Advancing beyond the system: telemedicine nurses’ clinical reasoning using a computerised decision support system for patients with COPD – an ethnographic study

Abstract

BackgroundTelemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses’ reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses’ clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated.MethodsIn this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis.ResultsWhen telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: “the process of telemedicine nurses’ reasoning to assess health change” and “the influence of the telemedicine setting on nurses’ reasoning and decision-making processes”. An overall theme, termed “advancing beyond the system”, represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses’ clinical reasoning process.ConclusionIn the telemedicine setting, when supported by a computerised decision support system, nurses’ reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses’ reasoning process. Nurses’ reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses’ reasoning process.

Tinkering and overruling the computer decision support system: Working strategies of telephone triage nurses who assess the urgency of callers suspected of having an acute cardiac event

“…Interactional dilemmas, earlier reported in the literature, are present in our study and described as the feeling of negotiating between the CDSS questions and the patient's narrative which may include diverse symptoms (Murdoch et al, ). In the few studies about interactional workability, which are not specifically about telephone triage nurses, the telemedicine setting both enabled and constrained the nurses’ reasoning and decision‐making (Barken et al, ; Murdoch et al, ). When the CDSS does not support the triage nurses’ decision‐making, this may lead to time delay, which worsens the patient's prognosis when having acute cardiac event (Rawshani et al, ).…”

“…In practice, triage nurses rarely use the recommendations from the CDSS in isolation. Instead, they combine and compare digital, clinical and subjective patient information to identify any conflicts (Barken et al, ; Dowding et al, ). The level of experience influences how nurses use decision support.…”

Knowledge to action framework for home health monitoring

“…16 Empowers patients self-management for better health outcomes, as they are able to recognize exacerbations at an earlier stage. 19 Evidence finds HHM increases knowledge and self-care behaviours. 20 Change management is required in the training of provider and patients to adopt to new technology.…”

Hvordan kan avstandsomsorg påvirke omsorgsforståelser?

“…En viktig forutsetning for avstandsomsorg er at de teknologiske innretningene som anvendes, blir anerkjent som like grunnleggende nødvendig for god omsorg som andre premisser for omsorg. Sykepleierne må derfor laere seg å se, lese og tolke brukerne på nye måter, gjøre faglige vurderinger og trekke slutninger på bakgrunn av nye typer data innhentet gjennom nye medier (Barken, Thygesen & Söderhamn, 2017;Lopriore et al, 2018;Pols, 2010;Pols & Moser, 2009). Kompetanseutvikling for å møte nye brukeroppfølgingsløsninger kan oppleves som en betydelig utfordring for helsepersonell.…”