Mari Tietze, PhD, RN-BC, FHIMSS She founded and leads the Upper Midwest Healthcare Legal Partnership Learning Collaborative. Does Ethics Education Influence the Moral Action of Practicing Nurses and Social Workers? Documentation in the nursing record must follow principles of “factuality, accuracy, completeness, timeliness, organization, and compliance” (ANA, 2015, p. 270). Ethical Judgment/Decision-making Models, Internet Sources for Ethical Judgment/Decision-Making Models, The University of Washington School of Medicine. Having practiced in the ED for ten years, Nancy may be respected by her nursing peers and physician colleagues and may question how her actions could potentially affect those professional relationships. The Ethical Intersection of Healthcare and Technology. Sometimes I have to go through 3-5 computers before finding one that works. 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). The adoption of EHRs in 2004, under President George W. Bush’s strategy and funding to improve patient safety, spurred significant growth in informatics nursing. (2014). This computational capacity may establish EHR information as authoritative, potentially displacing work processes critical to nurse-patient interaction. 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. (2006). System was not designed by the people who would use it. 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. Background:Technological advancement has created ethical practice dilemmas in critical care settings. I know first-hand of 2 sentinel events caused by the systems (X and Y). A thematic content analysis of the narrative responses to the open text question was used to analyze the data. EHRs are designed to facilitate easier provider order entry and have been shown to reduce prescription errors (Scruth, 2014). A survey of a large hospital corporation in London found that 53.2 percent of nurses considered their smartphone “very useful” or “useful” for helping with clinical duties. Additionally, the authors recommend further research into the moral distress noted in emerging evidence, including the TNA-TONE statewide study and the case scenario presented. 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). (2013). A nursing career in informatics Nurses at every level now work with informatics through patient records and other technology. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17907703, Lachman, V. D., Murray, J. S., Iseminger, K., & Ganske, K. M. (2012). The text narrative responses were then reorganized according to concepts and summarized into categorical statements. Sometimes I feel that the barcode scanning system for medication administration hinders critical thinking and prevents truly looking at what you are giving the patient. AHIMA Code of Ethics. She may have also been aware of her accountability in the situation as stated in the ANA Code of Ethics for Nurses with Interpretive Statements, “Systems and technologies that assist in clinical practice are adjunct to, not replacements for, the nurse’s knowledge and skill” (American Nurses Association [ANA], 2015, p.16; hereafter referred to as Code of Ethics). Retrieved from http://perspectives.ahima.org/electronic-health-records-what-are-the-most-important-barriers/, Brown, D. L. (2015). 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. 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. Very frustrating because we constantly have to do double work. Nancy questions the appropriateness of the physician orders, but follows physician instructions. Legal concerns over notification of federally regulated drug interactions, through pop-ups or alerts, can be overwhelming or desensitizing to the nurse (Sittig & Singh, 2011). Its development depends on an understanding of the ethical nature of the role as an obligation of the nursing profession (Milliken & Grace, 2017). (2016). Goodman, K. W. (2015). Additionally, alert fatigue and clinical information overrides must be addressed within the organization. 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). 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). Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. Grace, P. (2014). These same issues are reflected in a number of comments in Table 1 (e.g., overemphasis on documentation and measurement creating inefficiencies and a distraction to patient care). ANA explains: “Using ethical principles to arrive at a solution should be done in an atmosphere of caring, respect, openness, and honesty. What moral distress in nursing history could suggest about the future of health care. 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. This case scenario can be examined in terms of the overall context of ethical implications in use of the EHR. 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). Mari Tietze, PhD, RN-BC, FHIMSS The use of computers and communication technologies will impact more lives in the 21st century than any other technology, including stem cells, transplants, and nanomedicine (Goodman, 2015). September 1, 2017. Application of the FCM can assist clinical teams to explore and potentially resolve these issues. The ANA Scope and Standards of Practice for Nursing Administration (2009) cites the obligation of nurse administrators to advocate for practice that reflects the Code of Ethics (ANA, 2015). Retrieved from http://www.himss.org/ResourceLibrary/ResourceDetail.aspx?ItemNumber=11590, Pavlish, C., Hellyer, J., Brown-Saltzman, K., Miers, A., & Squire, K. (2013). (2009). Robichaux, C. (2017). . Please see the TNA/TONE HIT Web site for the long list of names. In fact nurses have to enter false information sometimes and work around the system (I use vendor X, Y and Z) and all have similar issues. Nursing informatics plays a critical role in implementing telehealth technologies designed to benefit patient-family and patient-clinician connected platforms in the inpatient setting. 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). Retrieved from https://www.ncoa.org/resources/10-common-chronic-conditions-adults-65/, Henry, J., Pylypchuk, Y., Searcy, T., & Patel, V. (2016). They are grouped by category of content. (2015). She is caring for a patient that presents to the ED with the following: These symptoms trigger the EHR CDS alert for sepsis because the patient scored high on the hospital sepsis screening tool built within the EHR. 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). Ethical Action Moral courage can also be “learned, practiced, and mentored” (Hawkins & Morse, 2014, p. 268). We conclude with a call to action for interprofessional teams, associations, industry, and others to collaboratively address these issues on behalf of the health and safety of the nation, and equally as important, the health and well-being of the healthcare workforce. Under this AHIMA principle, the noteworthy guideline to “ensure all voices are listened to and respected” (AHIMA, 2011, 11.4) demands that health information managers not only welcome input from nurses who find the technological determinism of EHRs violates ethical practice and clinical judgment, but also seek out that input. 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. This paper will discuss the evolution of nursing documentation, the immergence of health information technology, and the challenges it creates for the nursing profession. (2017). (2012). Individuals with moral courage have developed skills of effective engagement and “willingness to speak out and do what is right in the face of forces that would lead a person to act in some other way” (Lachman, 2007, p. 131). Technology enables care and enhances safety by au - tomating functions both simple and complex. 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). 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 CDS fires alerts that prompt the ordering physician to fluid resuscitate the patient according to the Center for Disease Control guidelines for suspected sepsis. (2015). Retrieved from https://depts.washington.edu/bioethx/tools/4boxes.html, Brown University. (2016). Wolf et al. For example, a false entry into an EHR can follow a patient for years. Violations of privacy laws and regulations may include: Failing to log off a computer when not in use. “Nursing informatics specialists are the translators that have evolved into health tech innovators who establish businesses, manage medical economics, create technology and amplify the voice of end-user clinicians,” said Danielle Siarri, MSN, RN, a HIMSS member and social media ambassador, global nursing expert and the lead publisher at InnoNurse. We provide a case scenario with application of the Four Component Model and describe a study of nurse experiences with the EHR. Although new technology may be a challenge for some, informatics will enhance nursing practice. 33(5):189-198, … ...a false entry into an EHR can follow a patient for years. Data breaches can occur if information is not secured, or if it is misused. Washington, DC: Office of National Coordinator for Health IT. Further, this case offers several ethical considerations for examination. ... 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. Ethical implications of the electronic health record: In the service of the patient. Use of Informatics in Professional Nursing (graded) How do you use informatics and technology in your nursing practice? A study in 2006 revealed that nurses spent a majority of indirect nursing time documenting in the EHR, demonstrating the critical necessity of proper usage to satisfy quality of patient care (Kim, 2006). Email: robichaux@uthscsa.edu. Electronic health records: What are the most important barriers? The copy and paste phenomenon has caused significant debate from those who argue its necessity for time efficiency weighed against the significant risk of inaccuracy and patient safety errors (Harrington, 2017). A., Teich, J. M., Levick, D., Saldana, L., Velasco, F. T., Sittig, D. F., . Retrieved from http://www.r2library.com/resource/title/9781558102675, American Nurses Association. A framework for making ethical decisions. A case-based approach to ethical decision-making. Nurses and electronic health records in a Canadian hospital: Examining the social organisation and programmed use of digitised nursing knowledge. Email: susan.mcbride@ttuhsc.edu. Nurses in administrative roles should promote a culture of safety in their settings that include reducing the risk of harm arising from inadequate EHR design, and usability (ANA, 2009). In the early 1990s ‘charting by exception’ was an acceptable method to decrease charting in nursing (de Ruiter et al., 2016). EHR documentation: The hype and the hope for improving nursing satisfaction and quality outcomes. Nancy questions the doctor order for aggressive fluid bolus and relates her concern that the patient is not septic. Austin, TX: Texas Nurses Association. Informatics in nursing … Annals of Internal Medicine, 162(4), 301. doi:10.7326/M14-2128, Lachman, V. D. (2010). How electronic health records structure communication, relationships, and meaning. Ethical Sensitivity Journal of General Internal Medicine, 32(8), 935-939. doi:10.1007/s11606-017-4030-1, U.S. Department of Health and Human Services. Susan McBride, PhD, RN-C, CPHIMS, FAAN Email: mtietze@twu.edu. Code of ethics for nurses with interpretive statements (2nd ed.). Tietze is the Doswell Endowed Chair for Nursing Informatics aimed at advancing nursing informatics at TWU. Ethical decision making. Ethics, medicine, and information technology: Intelligent machines and the transformation of health care (2nd ed.). The complexity arises out of the situational conflict in which obeying one would result in transgressing another. Health Informatics – Oregon Institute Of TechnologyOregon Institute of Technology Bachelor of Science degree in Health Informatics Program is the choice for students who are looking … Using email communication with your patients: Legal risks. Hospitals and clinics … Improving outcomes with CDS: An implementer’s guide (2nd ed.). Clinical teams often confront usability challenges that present ethical issues and require ethical decision-making models to support clinicians with appropriate action on behalf of safe and effective clinical care. This case presents a scenario happening across the nation in terms of EHR triggered protocols that capture electronic quality measures, often tied to value-based purchasing payer models upon which the organization will be penalized in the event measures are not met. These obstacles may characterize a unit ethical climate that does not promote patient/family advocacy and nurse moral agency. A number of healthcare organizations have implemented ‘copy and paste’ policies for documenting in the EHR. (2017). "It's a burden you carry": Describing moral distress in emergency nursing. Then, recommendations and a call to action are made based on the FCM in light of nursing practice standards, ethical issues, and where applicable legal issues. CIN: Computers, Informatics, Nursing, 35(1), 18-28. doi:10.1097/CIN.0000000000000290, McBride, S., Zolnierek, C., Tietze, M. F., Hanley, M. A., Thomas, L., & Song, H. (2015). Some EHR systems are designed as templates or ‘fill-in’ instruments, which allow for auto-population of lab results or other critical information (Sittig & Singh, 2011). Strategies necessary for moral courage. Telehealth is a new and valuable element in healthcare. Worldwide, 3.4 billion people own a smartphone, and half will be using mobile health apps. The authors wish to acknowledge the support for the study by Texas Nurses Association (TNA) and the Texas Organization of Nurse Executive (TONE). Trappings of technology: Casting palliative care nursing as legal relations. It may be challenging to remember what actions to take when encountering a situation that requires moral courage. Nursing documentation, electronic or handwritten, are legal documents that can, under some circumstances, be used in legal proceedings. It is not accurate and orders tend to disappear. Key Words: electronic health records, ethics, ethical decision making, moral distress, usability, unintended consequences, patient safety, quality, Health Information Technology, Rest Four Component Model. ... healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry. Could additional actions have been taken? Although the case study and the Texas nurses’ comments reflected ethical issues raised by nurses, there are significant implications for the entire care team given the EHR is the primary means of interprofessional communication. The Code of Ethics states, “Patients’ rights are the primary factor in any decisions regarding personal information, whether from or about the patient. Documentation that fails to meet these principles can result in undesirable outcomes for the nurse, patients and families, or for the healthcare organization (ANA, 2015). The AHIMA principles cite the primacy of accuracy, avoidance of conflicts of interest, and similar to the ANA code, “respect [for] the inherent dignity and worth of every person” (AHIMA, 2011, 11). 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. Ethical dilemmas resulting from data availability and sharing; Existing Health Informatics-Related Laws. Perhaps the most troubling ethical issue noted is the potential erosion of the patient-nurse relationship (de Ruiter, Liaschenko, & Angus, 2016; Rathert, Mittler, Banerjee, & McDaniel, 2016). Moral courage in action: Case studies. A sampling of these comments is provided by categories in Table 1. It plays a role in nearly every facet of life, and increasingly so in healthcare. Technology in nursing practice is not new, but the ways in which technology exists and contributes to healthcare is. We are unable to see any notes/assessments that we did not personally input. … Continued Copy-forward in electronic health records: Lipstick on a pig. ...formulaic alerts can present challenges to clinical decision making... One strength associated with certified EHRs under the HITECH Act of 2009 for supporting patient safety and quality is that evidenced-based protocols can be reinforced by using clinical decision support (CDS). The human connection is the art of nursing and nurses need to be actively involved in determining how best to use technology to supplement, not eliminate, human resources. It doesn’t replace nurses. She subsequently reports the request by the physician to drip slowly in a verbal handoff to the ICU nurse who receives the patient. Nancy questions the physician’s decision to follow the sepsis quality metric and not write an order in the EHR for slow intravenous fluid administration. Evidence is emerging that the use of the information and communication technologies (ICT) in healthcare settings facilitates better quality care. The FCM describes the deliberative thought processes that occur from initial recognition of a situation with ethical content to implementation of a justifiable action: sensitivity, judgment, motivation, and action (Rest, 1986; Robichaux, 2012; Robichaux, 2017; Rushton & Penticuff, 2007). This process should be based on a sound ethical, decision-making model, using the best evidence-based-practice guidelines available.” How to Deal With Ethical Dilemmas in Nursing How do you see that use changing in the future? For example, the following was one of 352 statements by nurses about EHR experiences: Yes, the documentation of "quality standards" has greatly improved, but patient care and patient safety has not. The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. 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. Retrieved from http://www.texasnurses.org/?page=HIT, Milliken, A. However, ethical issues surrounding dominance of institutional priorities over autonomous patient-centered practice and care driven by application of decision-support, templates, and/or clinical practice guidelines (CPGs) have been documented (Lown & Rodriguez, 2012; McBride, Tietze, Hanley, & Thomas, 2015; Sulmasy, López, & Horwitch, 2017). Copy and paste functionalities can result in unintentional reliance on outdated or inaccurate clinically relevant information, such as treatment plan; distracted notes; diagnostic biases; incorrect information for a specific patient visit; and expired patient symptoms and assessments (Scruth, 2014; Weis & Levy, 2014). An ethical dilemma or ethical paradox is a decision-making problem between two possible moral imperatives, neither of which is unambiguously acceptable or preferable. Liz serves as an Associate Editor for the Journal of Bioethical Inquiry and is a volunteer with the D.C. Bar Association. However, healthcare providers have experienced notable challenges to balance necessary time for patient care with computer entry (McBride et al., 2017; Wolf et al., 2016). Silver Spring, MD: American Nurses Association. The physician agrees with the nurse but states, "just drip it in slow, otherwise if we don’t follow protocol we may fall out of the sepsis quality metric for the hospital. Retrieved from https://www.ania.org/about-us/position-statements/addressing-safety-electronic-health-records, Ayatollahi, H., Mirani, N., & Haghani, H. (2014). You are currently offline. Susan McBride, PhD, RN-BC, CPHIMS, FAAN Nurses must be prepared to face these challenges and recognize the requirements of state and federal law, workplace policies, and obligations of the profession. Dr. Robichaux is an Adjunct Assistant Professor at University of Texas Health; San Antonio, Texas and The University of Mary in Bismarck, North Dakota. Systems and technologies such as EHRs that assist in clinical practice are adjunct to, not replacements for, nurse knowledge and skill (ANA, 2015). Ethical sensitivity is described as our ability to recognize an ethical problem, the moral implications of our decisions, and how our actions affect other people (Milliken, 2016). Kuhn, T., Basch, P., Barr, M., & Yackel, T. (2015). Healthcare delivery in the United States (U.S.) is changing at a rapid pace to keep up with the ever-growing population health needs and for management of chronic diseases (Healthy Aging Team, 2017). Doing the right thing: Pathways to moral courage. A., & Rodriguez, D. (2012). The growing role of informatics in nursing has also created a number of new job titles for those with clinical experience and an interest in working with data. (2011). Nursing is increasingly becoming as high tech as it is a high touch profession. The val-ue of technology hinges on how it’s used and whether it helps or hinders care. Nursing Informatics: Improving Patient Safety with Technology. Evidence is mounting that EHRs are resulting in unintended consequences with patient safety implications. 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). A nursing informatics specialist combines technology with the care and communicative aspects of nursing to customize software and hardware for care solutions. Nursing Ethical Dilemma with Using Informatics Technology @inproceedings{Elsol2018NursingED, title={Nursing Ethical Dilemma with Using Informatics Technology}, author={A. E. El-sol and Ragaa Gasim Ahmed Mohmmed}, year={2018} } Dr. Weber is a nurse attorney and Clinical Assistant Professor at the University of Minnesota School of Nursing, where she teaches ethics, leadership, and public policy in the context of a continuum of interprofessional healthcare. These recommendations may help mitigate ethical and legal issues arising as a result of the massive uptake of technology that has resulted in the digital age of healthcare delivery. As a result, implementations escalated across the nation, and informatics nurses have since been on the frontlines of EHR application and optimization t… 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. It's made the notes semi-worthless. Clinical Nurse Specialist, 28(6), 312-314. doi:10.1097/NUR.0000000000000085, Sittig, D. F., & Singh, H. (2011). Grace, P., Robinson, E., Jurchak, M., Zollfrank, A., & Lee, S. (2014). Dr. Tietze has been certified since 2000 by ANA in Informatics Nursing. Ethical Decision Making: A Process Influenced by Moral Intensity, Global health ethics: an introduction to prominent theories and relevant topics, Research across the disciplines: a road map for quality criteria in empirical ethics research, Ethical Principles of Psychologists and Code of Conduct, By clicking accept or continuing to use the site, you agree to the terms outlined in our. Commentary: Lost in translation? 4 Common Nursing Ethics Dilemmas. Two-thirds of nurses owning medical appsuse them as part of their clinical practice. Changing nursing practice safely New York: Springer Publishing Company. 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). Collectively, these trends impact nurses nationwide across all care settings. Also systems audits are being used to evaluate and discipline nurses; this is a big ethical issue as nurses are charting stuff for the wrong reasons/........creating a conflict of interest. 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). The current and potential positive impact of the EHR on quality care is not disputed. Todays nurses have more technology at their disposal than any nurses ever before, and as one might expect, its considerably improving patient care. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. Telehealth and apps. Email: liz.stokes@ana.org. Sociology of Health & Illness, 39(3), 365-379. doi:10.1111/1467-9566.12489, CMPA. Liz Stokes, JD, MA, RN These practices can result in timeliness issues or time-related accuracy of documentation in any EHR.

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