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Give Some Love to Nurses Who Don’t Love Computers: Why Nerd-Designed Clinical Systems Are Underused

April 9, 2008 News 12 Comments

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly "Best Of" series for HIStalk. This editorial originally appeared in the newsletter in May 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

In working with nurses for many years. I’m always amazed by two things: (a) they are shockingly caring and helpful to complete strangers who are experiencing pain, fright, and human emotion and I love and respect them for that; and (b) they are terrible computer users.

Before the nurse readers of Inside Healthcare Computing rise en masse to lynch me, allow me to present my flimsy, anecdotal evidence. I’ve known at least 500 nurses over the years, many of them in informatics or IT roles. I’ve yet to see more than a handful who are good computer users and no more than a couple who can program or fix hardware and software problems.
Watching them navigate through complex clinical applications is like watching your kid play tee-ball from the stands – we nerds try to help them with muttered urgings (“Press Alt-Tab … Alt-Tab”) or subtle body English. It doesn’t come natural.

The part of the brain that makes a great nurse has some sort of limbic dominance over the nerd center of the brain. That’s not the case with lab techs, pharmacists, physicians, or most other healthcare professionals. It’s not good or bad, it just is.

In  short, there are few geek nurses, which is great news if you’re a patient who needs comforting or complex clinical care. Do you want a nerdy programmer or network engineer inserting your urinary catheter?

Who are the main users of our clinical systems? Nurses. Who designs their systems? Nerds, with occasional help from nurses (usually formerly practicing nurses with a little more of the nerd center, actually.)

I can’t think of any other industry where the front-line workers (and darned busy ones at that) are expected to interact at a high level with computers at all times. Lawyers, professors, artists, executives, and salespeople don’t. Maybe we’re asking too much for good nurses to be good computer users, too.

That’s where software design comes in. We’re still installing software that assumes that end users know and love the programmer’s way: poorly designed screens, unhelpful edits, and workflow that doesn’t match reality.

A just-released study found that routine overrides policy: 44% don’t always follow the two-identifier rule and a fourth of ICU nurses give critical meds without a double check. I suspect we don’t want to know how often nurses fail to chart meds electronically, clear their work lists, or reconcile orders.

While IT people sit in meetings and see policies in black and white (just like the absolute right and wrong of computer programming,) nurses are out there caring without much of a safety net. They often don’t know or remember the rules; sometimes they break them because it makes sense.

I’m not blaming nurses. If you asked programmers to suddenly start taking care of their co-workers when they’re sick, you get the idea.

Systems being sold today require too much training and computer savvy to ever expect a large body of nurses to master. They are not usability tested or certified against a panel of typical nurses. Not surprisingly, they aren’t particularly well used, either.

Rewriting old applications to make sense to nurses isn’t easy or cheap. It isn’t even necessary, since the bar hasn’t been set all that high. Still, I can’t help but think that the lack of clinical system success will eventually be tracked back to sub-optimally designed applications, which might spur at least one vendor to market a system that thinks like nurses, is easy to use, and doesn’t require compromising workflow. That’s what I’d like to see.

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Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update.  To subscribe, please go to:  https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

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Currently there are "12 comments" on this Article:

  1. Couldn’t disagree with you more. I’ve watched many thousand nurses through the years do this just fine. Just like they use email, Excel, Word and the Internet for a variety of tasks. I think it may be affected by the type of hospital you work in. When you’re in a major medical center, most nurses are pretty tech savvy these days. Today, even in smaller community hospitals, they seem to do pretty darn well.

    I think nurses like all of us struggle with computers in general — computers are wha they are -> Better than paper, but not perfect.

    And, what really makes users cranky is that the computer represents ultimate accountability – every thing you do is now time / date / user stamped. Everyone can tell exactly who did what / documented what and when. And if you’re supposed to do bar code meds and you don’t, they know that too. You didn’t follow protocol, now everyone can see it.

    You talk about suboptimal design, but there should be some accountability here at home. Some of those designs get complex because there are more variants on the workflows that no one ever wants to give up than you could imagine. Even more intense when you get to physicians and CPOE. Look around at how many sites do order sets per doc still.

    This isn’t about nerds and nurses… this is about change. It’s reasonable change, and there are some systems out there like Epic and Eclipsys that get the job done for people in a reasonable way.

    The people that struggle every day of their career to find an easier way to help nurses shouldn’t be looked down on as idiots. If there was a trivial solution to this problem, we’d have found it by now. And the nurses who struggle to adapt need support at the point of care, not one more reason to reject the change.

    When you think about your kid, wife or mom in that hospital bed, I think most of us hope the nurse takes that very reasonable step and uses the computer. It makes a difference.

    And when did the “programmer’s way” definition turn out to be “poorly designed screens, unhelpful edits, and workflow that doesn’t match reality”.

    You’re just firing for effect. Maybe too many deadlines and demand on your time to do a thoughtful and responsible job writing about things that could make a real difference. A writer’s version of a programmers hack?

  2. I think you have not seen a broad enough population of informatics nurses… and as you say your suppositions are based on ‘flimsy antidotal evidence’ and thus should be taken with a grain of salt.

    Nurses are not terrible computer users, it’s just as a profession, the computer is yet another thing that comes between us and patient care. Thus we naturally avoid it and pretend it’s not there so we can focus on what we are there to do – provide nursing care.

    I sincerely disagree with your inferring that the parts of the brain that make a good nurse does not make them computer literate or suitable for a Nursing Informatics role. Nurses are Analytical (they collect data on their patient to determine what the problem is), they develop a care plan (flowchart / project plan with measurable goals and objectives to finalize in a “go live”) similar to the nurse doing discharge planning culminating when the patient leaves the hospital. They re-asses their patient constantly through this and modify their care plan (debugging and rewriting code) to assure that its optimized to provide for the earliest possible discharge (just like meeting the insurance agencies and federal compliance – they make sure that system resources are not exceeded and the plan (code) is optimized to be as streamlined with as least steps as possible to achieve the goal. – as you can see I find a lot of similarities to nursing and the informatics process.

    As for systems being too complex and nurses not being savvy… Many of us read 12 lead EKG’s and can diagnose a cardiac arrhythmia as well as the physician. Many of us calculate multiple medication dosages and drip rates and program IV pumps, analyze lab results for trends and make sure that the “good nurse saves the bad doctor”. We just haven’t been given the opportunity for learning the basic skills which are the foundation for learning the application. Many nurses don’t get their administration to allow basic computer classes and confidence before they have to learn the app… thus they go in cold. Sort of like taking a hang glider and giving them a couple lessons on an F16 and expecting them the next day to dogfight!

    Keep in mind… nurses know how to asses and intervene on problems and correct those to bring the most complex system back into operational health – the human body. It’s just that they spent 2 to 4 years or more studying chemistry, math, physics, anatomy and physiology and pharmacology rather than cobol, assembler, perl, java and windows OS and analog circuits.

    In my example, I am an RN and EMTP (Paramedic). I have been an EMT since 85, Medic since 87, Nurse since 91 and worked in the ER until 89 when I became a Systems Analyst in a Clinical Informatics department. All computer knowledge was self taught.

    Incidentally, at my job interview I was asked how a nurse could possibly be expected to have learned IT from books without having a networking lab or systems to test and practice on…. My answer was that compared to IT folks that have to test it all out and set it up to work in the lab first…. we don’t have that luxury as a nurse and our learning method is basically” Read One”, “See One”, “Do One” and then they know how to do it on a real body. We don’t have a test lab of bodies at home to practice on. I got the job.

    As for writing applications that make sense to clinicians… I believe strongly that you cannot easily take an IT person and teach them nursing and expect them to think like a nurse. You can, in my opinion and experience, take a nurse and teach them to think like an IT person. These are the people who should be directing the development of Clinical Applications. A nurse who has moved from mainstream nursing / patient care to Clinical Informatics Nursing – still a nurse, but working with clinical informatics systems and process.

    I wrote a clinical portal application that was used in our institution for a number of years with 75,000 to 100,000 hits a day looking up patient information in a half dozen clinical systems with oracle, SQL and other back end databases. A simple Apache web server, perl programs written with CGI scripting and ODBC connections to the databases. Made it simple and kept it simple and it worked.

    I program in PERL, tried Java but haven’t had time for formal classes. I know the databases to our clinical apps that I can dream out the schema of complex SQL’s overnight and come up with the code the next day. I can hand code HTML. I can do just about any hardware mod on a computer and have built most of my own since the IBMPC I first bought in 1981 – had to drive 500 miles to get it. I have at least a dozen web sites (of course servers in my study with static IP addresses, a home wifi network) a half dozen blog sites. 20 or so listservs.

    As for nursing skills, I am CPR, ACLS, PALS, ATLS certified with being an instructor in the past in all of them. I can run a code with the best of them, I have intubate patients, put intraosseos lines, done needle thoracotomy’s – and yes, have a very good technique passing urinary catheters. I have in the past also been a lab technician in research and published dozens of papers in academic journals, I have worked as a clinical lab tech in pathology and as a diener and did over 300 Autopsies with the pathologist over a couple year period.

    end of my point is…..

    There is a need to take clinical people and groom them for the IT field. They must be taken under the wing and given the time and the skill set and you will much more easily take that clinical person and give them the IT skills that they will be able to develop tremendously useful and end-user friendly applications. They may not necessarily write every piece of code, but they should lead the project team and oversee it!

    As for my long response… “Lord, I apologize for that right there, and please be with the starvin’ pygmies down there in New Guinea, A-men”

  3. Kudo’s to you for your insights & empathy. While it’s frustrating to think there has been money, time, & resources spent not only in R & D & validation efforts, but also training for implementation & post go-live support, the truth is….these systems overall are not user friendly & do negatively impact workflow. When activities can be performed with charting and checks & balances occuring without user input, then we’ll have incredible improvements in patient safety, staff satisfaction, patient satisfaction, & decreased costs from errors! Give me smart technology: automatic identifications and rules engines driving changes built on true analytics and decision support vessels for the populations they serve.

  4. This is a very interesting thread, and I believe it illustrates the formative years of IT. In the beginning we had to have geeks running the IT show because of the complexity and novelty of the applications.

    Now as IT and computing tools become more mainstream and easier to use they will become what they were meant to be…TOOLS. We all use a hammer right? We don’t bring in a hammer specialist when we hand to hang a photo.

    Oh yes, we will still bring in a contractor for those larger jobs, but I can imagine a day not too far into the future where we will be watching a TV show on the Home Computer Network Channel called This Old Network, where craftsmen geek IT people will show the handymen and do-it-yourselfers just how to create a well crafted database application.

  5. After 10 years of technical experience including programming, I went to nursing school. I graduated with honors and went to work in a specialty area. I was astonished by the workflow. Nurses are able to analyze and continuously reassess changing data points throughout the day on 2-10 patients. There is no linear thinking. Everything is a continuous barage of data, filtering into levels, of STAT, asap, and routine. There are scheduled meds and meals, and unscheduled physician visits and code emergencies. On top of this I was treated like a second-class citizen by the physicians. I could not wait to get back to a desk with a lamp and a chair.

    I enjoy my role as a clinical systems analyst now. One of my challenges is bringing nurses into the nerd pack. New nursing clinical analysts have to be taught to focus on the data and to follow the problem through from point A to point Z. Don’t go off on tangents, but follow a linear and logical path through the data. The ability to focus on one problem and methodically follow it through can be taught, but most experienced nurses don’t bring it to the table. They are used to absorbing data from a dozen different directions and simultaneously prioritizing and processing each path. They do this all with efficiency and grace even though they are treated with little respect from their physician colleagues. Show them the path, give them some respect, and be amazed by the results.

  6. While we can go back and forth on the correct combination of talents to build and install a clinical information system, the main point is that it must be a combination. It takes a floor nurse with years of bedside experience to know what will and will not work on the floor. It takes an IT person to provide the infrastructure to make it work where and when the nurse needs it. Nurses and Nursing informatics folks can bring the real world know how to the screens and flow. Techs can make it happen at the bedside, at the desktop, on the tablet and make it happen fast enough to keep the clinicians work flow going. If either is done in a silo without the input of the other, disaster waits right around the corner. Successful implementations dedicate the appropriate resources from both worlds and make them sit together until they understand (even a little) of what the other brings to the table. We need both areas of expertise because the folks who can walk in both worlds successfully are a rarity.

  7. You can’t diagnose what you don’t measure; you can’t nurse what you can’t measure; you can’t treat what you can’t measure. The unifying element in all three statements is patient data; a temperature, a medication, a glucose value, etc.

    I did not realize that Mr. H’s conciliatory olive branch article would receive such retort. It almost appears that there were a few “ringer” bloggers responding. But let us face the facts. How close are we to the electronic transformation of healthcare in America? It is the responsibility of the physician, or maybe the nurse and maybe hospital administration. Or maybe all our electronic problems (vendors call them opportunities) in healthcare delivery can be accomplished by putting the burden of documentation of care on the patient.

    Furthermore, might I propose only to diffuse the quasi-hostility and say that the “patient’ might want to consider a physician-style “scribe” and have the patient scribe admit with every patient to document every element of care for the patient and let the physicians and nursing staff do their things. Of course, if you cannot afford a scribe, a public scribe will be appointed to you.

  8. Kudos to Been There, Done Both. I have never heard of an IT person becoming a clinician. It is always formal healthcare training, clinical practice, and pick up IT along the way and/or go to school for IT. Churton hits it dead on. We need more clinicians to come to the IT side, and be mentored. Clinicians do have a hard time focusing on one line of thought because we are trying to do ten things at once. If you ask a nurse when she has an IV bag run dry, it is when she only has one patient with an IV. I dare say we need to have a barrage of information to function. That’s why we became nurses!

    Alchemist, care delivery is an art. It should be a best practice driven, defined, and measured art, but it is an art. The variables you describe are discrete data forms. That is only the tip of what we do. Documentation needs to be done and preferably in a way that you can mine the data for information to make decisions, or at least spot and analyze trends. THAT is where today’s clinical systems fail. How does what we document impact what happens to the patient? Is it enough to document what we do (interventions) or is what happens as a result of what we do (outcomes) more important? If someone creates a clinical system that is relevant to the patient improving in every clinical area (even with hospice, there are measurables, just different goals or outcomes desired) then you would have complete clinician buy in… Wouldn’t you?

  9. I don’t think IT is to blame for many of the troubles with nursing documentation. The regulated environment that we live in plays a large part. It’s hard to fit the hundreds of completely useless pieces of information that a nurse is required to document into a concise area. And how did they figure it out on paper? They didn’t, they wrote it wherever it fit. It may be easy to document, it’s impossible to read afterwards.

    On a related note: unfortunately, one of the things I’ve found is that nurses are real good at documenting the things I as a patient don’t think are too valuable (ie I got a granola bar at 5 o’clock and Aunt Sally came to visit at 9) and real good at ignoring some of the safety measures a system brings. If there’s one thing I want my nurse doing, it’s not educating a person with emphysema about the dangers of smoking or educating an obese person about healthy diets, I want them being diligent about things like barcoding meds. It kills me everytime I see a nurse skip the barcoding or give a half glance at an insulin dual signoff. In an ideal world, nurses could skip documenting the junk and I’d promise not to sue them because they didn’t give me the Jell-O I asked for.

  10. I am the Director of User Experience Design for a major HCIT vendor. This is a new role in a company who traditionally developed products as the author indicates: by engineers with clinician oversight. Today we bring Ethnographers, Interaction Designers and Industrial Designers to the table and put the end user at the very center of our process. As expected, our return on usability is in the hundreds of percent vs. the previous process, and clinicians love us for it.

    Unfortunately it’s too easy for developers to “train and blame” clinicians. But designers look at the situation differently: the nurse is never wrong. We leverage “constraint-based design” to design-out error, eliminate the need for training, and reduce the gulf that exists between human behavior and system behavior. The proof is quantifiable both in the usability lab and in our bottom-line.

    For those interested in learning more about this User-Centered approach, I highly recommend reading Alan Cooper’s excellent book “The Inmates are Running the Asylum.”

  11. As a practicing RN, who stopped working on an MSN degree to complete a second major in computer science – I thouroughly enjoyed the original article and everyone’s responses. The computer science world includes analyzing, assessing, planning and implementation – just like nursing process. However I have learned that my mind does not behave like my development engineering colleagues – I have had to learn from them the skill of thinking in a more linear fashion – not an easy task. I have also, however ,waited over 25 years for IT to finally be addressing technology that supports care delivery and not registration and billing. Development and use of technology by nurses requires a fine line between pushing nurses to think in a different manner(needed as we are very good at normalizing workarounds!) while providing them tools that can dramatically impact the cost, quality and delivery of healthcare whilte preserving their desire to take care of the patient.

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