a good idea. Keep it simple: "Hi, my name is . . . I
subscribed to this list because I am interested in . . . .
" When you post a question, be clear and to the point. Tell people
what information you want and how you want it. Do you want people to post their
replies to the list or reply to you privately? Similarly, if you are replying
to a message, know to whom you are replying. By default, all responses go to
the whole list.
If the nature of
the topic changes, change the subject line. This allows the list members to quickly scan and
delete messages that are not of interest.
Flaming is not a good idea. Aflame is when
someone attacks another person, usually in a virulent and violent manner.
Remember that the whole point of a list is to have a discussion; it is possible
to disagree with someone's ideas, but that does not mean you have to denigrate
the person in the process.
Finally, newbies (newcomers) are afforded a
wide degree of latitude, and mistakes are expected and accepted, but do your
best to learn the ropes and manage your subscription in a responsible and
professional manner. Although list owners are loathe to do
this, they can unsubscribe people who repeatedly post off topic, flame others,
send viruses, or mismanage their account. Keep these points in mind when you
join a list.
Chatting Online. Mailing lists are extremely useful, but what if you want to have a
synchronous (real time) conversation with someone else? To do this you need to
find a way to chat, which is not too hard to do as Internet chatting is
becoming as popular as e-mail. There are literally hundreds of chat rooms,
scattered all over the Internet, with people talking on every imaginable topic.
Chat rooms appeal to some people but not others. The only way to find out if
this is a communication medium that suits you is to dive in and try it.
To get started, you have two major options: the first
is to find a chat room that exists on the Internet. With that, you simply
"enter the room" and begin conversing. The second option is to
download software that allows you to chat, such as Internet relay chat (IRC) or
ICQ ("Iseek - you"). Many people use both
options. People tend to have favorites, so you may find certain friends in ICQ,
others on IRC, and yet others in chat rooms on America Online.
No matter which option you choose, certain rules of
etiquette govern chatting. You should also observe certain precautions to
protect yourself. One important rule: never give out personal information in a
chat room. Do not give out credit card information or passwords, no matter how
the request is made. You might want to investigate using moderated chat rooms.
Moderators are there to keep an eye on the content and flow of conversation.
They also have the authority to kick people who are misbehaving out of the
chats. As with mailing lists, rules of common courtesy prevail in chat rooms.
Do not harass others, do not flame, and avoid obscene and suggestive language.
If you chat regularly, you may begin to see familiar
names and become friends with your fellow chatters. You may fall in love. You
may meet someone and get married. I know people who have done all three. You
also may find yourself in a difficult and potentially dangerous situation. As
with anything in life, be careful. The Internet does have a dark side.
That said, I have met some great people on the
Internet, and we have met in person and become good friends. The Internet is
making our world smaller and giving all of us the opportunity to meet people we
might never have met otherwise. But I used caution and common sense in allowing
these friendships to develop. If you do the same, you will do much to guarantee
that your Internet interactive experiences are pleasant and rewarding.
Online Activities: Finding Information
The other major use of the
Internet is finding information. To do so, it is important to develop skills
for searching quickly and efficiently. There are a variety of strategies you
can use for searching, including quick and dirty searching, links, and brute
force. Keep in mind that you must be persistent: no one search strategy is going to work all the time, nor is any one search engine
more effective than any other. A study published in Science in 1998
(Lawrence and Giles, 1998) revealed that the best search engines found
approximately 33% of the information available on the Internet. That means, of
course, that 67% of useful information is being missed. Search engines are good
starting points, but you can augment their effectiveness by adding a few other
strategies to your Web exploration toolkit.
First, you should target
your search by conducting a "Purpose—Focus—Approach" (PFA)
assessment. To determine your purpose, ask yourself why you are doing the
search and why you need the information. Consider questions such as the
following:
• Is it for personal
interest?
• Do you want to obtain
information to share with co-workers or a client?
• Are you verifying
information given to you by someone else?
• Are you preparing a report
or writing a paper for a class or project? Based on your purpose, your focus
may be:
• Broad and general (basic
information for yourself).
• Lay oriented (to give
information to a patient) or professionally oriented (for colleagues).
• Narrow and technical with
a research orientation.
Purpose combined with focus
determines your approach. For example, information that is broad and general
can be found using brute force methods or quick and dirty searching. Lay
information can be quickly accessed at a few key sites, including MEDLINE plus
and consumer health organizations. Similarly, professional associations and
societies are a good starting point for professionally oriented information.
Scientific and research information usually requires literature resources that
can be found in databases such as MEDLINE or CINAHL.
Quick
and Dirty Searching. Quick and dirty searching is a very simple but surprisingly effective
search strategy. First, start with a search engine such as AltaVista
(www.altavista.com). Next type in the term of interest.
At this point, do not worry about being overly broad or general. You will
retrieve an enormous number of found references (called "hits") but
you are only interested in the first ten to twenty. Look at the URLs and try to
decipher what they mean. URLs usually start with www (for World Wide Web). Then
there is the "thing in the middle" followed by a domain. Pay
attention to the domains: .com is commercial; .edu is
an educational institution; .gov is the government.
Quickly visit a few sites. Look for the information you need, or useful links.
If a site is not relevant, use the back button to return to your search results
and go to the next site. Once you find a site that appears to be useful, begin
to explore the site. If there are links, use the links to connect to other
relevant sites. This process: quick search, quick review, clicking and linking,
can provide a starting point for useful information in a relatively short
period of time.
Brute
Force.
Brute force
searching is another alternative. To do this, type in an address and see what
happens. The worst outcome is an annoying error message, but you may land on a
site that is exactly what you want. Perhaps you are trying to find a school of
nursing at a certain university. What is the common name for the university?
www.unh.edu is the very logical URL for the
Take Advantage
of Links and Use the Bookmark Feature. Every website has links to other websites of related
interest. Take advantage of these links because the site developer has already
done some of the work of finding other useful resources. Combine quick and
dirty searching or brute force with links to get the information you need. Each
site you visit will have more links, and in this way the resources keep
building. Visiting a variety of sites will open up the vistas of information
that are available. When you find a site of interest, "bookmark" it
or add it to your list of favorites. This guarantees you will be able to return
to the site in the future.
Resources
for Professionals and Consumers. The preceding discussion has focused on strategies to use when you are
faced with a "needle in a haystack" searching situation—just dive in
and see what you find. The advantage of this method is that it is fast and
easy. The disadvantages are that sites of dubious quality may be obtained and
the process, although fast, is not terribly efficient.
Another approach is to
develop a "short list" of well-known, well-researched sites that can
be used as starting points for further exploration. Such a list is useful to
share with others so that they can begin their own exploration. These should be
sites that you have determined are trustworthy and reliable. Examples of such
sites include organizations and associations with which we are all familiar
such as the American Cancer Society (ACS). They have patient education and
consumer information materials, which can be obtained by a virtual visit to
www.cancer.org. In addition to the traditional types of resources available
from the ACS, at the website it is also possible to send an e-mail requesting
more information, sign up for regular updates and news, read news items, and obtain updated statistical information. The website is truly
a "value-added" version of the ACS. Practically any health
organization you can think of has created a virtual storefront on the Internet.
Professional associations in nursing, medicine, and
other disciplines are also becoming comprehensive resource sites on the
Internet. www.nursingcenter.com has a handy list of associations in nursing and
related disciplines. Use the "AssociationLink"
button on the home page to go to the complete listing.
Other resources are
Although these resources are
the Internet versions of known and useful organizations, there are also virtual
resources that exist only on the Internet. One such site that is particularly
impressive is MEDLINEplus (http://medlineplus.gov),
developed by the National Library of Medicine. A similar resource, specific to
oncology, is OncoLink at the
Literature
Resources.
Thinking back to
PFA, if you are searching for scientific, technical, or research oriented
information, you must search literature databases. In this case, the first
place to turn is to the National Library of Medicine (NLM), which is the home
of the MEDLARS (Medical Literature Analysis and Retrieval System), a
computerized system of databases and databanks offered by the NLM. A person may
search the computer files either to produce a list of publications
(bibliographic citations) or to retrieve factual information on a specific
question. The most well known of all the databases in
the MEDLARS system is MEDLINE, NLM's premier bibliographic database covering
the fields of medicine, nursing, dentistry, veterinary medicine, and the
preclinical sciences. Journal articles are indexed for MEDLINE, and their
citations are searchable, using NLM's controlled vocabulary, MeSH (Medical Subject Headings). MEDLINE contains all
citations published in Index Medicus and corresponds
in part to the International Nursing Index and the Index to Dental Literature.
Citations include the English abstract when published with the article
(approximately 76% of the current file). MEDLINE contains over 11
million records from 4000 health science journals. The file is updated weekly.
An individual can search MEDLINE for free, using one of two available search
engines: PubMed (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) or Internet GratefulMed (http:// igm.nim.nih.gov/). Whichever search
engine is used, there are no fees to the user to access the MEDLINE database.
Another literature resource to investigate is the
National Guideline Clearinghouse (NCG) (www.ngc.gov). Whereas MEDLINE includes
citations to articles in professional journals, the NGC is a comprehensive
database of evidence-based clinical practice guidelines and related documents
produced by the Agency for Healthcare Research and Quality in partnership with
the American Medical Association and the American Association of Health Plans.
The NGC mission is to provide physicians, nurses, other health professionals,
health care providers, health plans, integrated delivery systems, and
purchasers an accessible mechanism for obtaining objective, detailed
information on clinical practice guidelines and to further their dissemination,
implementation, and use.
There are also a variety of
other literature resources available on the Internet, some of which have fees
attached. However, do not automatically assume that you must pay the fee. Your
workplace or school may have licensing agreements in place with different
vendors, and as an employee or student you may have access to the literature
resources. Check with your library or information services department to see if
this applies to you.
The final element of
literature searching online is finding full text of articles. The databases so
far discussed (MEDLINE and others) do not contain full text; they just include
literature citations. Finding full text online at the present time is an
unorganized situation. Options range from journals that have full text
available either for free or for a fee, to forcing you to do things the
old-fashioned way, that is, a trip to the library and photocopying articles by
hand. Given the present state of confusion that exists, my best advice is to
begin exploring, using quick and dirty or brute force methods. You can also
visit the publisher's website to see if access to the journal is available. A
final option is to use a document delivery service, such as UnCover
(http://uncweb.carl.org/). This resource allows you to conduct a search. It
identifies which articles can be sent to you, and what the fees will be
(including article fees, service charges, and copyright fees). If you elect to
order the article, you can identify how you want to have it sent to you (mail,
fax, or other).
Evaluating Information Found on the Internet
Traveling through the
Internet, one must always use critical thinking skills to evaluate the
information that is found. The "wide open" nature of the Internet
means that just about anyone with a computer and online access can create a
home page and post it for the world to see. Although there are many excellent
health- and nursing-related sites, there are others that just do not measure up
in terms of accuracy, content, or currency.
It is important to differentiate between
problem analysis and decision making. The concepts are completely separate from
one another. Problem analysis must be done first, then
the information gathered in that process may be used towards decision making.
Problem Analysis
• Analyze
performance, what should the results be against what they actually are
•
Problems are merely deviations from performance standards
• Problem
must be precisely identified and described
•
Problems are caused by some change from a distinctive feature
•
Something can always be used to distinguish between what has
and hasn't been effected by a cause
• Causes
to problems can be deducted from relevant changes found in analyzing the
problem
• Most
likely cause to a problem is the one that exactly explains all the facts
Decision Making
•
Objectives must first be established
•
Objectives must be classified and placed in order of importance
•
Alternative actions must be developed
• The
alternative must be evaluated against all the objectives
• The
alternative that is able to achieve all the objectives is the tentative
decision
• The
tentative decision is evaluated for more possible consequences
• The
decisive actions are taken, and additional actions are taken to prevent any
adverse consequences from becoming problems and starting both systems (problem
analysis and decision making) all over again
• There
are steps that are generally followed that result in a decision model that can
be used to determine an optimal production plan.
Some of the decision making techniques
people use in everyday life include:
Simple
Prioritization: Choosing the alternative with the highest
probability-weighted utility for each
alternative (see Decision Analysis)
·
Satisficing: using
the first acceptable option found
·
Acquiesce to a person in authority or an "expert", just following orders
·
Flipism:
Flipping a coin, cutting a deck of playing cards, and other random or
coincidence methods
·
Prayer, tarot
cards, astrology, augurs, revelation, or other
forms of divination
·
Taking the most opposite action compared to the advice of
mistrusted authorities (parents, police officers, partners ...)
Developed by B. Aubrey Fisher, there are
four stages that should be involved in all group decision making. These stages,
or sometimes called phases, are important for the decision-making process to
begin
Orientation
stage- This phase is where members meet for the first time and
start to get to know each other.
Conflict stage- Once
group members become familiar with each other, disputes, little fights and
arguments occur. Group members eventually work it out.
Emergence stage- The
group begins to clear up vague opinions by talking about them.
Reinforcement
stage- Members finally make a decision, while justifying
themselves that it was the right decision.
Each step in the decision making process
includes social, cognitive and cultural obstacles to successfully negotiating
dilemmas. Becoming more aware of these obstacles allows one to better
anticipate and overcome them. Pijanowski (2009, p.7) developed eight stages of decision making
based on the work of James Rest:
1.
Establishing community: creating and nurturing the relationships, norms, and
procedures that will influence how problems are understood and communicated.
This stage takes place prior to and during a moral dilemma
2.
Perception: recognizing that a problem exists
3.
Interpretation: identifying competing explanations for the problem, and
evaluating the drivers behind those interpretations
4.
Judgment: sifting through various possible actions or responses and determining
which is more justifiable
5.
Motivation: examining the competing commitments which may distract from a more
moral course of action and then prioritizing and committing to moral values
over other personal, institutional or social values
6.
Action: following through with action that supports the more justified
decision. Integrity is supported by the ability to overcome distractions and obstacles,
developing implementing skills, and ego strength
7.
Reflection in action
8.
Reflection on action
When in an organization and faced with a
difficult decision, there are several steps one can take to ensure the best
possible solutions will be decided. These steps are put into seven effective
ways to go about this decision making process (McMahon 2007).
The first
step - Outline your goal and outcome. This will
enable decision makers to see exactly what they are trying to accomplish and
keep them on a specific path.
The second step - Gather data.
This will help decision makers have actual evidence to help them come up with a
solution.
The third
step - Brainstorm to develop alternatives. Coming up with more than one solution ables you to see which one can actually work.
The fourth step - List pros and
cons of each alternative. With the list of pros and cons, you can eliminate the
solutions that have more cons than pros, making your decision easier.
The fifth
step - Make the decision. Once you analyze each solution, you
should pick the one that has many pros (or the pros that are most significant),
and is a solution that everyone can agree with.
The sixth
step - Immediately take action. Once the
decision is picked, you should implement it right away.
The seventh step - Learn from,
and reflect on the decision making. This step allows you to see what you did
right and wrong when coming up, and putting the decision to use.
Biases
can creep into our decision making processes. Many different people have made a
decision about the same question (e.g. "Should I have a doctor look
at this troubling breast cancer symptom I've discovered?" "Why did I
ignore the evidence that the project was going over budget?") and then craft potential cognitive interventions aimed at
improving decision making outcomes.
Below is a list of some of the more
commonly debated cognitive
biases.
·
Selective search for evidence (a.k.a. Confirmation bias in psychology) (Scott Plous,
1993) – We tend to be willing to gather facts that support certain conclusions
but disregard other facts that support different conclusions. Individuals who
are highly defensive in this manner show significantly greater left prefrontal
cortex activity as measured by EEG than do less defensive individuals.
·
Premature termination of search for evidence – We tend to
accept the first alternative that looks like it might work.
·
Inertia –
Unwillingness to change thought patterns that we have used in the past in the
face of new circumstances.
·
Selective perception – We actively screen-out information
that we do not think is important. (See prejudice.) In one demonstration of this
effect, discounting of arguments with which one disagrees (by judging them as
untrue or irrelevant) was decreased by selective activation of right prefrontal
cortex.
·
Wishful thinking
or optimism bias – We tend to want to see
things in a positive light and this can distort our perception and thinking.
·
Choice-supportive bias occurs when we
distort our memories of chosen and rejected options to make the chosen options
seem more attractive.
·
Recency –
We tend to place more attention on more recent information and either ignore or
forget more distant information. (See semantic
priming.) The opposite effect in the first set of data or other information
is termed Primacy effect (Plous, 1993).
·
Repetition bias – A willingness to believe what we have
been told most often and by the greatest number of different sources.
·
Anchoring and adjustment – Decisions are
unduly influenced by initial information that shapes our view of subsequent
information.
·
Group think – Peer
pressure to conform to the opinions held by the group.
·
Source credibility bias – We reject something if we have
a bias against the person, organization, or group to which the person belongs:
We are inclined to accept a statement by someone we like. (See prejudice.)
·
Incremental decision making and escalating commitment –
We look at a decision as a small step in a process and this tends to perpetuate
a series of similar decisions. This can be contrasted with zero-based
decision making. (See slippery slope.)
·
Attribution asymmetry – We tend to attribute our
success to our abilities and talents, but we attribute our failures to bad luck
and external factors. We attribute other's success to good luck, and their
failures to their mistakes.
·
Role fulfillment (Self Fulfilling Prophecy) – We conform
to the decision making expectations that others have of someone in our
position.
·
Underestimating uncertainty
and the illusion of control – We tend to underestimate future uncertainty
because we tend to believe we have more control over events than we really do.
We believe we have control to minimize potential problems in our decisions.
·
Framing bias is best avoided by using numeracy with
absolute measures of efficacy.
Reference class forecasting was
developed to eliminate or reduce cognitive biases in decision making.
Evaluation and analysis of past
decisions is complementary to decision making; see also mental
accounting.
According to behavioralist Isabel Briggs Myers, a person's decision making
process depends to a significant degree on their cognitive style. Myers
developed a set of four bi-polar dimensions, called the Myers-Briggs Type Indicator (MBTI). The
terminal points on these dimensions are: thinking and feeling; extroversion
and introversion; judgment and perception; and sensing
and intuition. She claimed that a person's decision making style
correlates well with how they score on these four dimensions. For example,
someone who scored near the thinking, extroversion, sensing, and judgment ends
of the dimensions would tend to have a logical, analytical, objective,
critical, and empirical decision making style. However, some psychologists say
that the MBTI lacks reliability and validity and is poorly constructed.
Other studies suggest that these
national or cross-cultural differences exist across entire societies. For
example, Maris Martinsons
has found that American, Japanese and Chinese business leaders each exhibit a
distinctive national style of decision making.
Herbert
Simon coined the phrase "bounded rationality" to express the idea
that human decision-making is limited by available information, available time,
and the information-processing ability of the mind. Simon also defined two
cognitive styles: maximizers
try to make an optimal decision, whereas satisficers simply try to find a solution
that is "good enough". Maximizers
tend to take longer making decisions due to the need to maximize performance across
all variables and make tradeoffs carefully; they also tend to more often regret
their decisions (perhaps because they are more able than satisficers to recognise that a decision turned out to be
sub-optimal).
Styles and methods of decision making
were elaborated by the founder of Predispositioning
Theory, Aron Katsenelinboigen. In his analysis on styles and
methods Katsenelinboigen
referred to the game of chess, saying that “chess does disclose various methods
of operation, notably the creation of predisposition—methods which may be applicable
to other, more complex systems.”
In his book Katsenelinboigen states that apart from the methods
(reactive and selective) and sub-methods (randomization, predispositioning, programming),
there are two major styles – positional and combinational. Both styles are
utilized in the game of chess. According to Katsenelinboigen, the two styles reflect two basic
approaches to the uncertainty: deterministic (combinational style) and indeterministic (positional
style). Katsenelinboigen’s definition of the two styles are the following.
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The combinational style is characterized
by
·
a very narrow, clearly defined, primarily material goal,
and
·
a program that links the initial position with the final
outcome.
In defining the combinational style in
chess, Katsenelinboigen
writes:
The combinational style features a
clearly formulated limited objective, namely the capture of material (the main
constituent element of a chess position). The objective is implemented via a
well-defined and in some cases in a unique sequence of moves aimed at reaching
the set goal. As a rule, this sequence leaves no options for the opponent.
Finding a combinational objective allows the player to focus all his energies
on efficient execution, that is, the player’s analysis may be limited to the
pieces directly partaking in the combination. This approach is the crux of the
combination and the combinational style of play.
The positional style is distinguished by
·
a positional goal and
·
a formation of semi-complete linkages between the initial
step and final outcome.
“Unlike the combinational player, the
positional player is occupied, first and foremost, with the elaboration of the
position that will allow him to develop in the unknown future. In playing the
positional style, the player must evaluate relational and material parameters
as independent variables. ( … ) The positional style gives the player the
opportunity to develop a position until it becomes pregnant with a combination.
However, the combination is not the final goal of the positional player—it
helps him to achieve the desirable, keeping in mind a predisposition for the
future development. The Pyrrhic victory is the best example of one’s
inability to think positionally.”
The positional style serves to
a) create a predisposition to the future development of the
position;
b) induce the environment in a certain way;
c) absorb an unexpected outcome in one’s favor;
d) avoid the negative aspects of unexpected outcomes.
Katsenelinboigen writes:
“As the game progressed and defense
became more sophisticated the combinational style of play declined. The
positional style of chess does not eliminate the combinational one with its
attempt to see the entire program of action in advance. The positional style
merely prepares the transformation to a combination when the latter becomes
feasible.”
The anterior cingulate cortex (ACC), orbitofrontal cortex (and the overlapping ventromedial prefrontal cortex) are
brain regions involved in decision making processes. A recent neuroimaging
study found distinctive patterns of neural activation in these regions
depending on whether decisions were made on the basis of personal volition or following directions from someone
else. Patients with damage to the ventromedial prefrontal cortex have
difficulty making advantageous decisions.
A recent study involving Rhesus monkeys
found that neurons in the parietal cortex not only represent the formation of a
decision but also signal the degree of certainty (or "confidence")
associated with the decision. Another recent study found that lesions to the
ACC in the macaque
resulted in impaired decision making in the long run of reinforcement guided
tasks suggesting that the ACC may be involved in evaluating past reinforcement
information and guiding future action.
Emotion appears
to aid the decision making process: Decision making often occurs in the face of
uncertainty
about whether one's choices will lead to benefit or harm (see also Risk). The
somatic-marker hypothesis is a neurobiological theory of how decisions are made
in the face of uncertain outcome. This theory holds that such decisions are
aided by emotions, in the form of bodily states, that are elicited during the
deliberation of future consequences and that mark different options for
behavior as being advantageous or disadvantageous. This process involves an interplay between neural systems that elicit
emotional/bodily states and neural systems that map these emotional/bodily
states.
Although
it is unclear whether the studies generalize to all processing, there is
evidence that volitional movements are initiated, not by the conscious decision
making self, but by the
subconscious. See the Neuroscience of free will.
Various models of decision-making
Various views and theories of decision-making may be
found in the literature. The following list of views, supporting theories and
models is based upon categorisations
provided by Keen and Scott Morton (1978), Huber (1981), and Das and Teng (1999). Das and Teng’s list is, by itself, a
meta-classification. The last two items mentioned in the list below, namely naturalistic
decision-making and the multiple perspectives approach, are relatively new and
did not appear in the mentioned categorisations.
The rational model
The rational manager view assumes a rational and
completely informed decision-maker (“economic man”) as described by
neoclassical microeconomic theory around the middle of the previous century.
The process of rational decision-making comprises a number of steps, such as
those given by Simon (1977):
• Intelligence: finding occasions for making a
decision;
• Design: inventing, developing and analysing possible courses of
action;
• Choice: selecting a particular course of action from
those available; and
• Review: assessing past choices.
In classical or perfect rationality, methods of
decision analysis are used to attach numerical values or utilities to each of
the alternatives during the “choice” phase. The alternative with the highest
utility (or maximum subjective expected utility) is selected. When using the
rational model in this fashion, it is assumed that managers:
• “know of all possible alternatives;
• know the consequences of implementing each
alternative;
• have a well organised
set of preferences for these consequences; and
• have the computational ability to compare
consequences and to determine which is preferred.”
The model of bounded rationality
The “satisficing,” process-oriented view is based
primarily on Simon’s (1979) work on bounded rationality, admitting that the
rational manager does not always have complete information, and that optimal
choices are not always required. According to Simon (as quoted by Chase et al.
(1998)), “human rational behaviour
is shaped by a scissors whose two blades are the structure of task environments
and the computational capabilities of the actor.” These scissors cut the
problem space into a much smaller area that is feasible to search. Bounded
rationality is characterised
by the activities of searching and satisficing. Alternatives are searched for
and evaluated sequentially. If an alternative satisfies certain implicitly or
explicitly stated minimum criteria, it is said to “satisfice” and the search is
terminated. The process of searching might be made easier by the identification
of regularities in the task environment.
Although Simon has been highly acclaimed for the
theory of bounded rationality, it still describes (albeit constrained) rational
behaviour. For this reason,
a number of researchers, such as Huber (1981) and Das and Teng (1999), do not distinguish between perfect and
bounded rationality in their classification of decision-making models.
The incrementalist
view
The logical incrementalist
view involves a step-by-step process of incremental actions and keeps the
strategy open to adjustment. Under Lindblom’s
(1959) disjointed incrementalism
(“muddling through”) marginal, feasible changes are made, working from the status
quo to solve existing problems rather than towards goals. Other researchers
describe a process of “muddling with a purpose”.
The organisational
procedures view
The organisational
procedures view seeks to understand decisions as the output of standard
operating procedures invoked by organisational
subunits. March (1988) contributed to this theory. Huber names this view the
“program model,” indicating that the decisions are pre-programmed in existing
procedures as well as the routinised
thinking of the people involved. Das and Teng
(1999) refer to it as the “avoidance mode” which views decision-making as a
systematic process aimed at maintaining the status quo at the cost of
innovation. On the other hand, Krabuanrat
and Phelps (1998) regard this view in a positive light, namely as the use of
codified organisational
experience.
The political view
The political view sees decision-making as a personalised bargaining process,
driven by the agendas of participants rather than rational processes. People differ
on the organisation’s
goals, values and the relevance of information. The decision-making process
never ends, but remains a continuous battle between different coalitions. After
one group wins a round of the battle, other parties might regroup or become
even more determined to win the next round. Influence and power is wielded in a
deliberate manner and to further self-interest. The goals of the coalitions are
defined by self-interest rather than by what is good for the organisation as a whole. Pfeffer (1981) is one of the
major contributors on politics and power in decision-making.
In recent years criteria for website evaluation have
proliferated. They range from the simple and cursory to the elaborate and expansive.
I have found a simple mnemonic, "Are you PLEASED with the site?" to
be very helpful.* The mnemonic makes the seven
criteria very easy to remember, but I have found, in hundreds of hours of
surfing and evaluating, they are extremely comprehensive (Nicoll,
2000). To determine if you are PLEASED, consider the following:
P: Purpose. What is the author's purpose in developing the site?
Are the author's objectives clear? Many people will develop a website as a
hobby or way of sharing information they have gathered. It should be
immediately evident to you what the true purpose of the site is. At the same
time, consider your purpose (i.e., think back to your PFA assessment). There
should be congruence between the author's purpose and yours.
L: Links. Evaluate the links at the site. Are they working?
(Links that do not take you anywhere are called "dead links.") Do
they link to reliable sites? It is important to critically evaluate the links
at sites hosted by organizations, businesses, or institutions because these
entities are usually presenting themselves as authorities for the subject at
hand. Some pages, such as those created by individuals, are really nothing more
than a collection of links. These can be useful as a starting point for a
search, but it is still important to evaluate the links that are provided at
the site.
E: Editorial (site content). Is the information contained in the site accurate,
comprehensive, and current? Is there a particular bias or is the information
presented in an objective way? Who is the consumer of the site: is it designed
for health professionals, patients, consumers, or other audiences? Is the
information presented in an appropriate format for the intended audience? Look
at details, too. Are there misspellings and grammatical errors? "Under construction" banners that have been there
forever? I find that these types of errors can be very telling about the
overall quality of the site.
A: Author. Who is the author of the site? Does that person or
persons have the appropriate credentials? Is the author clearly identified by
name and is contact information provided? Many times I will double-check an
author's credentials by doing a literature search in MEDLINE. When people
advertise themselves as "the leading worldwide authority" on such-andsuch topic, I figure they should have a few publications
to their credit that establish their reputations. It is surprising how many
times this search brings up nothing.
Be wary of how a person presents his or her
credentials, too. I have seen many sites where "Dr. X" is touted as
an expert. On further exploration, I verify that, in fact, Dr. X does have a
PhD (or MD or EdD), but the discipline in which this
degree was obtained has nothing to do with the subject matter of the site.
Remember that there is no universal process of peer review on the Internet and
anyone can present himself or herself in any way that he or she wants. Be
suspicious.
Keep in mind that the webmaster and the author may be
two (or more) different people. The webmaster is the person who designed the
site and is responsible for its upkeep. The author is the person who is
responsible for the content and is the expert in the subject matter provided.
In your evaluation, make sure to determine who these people are.
S: Site. Is the site easy to navigate? Is it attractive? Does it download quickly
or have too many graphics and other features that make it inefficient? A site
that is pleasing to the eye will invite you to return. Sites that cause my
computer to crash go on the "never visit again" list. I am also not
fond of sites that have annoying music that cannot be turned off.
E: Ethical. Is there contact information for the site developer
and author? Is there full disclosure of who the author is and the purpose of
the site? Is this information easy to find or is it buried deep in the website?
There are many commercial services, particularly pharmaceutical companies, that have excellent websites with very useful
information. But some of them exist only to sell their product, although this
is not immediately evident on evaluation.
D: Date. When was the site last updated? Is it current?
Is the information something that needs to be updated regularly? Generally,
with health and nursing information, the answer to that last question is yes. I
become concerned with sites that have not been updated within 12 to 18 months.
The date the site was last updated should be prominently displayed on the site.
Keep in mind that different pages within the site may be updated at different
times. Be sure to check the date on each of the pages that you visit.
As you become more proficient at website evaluation,
you may have additional criteria that you would add to this list or criteria
that are important to you for a specific purpose. But I have found that this
simple group of seven has served me well on countless Internet journeys. Test
them for yourself. Do a quick search on a topic of
interest, visit a number of sites, and determine just how PLEASED you are with
what you find.
SUMMARY
Computers have opened a world of information; at the
same time, they have given us the responsibility to learn how to use them and
use them well. As a nurse, you have the opportunity to specialize in the
expanding field of nursing informatics. Within this role, you will provide a
vital link between the world of information science and clinical nursing
practice. Even if you choose not to specialize in informatics, you will still
be using computers on a day-to-day basis and thus must be computer literate. To
be computer literate, it is not enough to know how to turn on the computer and
to complete a few simple tasks. A nurse must know generalized applications such
as word processing, as well as specialized applications such as clinical
information systems. The nurse must also know how to access the online world of
information and resources and how to critically evaluate the information that
is found. None of this is going to change. As the Internet continues to grow
and as computers become smaller and more powerful, they will undoubtedly
continue to have a major impact on how health is conceptualized and delivered.