what technique(s) best encourage(s) a patient to tell his or her full story?
ANS Adv Nurs Sci. Author manuscript; available in PMC 2014 Oct 1.
Published in terminal edited form as:
PMCID: PMC4000752
NIHMSID: NIHMS541669
Information Needed to Support Knowing the Patient
Tiffany Kelley, Ph.D., MBA, RN, 
Sharron Docherty, Ph.D., CPNP (AC/PC), Associate Professor, and Debra Brandon, Ph.D., RN, CCNS, FAAN, Acquaintance Professor
Tiffany Kelley
Knuckles University Schoolhouse of Nursing, Box 3322, 307 Trent Drive, Room 3080, Durham, NC, 27710, Phone: (857)-919-0600, Fax: (919)-684-8899
Sharron Docherty
Duke University School of Nursing, Pediatric Nurse Practitioner, Children's Health Centre, Duke Academy Hospital, Box 3322, 307 Trent Drive, Durham, NC, 27710
Debra Brandon
Duke Academy School of Nursing, Department of Pediatrics, Box 3322, 307 Trent Bulldoze, Durham, NC, 27710
Imagine a fourth dimension when you lot, as a nurse, are providing care to a patient on your unit. Someone from the health care team comes to ask you a question about some other patient, and you find yourself maxim, "Yeah, I know that patient." Or, maybe the person is asking about a patient whom y'all have never cared for and y'all say, "No, I don't know that patient. I accept never cared for that patient." The expression "I know that patient" is commonly heard in do settings. However, what does knowing the patient really mean? Additionally how exercise nurses obtain the information needed to know their patients? This paper explores the pregnant of "knowing the patient" and presents results from a study of how nurses obtain the information they need to support their knowledge of the patient for the commitment of care.
Knowing in Nursing
Several cardinal scholars introduced the profession to the critical nature of "knowing the patient". Cynic1 conducted the seminal work, exploring the sources that nurses use to develop knowledge and behavior about their practice and patient care. She described 4 patterns of knowing: aesthetic, moral, empirical and personal. Artful knowing referred to the fine art of nursing; moral as knowing right and wrong for the patient; empirical knowing every bit objective and factual knowledge that could be generalized to others; and personal knowing as knowing oneself. These patterns of knowing are not mutually exclusive and nurses utilize attributes of all 4 patterns to successfully care for patients.1 Post-obit Carper, advances in how nurses come up to know the patient became rooted in theory and enquiry on caring. Watson's Transpersonal Caring theory 2 has evolved since it originated in 1979, but the persistence of the key suggestion that nurses proceeds insight into a patient's response to illness through a relationship exemplified by respect, compassion, and support, points out the critical link between a deep connection with the patient and the nurse's knowing. Every bit one of five caring processes Swanson3, in her middle range theory of caring, further delineated knowing to include dimensions of avoiding assumptions, centering on the 1 cared for, thorough cess, cue seeking, and engagement of self.
Tanner and colleagues4 shed light on the recurring soapbox of nurses on knowing the patient with their study of intensive care nurses and described it as central to skilled clinical judgment and involved knowledge of the patients' day-to-day routines, clinical patterns and responses to care. Benner and Tanner5 examined the clinical judgment of nurses in intensive care settings that linked "knowing the patient" to skills in pattern recognition. Research suggests advice with the patient is required to support knowing the patient.6 Several studies followed this line of investigation of knowing and were able to link clinical judgment and decision making to communication, interactions, and the nurse-patient human relationship.4, 6–10 Other scholars proposed that knowing the patient is an essential precursor to the delivery of loftier quality patient care.11,12 In addition, as sources of information, nurses integrate knowledge gained from prior clinical experiences to each new patient,8–ten and through interactions with the patient and family, nurses collect personalized characteristics that go beyond diagnosis or condition. 8,9
To summarize, the work of these scholars take provided a firm foundation to the concept of knowing every bit emerging from a deep relationship between the nurse and patient, in which the nurse engages in a continuous assessment and striving to sympathise and interpret the patient's needs across dimensions. Most nurses accept a collective understanding of knowing the patient that defies articulation. The concept has been linked in the literature with safe and efficient care. 4, 7–10 While nurses use prior clinical experiences and interactions with the patient as important sources of knowledge, these sources are constrained for nurses with less experience, and in care situations in which the patient's ability to interact may be limited by developmental age (e.chiliad., an infant) or medical state (e.1000., intubated). Families may non always be present at the patient's bedside to serve as an informant. It is apparent and so, that nurses rely on other information sources that have non previously been identified in the literature. Thus, in edifice upon the strong conceptual foundation of the meaning of knowing, we sought to deepen our understanding of how nurses ascertain knowing the patient, and exemplify the essential sources of information nurses use to know the patient.
Information Sources
While prior studies have alluded to the influence of "other information sources" to know the patient,7,13 little bear witness exists to describe specific types of information sources and the information needed from these sources. In hospital settings, nurses have several fundamental information sources that they use to support knowing the patient.14–nineteen In addition to verbal interactions with the patient and family, nurses as well obtain data through verbal interactions with other members of the health intendance squad. Components of the patient's medical record (e.grand., nursing documentation menstruum sheets, nursing notes, orders, provider notes and consultant notes) are also sources of patient information and nurses utilise nursing documentation equally the primary machinery to collect and communicate patient information.20 In response to federal regulations of the 2009 American Recovery and Reinvestment Act 21, health care settings in the United States are in the process of integrating a fully electronic patient tape over the adjacent several years, thus currently the patient's medical tape may be in a paper-based format, an electronic format, or a combination of the two (e.yard., hybrid). There is a critical need to sympathise and contrast how nurses apply paper and electronic-based nursing documentation sources how these information sources support knowing the patient. 22
In addition to the use of nursing documentation and the broader patient record, nurses have a ritual of using a newspaper-based report sheet that is non role of the medical record during handoffs.23 Nurses often employ these unique, personal notes to store information that is communicated by the patient's care nurse from the prior shift. 24 Thus, in addition to the medical record and verbal interactions with patients, families, and health care providers, the paper-based written report canvass appears to be used as a key information source to support knowing the patient. Notwithstanding, little is known about how nurses use these report sheets nor the specific types of information that is stored on them.
In order to exemplify the significant of knowing the patient, as well as the type of data sources nurses use to know the patient, we chose to written report a highly vulnerable patient population and care setting that was likely to challenge the nurses' power to know the patient. Pediatric patients require vigilant nursing attending due to their rapidly changing physiology 25–thirty and these patients are at a greater risk for medical error compared to other age groups. 28,29 Because of their developing cerebral and structural systems, pediatric patients may exist limited in their ability to serve equally a verbal source of information. Pediatric patients in intensive care settings oftentimes require mechanical ventilation and sedation, 21 thus further limiting their ability to communicate with the nurse and serve equally a source of verbal information. Thus the study of information sources used to know the patient in this clinical setting serves to illuminate this phenomenon. Therefore, the purposes of this study were to depict the meaning of "knowing the patient" from the perspective of nurses caring for pediatric patients in an intensive care unit (ICU), and describe the information sources nurses use to back up knowing the patient.
Methods
Setting and Sample
Two pediatric intensive care units (PICUs) within a children'southward infirmary in a southeastern bookish medical heart in the U.s. were purposively sampled to serve equally the study setting. These units provide care for pediatric patients ranging in age from birth through young adulthood. One unit provides intendance primarily to pediatric patients with complex cardiac conditions that require medical or surgical interventions. The second PICU provides care to a range of not-cardiac medical and surgical pediatric conditions. At the time the written report was conducted, both PICUs maintained a hybrid patient medical record system with electronic nursing documentation, order entry and results, and newspaper-based clinical notes and medication assistants records.
Information Collection Procedures
Later on obtaining IRB approval, the nursing leadership from both PICUs provided a roster of nurses' names, their corresponding years of nursing feel, and their email addresses. The principal investigator (first author) attended a staff meeting on each of the 2 PICUs to provide information on the purpose, potential risks, and benefits of participating in the report. During the coming together, the investigator told the nurses they may receive an email inviting them to participate in the study.
A total of 123 nurses were employed on either of the two PICUs during the study timeframe (July through September 2009). While prior studies primarily recruited nurses with all-encompassing clinical practice feel, viii–x nosotros wanted to include nurses with a range of experience to broaden the understanding. Therefore, exclusions were express to nurses who had less than six months of experience, nurses who were not employed past either PICU (due east.yard., travel, bladder, or bureau nurses), and nurses who no longer provided direct patient care. These criteria were set to ensure that the participants had completed the orientation period and were familiar with the patient population on the unit. We used a convenience sampling technique to recruit study participants.
Using the nursing roster, and a convenience sampling technique, study invitations were staggered past only sending out two to three emails every few days. Within the text of the email, the PI requested that the nurse reply to the email if he/she was interested in participating in the study. If no response was received later 3 days, the adjacent nurse was contacted from the staff nurse roster. The staggered email invitations controlled the number of nurses engaged in data collection at a time and immune the investigators to brainstorm to clarify the data while data collection was ongoing and judge when data saturation occurred. Data saturation, or the point at which no new information was seen in the interview data, was reached following the 12th participant. At the fourth dimension that we reached saturation, a total of 52 nurses were contacted and 15 nurses volunteered to participate for a response rate of 29%. Three nurses responded to the invitation to participate later on nosotros had reached data saturation.
The PI met with each participant individually to obtain informed consent. Recruitment and information collection occurred over 9 weeks. Each participant completed a demographic canvass asking for the historic period, gender, ethnicity, and teaching level of the nurse. Each nurse then participated in an audio-recorded semi-structured interview either face-to-face (N=viii) or over the telephone (Northward=four). The interviews that could not exist arranged contiguous were conducted over the phone at a time convenient for the participant. The investigators did not detect any differences in information from the interviews that were conducted contiguous and the interviews conducted over the telephone.
The interviews ranged in duration from 20 to sixty minutes. The interview began by request the nurse to "tell me what knowing the patient means to you." Subsequently the nurse responded, the investigator probed farther to get a more detailed description. Next, each nurse was asked to describe how he/she went most getting to know the patient. Probes about the influence of each information source on knowing the patient was further explored past using phrases such as "tell me more about that" or "what do y'all mean by that". Once the investigator had completed the interview questions, each nurse was offered the opportunity to offer boosted data he/she felt relevant that may not take been prompted from the questions.
Data Assay
The audio-recorded interviews were transcribed verbatim and double-checked for accuracy. The transcripts were analyzed using content analysis.31,32 Each interview was outset read in its entirety to gain an overall sense of the nurse's perspective. Adjacent, the transcripts were analyzed line-past-line and coded using an inductive procedure. Provisional codes were practical to sections of meaningful text and once the codebook became nigh fully developed the labels were derived using a consensus procedure with 2 of the investigators (TK and DB). Next, codes were amassed into categories and the core themes developed.32
Throughout the design of the report and analysis procedure we implemented a range of techniques to back up transferability, dependability, confirmability, and credibility in order to ensure trustworthiness of the study findings.32 Nosotros present a rich clarification of the results to let the reader to examine the transferability of the findings to other care settings and patient populations. Consistent information collection procedures and methods of analyzing the interview transcripts enhanced the dependability of the data. We maintained an audit trail of the stages of the analysis and decisions made that led to the final themes. The tertiary author analyzed every other interview transcript to ostend that the findings were consequent betwixt the two authors. Nosotros met weekly for several months to discuss the study progress and ensure that we did not impose any of our own individual biases on the data. One time the findings were agreed upon, we presented the results to nurses on both PICUs during staff meetings as some other strategy to validate the credibility of the findings.32 The nurses provided additional details supportive of the written report findings notwithstanding, the findings did not change based on their comments.
Results
We sought to answer two primary aims in this written report. First, we aimed to describe the meaning of knowing the patient from the perspective of nurses providing care to a vulnerable patient population. Nosotros nurses caring for pediatric patients in an intensive care setting in order to illuminate the phenomenon of knowing the patient in a challenging clinical setting. Second, we aimed to sympathize how nurses used available information sources to support knowing the patient.
The final study sample consisted of nine female and 3 male nurses. One nurse self-identified as Asian. All other nurses cocky-identified as Caucasians. The average age was 32 years (range= 23–52). In an effort to empathize the concept of knowing the patient from nurses of all feel levels, the terminal sample consisted of nurses with 1 to thirty years (median =v years) of feel. Four nurses had an associate's degree, seven had a bachelor's degree and one had a principal'due south degree.
Analysis of the interviews revealed the meaning of knowing the patient consisted of two broad domains of information needs. Nurses emphasized the need for knowing clinical information and knowing personal information about the patient. By knowing both the clinical and personal information about the patient, nurses were able to provide individualized care to the patient. In response to exemplifying the data sources that were essential for nurses to obtain the clinical and personal information needed to know the patient, nurses described needing to obtain information through verbal interactions , nursing documentation within the patient's medical record , and the nurses' paper-based report sheet . The types of data sources may appear obvious notwithstanding, the less obvious findings existed in how the information sources were or were not used to obtain the clinical and personal data needed to know the patient.
Knowing the Patient
Need for Knowing Clinical Information
In response to the outset question, "tell me what knowing the patient means to you", most of the nurses began past listing clinical information virtually each patient that he or she needs to know the patient. Clinical information included characteristics such as the age, weight, allergies, current diagnosis, and the by medical history of the patient. The nurses also expressed needing to know the patient's physiological and psychosocial assessment, prior clinical events, and the patient's treatment program going forward. One nurse described the physiological information needs as, "getting to know the patient neurologically, respiratory, cardiovascular, and all of the systems individually". Another nurse provided an account of the importance of a psychosocial cess, "some of them (patients) are more anxious and naive. They come up into the unit with a very scared attitude. So getting to know where their state, is very important to me."
Both the physical and psychosocial assessments contributed to knowing the patient's current clinical condition. Nonetheless, nurses as well wanted to know trends and normative patterns in the patient's clinical condition over fourth dimension. From theses nurses were able to place when patients required a change in their treatment plan. As i nurse pointed out, "perhaps there is also much fluid on them (patients), or you've dehydrated them also much with diuretics. That is important to look at the trends." Together the patient's clinical information allowed nurses to know how clinical changes over time foreshadowed the patient'due south current and hereafter care needs. While all nurses in the report described the need for clinical information, they as well emphasized that the clinical information was not the only domain needed to know the patient.
Knowing Personal Data
To know the patient, nurses too reported that personal data nearly their patients was important. The personal information immune nurses to know each patient beyond his or her clinical diagnoses. This information included knowing the patient'due south typical behaviors, schedules and preferences at home and while staying in the hospital. For example, nurses wanted to know "what was he like at home? What kinds of things does he similar? Is he potty trained or walking appropriately?" By knowing what the patient was like at domicile and what he or she was able to practise, the nurses were able to estimate how to address the patient'due south care needs. Another nurse further explained the need for this information in relation to a patient'south preferences, "they (patients) have all got their intricacies. This one likes to exist bundled. This one won't tolerate it." In the example described, while the nurses would often package all patients in a certain age group, i babe was not able to maintain his oxygen saturations when tightly arranged. Thus, the nurses would arrange their care delivery co-ordinate to how the patient responded and this highlighted the individualized personal care needs. Additionally, the patients may accept specific home schedules that could be incorporated into the intendance while in the infirmary. By incorporating the domicile schedules, nurses felt that the patients would exist amend able to suit to the hospital stay.
The nurses described the challenges in assessing personal information and how it was not always possible to gather this type of information. Some patients, such as newborns, don't take established behaviors or schedules and thus the personal information may be more limited. However, for the patients who had spent time at abode with their family, the nurses wanted to know how they could personalize the nursing care to address the patient'due south preferences, routines at home and baseline behavioral responses to intendance.
Knowing Clinical and Personal Information for Individualized Intendance
Together the clinical information and the personal information provided nurses with the data they needed to individualize care for the patients. Each nurse strived to make each patient feel equally though he or she was being cared for based on the private needs. Having both the clinical and personal information allowed nurses to constitute that individualized plan of care. As 1 nurse described, "on the clinical level is all of the tangible things you lot do. What are the vital signs? What is the fluid balance? The personal level is getting to know the patient a piffling bit better and that is getting a meliorate experience for how this patient reacts and knowing their typical behaviors." This is only i instance that depicts both domains of information that are needed to know the patient. Together, the information, "helps u.s. understand the patient'southward situation as a whole". By knowing the patient every bit a whole person, the nurses could aim to understand and anticipate the "little things that each patient does on every unmarried shift". If prepared for the individual needs and responses, the nurse could effectively appraise, programme, arbitrate, and evaluate the patient in a way that synchronizes with the routine that the patient has experienced while hospitalized and brand the patient feel as though his or her nurse really "knows" him or her.
Types of Data Sources Needed to Back up "Knowing the Patient"
After the nurses described the pregnant of knowing the patient from their perspective, each nurse was and so asked, "How would you obtain the information you need to know the patient?" The authors expected that nurses would describe the need to interact with the patient and family unit as was previously identified in prior studies. The nurses described the apply of available verbal interactions, the nursing documentation within the patient's medical record, and the nurses' newspaper-based report sheets. The verbal interactions occurred between the patient (when developmentally/clinically viable), family unit members, other nurses and the larger health care team. Additionally, the nursing documentation within the patient's medical record served as a standing source of information needed to know the patient. Notwithstanding, the paper-based report sheets were consistently described as the nigh valuable information source used past the nurses to back up knowing the patient over the other available sources.
Verbal Interactions
Nurses in this study immediately recognized that conversing with the patient was the ideal exact interaction for obtaining information needed to know the patient. However, due to the patient population and severity of disease for the majority of the patients cared for on the two PICU study units, the nurses recognize that interacting with the patient was an infrequent possibility. One nurse stated, "Most of the time they are intubated and if they are of the age they could actually talk to us they are besides sick and in a dissimilar environs. Then, they are more scared and shy. They are not going to tell us a lot of information." While this placed the nurses at a disadvantage to getting to know the patient, the nurses simply turned to the next source: the patient'due south family.
The parents were oftentimes the next source after the patient to describe the patient's individual needs. Ane nurse described the importance of knowing the patient's baseline, "if the parents tell me that the child hasn't really started talking however but he volition say a few words that is good for me to know. From that, I know what the goal is, of what I want the kid to do later on." Beyond the long-term responses to care, the parents were often a valuable source of informing the nurse of short-term interventions that would brand the patient's experience more pleasant while in the PICU. Nurses would inquire the parents, "practice they have a comfort object, a blanket they need with them? How do they respond to procedures?" Past having this information, nurses could disseminate to the larger health care team and ensure that all advisable specialists were involved in the patient's handling program.
Beyond the patient and the patient's family, the nurse also verbally interacted with the extended health care team. To proper name simply a few roles, the nurses described verbal interactions with other nurses, social workers and therapists (e.m., respiratory, physical, occupational) and providers well-nigh the PICU patients. Each individual role group provided different insights that supported the nurse in his or her ability to provide individualized care to the patient. For example, nurses interacted with other nurses at the very commencement of the workday during handoffs. A nursing handoff, sometimes referred to as a shift written report, is the process of handing off the care responsibility of a patient from ane nurse to another. In our study, nurses highly valued the verbal nursing handoff, as oft the data shared during these verbal interactions was not written in the electronic medical record. For example, i nurse described a sure state of affairs, "a patient that might exist an impossible stick (Four stick), is nowhere in the chart merely it is really valuable to know. That is something you will simply get in report." From the providers, nurses gained insight into changes in the patient's medical plan of treat the mean solar day. The social workers were available to inform the nurses almost whatsoever family unit dynamic issues that may bear on the nurse's power toward discharge planning. Each health care team member provided a supportive office for the nurse gain the clinical and personal data that immune the nurse to better constitute his or her knowledge of the patient.
Nursing Documentation within the Patient's Medical Record
Nurses primarily relied on electronic nursing documentation for clinical information about the patient. Nurses used the nursing documentation as a supportive information tool to inform the patient's physiological assessment, ongoing vital signs, intake and output totals and any associated hemodynamic or hydration related trends and norms. The discrete data values were informative as a unmarried instance of the patient'southward response to treatment. Nonetheless, of even greater value was the ability to scan the data when the patient's physiological response was not within the normative patterns that the patient was previously experiencing. The trends and norms almost the patient allow the nurse to differentiate between what is normal for the patient and when to notify the physician for further intervention. 1 nurse provides an example past stating, "I had a patient that had got hypotensive and I had to look back at the claret pressures to run into what they were tolerating and see how depression they had gotten. This (blood pressure) was manner lower than whatever of the charting had shown. I knew to immediately telephone call the resident and push volume because this was a change away from the threshold." Through the menstruum sheet, the nurse could visually scan for highs and lows, make a cerebral cess most the patient'south condition, and decide how best to intervene for the patient'southward condition.
Yet, despite the value of the electronic nursing documentation for knowing the patient'southward clinical data, the electronic nursing documentation was viewed every bit the least valuable source to collect the personal information needed to know the patient. Nurses often felt as though the structure of the electronic documentation did not fully allow the nurse to elaborate on the emotional state and intricacies of the patient. As described by one nurse, "maybe our documentation doesn't requite us enough reign. Maybe it is besides tight so we are not able to elaborate." While nurses could enter a narrative comment, the comments and structured fields did not provide the nurse with the full flick of the patient's personal needs. We are able to enter notes into dissimilar parts of our charting just a lot of times, you are not actually able to elaborate on a situation without but telling someone." The struggle to draw the personal information needed for care within the confines of structured fields led nurses to further rely on their own verbal interactions with each another. Additionally, nurses had their newspaper-based report sail every bit another supportive information source.
Nurses' Paper-based Report Sheet
The nurses in this report described the use of a unique, individualized paper-based report sheet as essential to knowing the patient as information technology temporarily stored much of the clinical and personal information needed to know the patient. Every bit described by a nurse participant, "information technology (paper-based report sheet) puts all of the salient details that a nurse needs to know into one nice packet. Another nurse described the value she saw in the paper-based report sheet by stating, "it'south (newspaper-based report sheet) frankly the Bible."
In both PICU settings each nurse typed their written report sheet information into a discussion document template before the end of the nurse's workday. The typed report sheet was prepared for the next nurse to use during his or her workday. Each nurse was expected to update and edit clinical and personal data that the oncoming nurse would need to know near the patient. The transcribed data from the newspaper-based report sheet was printed and given to the oncoming nurse who was about to start his or her workday. The oncoming nurse would as well temporarily shop by handwriting boosted information every bit needed to support his or her information needs to know the patient.
The paper-based written report canvass served as a quick reference for the nurse about his or her patient. As described by one nurse, "this [report canvass] is something that lasts that shift and the nurse will have it kept in a pocket, in the room at the patient'south bedside, or tucked inside the front side of our red chart [bedside chart]." By having the information about the patient on ane sheet of newspaper, the nurse could quickly look back at the sheet and notice the clinical or personal information the nurse needed at that moment in fourth dimension. The nurses consistently described the critical importance and high value of the report sheet when caring for a new patient, "so a lot of times when I accept a patient that I've never had before, I'll look dorsum on that sheet real quick and go a quick gist of their history." In add-on to knowing the patient'southward history the written report sail served as a quick reminder of the patients scheduled intendance needs. Ane nurse stated, "you lot look dorsum at that [written report sheet] because information technology definitely tells y'all what you are doing." Thus in add-on to providing the clinical and personal information almost the patient, the paper-based report sheet was an accessible and trusted source of information to support nurses in the provision of their individualized care.
The value of newspaper-based study sheet was heightened because nurses found information technology to be more accessible than the patient's medical record. In improver to accessibility, the nurses stated that important information found on the report sheet was unlikely to be found in the nursing documentation or possibly difficult to locate in comparison to the report sail. For example, ane nurse described a patient'due south feeding regimen: "In that location is nowhere in our computer charting like if your feeds are going to accelerate 5 cc q 3 or any information technology is, to a goal of 25, that is not charted anywhere in our computer charting." All the same, despite the expressed value and unique information provided past the paper-based report canvass, information technology is not included as part of the patient'due south medical record. In fact, the report sheet is shredded at the end of each nurse's workday. The side by side nurse receives a new printed study canvas for his or her workday. This procedure takes place twice per day, per patient in the PICUs.
Discussion
In this written report, we described the significant of knowing the patient from the perspective of nurses caring for a vulnerable patient population. Knowing the patient in this written report was divers as knowing clinical and personal information about the patient. Both domains of information were essential for the nurse to be able to intendance for the patient, every bit a unique person with individual intendance needs instead of a diagnosis. Clinical information included characteristics about the patient, the physiological and psychosocial status, as well as trends and identified norms for that patient'south clinical condition. Personal data included unique characteristics of the patient's behaviors and responses to treatments, schedules at home and preferences for care during the hospitalization. Prior studies take described the importance of knowing the patient'southward patterns and responses to care.4, 6–8,10,11 This study supports that finding and expands the definition of knowing the patient by describing ii broad domains of data that can be congenital upon in hereafter studies to identify the discrete categories of data inside the two domains of information needed to know the patient. From such enquiry, efforts can be fabricated to improve nurses ability to articulate and measure knowing the patient in do.
Findings from this study besides advance the concept of "knowing the patient" by exploring nurses' employ of available information sources to obtain the data needed to know the patient. In prior studies, the nurse'due south exact interaction with the patient and the family was identified as integral to knowing the patient.four, half dozen,seven,10 Nurses in this study as well support the demand to have verbal interactions with the patient, the patient'due south parents, and extended families. This finding is consistent with recent findings by Bundgaard et al. in 2011. Yet, the nurses recognized the potential for limited verbal interactions with the patient in a PICU setting due to the patient's illness severity, age or developmental condition. Therefore, when possible, nurses need to rely on information collected verbally from the patient's parents and extended family in an effort to know the patient. In the instances where the parents and extended family either are not available to the nurse, or they have not established the patterns of a newborn babe, the nurse is often left with a relative information arrears.
Electronic Nursing Documentation in the Patient'due south Medical Record
The electronic nursing documentation was the primary source of the patient'south medical record that nurses used to obtain any data to know the patient. The authors expected that nurses in the study would report using the electronic nursing documentation (e.thousand., flow sheets, narrative notes, assessments) equally a chief information source needed to know the patient. However, the results demonstrated that nurses used the electronic nursing documentation primarily for clinical information. The nurses described limited use of the electronic nursing documentation for the personal information. Office of the express use of the electronic nursing documentation may be due to accessibility of the data within the nursing documentation and the time required to recollect the data from the electronic nursing documentation. For instance, Bundgaard et al. discussed the importance of medical record documents for knowing the patient only found the nurses had limited time to refer back to the documents for data about the patient. A future written report incorporating direct observations to visualize nurses' behavioral employ of information sources would let exploration of Bundgaard et al.'s finding.
Of larger importance is the finding that nurses perceived limited benefits of the electronic nursing documentation to collect all of the clinical and personal data needed to know the patient. A patient's medical tape should be comprehensive and support the total data needs and work processes of nurses and the larger health care team. Nurses expressed the difficulty in findings a "spot" or place to put the personal information needs that would capture the data in a fashion that could be easily found by other nurses. The structure of the electronic nursing documentation encouraged the utilise of pick lists and drop down menus with few open free-text options. The free-text was available equally a comment in the patient's tape just the comments were hidden backside each field and required the nurse to "hover" with a mouse to visualize the data. It may be difficult to provide the details needed, such equally the feeding schedule described in the results section, when reducing this data to a few words within a drop-downwardly card or pick list. Thus additional enquiry efforts are needed to empathize the specific clinical and personal information required to know the patient and how to comprise these requirements into the current patient record system.
Nurses' Paper-Based Report Sheets
The nurses' paper-based written report sheets in this study were the most comprehensive tangible information source nurses used to collect the information needed to know the patient. Still, the report sheets were created past each private nurse and were not part of the patient'due south medical record. The cosmos of and use of the paper-based report sheet as an information source tin be viewed as a systemic piece of work-around created by the nurses in gild to ensure they accept the data they need in a usable and efficient modality. Notwithstanding, due to the highly individualized nature of the paper-based written report canvass for each nurse, and not existence office of the medical tape, there is the potential for loss of information needed to know the patient across caregivers. Such a limitation could contribute to gaps in the continuity of intendance every bit nurses hand over intendance responsibleness to one another.
Nosotros believe that the use of a paper-based report sheet is not isolated to the nurses in this written report and that nearly bedside intendance nurses volition be able to connect with the studied nurses' description and utilize of a written report sheet. To date, the pregnant and use of the newspaper-based report sheets for knowing the patient are non well understood in the literature.23 The legal, upstanding, intendance (rubber and quality), and system related implications of the use of a paper-based report sheet, that is not considered office of the permanent patient record, as a source of data to know the patient, needs to be more fully explored and studied. 28,29
Futurity Directions in Do Settings
The findings from how the information sources were and were not used accept significant implications for redesigning supportive tools for nurses to provide care. Information technology is important for nursing leaders, educators and staff nurses to view the data sources institute within the patient'due south medical record as a mechanism by which nurses tin collect and communicate information in an endeavour to know their patients. Often the use of the medical record is relegated to and viewed equally a means past which to certificate care to remain in compliance with requirements fix forth by the unit, infirmary or regulatory agencies. While electronic nursing documentation supports nurses in knowing the clinical information, much of the personal information needed to intendance for the patient is not bachelor or easily attainable in the patient'due south electronic nursing documentation tape. Instead, nurses communicate much of the patient's personal information during nursing handoff through verbal communication and the temporary storage of the information on the newspaper-based report sheets. Inherent in this electric current practice, is the potential take a chance for error or omission of the nurses' necessary clinical and personal data due to variability betwixt individual nurses and the reliance on an information source that is non considered part of the patient'southward medical record. The potential loss of information may impact the delivery of safe, high quality care. The limited empirical bear witness on the utilize of nurses' report sheets17 suggests that the nurses' apply of report sheets is not completely understood and may represent a hidden attribute of nursing practice. Withal, perhaps we can leverage the established practise to blueprint clinical information tools that provide the data needed for intendance in a manner that supports the uses and inherent values of the newspaper-based report canvas while promoting rubber and individualized care.
Implications for Future Research
To our cognition, this study was the showtime study to explore the meaning of knowing the patient from the perspective of nurses providing care to patients in pediatric intensive intendance settings. Further, we used a convenience sample that resulted in nurses with a xxx-twelvemonth range of nursing experience. It was beyond the design and scope of this study to compare and contrast the findings betwixt nurses with dissimilar levels of experience. Time to come inquiry seeking to sympathise such differences would need to include a larger sample using a stratified purposive sampling technique to recruit based on years of nursing experience. Finally, nurses in this study used nursing documentation in an electronic format whereas other nursing units may yet be using paper-based forms.
A study utilizing behavioral observations of nurses delivering patient intendance is needed in order to understand how information needed to know the patient is discretely nerveless and communicated using the bachelor sources. By directly observing nurses, researchers could place the categories of the clinical and personal information nurses need to know the patient and develop an observational measure. By knowing the discrete information needs and the associated information sources, we tin begin to understand the specific uses of verbal, paper-based and electronic information sources for specific categories of data needed to know the patient. Additional research is needed to sympathise why and how the patient'south medical tape, especially the nursing documentation, does not allow the nurse to collect the patient information needed to intendance for the patient. This noesis is necessary especially in the current climate of healthcare it where hospitals across the U.S. are existence incentivized to adopt and utilise electronic wellness records in efforts to improve the quality of intendance delivered to patients.28 Finally, findings from this study advise that further research is needed to sympathise the preferred methods of exchanging the information through available information sources. The paper-based report sheets introduced a method of temporarily storing information needed to know the patient however presents great risks. Thus connected efforts through observational inquiry would reveal ways where EHRs could be designed to more effectively collect the data needed for care to the patient.
Conclusion
"Knowing the patient" is an essential element to the practice of nursing. Every nurse should have the power to obtain the clinical and personal data needed to know the patient. Additionally, the information should be consistent across all nurses and only vary based on the individual patient's care needs. In this report, we were able to expand on the concept of knowing the patient. We revealed that while available verbal interactions and the patient's medical tape provided nurses with some clinical and personal data, the use of these sources were non sufficient on their own. Instead, the nurses' newspaper-based report canvass provided the most comprehensive data source for the nurses to obtain the clinical and personal information needed to know the patient. Future studies are needed to explore the specific information temporarily stored on the paper-based report sheets and the work processes supported by the written report sheets. From these studies, we tin can begin to sympathize the current limitations of existing patient record systems and design supportive tools that tin can arrange nurses' information needs. Such supportive tools may also allow for improved standardization of information across caregivers and reduction in the need for tangible information sources that are not considered function of the patient's medical record.
Acknowledgments
This inquiry was supported in part past Duke University's Eye for Translational Science Laurels (CTSA) NIH Grant 1 TL1 RR024126. We would like to thank and acknowledge the nurses that participated in this study for their contributions.
Contributor Information
Tiffany Kelley, Duke University School of Nursing, Box 3322, 307 Trent Drive, Room 3080, Durham, NC, 27710, Telephone: (857)-919-0600, Fax: (919)-684-8899.
Sharron Docherty, Duke University Schoolhouse of Nursing, Pediatric Nurse Practitioner, Children's Health Center, Knuckles University Hospital, Box 3322, 307 Trent Drive, Durham, NC, 27710.
Debra Brandon, Knuckles University School of Nursing, Section of Pediatrics, Box 3322, 307 Trent Drive, Durham, NC, 27710.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000752/
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