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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.

Data Collection Through Investigations

This article is still in the process of being written.

Importance of Investigations Data

In addition to information gathered during the process of clinical data gathering, further data collection is accomplished through:

  1. Investigations
  2. Monitoring and observations
  3. Progress review (interview and examination)

In general, further information obtained from investigations is required to:

  1. Determine or clarify the diagnosis
  2. Add further details to the patient profile
  3. Monitor progress of the illness
  4. Monitor effects of whatever early treatment that has been given

Value of Various Types of Investigations

In general, investigations provide data that is objective i.e. more accurate and specific. The information gained can disclose general aspects of the health of the patient or specific changes relating to the disease affecting him/her. Tests that give specific information concerning a disease are used to clarify the diagnosis and are called diagnostic investigations. Usually, diagnosis becomes increasingly more accurate when investigation results clarify the change in morphology (shape, size, depth) and pathophysiology (alteration of function) brought about by the disease.

Tests also help the care-giver to understand the health status of the patient including preexisting health problems and those associated with the disease.

For monitoring progress of the disease and effects of treatment, investigations are repeated so as to detect variations in their values over time. This can be used as the criteria to help indicate:

    1. disease improvement or deterioration
    2. effectiveness of the treatment
    3. occurrence of adverse effects of treatment

Modalities Used for Investigation

Various technology or modalities are used for investigations. They include:

      1. Imaging studies
        1. Radiology
        2. Radio-isotope Scans
      2. Laboratory tests
        • Biochemistry
        • Immunology
        • Microbiology
        • Haematology
        • Histopatholgy, Cytology and Cytogenetics
      3. Endoscopic examination
      4. Tests of Physiological Function

Salient Features of Various Modalities

Imaging Studies

Imaging studies make it possible for the clinician to detect changes in morphology (anatomy) of regions and organs caused by disease and in doing so indicate the location and extent of the disease. These changes in appearance include variation in size, shape and extent or the appearance of something unusual (a lesion). The information  can point to the organ or tissue involved by the disease, the probable pathology and also show how far the disease has spread. Some examinations may also demonstrate variations in function. Examples include flouroscopy, contrast studies, ultrasound, Doppler ultrasound angiography and radio-isotope studies.

Repeat imaging tests can be used for re-assessment of the progress of the disease by detecting the variation in morphology and function over time.

Laboratory Tests

Biochemical tests are used mainly to determine

  • the status of physiological functions
  • presence of abnormal cells or tissue
  • appearance of an abnormal chemical, cells or material (e.g. markers, abnormal products of metabolism, casts in the urine etc.)

Abnormal results can point to the degree of change in the activity of certain organs or systems. When the results of initial tests performed are taken together with symptoms and signs the data can point to the provisional diagnosis of a certain syndrome. The diagnosis help indicate what further tests need to be done.

Immunology tests are capable of providing specific results. The presence of antigens and antibodies may indicate a certain disease or disease group. Often immunology tests need to be repeated to see a rise in the titre hence demonstrating an active or evolving disease. Immunoassays are useful to detect presence of certain disease causing agents or products of the disease when they are present in very small amounts including microorganisms, antibodies and other proteins produced by the body in response to a disease.

Microbiology tests are used to detect the presence and identification of microorganisms (bacteria, fungi and virus) via direct microscopy, culture and special tests on the organism grown. The tests are done on various body fluids and tissue. Positive results are often diagnostic. Because it is often difficult to detect or grow microorganisms, negative tests may or may not exclude a disease.

Haematology are tests done on blood, bone-marrow or fluids where blood is present. It can indicate changes in the composition, alteration in morphology of cells and presence of abnormal cells. Changes in composition and morphology gives syndromic diagnosis such as anaemia, polycythemia, agranulocytosis, neutropenia and pancytopenia. They make it possible for the clinician to think of various differential diagnosis.  Presence of abnormal cells are often diagnostic.

Histopatholgy, Cytology and Cytogenetics are tests on tissue or cells often taken through biopsy or after surgical removal of an organ or part of it. The tissue or cells are made to react with certain chemicals (stains) or markers and exmianed under the microscope. Deviation from normal of the tissue structure, the changes in the cells themselves and the extent of spread are looked for. Their findings are often diagnostic

Endoscopic Examination

Endoscopy is the technique of viewing the internal surface of various hollow organs (the mucosa or endothelium) either directly or using a miniature camera. It provides the means to determine the changes in shape, contour, texture and other morphologic changes. The views can be characteristic of a disease. Via endoscopy, biopsies can be taken for Histopatholgy and Cytology examinations which can then  provide a definite diagnosis.

Video or photographs of endoscopic pictures can be kept and used to compare with subsequent examinations for purposes of monitoring and reevaluation.

Tests of Physiological Function

Many tests have been developed to demonstrate the functions of various organs or physiologic systems. These include:

    • Pulmonary (lung) function tests
    • Tests of cardiac function
    • Neuromuscular function tests
    • Neurologic tests
    • Hearing tests (Audiometry)
    • Vision tests (Optometry)

Most of these tests are repeatable making them useful for assessment of progress of a function or disease.

Initial Investigations

Initial investigations may be ordered at the time of initial clinical data gathering or slightly later mainly to:

  1. Clarify the diagnosis
  2. Add further details to the patient profile

A particular investigations may be useful for one or both purposes.

Investigations to Clarify the Diagnosis

After the initial clinical data gathering, the diagnosis reached is often of a low-level of accuracy i.e. either a symptom complex or a syndrome. Nevertheless, it provides a pointer to the possible differential diagnosis. The clinician will use the differential diagnosis to decide on the appropriate investigations to perform in order to obtain objective data to narrow down the diagnosis.

Commonly available and relatively simple and inexpensive investigations are usually performed first and may also be done as a routine. Some are available at the clinical work place itself (the point of care). Subsequently, the clinician will order the more specific tests as indicated by the information obtained.

However if, based on history and physical findings the likelihood of a particular diagnosis is high, tests that give fairly specific hence diagnostic results can be ordered. Indeed, where indicated (especially in an emergency), it is not necessary to wait for results of general (routine) tests before performing special complicated tests if such tests would hasten the diagnosis.

Investigations that Add Further Details to the Patient Profile

To know the health profile of a patient in more detail, information from clinical data gathering (by interview and physical examination) can be augmented by investigations. Often certain basic investigations are performed routinely for this purpose. The purpose is to detect :

  1. the presence of certain  diseases common among the demographic or social group that the patient belongs to
  2. the effects of the current illness on various body systems

This more complete health profile will allow the care provider to anticipate various needs of the patient and provide comprehensive care.

Investigations to Determine the Diagnosis with Certainty

Usually, diagnosis becomes increasingly more accurate as more investigations are done. When the initial investigations point to the possibility of a certain diagnosis, the relevant specific investigations are performed. The clinician can then use the results to determine a diagnosis with a high level of accuracy. Hence, at the beginning, investigations can help the clinician make a diagnosis as syndrome or disease class i.e. together with the symptoms and signs link it to a body system (anatomic and physiologic) or aetiology. Specific investigations make it possible for the clinician to ascertain the diagnosis as a specific disease.

Investigations that Are Diagnostic

Definitive diagnosis is one with a high degree of probability/accuracy because adequate, accurate and pertinent data are available. Usually, the additional more accurate data are derived from or are arrived at from the:

  1. Results of investigations and diagnostic procedures including imaging studies, specific biochemical or immunological tests, demonstration of presence of a particular microorganism and cytological or histopathological examination of diseased tissues
  2. Improved view or access e.g. from endoscopy, examination under anesthesia or surgical exposure
  3. Subsequent emergence of characteristic patterns of symptoms or signs during observation
  4. Response to specific treatment

Quite often certain simple investigations can be used to make an accurate diagnosis. This occurs when findings of the tests are peculiar to the disease.

Usually it is the more complex investigations that can be the basis for making a diagnosis with a high level of certainty. Yet at other times it is the combination of information from various tests by satisfying a set of criteria is used to make a definite diagnosis.

Positive and Negative Results

A test is useful if it can pick up an abnormality it is supposed to detect. A positive result is when the variation from normal or presence of an abnormal substance is detected. A test result is said to be negative if what is being tested is not found or the result is within normal limits. A result can turn out to be negative if the  quantity of substance looked for is too small or if the test is not performed correctly. Sometimes it may be necessary to repeat tests with negative results.

Sensitivity

A sensitive test would detect an abnormality easily. If a test is not very sensitive it would fail to provide a positive result in some cases. However, in a very sensitive test, a positive result may not mean that the patient has the disease (false positive). Often because of this tests are performed in two steps. A fairly sensitive (usually less expensive or complicated) test is used first and a second more specific test is done if the result of the former is positive.

Specificity

To be diagnostic, a test should only be positive in patients having that particular disease i.e. it is specific to the disease. Some tests may be positive in cases that do not actually have the disease. In that case, it acts as a screening test, a more specific test need to be done or the clinician should consider the result together with data from other tests or other sources.

Usefulness of Tests of Various Modalities for Diagnosis

 Biochemical Tests

For example Serum Amylase or Lipase is diagnostic of Acute pancreatitis, direct microscopy of a stained slide of pus may be diagnostic for Gonorrhea.

Immunoassays

Immunoassays are used to identify different proteins, hormones and antibodies in blood, urine or other body fluids. The test is based on the reaction of an antigen with an antibody. Antibodies together with suitable  markers are usually used as reagents to detect the protein or other molecules (analyte) present in the patient. In some instances, an antigen may also be used as the reagent.

If Monoclonal antibodies i.e. those that are specific to a particualr antigen looked for is used then the presence or abscence of the antigen is usually diagnostic.

Microbiology

Imaging Studies

Spontaneous pneumothorax is diagnosed based on a plain chest x-ray.

Endoscopy

Physiological tests

Use of Investigation for Monitoring Reassessment and Reevaluation

Monitoring is the performance and documentation of planned serial measurements at regular intervals. These information and results are interpreted by comparing them with the condition at the first visit to determine progress. A target measure can also be set to determine whether the treatment objectives are being met. Test of function and levels of certain parameters may be used to anticipate and detect side effects of treatment.

Many of these tests are done regularly and charted on a table or graph. The use of a Laboratory Information System (LIS) is useful for this purpose. Trends can then be discerned. The frequency of measurement of parameters used for monitoring and evaluation selected depends on:

  1. Nature of the parameter in terms of how rapidly discernible changes occurs
  2. Desirability (benefit), efficiency and cost effectiveness

Even complex tests such as Microbiological, Hematological tests, Imaging studies and endoscopy may be repeated at planned intervals or when certain events occur. They are useful in evaluating the progress of the disease especially in response to treatment. The findings can help the clinician in deciding to continue, change or cease treatment.
Radiological studies and radioisotope scans (e.g. PET CT) are often repeated to determine progress. Due consideration need to be given to cumulative exposure to radiation. Ultrasound examinations are very suitable for monitoring and evaluation because tehy are relatively easy to do, safe and inexpensive. The ability to store images and retrieve them for comparison is made easy by the use of Radiology Information system (RIS) and PACS system.
Video or photographs of endoscopic captured during sequential examinations can be compared to determine healing or spread.

Images of histologic and cytologic slides before treatment (biopsies) and after treatment (surgical specimen or re-biopsy) can also be compared.

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.