nursing ethical dilemma with using informatics technology

The complexity arises out of the situational conflict in which obeying one would result in transgressing another. The discipline of nursing informatics is a well-established specialty that has grown past the point where nurses simply help IT to design electronic health records (EHR). doi:10.1542/peds.2010-2184, Sulmasy, L., López, A., & Horwitch, C. (2017). Retrieved from http://perspectives.ahima.org/electronic-health-records-what-are-the-most-important-barriers/, Brown, D. L. (2015). (Jameton, 2017, p. 617). Rethinking the role of clinical practice guidelines in pharmacy education. Statewide study assessing the experience of nurses with their electronic health records. (Master's Thesis). Moral courage can also be “learned, practiced, and mentored” (Hawkins & Morse, 2014, p. 268). At the end of 2013, 80% of hospitals and 50% of healthcare providers implemented EHRs.1 But, the â¦ Trappings of technology: Casting palliative care nursing as legal relations. Retrieved from https://depts.washington.edu/bioethx/tools/4boxes.html, Brown University. This emphasizes the need for continuing education for novice and expert nurses in EHR management and documentation. (2012). Nursing Informatics: Improving Patient Safety with Technology. The MUMSI allowed for analysis that addressed differing levels of functional status, or maturity of the given EHR using the meaningful use (MU) measures as a proxy for maturity (McBride et al., 2017). Nursing Informatics Vs. Medical Informatics: Whatâs The â¦Nursing Informatics vs. Medical Informatics: Whatâs the Difference? Perspectives in Health Information Management / AHIMA, American Health Information Management Association, 11, 1c. 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. The auto-fill function can result in unintentional documentation of a clinical finding that may not be within a nurse's clinical purview (Sittig & Singh, 2011). Mari Tietze, PhD, RN-BC, FHIMSS This computational capacity may establish EHR information as authoritative, potentially displacing work processes critical to nurse-patient interaction. Sometimes called ethical paradoxes in moral philosophy, ethical dilemmas may be invoked to refute an ethical system or moral code, or to improve it so as to resolve the paradox. Retrieved from https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/. Lack of supervisory support, fear of reprisal, and hierarchal decision-making may silence nurses’ moral voices (Pavlish, Hellyer, Brown-Saltzman, Miers, & Squire, 2013). As one expert cautions, automation should occur in nursing, not of nursing. Dr. Robichaux is an Adjunct Assistant Professor at University of Texas Health; San Antonio, Texas and The University of Mary in Bismarck, North Dakota. Retrieved from https://www.ncoa.org/resources/10-common-chronic-conditions-adults-65/, Henry, J., Pylypchuk, Y., Searcy, T., & Patel, V. (2016). 23, No. 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). 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. Retrieved from doi:10.1016/j.jcjq.2017.04.007, Hawkins, S. F., & Morse, J. . She suspects that the afebrile patient does not have sepsis, but instead has an exacerbation of HF with possible pulmonary edema... Nancy has worked in a busy community hospital emergency department (ED) for over ten years. It plays a role in nearly every facet of life, and increasingly so in healthcare. Ethical competence in nursing practice: Competencies, skills, decision-making (1st ed.). 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). This case scenario can be examined in terms of the overall context of ethical implications in use of the EHR. Randall Owen, PA-C â Fellowship in Bioethics. It's made the notes semi-worthless. Developing moral courage may assist in overcoming personal and institutional barriers to further nurse advocacy. Tietze is the Doswell Endowed Chair for Nursing Informatics aimed at advancing nursing informatics at TWU. 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). Nursing informatics is a growing field. "It's a burden you carry": Describing moral distress in emergency nursing. Jenders, R. A. Additionally, alert fatigue and clinical information overrides must be addressed within the organization. Clinical Nurse Specialist, 28(6), 312-314. doi:10.1097/NUR.0000000000000085, Sittig, D. F., & Singh, H. (2011). The accelerated growth and adoption of the EHR has produced a situation that repeatedly occurs in the history of technology and parallels the rise of bioethics. Austin, TX: Texas Nurses Association. (2011). The CODE mnemonic strategy helps nurses to recall these actions and includes ways to overcome fear and reluctance to speak up including reflection, reframing, and assertiveness skills. Washington, DC: Office of National Coordinator for Health IT. The field of nursing informatics combines nursing and information technology disciplines. Corpus ID: 54646969. It specifies duties that nurses in leadership and managerial roles have, particularly in transformational and servant leadership frameworks, to open communication and to act “entirely on the behalf of those led” (ANA, 2009, p. 8) to identify problems and integrate ethical provisions in all areas of practice. Burlington, MA: Jones & Bartlett Learning. 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). Nursing administration: Scope and standards of practice (3rd ed.). Sometimes I have to go through 3-5 computers before finding one that works. nursing care Here are the discussion questions. Nurses experience moral distress, a concept first highlighted by Andrew Jameton in 1984, when they "know the right thing to do while being in a situation in which it is nearly impossible to do it." HITECH act enforcement interim final rule. Ethical Motivation Addressing the safety of electronic health records: Position statement. Effective communication is vital to this relationship, and the EHR may have a negative effect. She worked as a consultant for the D.C. Board of Nursing interpreting professional ethics provisions and recently completed her masters in bioethics. Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN What ethical issues have arisen or might arise from use of technology and informatics in professional nursing.How do you use informatics and technology in your nursing practice? 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. The nursing Code of Ethics, Nursing Scope and Standards, and Legal Implications are reviewed, and we conclude with recommendations and a call to action. As a result, implementations escalated across the nation, and informatics nurses have since been on the frontlines of EHR application and optimization tâ¦ There is a lot of interest in the ways technology enhances the medical field. Retrieved from https://www.americannursetoday.com/doing-the-right-thing-pathways-to-moral-courage/, Larsen, A. It is not accurate and orders tend to disappear. 1. 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. challenging. She points out the history of HF, which creates a risk for fluid overload with the bolus. Worldwide, 3.4 billion people own a smartphone, and half will be using mobile health apps. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association, 42(1), 37. doi: 10.1016/j.jen.2015.08.008, Substance Use Disorders and Related Concerns, The 200th Birthday of Florence Nightingale, Addressing Social Determinants of Health: Progress and Opportunities, Translational Research: From Knowledge to Practice, Catherine Robichaux, PhD, RN, CNS, Alumnus CCRN, Code of Ethics, Nursing Scope and Standards, and Legal Implications, U.S. Department of Health and Human Services, 2012, Office of National Coordinator for Health Information Technology, 2017, https://depts.washington.edu/bioethx/tools/4boxes.html, https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions, https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/, Grace, Robinson, Jurchak, Zollfrank, & Lee, 2014, Pavlish, Hellyer, Brown-Saltzman, Miers, & Squire, 2013, Lachman, Murray, Iseminger, & Ganske, 2012, Rathert, Mittler, Banerjee, & McDaniel, 2016, OʼBrien, Weaver, Settergren, Hook, & Ivory, 2015, http://bok.ahima.org/doc?oid=105098#.WmtkOmQ-doE, http://www.r2library.com/resource/title/9781558102675, http://www.r2library.com/resource/title/9781558105997, https://www.ania.org/about-us/position-statements/addressing-safety-electronic-health-records, http://perspectives.ahima.org/electronic-health-records-what-are-the-most-important-barriers/, https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2005/using-email-communication-with-your-patients-legal-risks, https://dashboard.healthit.gov/evaluations/data-briefs/non-federal-acute-care-hospital-ehr-adoption-2008-2015.php, http://www.ncbi.nlm.nih.gov/pubmed/17907703, https://www.americannursetoday.com/doing-the-right-thing-pathways-to-moral-courage/, https://c.ymcdn.com/sites/www.texasnurses.org/resource/resmgr/HIT_Files/HIT_Survey_Report-Final.pdf, https://dashboard.healthit.gov/quickstats/quickstats.php, http://www.himss.org/ResourceLibrary/ResourceDetail.aspx?ItemNumber=11590, http://catalog.hathitrust.org/Record/000441705, http://www.hhs.gov/hipaa/for-professionals/special-topics/HITECH-act-enforcement-interim-final-rule/, Enhancing Nurse Moral Agency: The Leadership Promise of Doctor of Nursing Practice Preparation, Ethical Nursing Care Versus Cost Containment: Considerations to Enhance RN Practice, Ethics Education in Nursing: Instruction for Future Generations of Nurses, Ethical Awareness: What It Is and Why It Matters. Eileen Weber, DNP, JD, BSN, RN, PHN. (2014). 10 most chronic conditions in adults 65+. A nursing informatics specialist combines technology with the care and communicative aspects of nursing to customize software and hardware for care solutions. It takes several hours to get thru discharges due to links that do not work. When moral courage and ethical action are thwarted by constraints outside the nurse's control, moral distress can result. Nancy questions the appropriateness of the physician orders, but follows physician instructions. The pharmacy part allows expired orders to carry on and continue to be active even after stop dates which lead to medication errors. 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). 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. How do you see that use changing in the future? Medsurg Nursing: Official Journal of the Academy of Medical-Surgical Nurses, 16(4), 275. This case study illustrates evolving guidelines that require clinical teams to use critical thinking skills when presented with CDS or information within the EHR that is not aligned with the clinical judgment of the entire clinical team. Historically, it was assumed that all standards of care were met unless documented otherwise. 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). A thematic content analysis of the narrative responses to the open text question was used to analyze the data. Quick stats. The patient requires intubation due to flash pulmonary edema with a subsequent diagnosis of acute onset of exacerbated fluid overload, secondary to rapid administration of intravenous (IV) fluid bolus and complication of HF. 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). The purpose of this article is to identify and address ethical issues raised by nurses in use of EHRs. Moral courage in action: Case studies. Online Journal of Issues in Nursing, 15(3), Manuscript 3. doi:10.3912/OJIN.Vol15No03Man03, Lachman, V. D. (2007). (2017). Cambridge, England: Cambridge University Press. This system has quadrupled our workload. Retrieved from https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions, Santa Clara University Markula Center for Applied Ethics. Annals of Internal Medicine, 162(4), 301. doi:10.7326/M14-2128, Lachman, V. D. (2010). Informatics specialty nurses and advanced practice nurses can serve as leaders to assess and research documentation for timeliness and accuracy, along with providing continuing education on a frequent basis (Scruth, 2014). American Journal of Pharmaceutical Education, 79(10), 148. doi:10.5688/ajpe7910148, Campbell, M. L., & Rankin, J. M. (2017). Collectively, these trends impact nurses nationwide across all care settings. (2006). The purpose of this article is to identify and address ethical issues raised by nurses in use of electronic health records. She founded and leads the Upper Midwest Healthcare Legal Partnership Learning Collaborative. This results in ethical situations often associated with feelings of moral distress. These are noted in Figure 1. Finally, we acknowledge the many subject-matter experts who, through numerous focus groups, helped yield the final surveys. Texts were organized in a spreadsheet and reviewed systematically by two qualitative researchers from the TNA/TONE committee research subgroup to identify key concepts. In 2009, President Barack Obama further advanced the use of EHRs through Medicare and Medicaid incentive programs that reward hospitals and providers who demonstrate meaningful use of EHRs. Using email communication with your patients: Legal risks. These obstacles may characterize a unit ethical climate that does not promote patient/family advocacy and nurse moral agency. (2017). Retrieved from http://catalog.hathitrust.org/Record/000441705, Robichaux, C. (2012). It is just as important, however, to address accessibility, especially for members of the Deaf and Hard of Hearing community. Two-thirds of nurses owning medical appsuse them as part of their clinical practice. 4 Common Nursing Ethics Dilemmas. Nurse managers and executives have a particular obligation to ensure that direct care nurses are empowered to identify and engage in ethical situations associated with EHRs. (2009). She verbally reports this information to the receiving ICU nurse and hopes “for the best outcome” for the patient. The case scenario above provides an opportunity to explore a holistic framework, the Four Component Model (Rest, 1986), to identify and address ethical issues in nursing practice. Data breaches can occur if information is not secured, or if it is misused. This paper will discuss the evolution of nursing documentation, the immergence of health information technology, and the challenges it creates for the nursing profession. Chest, 145(3), 632. doi:10.1378/chest.13-0886, Wolf, L. A., Perhats, C., Delao, A. M., Moon, M. D., Clark, P. R., & Zavotsky, K. E. (2016). A sampling of these comments is provided by categories in Table 1. She subsequently reports the request by the physician to drip slowly in a verbal handoff to the ICU nurse who receives the patient. Defining Nursing Informatics 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). 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. 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. Nancy recognizes that not only does this patient have symptoms that could be evolving sepsis, but the EHR indicates the patient has previously been admitted for fluid overload from heart failure (HF). 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. A case-based approach to ethical decision-making. Patient Education and Counseling, 100(1), 50-64. doi:10.1016/j.pec.2016.07.031, Rest, J. R. (1986). Liz Stokes, JD, MA, RN Nursing informatics and healthcare go hand-in-hand these days. Advances in Nursing Science, 36(4), 304-319. doi:10.1097/ANS.0000000000000004, Rathert, C., Mittler, J. N., Banerjee, S., & McDaniel, J. Retrieved from https://www.ania.org/about-us/position-statements/addressing-safety-electronic-health-records, Ayatollahi, H., Mirani, N., & Haghani, H. (2014). ANA explains: âUsing ethical principles to arrive at a solution should be done in an atmosphere of caring, respect, openness, and honesty. The scenario also reinforces nurses’ statements as reported in 2015 via the Texas Nurses Association-Texas Organization of Nurse Executives (TNA-TONE) statewide study on EHRs (McBride et al., 2015). Technology in nursing practice is not new, but the ways in which technology exists and contributes to healthcare is. She has taught ethics at the undergraduate and graduate levels and conducted research on moral distress and ethical climate among other issues. Commentary: Lost in translation? Technology enables care and enhances safety by au - tomating functions both simple and complex. Critical Care Nurse, 32(2), 65-72. doi:10.4037/ccn2012929. (2016). The Ethical Intersection of Healthcare and Technology. 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} } 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). EHR documentation: The hype and the hope for improving nursing satisfaction and quality outcomes. Most importantly, the EHR must not substitute for a current and accurate clinical assessment, and appropriate intervention (Campbell & Rankin, 2017; Lown & Rodriguez, 2012; Sulmasy et al., 2017). These rights of privacy and confidentiality pertain to all information in any manner that is communicated or transmitted” (ANA, 2015, p. 10). Nursing informatics plays a critical role in implementing telehealth technologies designed to benefit patient-family and patient-clinician connected platforms in the inpatient setting. Moral development: Advances in research and theory. Does Ethics Education Influence the Moral Action of Practicing Nurses and Social Workers? (2014). Strategies necessary for moral courage. The ED physician follows the CDS sepsis alerts that call for fluid resuscitation. 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. I have almost no training on the "System.” I have to fumble around to do anything on this "System" and it is purely an accident when I do find what I need. What ethical issues have arisen or might arise from use of technology and informatics in professional nursing? 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). (No. Pediatrics, 127(4), e1047. Specific themes reflected in the case scenario and noted by Wolf and colleagues’ (2016) qualitative investigation relate to moral distress due to overemphasis on documentation, tasks, and metrics at the expense of patient care, as well as role conflicts resulting from hierarchical decision making. Hospitals and clinics â¦ 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). Telehealth and apps. Since 2010, she has been the co-chair of the Texas Nurses Association/Texas Organization of Nurse Executives Health Information Technology committee to represent nurses' experiences related to information technology use in their practice of patient care delivery. Retrieved from http://www.r2library.com/resource/title/9781558102675, American Nurses Association. Research suggests that it can become a “third party “in the process, potentially reshaping the interaction, changing the patient narrative, and diverting nurse attention away from the patient (Rathert et al., 2016). The ethical considerations of the use of informatics in nursing and health care are above all related to data security and data quality issues. A survey of a large hospital corporation in London found that 53.2 percent of nurses considered their smartphone âvery usefulâ or âusefulâ for helping with clinical duties. Canadian Medical Protective Association, 2015(May), 1-3. Nancy questions the doctor order for aggressive fluid bolus and relates her concern that the patient is not septic. 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.
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