A framework for analysis of ethical dilemmas in critical care nursing.AACN Advanced Critical Care, 18(3), 323-328. doi:10.1097/01.AACN.0000284434.83652.d5, Scruth, E. (2014). Retrieved from https://www.americannursetoday.com/doing-the-right-thing-pathways-to-moral-courage/, Larsen, A. Evidence is mounting that EHRs are resulting in unintended consequences with patient safety implications. The field of nursing informatics combines nursing and information technology disciplines. Jenders, R. A. The CDS fires alerts that prompt the ordering physician to fluid resuscitate the patient according to the Center for Disease Control guidelines for suspected sepsis. It specifies duties that nurses in leadership and managerial roles have, particularly in transformational and servant leadership frameworks, to open communication and to act “entirely on the behalf of those led” (ANA, 2009, p. 8) to identify problems and integrate ethical provisions in all areas of practice. New York: Praiger. Healthcare informatics has opened a whole new dimension of patient care using technology across many healthcare departments. As a result of the HITECH Act in 2009, the TNA Board of Directors formed a Health Information Technology advisory committee. From the beginning in 2010 when the TNA Board of Directors resolution was passed, the two organizations created the partnership that provided cumulative guidance, funding, and dissemination efforts throughout the years. Evidence is emerging that the use of the information and communication technologies (ICT) in healthcare settings facilitates better quality care. Competing personal values... can impede motivation and action. nursing care Here are the discussion questions. Retrieved from https://c.ymcdn.com/sites/www.texasnurses.org/resource/resmgr/HIT_Files/HIT_Survey_Report-Final.pdf, McBride, S., Tietze, M., Hanley, M. A., & Thomas, L. (2017). Jameton described three components that can apply to the pain expressed by the nurses that contributed to the Texas study: knowing what is right, being in a situation that constrains acting on that knowledge, and the psychological distress resulting from that inability to do the right thing (Jameton, 2017). Nurse managers and executives have a particular obligation to ensure that direct care nurses are empowered to identify and engage in ethical situations associated with EHRs. When examining ethical issues and applying frameworks to analyze a situation, clinical scenarios often help to ground discussions of problems in the day-to-day clinical care that commonly occur in healthcare delivery. Education Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship. Note that “Patient Safety and Quality” is a major theme, with a minor theme “documentation/legality.” This suggested that practice challenges associated with patient safety and quality were experienced. Doing the right thing: Pathways to moral courage. (2016). Legal, ethical, and financial dilemmas in electronic health record adoption and use. Academic Medicine: Journal of the Association of American Medical Colleges, 87(4), 392. doi:10.1097/ACM.0b013e318248e5ae, McBride, S., Tietze, M., Hanley, M. A., & Thomas, L. (2015). Sometimes I have to go through 3-5 computers before finding one that works. 1, Manuscript 5. This paper will discuss the evolution of nursing documentation, the immergence of health information technology, and the challenges it creates for the nursing profession. Could additional actions have been taken? She feels very distressed but hopes for the best outcome for this patient. From cardiopulmonary resuscitation (CPR) to genetic engineering, the creation and use of an innovative tool may surpass the knowledge and resources required to ensure an ethical and appropriate use (Goodman, 2015). However, with the introduction of the EHR, complete documentation requires charting of all clinical assessments, care plans, interventions, and outcomes requiring more time for documentation (de Ruiter et al., 2016). The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. Dr. McBride is a Professor at the Texas Tech University Health Sciences Center School of Nursing whose research focus is on methods development for implementing, evaluating and utilizing health information technology to address patient safety, quality and population health. (2017). Clinical teams confront usability challenges that can present ethical issues requiring ethical decision-making models to support clinicians in appropriate action on behalf of safe, effective clinical care. Canadian Medical Protective Association, 2015(May), 1-3. Predicting Nursesâ Use of Healthcare Technology Using the Technology Acceptance Model: An Integrative Review STRUDWICK, GILLIAN CIN: Computers, Informatics, Nursing. She is a professor with teaching responsibilities supporting graduate courses in statistics, informatics, and epidemiology. By using powerful analytics engines, medical informatics delves deeper into healthcare data than ever before, revealing trends and correlations that otherwise might go undetected to improve patient outcomes as well as organizational efficiency. Analysis of nurse's job in general hospital using hospital information system after introduction of electronic nursing record system. Systems and technologies such as EHRs that assist in clinical practice are adjunct to, not replacements for, nurse knowledge and skill (ANA, 2015). Nurses and electronic health records in a Canadian hospital: Examining the social organisation and programmed use of digitised nursing knowledge. A survey of a large hospital corporation in London found that 53.2 percent of nurses considered their smartphone âvery usefulâ or âusefulâ for helping with clinical duties. As a result of time constraints and usability issues, nurses have reportedly been intentionally entering false information to bypass or ‘work-around’ EHR systems (McBride & Tietze, 2017). Recognizing the potential harm of following the sepsis guidelines in a patient with suspected pulmonary edema, Nancy decides to share her concerns with the physician. Moral development: Advances in research and theory. Patient-centered communication in the era of electronic health records: What does the evidence say? A case-based approach to ethical decision-making. Nancy recognizes that not only does this patient have symptoms that could be evolving sepsis, but the EHR indicates the patient has previously been admitted for fluid overload from heart failure (HF). Retrieved from http://www.r2library.com/resource/title/9781558102675, American Nurses Association. However, analysis of text comments found patterns and trends that reflected distress related to moral issues and ethical dilemmas (please note that we are using the terms "moral" and "ethical" interchangeably in accordance with the current literature). The American Health Information Management Association (AHIMA, 2011) Code of Ethics has 11 principles with interpretive statements, referred to as guidelines, that seem to underscore the importance of practices that stand in stark contrast to the experiences of nurse participants in the Texas nursing research (McBride et al., 2015). 23, No. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. With the ER after two weeks on the program, it developed an application error that would not let nurses go back to add information while the patient is still active and document is active. Use of Informatics in Professional Nursing (graded) How do you use informatics and technology in your nursing practice? Collectively, these trends impact nurses nationwide across all care settings. Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN Things do not work well. The MUMSI allowed for analysis that addressed differing levels of functional status, or maturity of the given EHR using the meaningful use (MU) measures as a proxy for maturity (McBride et al., 2017). The ICU nurse, recognizing that the drip does not follow the EHR recorded order, opens up the drip according to the computer provider order entry (CPOE). To do that, the authors suggest the following recommendations to address challenges with EHRs. As evidenced in the study themes and the case scenario presented, critical thinking may be hindered and experiential knowledge devalued (Campbell & Rankin, 2017). (No. It may be challenging to remember what actions to take when encountering a situation that requires moral courage (Lachman, 2010; Lachman, Murray, Iseminger, & Ganske, 2012) Lachman et al. These same formulaic alerts can present challenges to clinical decision making for clinical teams working with an actual patient, raising practical and ethical considerations. With the passage of the Health Information Technology for Economic and Clinical Health Act in 2009, the United States, as of 2017, has achieved 95% saturation with electronic health records as a means to document healthcare delivery in acute care hospitals and guide clinical decision making. Todays nurses have more technology at their disposal than any nurses ever before, and as one might expect, its considerably improving patient care. For care characterized by “screen-driven information gathering” (Lown & Rodriguez, 2012, p. 393) the patient’s story of his/her illness may be lost to the goal of generating standard data points that, in turn, trigger algorithms and practice recommendations (Brown, 2015). Silver Spring, MD: American Nurses Association. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association, 42(1), 37. doi: 10.1016/j.jen.2015.08.008, Substance Use Disorders and Related Concerns, The 200th Birthday of Florence Nightingale, Addressing Social Determinants of Health: Progress and Opportunities, Translational Research: From Knowledge to Practice, Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN, Code of Ethics, Nursing Scope and Standards, and Legal Implications, U.S. Department of Health and Human Services, 2012, Office of National Coordinator for Health Information Technology, 2017, https://depts.washington.edu/bioethx/tools/4boxes.html, https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions, https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/, Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014, Pavlish, Hellyer, Brown-Saltzman, Miers, & Squire, 2013, Lachman, Murray, Iseminger, & Ganske, 2012, Rathert, Mittler, Banerjee, & McDaniel, 2016, OʼBrien, Weaver, Settergren, Hook, & Ivory, 2015, http://bok.ahima.org/doc?oid=105098#.WmtkOmQ-doE, http://www.r2library.com/resource/title/9781558102675, http://www.r2library.com/resource/title/9781558105997, https://www.ania.org/about-us/position-statements/addressing-safety-electronic-health-records, http://perspectives.ahima.org/electronic-health-records-what-are-the-most-important-barriers/, https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2005/using-email-communication-with-your-patients-legal-risks, https://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php, http://www.ncbi.nlm.nih.gov/pubmed/17907703, https://www.americannursetoday.com/doing-the-right-thing-pathways-to-moral-courage/, https://c.ymcdn.com/sites/www.texasnurses.org/resource/resmgr/HIT_Files/HIT_Survey_Report-Final.pdf, https://dashboard.healthit.gov/quickstats/quickstats.php, http://www.himss.org/ResourceLibrary/ResourceDetail.aspx?ItemNumber=11590, http://catalog.hathitrust.org/Record/000441705, http://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/, Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation, Ethical Nursing Care Versus Cost Containment: Considerations to Enhance RN Practice, Ethics Education in Nursing: Instruction for Future Generations of Nurses, Ethical Awareness: What It Is and Why It Matters. EHRs are designed to facilitate easier provider order entry and have been shown to reduce prescription errors (Scruth, 2014). TNA/TONE2015). Electronic health records: What are the most important barriers? She has taught ethics at the undergraduate and graduate levels and conducted research on moral distress and ethical climate among other issues. Nurses must have a seamless mechanism for reporting EHR challenges (e.g., inappropriate or cumbersome alerts) without an arduous process or fear of reprisal. ⦠Continued Competing personal values such as protecting one’s position or reputation can impede motivation and action. Tietze is the Doswell Endowed Chair for Nursing Informatics aimed at advancing nursing informatics at TWU. Nurse ethical awareness: Understanding the nature of everyday practice.Nursing Ethics, 24(5), 517-524. doi:10.1177/0969733015615172, Office of National Coordinator for Health Information Technology. Catherine was a member of the Steering Committee to revise the Code of Ethics and is currently a member of the ANA Ethics Advisory Board. Journal of General Internal Medicine, 32(8), 935-939. doi:10.1007/s11606-017-4030-1, U.S. Department of Health and Human Services. Its development depends on an understanding of the ethical nature of the role as an obligation of the nursing profession (Milliken & Grace, 2017). Major and minor themes related to qualitative study comments. Clinical ethics residency for nurses: An education model to decrease moral distress and strengthen nurse retention in acute care. The TNA Board joined with the Texas Organization of Nurse Executives (TONE) to create a statewide partnership with nursing leaders to address the impact of health information technology (HIT) on nursing in the state of Texas. (2012). The scenario also reinforces nurses’ statements as reported in 2015 via the Texas Nurses Association-Texas Organization of Nurse Executives (TNA-TONE) statewide study on EHRs (McBride et al., 2015). Although privacy, security, and confidentiality have been identified as three main areas of concern when using EHRs, little attention has focused on false entries, work-arounds, or system bypasses (Ayatollahi, Mirani, & Haghani, 2014; CMPA, 2015). Specific themes reflected in the case scenario and noted by Wolf and colleagues’ (2016) qualitative investigation relate to moral distress due to overemphasis on documentation, tasks, and metrics at the expense of patient care, as well as role conflicts resulting from hierarchical decision making. Telehealth is a new and valuable element in healthcare. Most importantly, the EHR must not substitute for a current and accurate clinical assessment, and appropriate intervention. We provide a case scenario with application of the Four Component Model and describe a study of nurse experiences with the EHR. The ethical dilemma is whether virtue is something that can be taught or whether it is something within our human nature that cannot be changed and an individual is pre-disposed to it. sepsis suspected due to possible pneumonia, oxygen saturation 88% on 4 liters of O2 via nasal cannula. A statewide study was initiated to evaluate nurse perceptions about clinical information systems such as EHRs. The centrality of the patient-nurse relationship to the nursing discipline is reflected in the interpretive statement, “The nurse’s primary commitment is to the recipients of nursing and health care services” (ANA, 2015, p. 5). Data breaches can occur if information is not secured, or if it is misused. Ethical Judgment Through pairing data and smart tech with the human aspect of care, care solutions are evolving. The copy and paste functionality includes copying, pasting, cloning, auto-filling, carrying forward, replicating data and reusing content from one section to another within the EHR (Scruth, 2014). The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. The TNA-TONE HIT committee was charged with examining how Texas nurses were impacted by newly implemented EHRs across the state and to establish baseline measures of nurse satisfaction to inform evidence-based improvement strategies. Although they may recognize an ethical issue and be aware of their role-associated obligations, personal and/or institutional barriers may impede their motivation to act. Healthcare Informatics Research, 22(4), 270. doi:10.4258/hir.2016.22.4.270, American Health Information Management Association (AHIMA). The CODE mnemonic strategy helps nurses to recall these actions and includes ways to overcome fear and reluctance to speak up including reflection, reframing, and assertiveness skills. The ANA News release (July, 6, 2020), “AMA, AHA, ANA Issue Open Letter Urging Public to Wear a Mask to Stop Covid-19 Spread” makes the case that wearing a face mask is now vital. These obstacles may characterize a unit ethical climate that does not promote patient/family advocacy and nurse moral agency. Kim, D. Y. CDS is designed to trigger, or alert, the clinical team with the right information, through the right channels, to the right person, at the right time, for the right patient, via the correct route of the EHR or supporting technologies (Osheroff et al., 2012). She points out the history of HF, which creates a risk for fluid overload with the bolus. Nurses experience moral distress, a concept first highlighted by Andrew Jameton in 1984, when they "know the right thing to do while being in a situation in which it is nearly impossible to do it." Factors associated with the timeliness of electronic nursing documentation. Evidence is mounting that these same systems are also resulting in unintended consequences with patient safety implications, potentially contributing to provider moral distress (Henry, Pylypchuk, Searcy, & Patel, 2016). The authors wish to acknowledge the support for the study by Texas Nurses Association (TNA) and the Texas Organization of Nurse Executive (TONE). Nursing informatics plays a critical role in implementing telehealth technologies designed to benefit patient-family and patient-clinician connected platforms in the inpatient setting. But, nursing informatics also has drawbacks because it may create ethical dilemmas for nurses. We learned that these were reflected, among other ways, in the EHR-based documentation that varied from established interprofessional practice standards. Citation: McBride, S., Tietze, M., Robichaux, C., Stokes, L., Weber, E., (January 31, 2018) "Identifying and Addressing Ethical Issues with Use of Electronic Health Records" OJIN: The Online Journal of Issues in Nursing Vol. Not all issues will require an in-depth consideration of all elements in a specific model, and the goal is to reach a prudent choice, not certainty (Grace, 2014; Milliken & Grace, 2017; Robichaux, 2017). Hospitals and clinics â¦
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