Using the Electronic Health Record in Nursing Research: Challenges and Opportunities.

Changes in the patient record from the paper to the electronic health record format present challenges and opportunities for the nurse researcher. Current use of data from the electronic health record is in a state of flux. Novel data analytic techniques and massive data sets provide new opportunities for nursing science. Realization of a strong electronic data output future relies on meeting challenges of system use and operability, data presentation, and privacy. Nurse researchers need to rethink aspects of proposal development. Joining ongoing national efforts aimed at creating usable data output is encouraged as a means to affect system design. Working to address challenges and embrace opportunities will help grow the science in a way that answers important patient care questions.

Opportunities to improve pain management outcomes in total knee replacements: patient-centered care across the continuum.

Despite the importance of pain management to each patient's overall experience with a total knee replacement, opportunities to improve pain care exist. The authors target an unnecessarily fragmented pain management trajectory as one cause of variability in pain outcomes. They propose that a technology-enhanced patient-centered pain management continuum running from the preoperative through the recovery phase offers effective and efficient pain management.

The Affordable Care Act 2010: educational needs of bedside nurses.

The Patient Protection and Affordable Care Act of 2010 (ACA) significantly impacts bedside nurses who must participate in organizational change and provide resources to patients. A health reform educational needs assessment was distributed to nurses from a midsized community hospital located in an elevated-need and medically underserved area in New England. Many nurses indicated that more knowledge was needed and they lacked information about the educational incentives. Health policy professional development opportunities are required to inform bedside nursing practice.

Determining the value of postoperative pain management using timed electronic data.

Achieving value in postoperative pain management requires attaining the best patient outcomes using the least resources. While nurses are assessing and intervening more frequently for greater severity, their actions are not necessarily generating positive outcomes. To optimize value, it is recommended that pain assessment frequency be evaluated for patients reporting mild or no pain. Efficiencies in pain management may be gained by reconceptualizing thinking time as value added, especially when considering the impact of outliers on resource use. Adopting a strategy of pain prevention or early intervention when pain is less severe may increase the overall value of nursing care.

The impact of assessment and reassessment documentation on the trajectory of postoperative pain severity: a pilot study.

Comparing organizational approaches to pain management is warranted to understand best practices and provide decision makers with evidence on which to base resource intensive documentation policy decisions. To provide this evidence, a multilevel modeling (MLM) approach is required to accommodate the interrelatedness and nested nature of pain management factors affecting outcomes. Along with MLM, the widespread adoption of the electronic record provides an ability to capitalize on the repeated measurement benefit of the current pain management documentation output by using pain severity trajectory (PST) as a precise and clinically relevant outcome of interest. Therefore, the purpose of this pilot study was to examine the methodological issues that arise when conducting MLM research aimed to answer the question: what is the impact of assessment and reassessment documentation routines on postoperative pain severity trajectory? Researchers used timed pain management documentation data output to construct a growth model of a patient's PST and performed a two-level analysis from a convenience sample of 3 hospitals and 146 patients. Analyses revealed that the hospital where care occurred, the type of surgical procedure, and the presence of reassessment documentation within one hour of intervention affected the PST. Pilot work showed that pain management documentation output could be reformulated into research variables for hypothesis testing. The presentation of the reassessment data output posed a measurement limitation. An interdisciplinary research team is needed to adequately compare organizational practices. Basing policies on evidence has the potential to improve pain management care.

The regulation of dietary supplements in the United States: advocating for a reasonable approach, protecting patient safety, and the role of nursing.

Many Americans report using dietary supplements (DS) and there is evidence that the use of such products is increasing. Under the current regulatory system DS are not tested for safety or effectiveness, as with over the counter and prescription drugs, and the Food and Drug Administration (FDA) has limited authority to protect Americans from potential harm. DS in the United States have become a major public health and patient safety issue with injuries, illnesses, and deaths attributed to their use. Efforts in congress to legislate safer regulations have been met with limited success, in part because of the lobbying efforts of the DS industry. Although there is near consensus in the literature and among stakeholder government agencies that a modified FDA role is needed, resolving the issue requires a multifaceted approach. Along with political and legislative action, effort must be made to increase the American public's knowledge of DS.

Analyzing variability in pain management using electronic health record data.

Variability in pain management processes may affect outcomes. Researchers collected pain management documentation from electronic health record systems of 3 hospitals and constructed process and outcome variables. Simple linear regressions revealed that relationships exist between increased pain variability and less frequent assessment and more frequent intervention, identifying targeted areas for improvement. Researchers demonstrated the use of the electronic record output for improvement purposes.

Abstracting pain management documentation from the electronic medical record: comparison of three hospitals.

BACKGROUND: Pain management science results are derived from research conducted using medical record. APPROACH: This article describes methodological issues arising from abstracting pain management documentation (PMD) from the electronic medical record in three hospitals. After approval, PMD data were collected from the patient's history and physical, discharge summary, operative care notes, computerized nursing flow sheets, progress notes, and medication records. RESULTS: Each acute care facility required a different approach to abstract data. Inconsistent documentation in pain management assessments, interventions, and reassessments were identified across hospitals. DISCUSSION: Inconsistencies pose measurement threats and hinder benchmarking efforts. Work to standardize PMD across propriety computer systems is warranted.

Pain management documentation: analyzing one hospital's computerized clinical records.

Pain management documentation, consisting of assessment, interventions, and reassessment, can help provide an important means of communication among practitioners to individualize care. Standard-setting organizations use pain management documentation as a key indicator of quality. Adoption of the electronic medical record alters the presentation of pain management documentation data for clinical and quality evaluation use. The purpose of this study was to describe pain management documentation output from the electronic medical record to gain an understanding of its presentation and evaluate the quantity and quality of the output. After institutional review board approval, data were abstracted from 51 electronic records of postsurgical patients in a 100-bed community hospital. Time-variant pain assessments, interventions, and reassessments were organized into pain management episodes to provide clinically interpretable data for evaluation. Data sources were identified. Data generated 1499 episodes for analysis. Analysis of variance results implied that pain management documentation changes with pain severity. Despite legibility and date and time stamping, inconsistencies and omitted and duplicated documentation were identified. Inconsistent data origination posed difficulty for interpreting clinically relevant associations. Improvements are required to streamline fields and consolidate entries to allow for output in alignment with care.

The application of high-reliability theory to promote pain management.

Evidence-based pain management, a high-volume hospital service, impacts resource utilization and quality indicators. Despite extensive efforts to improve care, outcomes remain poor, and barriers seem insurmountable. Change management strategies that embrace organizational and individual accountabilities are warranted. Conceptualizing evidence-based pain management within the context of high-reliability theory may help redesign systems and processes to better meet needs of patients. The author discusses using a high-reliability framework as a change management strategy.

Senior nursing students' clinical judgments in pain management.

Sustained improvement in pain management depends on new nurses entering the healthcare system with strong practice knowledge and competent clinical judgment. The recent call to revamp nursing education to meet practice realities recommended integrating classroom and clinical teaching using a variety of pedagogies to develop students' clinical judgment skills. Understanding the pain management clinical judgments occurring in practice helps to methodically construct meaningful teaching interventions and guide faculty support of students. The authors discuss their study, and its outcomes, related to the pain management clinical judgments of senior students.

Evidence-based pain management: analyzing the practice environment and clinical expertise.

PURPOSE/OBJECTIVES: Evidence regarding pain and pain control has been available for more than 30 years. Implementation of evidence-based pain management (EBPM) is impacted by both individual and organizational factors. Clinical nurse specialists, responsible for EBPM implementation need information to help target interventions. Using the Theory of Planned Behavior, the purpose of this study was to analyze the effect of the perception of the practice environment and clinical expertise on the adoption of EBPM. DESIGN: A descriptive, retrospective study took place in 2006. SAMPLE: A convenience sample of 85 nurses from 2 teaching hospitals and 3 surgical units in the Northeast volunteered to participate. METHODS: Nurses completed the Practice Environment Scale of the Revised Nursing Work Index and the Clinical Nursing Expertise instruments to measure the independent variables. The researcher then reviewed 4 of their pain management documentation entries. Each entry was scored using the Samuels' Pain Management Documentation Rating Scale and averaged to compute an individual rating score for each nurse. Data were analyzed first descriptively, then with multiple regression. FINDINGS: Results showed that the perception of the practice environment did not contribute to pain management documentation, whereas clinical expertise explained 4.4% of the variance. The more clinically expert practitioners had relatively poorer documentation scores. CONCLUSIONS: : Expertise may impact the implementation of evidence especially in areas where practice patterns are well established. IMPLICATIONS: Adapting implementation strategies to target expertise levels are warranted.

Pain management documentation quality as a reflection of nurses' clinical judgment.

Pain management documentation (PMD) is the chief method used by administrators, surveyors, and quality improvement managers to measure the quality of pain management. Eighty-five nurses from 2 hospitals generated 340 PMD record entries, which were scored using the Samuels PMD Rating Scale. Nurses' PMD scores ranged from 2.5 to 6.5 (SD = 0.77). Less than 50% of the entries met Joint Commission standards. Documentation results may reflect nurses' pain management clinical judgment. Targeted interventions are recommended.

Development of the Samuels Scale to rate pain management documentation.

Charting deficits and nominal-level data create difficulties when rating pain management documentation (PMD) quality. Researchers developed an interval level rating scale using Q-methodology. Pain entries (340), sorted into patterns, were rank ordered by nine pain management experts and distributed across a 7-point scale. Rankings demonstrated agreement (intraclass correlation coefficient = .96). One factor explained 77.19% of the variance. Reliability and validity were supported. Interval level data enable more robust testing of interventions to improve PMD outcomes.