A nursing domain model: Prevention of pressure ulcers
TABLE OF CONTENTS Chapter I: The Study Problem Introduction 1 Background 2 Patient safety 2 Clinical information systems 3 Pressure ulcers 7 Problem 9 Purpose 9 Aims and research questions 9 Significance to Nursing and Health Care Informatics 10 Conceptual framework 12 Definition of Terms 13 Assumptions 18 Limitations 18 Summary 18 Chapter II: Review of Literature Clinical Information System 20 Interface Terminology 22 Clinical Decision Support System 23 Nursing Domain Model 27 Pressure Ulcer Prevention 30 Summary 33 Chapter III: Method Content Analysis 36 Question One 37 Purpose 37 Planned analysis 38 Question Two 52 Purpose 52 Planned analysis 53 Question Three 59 Purpose 59 Planned analysis 60 Summary 63 Chapter IV: Results Research Question One 64 Assessment 66 Diagnosis 71 Outcome 71 Intervention 74 Summary 77 vi
Research Question Two 77 Pressure Ulcer Prevention Risk Factor Entity 78 Pressure Ulcer Prevention Skin Assessment Entity 82 Pressure Ulcer Prevention Diagnosis Entity 83 Pressure Ulcer Prevention Intervention Entity 86 Pressure Ulcer Prevention Outcome Entity 87 Nursing Domain Model for the Prevention of Pressure Ulcers 90 Summary 92 Research Question Three 93 Pressure Ulcer Risk Factors 94 Pressure Ulcer Prevention Skin Assessment 96 Pressure Ulcer Prevention Diagnosis 98 Pressure Ulcer Prevention Intervention 99 Pressure Ulcer Prevention Outcome 102 Summary 103 Chapter V: Discussion of Findings Implications for Nursing Practice 106 Implications for Nursing Informatics 110 Implications for Nursing Research 112 References 119 Appendices A. Knowledge-Based Nursing Initiative Risk for Pressure Ulcers in Adults in Acute Care Synthesis Document 127 B. Spreadsheets Used to Prepare Evidence-Based Practice Recommendations and Extract Concepts 136 C. Assessment Finding Concept Extraction Using ISO Standard 18104:2003 140 D. Diagnosis Concept Extraction Using ISO Standard 18104:2003 155 E. Outcome Concept Extraction Using ISO Standard 18104:2003 157 F. Intervention Concept Extraction Using ISO Standard 18104:2003 161 G. Pressure Ulcer Prevention Skin Assessment Entity 196 H. Pressure Ulcer Prevention Intervention Entity 199 I. Updated Pressure Ulcer Prevention Skin Assessment Entity 203 Curriculum Vita 209 vn
LIST OF FIGURES Figure 1: The Four Worlds of Information Systems Development 13 Figure 2: Reference Terminology Model for Nursing Diagnoses 48 Figure 3: Reference Terminology Model for Nursing Actions 49 Figure 4: Business View Model for Pressure Ulcer Prevention 55 Figure 5: Nursing Domain Model for the Prevention of Pressure Ulcers 90 vin
LIST OF TABLES Table 1: Summary of Extracted and Excluded Recommendations 44 Table 2: Spreadsheet Used for Pressure Ulcer Prevention Risk Assessment Entity 57 Table 3: Spreadsheet Used for Pressure Ulcer Prevention Skin Assessment Entity 57 Table 4: Spreadsheet Used for Pressure Ulcer Prevention Diagnosis Entity 58 Table 5: Spreadsheet Used for Pressure Ulcer Prevention Intervention Entity 58 Table 6: Spreadsheet Used for Pressure Ulcer Prevention Outcome Entity 58 Table 7: Clinical Information System Data Element Hierarchy Example 62 Table 8: Total Concepts Extracted from Recommendations 66 Table 9: Results of Concept Extraction Using Reference Terminology Model for Nursing Diagnoses 67 Table 10: Examples and Frequencies of Extracted Assessment Finding Concepts 70 Table 11: Examples and Frequencies of Extracted Diagnosis Concepts 71 Table 12: Examples and Frequencies of Extracted Outcome Concepts 73 Table 13: Results of Concept Extraction Using Reference Terminology Model for Nursing Actions 74 Table 14: Examples and Frequencies of Extracted Intervention Concepts 76 Table 15: Pressure Ulcer Prevention Risk Factor Entity 80 Table 16: Pressure Ulcer Prevention Diagnosis Entity 85 Table 17: Pressure Ulcer Prevention Outcome Entity 88 Table 18: Frequency of Skin Assessment Data Elements in Clinical Information System 96 Table 19: Frequency of Pressure Ulcer Intervention Data Element in Clinical Information System 100 ix
LIST OF ABBREVIATIONS ANA American Nurses Association CIS Clinical Information System CMS Centers for Medicare and Medicaid Services DM Domain Model EPUAP European Pressure Ulcer Advisory Panel EBPR Evidence Based Practice Recommendations HITECH Health Information Technology for Economic and Clinical Health Act IOM Institute of Medicine ICNP International Classification of Nursing Practice ISO International Organization for Standardization KBNI Knowledge Based Nursing Initiative NPUAP National Pressure Ulcer Advisory Panel UoD Universe of Discourse WOCN Wound Ostomy and Continence Nurses Society x
ACKNOWLEDGEMENTS I would like to thank my committee. First I would like to express my appreciation to Dr. Amy Coenen, chair of my dissertation committee, for her commitment to my study, and guidance, support and encouragement throughout my doctoral studies. I am also grateful to the members of my committee, Dr. Tae Youn Kim, Dr. Timothy Patrick, Dr. Norma Lang, and Dr. Beth Rodgers for their guidance, willingness to share their knowledge, and support throughout my dissertation process. I would like to thank my husband and son for their support and encouragement throughout this entire process. Your belief in me and patience helped guide me along this journey. Finally, I would like to thank my friends, who supported me with words of encouragement. Permission was received from the American National Standards Institute (ANSI) on behalf of the International Organization for Standardization (ISO) to use ISO standard 18104:2003 in this dissertation. No part of this material may be copied or reproduced in any form, electronic retrieval system or otherwise or made available on the Internet, a public network, by satellite or otherwise without the prior written consent of the ANSI. Copies of this standard may be purchased from the ANSI, 25 West 43rd Street, New York, NY 10036, (212) 642-4900, http://webstore.ansi.org The University of Wisconsin-Milwaukee Vice Chancellor for Research and Dean of the Graduate School authorized the use of the Knowledge Based Nursing Initiative Synthesis Document for the Risk of Pressure Ulcers in Adults in Acute Care for this research study. Authorization included this researcher to use, release to others, XI
reproduce, distribute, or publish, for non-profit educational and research purposes only, any portion of such work(s) which is original work of authorship. No part of this material may be copied or reproduced in any form, electronic retrieval system or otherwise, or made available on the Internet, a public network or otherwise without prior written consent. Permission was received from Prevention Plus to use the Braden Scale for Predicting Pressure Sore Risk. xn
1 Chapter I The Study Problem Introduction The use of evidence to guide nursing practice has been in existence since Florence Nightingale systematically collected data to track disease and mortality rates, and used these data to change the way nursing care was delivered to patients (McDonald, 2001). This trend continues today as evidence-based practice guidelines and recommendations are developed by nursing specialty organizations or government agencies to promote the best care for a specific patient population, procedure, or phenomenon of interest. Evidence-based nursing has been described as the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patients' preferences (DiCenso et al., 2004). Evidence-based practice guidelines are developed based on a synthesis of research and provide a framework for delivering and evaluating nursing practice. The use of evidence-based practice guidelines can decrease variability in practice, reduce cost of care, improve quality of care, and provide assistance with decision making by providing nurses with the best intervention options to consider (Dean-Barr, 2001). A variety of strategies have been used when implementing evidence-based practice guidelines into practice. Strategies have included incorporating evidence-based practice guidelines in policy, educating staff, and embedding evidence-based practice guidelines into a clinical information system. Once an evidence-based practice guideline is implemented in an organization it becomes a standard of care (Titler, 2008).
2 The Institute of Medicine (IOM) (2001) has identified the use of a clinical information system as one tool to improve patient safety. Specifically, the use of a clinical decision support system at the point of care has the potential to deliver information to the clinician based on the best available science thereby potentially improving patient outcomes (Berner, 2009). Implementing decision support systems in a clinical information system has the potential to bring evidence directly to the point of care and improve accessibility of information and thus impact quality of care. Many informatics technologies and tools are needed to bring evidence-based decision support systems into clinical information systems. This study focused on the development of a health informatics architectural technology, a nursing domain model, to represent the nursing science to support nursing practice for the prevention of pressure ulcers. Background Patient safety. Promoting patient safety is a major focus in health care today. Health care organizations' interest in nursing's impact on patients' health outcomes is increasing. The American Nurses Association, The Joint Commission, and the Institute for Healthcare Improvement have identified specific nursing practice outcomes that acute care settings should measure and improve upon. These are sometimes referred to as nurse-sensitive indicators or quality indicators and are used to indicate performance of nursing care. Nurses are obligated to measure performance and to improve patient outcomes (American Nurses Association [ANA], 2010). Measuring nurses' contribution to patients' outcomes is difficult. Nurses' documentation of patient assessments, diagnoses, interventions, and outcomes are not easily accessible in a format that is easily retrieved.
3 Clinical information systems. Clinical information systems (CIS) application features and functions are intended to support clinical care. CIS include electronic health records, data repositories, clinical decision support systems, interfaces, and standardized terminologies (Androwich et al., 2003). A CIS can be further defined as a "computer- based system that is dedicated to the collection, storage, manipulation, and presentation of all the clinical information important to delivery of patient care" (Sittig et al., 2002, p. 62). The CIS has the potential to support clinical decision making and improve patient outcomes (IOM, 2001). Nurses may encounter challenges when documenting the complexity of nursing care. Nursing documentation provides a written record of actual nursing practice. While paper records have been used for many years, data in paper records are difficult to locate and retrieve for reuse. Reports and test results can be easily misplaced or filed in an incorrect chart. Paper records often contain data that are illegible, inaccurate or incomplete (Hassett & Thede, 2003). In order to support nursing documentation, the CIS is able to improve legibility and quality of nursing documentation, organize patient data, and provide timely retrieval and reporting of data (Hassett & Thede, 2003). Research is ongoing to examine how features of a CIS support nursing practice and impact patient outcomes. Clinical decision support system. In the course of patient care, nurses make numerous clinical decisions. These decisions are sometimes made rapidly in response to patients' changing condition. Patients' outcomes are dependent on the decisions that nurses make. For example, if patients' pressure ulcer risk factors are not identified, prevention interventions are delayed and a pressure ulcer may develop during the course of hospitalization. An observational study by Currie et al., (2003) examined the
4 information needs of medical personnel using a CIS. During a one hour time period clinicians, on average, sought information eleven times. These results suggested that the information clinicians need must be readily available at the time needed. The internet provides a vast array of health care information which requires nurses to sift through for clinical relevance. In addition, health care organizations may provide policies and procedures in an internal information system, or worse they could be maintained in a paper format that may not be up to date. Both of these options require that nurses know where the needed information exists, has the time to access the information, and the time to perform the search. The use of a clinical decision support system can provide nurses with automated decision support through the use of a CIS. A clinical decision support system is defined as "computer systems designed to impact clinician decision making about individual patients at the point in time that these decisions are made" (Berner & LaLande, 2007, p. 3). According to Brennan (as cited in Abbott & Zytkowski, 2002), a clinical decision support system is a tool that can provide "nurses with strategies to analyze, evaluate, develop, and select effective solutions to complex problems in complex environments". The clinical decision support system can support, improve, expand, and enhance clinicians' decision making capability (Berner & LaLande, 2007) with intervention options that are evidence-based and may not have been previously considered. Clinical decision support systems have been developed in medicine to provide support for laboratory test orders, medication orders, and suggestions for potential diagnoses (Berner & LaLande, 2007). Clinical decision support systems can appear as alerts and reminders, order sets, documentation templates, or clinical guidelines
5 (Osheroff et al., 2007). Decision support available through these mechanisms has the potential to bring the best available evidence to nurses when it is needed. Interface terminology. The interface is the part of the clinical information system (CIS) that users can "see, hear, touch, talk to, or otherwise understand or direct" (Galitz, 2002, p. 4), and is arguably the most important part. The interface consists of two components: input and output. The input includes methodologies for communicating with the CIS, such as the keyboard and mouse. The output includes the display of the CIS computations and requirements, such as the display screen, layout, and terminology that appear on the screen (Galitz, 2002). Interface terminology is defined as the health care concepts used to support the entry of patients' health information into a CIS (Rosenbloom, Miller, Johnson, Elkin, & Brown, 2006). The interface terminology embedded in a CIS is often a standard application that does not support the requirements for documenting evidence-based practice. The use of free text can lead to unintended interpretation of clinical documentation by the reader. Interface terminology, represented as structured data, rather than free text, increases the accuracy and reduces the burden of data collection (Hardiker & Bakken, 2004). One solution is to build interface terminologies that support evidence-based practice. The development of clinical decision support systems can be accomplished by embedding interface terminology that represents and supports the concepts of evidence-based practice guidelines, in the CIS, using structured data entry fields. In this study, the terminology of a user interface in a CIS was examined. Nursing domain model. A clinical decision support system is composed of several important components, which includes the purpose, and structure, or architecture
6 (Greenes, 2007). In order for clinical decision support system to be successfully embedded in a clinical information system (CIS) and used, considerable attention should be given to its structure. It is suggested that data gathered during clinical encounters are either not captured in the CIS, due to barriers to data entry, or captured in a form that is only readable by the CIS. This creates data that may be accessible by nurses but does not provide more efficient use of data (Greenes, 2007). Improving the structure of the CIS can improve the quality of data for reuse. The Health Information Technology for Economic and Clinical Health Act (HITECH) includes several goals to promote implementation of electronic health records. One goal is the "meaningful use" of electronic health records to promote improved care through core objectives which focus on the collection of data and use of clinical decision support system. The HITECH Act requires the use of certified electronic health record technology, ensuring consistent standards which results in interoperability and increased exchange of health information (Electronic Health Record Incentive Program, 2010). Interoperability is the "ability to transfer data to and use data in any conforming system such that the original semantics of the data are retained irrespective of its point of access" (Qamar & Rector, 2007, p. 674). A nursing domain model (DM) provides a means of organizing and documenting data for embedding in a CIS. The nursing DM represents knowledge on a clinical practice area, and includes the people, places, or things related to the domain, and identifies how these components are related to each other (Dennis, Wixom, & Roth, 2006). A nursing DM provides a graphical view of the organizations data, similar to a blueprint (Bourke, 1994). The literature supports many different terms used to describe a
7 nursing domain model, such as domain analysis model, data model, entity relationship model, or detailed clinical model (Bernhart-Just, Lassen, and Schwendimann, 2010; Dykes et al, 2009; Goosen, 2008; Health Level 7, 2011; Kim, Harris, Savova, & Chute; Lu, Street, Currim, Hylock, & Delaney, 2009). For the purposes of this research study nursing domain model (DM) was used. A nursing DM is a model, used for organizing, capturing and storing clinical data in a CIS, which represents a nursing practice area or domain. The nursing DM focuses on nursing practice, and can be used to identify knowledge specific to nursing practice for the prevention of pressure ulcers. For the purposes of this study a nursing DM was developed that represented evidence-based knowledge on risk identification and prevention of pressure ulcers. In order to support the use and reuse of data for clinical decision support systems, and interoperability of systems a nursing domain model is necessary. Pressure ulcers. A pressure ulcer is localized injury to the skin which usually occurs over a bony prominence or vulnerable pressure point. It occurs as a result of unrelieved pressure or pressure combined with shear (National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel [NPUAP & EPUAP], 2009). Pressure ulcers can have a negative impact on patients. Researchers from two qualitative studies identified that pressure ulcers are painful, costly, and affect how individuals cope with activities of daily living (Hopkins, Dealey, Bale, Defloor, & Worboys, 2006; Spilsbury et al., 2007). The maintenance of skin integrity, or the prevention of hospital-acquired pressure ulcers, is important for patients and health care organizations. Identifying
8 patients at risk for development of pressure ulcers is an integral part of pressure ulcer prevention; interventions should be initiated based on identified risk factors. The prevention of hospital-acquired pressure ulcers is critical. As of October 1, 2008 the Centers for Medicare and Medicaid Services (CMS) will not reimburse hospital costs for select conditions which were not present on admission. In other words, costs for hospital-acquired conditions will not be reimbursed by CMS. According to CMS, Stage III and Stage IV pressure ulcers are non-reimbursed hospital acquired conditions. This ruling by CMS has potential to encourage hospitals to focus on the prevention of hospital acquired conditions. The National Database of Nursing Quality Indicators, established by the American Nurses Association, has also identified the prevention of pressure ulcers as a nursing-sensitive indicator (Montalvo, 2007), meaning that pressure ulcers are a measure of the quality of nursing practice. In addition, the Quality Measures Workgroup, a subcommittee of the Health Information Technology Committee, has recommended that the measure (occurrence and treatment) of pressure ulcers are a quality measure for Meaningful Use, Stage 3. The proposed measures include Braden Scale score, intervention and prevention treatment plan, and presence of pressure ulcer on admission (Quality Measures Workgroup, 2011). The impact for health care organizations is to ensure that the data entered into the clinical information system is clear and concise. A nursing domain model developed based on evidence-based practice recommendations can assist with capturing the data necessary for recommended quality reporting.
9 Problem For nurses at the point of care, clinical information systems (CIS) have potential to provide decision support based on evidence-based practice recommendations (EBPR). In order for the clinical decision support system to meet its potential the use of a nursing domain model (DM) can provide the architecture necessary to support nurses' decisions at the point of care when needed. Clinical decision support systems can be used to identify patients at risk for the development of a pressure ulcer, recommend prevention interventions, and recall patients' past treatment preferences. For researchers, the CIS can provide a rich source of data, on pressure ulcer risk factors and prevention interventions, to improve patients' health outcomes. Purpose The overall purpose of this study was to develop and evaluate a nursing domain model (DM) for the prevention of pressure ulcers. Aims and research questions. Aims and research questions of the study included: 1. Develop an evidence-based nursing DM for the prevention of pressure ulcers. This aim was addressed with two research questions, and resulted in a proposed nursing DM for the prevention of pressure ulcers. a. What concepts represent evidence-based nursing practice for the prevention of pressure ulcers? b. What nursing DM best represented the evidence-based practice recommendations for prevention of pressure ulcers?
10 2. Examine an existing CIS for the concepts and relationships derived from the evidence-based practice recommendations for the prevention of pressure ulcers. This aim was addressed with one research question and resulted in the analysis of how a CIS used by nurses supports, delivers, and represents prevention of pressure ulcer evidence-based content for nursing. a. How are concepts from the nursing DM for the prevention of pressure ulcers represented in a CIS at the user interface? Significance to Nursing and Health Care Informatics The findings of this study contributed to the science of nursing in several ways. First this study identified an evidence-based nursing domain model (DM) for the prevention of pressure ulcers for adults in an acute care setting. Second, the researcher identified how the evidence-based concepts for the prevention of pressure ulcers, including their structure and relationships are represented in a clinical information system (CIS). Third, this study identified the gaps between the evidence-based nursing DM for the prevention of pressure ulcers and representation in a CIS application to evaluate the DM and make recommendations for future CIS development. The prevention of hospital acquired pressure ulcers is important to nurses. The incidence of pressure ulcers in the acute care setting ranges from 0.4 percent to 23.9 percent, according to the National Pressure Ulcer Advisory Panel (NPUAP) (Lyder & Ayello, 2008). A recent report by the Agency for Healthcare Research and Quality examined the patterns and costs of adult hospitalized patients with a pressure ulcer (Russo, Steiner, & Spector, 2008). The 2006 data from this report found adults with a pressure ulcer in a hospital setting incurred health care costs totaling $11 billion dollars.
11 In addition, a 78.9% increase in pressure ulcers has occurred since 1993 while the total number of hospitalizations only increased by 15% during the same time period (Russo et al., 2008). This financial burden can impact health care organizations. It is important to note that estimates for the cost of preventing pressure ulcers or measuring pressure ulcer prevention interventions could not be found in the literature. The use of evidence-based practice recommendations (EBPR) can guide clinical practice and support consistency in nurses' practice, which can result in decreased health care costs and improve health care outcomes for patients (Dean-Barr, 2001). The EBPR used in this study can support nurses' decision-making for adult patients who are at risk for the development of pressure ulcers. The EBPR can also be used to develop clinical decision support systems in a CIS. In order to develop clinical decision support system a nursing DM is necessary. The nursing DM has several benefits for nurses, which include providing consistency with data, or concept clarity; improving the quality of data that is entered; and supporting the development of the interface terminology (Huff, Rocha, Coyle, & Narus, 2004). These benefits can support the reporting of data to organizations, such as the Centers for Medicare and Medicaid Services, nursing research, and data mining. Embedding EBPR into a CIS using a nursing DM will enable best evidence to be available to nurses at the point of care, thereby supporting clinical decision making. Interface terminology based on evidence can support the development of clearly defined concepts that are relevant to the risk and prevention of pressure ulcers. Increased clarity of nurses' documentation can inform other disciplines and impact patient care.
12 Conceptual framework The conceptual framework that was used to guide this study was adapted from the four worlds involved in the development of information systems, originally introduced by Jarke, Mylopoulos, Schmidt, and Vassiliou (1992) (Figure 1) and further defined by Halpin and Morgan (2008). The four worlds included: subject, system, usage, and development. The subject world, also known as the universe of discourse (UoD), represents the application area being modeled. The UoD needs to be clearly described to provide a good understanding of the world that is being modeled (Halpin & Morgan, 2008). In this research study the UoD were the EBPR for the prevention of pressure ulcers. The system world was the data model that represents the UoD (Halpin & Morgan, 2008). In this research study a nursing domain model (DM) was developed from the concepts and relationships extracted from the evidence based practice recommendations (EBPR). The usage world is the organizational world where the information system functions, and includes system users, interfaces, and activities (Halpin & Morgan, 2008). This research study examined the interface terminology in a clinical information system (CIS) application for representation of the nursing DM concepts for the prevention of pressure ulcers. The development world includes the environment and processes used to develop the information system (Halpin & Morgan, 2008). In this study the development world was not examined. It was not the purpose of this study to examine how the CIS was developed. Instead this study developed a candidate nursing DM based on evidence- based practice recommendations for the prevention of pressure ulcers. Further, the process of developing the nursing DM was an outcome of this study.
13 _ , . / Subject World \ System / ' _ , *• —i _ 1 E B P R f or / ,-'" \ Prevention of / \ \ / / \ Pressure Ulcers / \ ^ / f /System World \ / , X - T ~ / X V l I \ Domain Model \ \ / Development \. u World ^ ^ i for the \ Prevention of - \Pressure Ul cer s/ I Usage World CIS concepts and \ • v^j interface W ^ terminology for / the Prevention of x JPressure Ulcers, Figure 1. The Four Worlds of Information Systems Development Note. EBPR=Evidence Based Practice Recommendations; CIS=Clinical Information System Adapted from "DAIDA: An Environment for Evolving Information Systems," by M. Jarke, J. Mylopoulos, J. W. Schmidt, and Y. Vassiliou, 1992, ACM Transactions on Information Systems, 70(1), pp. 1-50. Definition of Terms Definition of terms used in this study are presented in this section. These terms include: clinical information systems, concept, data rule, domain model (nursing domain model, and nursing science), evidence-based practice recommendation (assessment, diagnosis, intervention, and outcome), interface terminology, pressure ulcer, and universe of discourse. Clinical information systems (CIS). Clinical information systems are the application features and functions that are used to support clinical care. They include electronic health records, data repositories, clinical decision support systems, interfaces,