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The Job of a Nurse and the Nursing Function

The Job of a Nurse and the Nursing Function

I have, for a long time, wished to write an entire article on this subject. May be a short post can be a start.

Nursing is an activity performed by all members of the community. We talk/hear about a mother nursing her child, daughters nursing their parents in their old age and wives nursing their debilitated husbands. Nor is nursing confined to women. We read about husbands nursing their wives back to health. In fact, stories had been written of a whole a community nursing an injured soldier. In Malay the word ‘rawat’ means ‘to take care of’. A synonym is ‘menjaga’ which means to do a day and night vigil to look after a sick person. It includes performing tasks to provide comfort, to assist in the performance of basic activities of daily living and to give hope.
At a certain point in history, groups of women take on the task of nursing as a defined activity which later became important enough to be recognized as a profession. The nurse then becomes a member of the healthcare team, joining other healthcare professionals and complementing them by providing ‘nursing’.

Yet, today, the job of a nurse has evolved in such a way as to expand beyond her/his role to include those tasks other than nursing. She/he has taken on or has been given additional tasks in the care of sick persons as well as in health promotion, disease prevention, early detection of diseases/illnesses/health problems and in rehabilitation. Currently, she/he is expected to perform parts of the tasks of the doctor, the pharmacist, the rehabilitation professional, the phlebotomist and other professions not to mention that of porters/orderlies. Included in these is the recording of data. On top of that, they are also saddled with administrative and managerial tasks.
Why does the job of the nurse encompass so much responsibilities? This stems from the tradition of the nurse being on a 24-hour vigil (‘berjaga’ means ‘not to sleep’). The healthcare service has been designed so that (more so in in-patient care) the nurse is there by the side of the patient and within the location allocated to her/him all the time. To achieve this, nurses work in continuous shifts. Somehow, it is thought that at night there is less work and the nurse can work a longer shift (to keep a vigil is after all a sacrifice expected of a carer).

Much of the work that is not necessarily ‘nursing’ in nature is given to the nurse because she is always there. The first of this is observation and monitoring which, by nature, are continual. Dispensing medication is her/her role because we do not expect pharmacists to come in at night, do we? Who is more appropriate to teach, observe and cajole patients to do various physiotherapy exercises than a nurse? After all it is simple and within their capability. If the nurse can withdraw blood, who needs a phlebotomist. Somehow, porters are always short in supply, it is not beneath the nurse to push a patient. It is better because she/he can keep watch on the patient. The list goes on and on.
To be part of the health-care team effectively, the nursing profession need to reconcile with these needs and arrangements. They should be proud to take on the responsibility of executing the key components of the overall care plan instead of complaining of being the ‘hand-maiden of the doctor’. Looking at it that way means that they are servants also of all other health care professionals mentioned above. They must also acquire sufficient knowledge and skills to do so.

On the other hand, health care service managers must recognize the importance and gravity of the nursing job. Numbers of staff assigned to various services must commiserate with the amount and complexity of the tasks to be performed. The contribution of nurses must be compensated equitably.
In modern healthcare practice, the role of the nurse goes beyond ‘nursing’. The difference between the job of a nurse and the function of nursing needs to be understood.

Failure of EMR to Give Expected Benefits in USA

 

I have just read an article about EMR from Scientific American

.Below are my comments.

Statements in the article like Digitization of patient charts”, “Medical records suck”. “EHR, one that is not simply a digital file folder and “to transition from paper charts to EHRs” reflects the confusion that arise from the use in the USA of the term EMR for the information system. In other places people call the system the Healthcare Information System. In my hospital we call it the Total Hospital Information System. The latter name gives it a different perspective. It is a system to facilitate work just like systems in a shop, manufacturing plant or an airport.
Identification of patient types, instances of care (encounters and tasks) and role of the care provider allow the system to provide forms and views of data appropriate to them. This is done through planning based on deep thinking.
It states that systems “varied widely from site to site and even between sites using the same system”. This is probably not the fault of the system but on the choice on how to implement them. A major problem in US is the lack of desire to streamline and to standardize. “Blood sugar from patients at one hospital, “there were literally thousands of different ways they were entered in the EHR.” Strict clinical governance will alleviate many of these problems.
“To prescribe medications, a doctor has to locate them. a simple search for Tylenol brings up a list of more than 80 options. a simple task has taken precious minutes”. As early as 1999, there are systems that can be customised for each doctor called the ‘favourite list’ and different lists containing selected drugs used in a department.
“The physicians often made dosage mistakes. At one site the error rate reached 50 percent. We’ve seen patients being harmed and even patients dying because of errors or issues that arise from usability of the system”. A good pharmacy system is integrated with a drug decision support system (like MIMS) which will warn doctors about wrong dosage, drug interaction, contraindications due to allergy or pregnancy. Errors should be reduced in a computerised system.

Physicians complain about clunky interfaces and time-consuming data entry. Polls suggest that they spend more time interacting with a patient’s file than with the actual patient”. When paper records were used, doctors and nurses also spend a lot of time writing notes or charting. The difference is they can write whatever they choose and often later. In a computerised system there is a need for data to be structured. If what the doctor is supposed to enter is anticipated and the GUI is intuitive data entry will be faster. Again, there is undue emphasis on the difficulty to record data but not placing importance to provision of information by the system. In my hospital care providers are very grateful that laboratory results, X-ray reports and vital signs are readily available without hassle.

“EHRs turned physicians into data-entry clerks”. “Doctors have to type up their narrative of the visit, but they also enter much of the same information when they order lab tests, prescribe medications and enter billing codes”. This stemmed obviously from a failure to understand the use of a database (maligned in this article). It is a fundamental dictum that data is entered only once and used repeatedly for various purposes. It is also typical in USA to think that the system (as a result of misleadingly called EMR) is for doctors rather than for all stakeholders.

“Information still does not flow easily between providers”. In reality, most patients are manged at a single facility. Within the facility itself there is no reason at all for inability to share data. When they are transferred to another facility only a referral letter with a summary is sufficient to ensure continuity of care. Patient can carry summaries with them on their handphone, a thumb drive or as a printed document. It is not about using the most advanced technology but about using the most appropriate technology.

In Malaysia we run into the same problems in the past and will continue to dos so because we do to learn from our mistakes and successes.

First of all the attitude. I hear statements from people high up. “I don’t know much about IT in health but I think its no good”. People don’t want to learn let alone study in depth.
When we had the Telemedicine program together with Hospital / clinic information systems the leadership cannot see their congruence. We cannot have one without the other. Until now we have a Telemedicine unit when we should have an integrated Health IT and Information management unit. The importance of Telemedicine and a central operational database is highly exaggerated.
We should concentrate first at where data is generated and its use for operations i.e. help workers to do work. At the beginning we had it right by calling it THIS. Last year some smart alack has called it EMR (I suppose to follow the USA).
Yes, for managerial use of data we need a data warehouse. But why don’t we think of where the data is to come from and how. I remembered attending workshops regarding Lifetime health record (LHR) and Data warehouse where I asked: “What do you want to do with the data” The answer they give me was: We just collect it, for people to use for whatever purpose.”
We still have a long way to go.

Healthcare Data Retention and Migration

Retention of the Electronic Medical Record (EMR) needs to be differentiated from data migration. The latter is one method of retaining data. For a paper-based record, retention means keeping it for a desired period of time in its original structure. By ensuring that the structure is intact, the original content is also preserved.
Retaining the EMR poses peculiar problems. First of all, the structure and content of the EMR need to be more clearly defined if it is to be retained. Even though many software providers name their applications as EMR, they are actually providing a system to facilitate clinicians to perform clinical care activities i.e. an application more appropriately named the Clinical Information System (CIS). The CIS contains a lot more data that what constitutes the EMR. No software developers in their right mind would develop systems just for the recording of events or incidents.
There are 3 purposes for which data need to be retained:

  1. Business continuity
  2. Continuity of care
  3. Preservation of a historical record

The continuity of care problem that emerges when a changeover to new system occurs is similar to the situation that exists when a patient is referred to another institution (using a different system) where the care provider provides sufficient information to his/her counterpart to enable continuity of care. Such information consists of  a letter and a summary of all events, findings and results for all visits made in the referring facility. For most instances in an electronic system, it is adequate to provide a summary of historical data regarding all events, findings and results for all visits made rather than carrying over the entire data contained in the CIS or Medical Record. The summary is actually a report created by extracting historical data from the database. It is quite possible to extract the entire data making up the Medical Record but for continuity of care this is quite unnecessary.
Data migration is essential only in instances where the critical points in the clinical care process, i.e. the clarification of diagnosis and firming up of the treatment plan, has not been sorted out. In cases where the definite diagnosis has been made and the treatment plan has been decided on, a case summary would be sufficient to enable the subsequent care provider to gain an insight on what had transpired earlier.
On the other hand, preservation of Medical Record for a certain duration is required by law. It would be simple if it is already created for each patient at each visit. Unfortunately, very few if any HIS have a built in facility to extract and present the EMR at the end of a visit. Most CIS (or even the so called ‘Electronic Medical Record System’) do not have this capability. Most institutions or software developers think that in order to preserve the Medical Record, the entire CIS need to be retained. I am advocating here that the EMR being a record need only be preserved in the form of a readable document created from a report extracted from the CIS. So, efforts should be made to define the data elements that make up the EMR, standardize its structure (sequence and arrangement) and develop the means of constructing it.
Read more about this subject in my article

Use of HIS for Medical Education and Research

I have just completed an article on “Leveraging the Computerized Hospital Information System for Medical Education and Research“. It is a concept paper. I do not know if such a system has been implemented anywhere. In the hospital I worked in previously, domains have been created for Operations, Analytical function, Train and Build. However, despite being a hospital for training undergraduates and postgraduates, the benefits of HIS have not been optimized for teaching and learning.
I think there are extensive possibilities and would like to realize them if given the chance.

A PDF version is available.