вторник, 18 сентября 2012 г.

Rationales for developing a perioperative web-based resource: informatics in action. - AORN Journal

The field of health care has witnessed many technological advances during the past 20 years, and the trend most likely will continue into the future. Perioperative nurses are fortunate to be able to witness the health care marvels made possible by new technology. They may feel overwhelmed, however, by the magnitude of the responsibility and learning that is necessary to manage the evolving presence of technology in modern ORs. Advances in microscopic and video equipment, robots, lasers, specialized implants, minimally invasive instrumentation, and electronic hemostatic and dissection devices necessitate a level of technological knowledge and specialization that was not required when many perioperative nurses began their careers.

The business of surgery also has placed additional stressors on the surgical team. Gone are the days when a resource such as an OR suite could sit idle. Health care services, and surgical services in particular, have become increasingly expensive to deliver, while reimbursements for these services have flattened. The OR has become the driver of financial stability for many institutions, and often it is considered to be the facility's profit center. Health care administrators acknowledge that the efficiency of the OR directly correlates to the facility's bottom line. Close to 60% of the revenue generated for a hospital can be attributed to the OR. (1)

Issues surrounding time management, billing, scheduling, quality assurance, payroll, budgeting, and utilization now are tracked and monitored to eliminate inefficiency. To facilitate the capturing of necessary data, computers are commonly found in the OR. Perioperative nurses now are responsible for the safe delivery of nursing care while, at the same time, acting as crucial stakeholders in providing data for the facility's business model. Without the recording and monitoring of data, the business of providing health care will fail. Technologic advances will continue to affect perioperative nurses, so a reasonable response is to use nursing informatics to bring helpful information directly to the team in the operating suite.


The American Nurses Association defines nursing informatics as

    a specialty that integrates nursing science, computer science, and    information science to manage and communicate data, information,    and knowledge in nursing practice. Nursing informatics facilitates    the integration of data, information, and knowledge to support    patients, nurses, and other providers in their decisionmaking in    all roles and settings. This support is accomplished through the    use of information structures, information processes, and    information technology. (2) 

Using nursing informatics, a web-based resource (WBR) can be developed that takes an institution's existing computer infrastructure and increase its usefulness as an information tool for perioperative staff members.

For the purpose of this article, a WBR is defined as a web site built specifically for the teaching and orientation of perioperative nurses and staff members (Figure 1). Web-based technology can provide pertinent and customized information to an entire staff at any time and from any computer. This resource can be made dynamic and engaging through the use of text, still images, video, audio files, and various web design techniques. This makes a WBR a more efficient and enjoyable learning tool than a paper resource alone. The types of information that can be made available include

* video inservice and teaching presentations,

* orientation guides,

* policy and procedural updates,

* OR news and schedules,

* mandatory educational offerings,

* new staff announcements, and

* important links to other available resources. Additionally, the proper use of equipment or specialized instruments can be illustrated, and instructions for nursing staff members regarding specific procedures or specific surgeon preferences also can be made available (Figure 2).



Rather than illustrating how to build a web site, the purpose of this article is to advocate for the use of information technology and provide a justification for the time and energy needed to build a WBR. A review of current literature reveals evidence of the effectiveness of web-based education; however, there is a gap in the literature related to the specific applications proposed here. The rationale for the development of the WBR featured in this article is based on staff-member feedback within one institution in Rochester, New York, and an intuitive sense of

how health care can be positively affected when perioperative nurses are given the right information at the right time. A WBR can be an effective method of transforming perioperative nursing culture by using nursing informatics.

This information may help other perioperative nurses consider the types of customized information that can be made available to staff members, and it also may help justify the importance and expense of a similar product to health care managers in other facilities. Determinants of success are based on how access to a WBR can positively affect the health care team's efficiency, knowledge, retention, and recruitment. In addition, consideration is given to how this technology can have a positive effect on team building, professional development, knowledge management, evidence-based practice, and, most important, patient safety.


Robert Hance, RN, a perioperarive vascular nurse at the University of Rochester Medical Center, New York, a tertiary care institution with a level i trauma designation, wanted to make information available to all staff members about endovascular abdominal aortic aneurysm repairs. He chose to develop a WBR specific to this need, reasoning that if staff members had not been trained for the vascular team, it would be difficult for them to become familiar with these procedures. This information also would be a valuable resource for off-shift staff members. Making detailed information like this available on a WBR also helps engender a sense of transparency and might encourage other nurses to join the vascular surgery nursing team.

To create the WBR, Hance first detailed the pathophysiology of the condition. The procedure then was broken down into components using the nursing process (Figure 3). Next, the preoperative nursing assessment, planning, interventions, and expected postoperative outcomes were reviewed. Schematics of OR, back table, and Mayo stand setups were made available as were the draping procedures (Figure 4). Photos of specialized equipment, instruments, and disposable items helped inform the user of their proper use and location (Figures 5 and 6). Potential interventions and surgeon preferences also were discussed. With this information available, the transition process was easier in the instances in which a procedure progressed to an open surgery because supportive text, explanations, and images were readily available.



The information structure of a WBR can allow staff members to retrieve relevant and specific information at any time and in any place that a computer is available. This provides several benefits to nurses.

* Staff members working off shifts can access information to help them when there are fewer personnel resources available.

* The WBR can help team members anticipate specific needs for their next procedure.

* Team members can view the information from home before a planned procedure to help them brush up on what to expect.

* The WBR can be used to present best practice models, which helps promote efficiency in how nurses provide perioperative care.

Traveling nurses also could be given access to a WBR via the Internet to assist them to self-orient, thus promoting efficiency even before their first day on the job.

Inservice training sessions are an ongoing and necessary educational format in nursing. It would be impossible for all staff members to attend an inservice program at the same time, and some presentations may be offered only once. A video recording of the inservice program could be posted to the WBR so everyone could benefit from it, including any staff members who are hired in the future.

A WBR generally is more efficient to update than any paper resource. In the time required for a paper resource to be edited in a word processing program, printed, and distributed, the same document could be converted to the basic language of the Internet (ie, hypertext markup language) and uploaded to a web site. Moreover, this can be done without individual staff members having to locate the appropriate resource manuals to replace the document or pages by hand.

Surgeons and anesthesia care providers also may find the concept of a WBR useful as it applies to safety and efficiency of care. Often, it is the members of these professions who are the ones who help champion the concept of the WBR and become active participants in its construction.


A compelling reason for building a perioperative WBR is the management and recording of information as well as knowledge accumulated by staff members. The need for recording this knowledge will become increasingly important during the next 15 years, as more than 40% of the RN population in the United States retires. (3) The loss of these nurses from the workforce is expected to result in a national shortage of 400,000 nurses by 2010, largely because of retirement, decreased nursing program enrollment, career changes, and the aging population. (4) When these data are put into the context of lost years of experience, the nursing profession and subspecialties such as perioperative nursing will suffer a significant 'brain drain' and loss of collective knowledge. According to researchers De Long and Mann,

    This brain drain phenomenon is occurring in both the public sector    and the private sector, including the chemical, utilities, oil and    gas, healthcare, automotive, aerospace and defense industries. (5) 

Most managers are aware that a number of workers will be retiring; however, few are doing much to prepare for this eventuality. Much of this failure to act is the result of the difficulty in quantifying the cost of losing knowledge? (6)

The loss of knowledge may become more acute as perioperative nurses become increasingly specialized. Historically, experienced perioperative nurses have verbally passed a great deal of knowledge on to novice nurses. Much of this information may be specific to an institution. This is an efficient and appropriate method in a preceptor-based educational model where experts are readily available for individualized teaching. If experienced nurses retire without passing on this critical information, however, it will be lost. The result is a reduction in efficiency while this information is relearned, and nurses may become frustrated in the process. A WBR can help promote a cultural shift to digitize the information that perioperative nurses use on a daily basis but may not have passed on to other colleagues or otherwise documented.


The sheer volume of information that can be built into the WBR may elicit apprehension among facility staff members. If the collection of information is a shared process (ie, one that incorporates the ideals that support a typical clinical ladder system or other development or recognition program), it can be turned into a positive force. The clinical ladder is an important component of staff-member development that has a profound effect on recruitment and retention. A facility's clinical ladder must be designed to attract, retain, and reward nurses for their contributions to patient care, clinical research, education, and leadership. (7) Patricia Benner's book From Novice to Beginner (8) has provided the basis for many clinical ladder programs. According to Benner, a nurse's transformation from novice to expert involves the incorporation of nursing fundamentals, theory, and clinical experience as he or she progresses toward an intuitive understanding of clinical situations. ((8)(p32)) A WBR project can provide a venue to facilitate this transformational process, assisting staff members as they develop their clinical skills and knowledge and then share their experiences with others.

TEAM BUILDING, A WBR project also could be used to develop an arena to promote teambuilding activities. Professional growth and development can be enhanced for nursing staff members of all levels of experience as they come together to accomplish a tangible goal as valued members of the WBR team. The WBR development process involves the

* analysis of staff learning needs,

* collection of information, and

* formulation of the best method of presenting the results to facility staff members. The necessary information can be divided into manageable parts, allowing members to contribute independently but with an understanding that they are valued members of the team.

CREATIVITY. Building a WBR is a creative process. With so many second-career nurses in the workforce, a skill review of OR staff members may uncover individuals with prior experience in information technology, web design, and photography who are particularly well suited to helping with the construction of the WBR. The skill sets of second-career nurses otherwise might be overlooked, causing facilities to miss out on the value these individuals can contribute.


Presently, the nurse recruitment market is quite competitive, with clinical specialties such as perioperative nursing being hit particularly hard by the nursing shortage. Having something extra to offer to both new and experienced candidates can be beneficial to any health care organization. In the report Health Care at the Crossroads, the Joint Commission suggests that hospital-based orientations for new nurses, continuing education programs, and inservice offerings have decreased as a result of cost and staffing pressures? Given the general lack of perioperative education in current nursing programs, the WBR could become an excellent showpiece for presentations given at nursing schools and in high schools or during a recruitment open house. The presence of a WBR tool also would demonstrate to experienced recruits that OR managers are proactive in the orientation and education process.

Considering the pace at which technology is progressing and the fact that patient outcomes are being benchmarked, hospitals cannot afford to underfund critical education and training. Computer-based training, simulation, and distance learning provide alternative methods of inservice training and continuing education, and nurses need to be actively involved in selecting the content? (9)


Evidence-based practice is becoming the mantra of improvement in health care delivery. The pioneer of evidence-based practice, David Sackett, MD, defined evidence-based practice as 'the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.' ((10)(p71)) This philosophy is driving a movement of change in nursing practice toward using research and best evidence as foundations for clinical decision making. The criteria for the much-valued Magnet hospital designation assumes the existence of evidence-based nursing as well as the related research support structures, which are the hallmark of excellence in nursing. (11)

A perioperative nurse may witness a practice that is unique to an institution and one that is not necessarily based on evidence or rationale. He or she may be told that 'this is the way we've always done things.' Undoubtedly, every nurse has wondered or asked, 'How effective is this practice?' or 'Why am I doing this?' (12) A WBR could be used to help promote an evidence-based nursing culture. Publishing of information about perioperative nursing care practices and techniques to a secured web site, would enable all staff members to learn, evaluate, and question how their colleagues manage patients. Transparency can help teach good practices and may help reveal practices that have no basis in evidence, which then should be questioned and reevaluated.

Evidence-based practice is not limited to patient-care interventions only; it also can include evaluation of time and materials use with an emphasis on improved efficiencies and cost savings. The most important factor in evidence-based practice is promoting an environment that allows staff members to question current clinical practices. (12) By establishing a forum in which staff members can be taught and can share in formation, a WBR may be helpful in soliciting complex questions and building a nursing culture that promotes practices based on sound evidence.


The current nursing shortage has prompted hospital administrators to focus on the reasons that motivate nurses to remain at a facility, and leaders are seeking creative methods to provide those motivators. (13) Employers tend to rely almost exclusively on salary increases and hiring bonuses to retain and hire experienced nurses, and often they ignore the developmental needs nurses have throughout their careers. (14,15) The hospitals that are more successful in retaining nurses are those that provide nurses with a good working environment, opportunities for professional development, a sense of empowerment, and options to grow in their careers. (13) The process of building a WBR can provide an engaging project to assist professional development, and it also promotes team-building skills that are necessary for a good working environment. Finally, the support offered by a WBR may be a compelling reason for nurses and other staff members to stay with a facility, particularly when competing facilities do not have similar resources.


Perhaps the most compelling reason for building a perioperative WBR is that it promotes a safer environment for patients. Information technology can become a valuable asset in reducing perioperative errors, because it uses the principles of nursing informatics to bring the right information to the right person at the right time. (15) Consider the following example:

    It is 10 PM and staff members in OR 5 are performing a procedure to    remove a small bowel obstruction on an older adult patient with    several comorbidities. The circulating nurse is a traveling nurse    who works the evening shift, and the scrub nurse, who is new to    perioperative nursing and has only recently started taking call,    was called in from home. Both nurses were unable to attend the    inservice meeting a few weeks ago about the new surgical stapling    system. The scrub nurse has never handled the new stapler but    reloads it thinking that it looks 'okay.' When the surgeon uses it,    however, the stapler misfires because the reload was not properly    seated. This causes a tear in the patient's bowel. As a result, the    surgery takes longer, which puts the patient at risk for further    complications. 

In this situation, if the scrub nurse had been able to access a video monitor in the OR and watch a 30-second demonstration of the proper loading of that particular stapler unit, the misfire could have been avoided. When critical information is readily available, errors such as this could be prevented. Surgical team members as well as the patient would benefit from having this technology available. Surgeons also may welcome processes that use information technology to assist nursing staff members. By cultivating surgeons' interest as stakeholders in the WBR, the development team could improve a facility's access to educational materials, product information, and other necessary resources for a comprehensive WBR.

FAMILIARIZATION. There always is the possibility that perioperative staff members will be assigned to an unfamiliar procedure or be assigned to one in which they have not participated for many years. A WBR can provide them and their patients a safer experience by giving the staff member access to critical information. Additionally, traveling nurses, a necessary staffing component in many ORs, also may benefit from the availability of a WBR. The Joint Commission reported that,

    While temporary nurses today are typically well educated and    experienced, there are inherent risks in bringing nurses in who are    unfamiliar with the hospital's practices and policies. (9) 

A WBR could be developed to help familiarize these nurses with hospital-specific practices and procedures.


As paper-and-ink processes give way to digitization, nurses must embrace the opportunities they have to shape information technology to fit nursing practice rather than adapting nursing practice to fit the needs of technology. (16) In an age in which banking, college coursework, and grocery buying can be done online, it is reasonable not only to expect but also to embrace web-based processes that assist perioperative nurses in the OR. The necessary infrastructure already exists within many ORs, but it will require proactive leaders and determination to develop web resources that support comprehensive perioperative nursing orientation and education. Considering the magnitude of the current nursing shortage, nurses must welcome these developing technologies, keeping in mind that they will help attract new nurses to the perioperative field. This will ensure that the field of perioperative nursing, and the crucial contribution these nurses make to patient care, will be sustained in the future.


(1.) Jackson RL. The business of surgery: managing the OR as a profit center requires more than just IT. It requires a profit-making mindset, too. Health Manage Technol. 2002;23:20-22. http://www.healthmgttech.com /cgi-bin/arttop.asp?Page=h0702systems.htm. Accessed June 12, 2007.

(2.) American Nurses Association. Scope and Standards of Nursing Informatics Practice. Washington, DC: American Nurses Publishing; 2001.

(3.) Norman LD, Donelan K, Buerhaus PI, et al. The older nurse in the workplace: does age matter? Nurs Econ. 2005;23(6):282-289.

(4.) US Health Resources and Services Administration. What is Behind HRSA's Projected Supply, Demand, and Shortage of Registered Nurses? Washington, DC: US Department of Health and Human Services; 2006. http://bhpr.hrsa.gov/healthwork force/reports/behindrnprojections/index.htm. Accessed June 12, 2007.

(5.) DeLong DW, Mann TO. Stemming the brain drain. Outlook J. January 2003;1:39-43. http://www .accenture.com/Global/Research_and_Insights /Outlook/By_Alphabet/StemmingTheBrainDrain .htm. Accessed June 12, 2007.

(6.) Patton S. Beating the boomer brain drain blues. CIO Mag. February 3, 2006:1-4. http://www.cio.com.au /index.php?id=1594109736. Accessed June 12, 2007.

(7.) Ridge RA. A dynamic duo: staff development and you. Nurs Manage. 2005;36(7):28-34.

(8.) Benner PE. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984.

(9.) The Joint Commission. Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Oakbrook Terrace, IL: Joint Commission Re sources; 2007. http://www.jointcommission.org /NR/rdonlyres/5C138711-ED76-4D6F-909F-B06E03 09F36D/0/health_care at the crossroads.pdf. Accessed June 12, 2007.

(10.) Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. 1996. Clin Orthop Relat Res. February 2007;455:3-5.

(11.) Shirey MR. Evidence-based practice: how nurse leaders can facilitate innovation. Nurs Adm Q. 2006; 30(3):252-265.

(12.) Beyea SC. Why should perioperative RNs care about evidence-based practice? AORN J. 2000;72(1): 109-111.

(13.) Runy LA. Nurse retention: an executive's guide to keeping one of your hospital's most valuable resources. Hosp Health Netw. 2006;80(1):53-60.

(14.) Andrews DR, Dziegielewski SF. The nurse manager: job satisfaction, the nursing shortage and retention. J Nurs Manag. 2005;13(4):286-295.

(15.) Tanner CA, Bellack JP. Resolving the nursing shortage: replacement plus one! J Nurs Educ. 2001; 40(3):99-100.

(16.) McCartney PR. Leadership in nursing informatics. J Obstet Gynecol Neonatal Nurs. 2004;33(3):371-380.

Jim Smithers, RN, BSN, CNOR, is a a senior clinical analyst within the Information Systems Division of the University of Rochester Medical Center, NY.