texa s nu r s e s .o rg
TEXASNURSING M A G A Z I N E
TECHNOLOGY
The Good, The Bad, The Unknown
T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | I s s u e 4 , 2 0 2 3
ISSUE 4, 2023 Volume 97, Number 4 EDITOR IN CHIEF: Serena Bumpus, DNP, RN, NEA-BC MANAGING EDITOR: Lisa Maxwell COPY EDITORS: Gabi Nintunze, Natalie Hill
BOARD OF DIRECTORS OFFICERS: Joyce Batcheller DNP, RN, NEA-BC, FAONL, FAAN, President jbatcheller7@yahoo.com Amy McCarthy, DNP, RNC-MNN, NE-BC, President-elect amccarthyrn@gmail.com
4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648
Gloria Lorea, DNP, RN, NEA-BC, Treasurer glorialoeradnp@gmail.com
tna@texasnurses.org | texasnurses.org
Missam Merchant, MBA, BSN, RN, CENP, CCRN-K, PCCN, CV-BC, GERO-BC, MEDSURG-BC, NE-BC, Secretary sam.merchant2017@gmail.com
MISSION Empowering Texas Nurses to advance the profession
DIRECTORS: Jose Alejandro, PhD, RN, NEA-BC, MBA, CNE, FACHE, FAAN - Dallas josealexrn@gmail.com Patricia “Pat” Francis-Johnson DNP, RN, CDP – Lubbock patricia.francis@ttuhsc.edu
VISION
Edtrina Moss, PhD, RN-BC edtrina@comcast.net
Nurses transforming health TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg. 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas. One-year subscriptions: $30 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $35; single copy $3.00. Subscription is not available to non-member Texas nurses. Some back issues may be viewed online at texasnurses.org. PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries: call Chellie Thompson at 512.293.9277. TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index. 16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044. Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg. 3, Suite 100, Austin, TX 78759-8444. ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org. Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you. FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org. Copyright 2023 © Texas Nurses Association
T E X A S N U R S I N G M AGA Z I N E | I S S U E 4 , 2 0 23
Brandon “Kit” Bredimus, DNP, RN, CEN, CPEN, CNML, NE-BC, CENP, NEA-BC kit.bredimus@midlandhealth.org Mary Vitullo, MBA, MSN, RN-BC, PCCN, NE-BC, CLSBB vitullo.mary@yahoo.com CHIEF EXECUTIVE OFFICER: Serena Bumpus, DNP, RN, NEA-BC sbumpus@texasnurses.org
TNA DISTRICT PRESIDENTS Dist. 1:
Jackeline Biddle Richard, DNP, JD, RN, CNE, jackie.richard1@icloud.com
Dist. 3:
Christopher Rougeux, MSN, RN, crougeux99@gmail.com; District office: Jamie R. Rivera, JamieRivera@texashealth.org
Dist. 4:
Alaina Tellson, PhD, RN, CLNC, NPD-BC, NE-BC alaina@tellson.net; tnad4.nursingnetwork.com; District Secretary Lori Batchelor, batchelorb@prodigy.net
Dist. 5:
Chelsea Vaughan, RN, chelseareneevaughan@gmail.com, tna5.org
Dist. 7:
Connie Barker, APRN. PhD. FNP-C, crbarker1@yahoo.com, tnadistrict7@gmail.com
Dist. 8:
Nelson Tuazon, DNP, DBA, RN, NEA-BC, FNAP, FACHE, FAAN, nelsonactuazon@gmail.com
Dist. 9:
Marco Ollervides, MSN, RN, marco.ollervides@memorialhermann.org District office: Melanie Truong, RN, Executive Secretary, tna9@tnadistrict9.com, tnadistrict9.com
Dist. 17:
Mari Cuellar, NEA-BC, MSN, RN, mari.cuellar@christushealth.org
Dist. 18:
Rebecca Clark, DNP, RN, CNE, MEDSURG-BC, rebecca.clark@ttuhsc.edu
Dist. 19:
Dixie R. Rose, RN, dixiegtc@gmail.com
Dist. 35:
Karen Koerber-Timmons, PhD, RN, CLNC, CNE, NEA-BC, CCRN, RN-BC mkkoerbertimmons@gmail.com
At-Large: Contact TNA, 800-862-2022, ext. 129, brichey@texasnurses.org
Issue Credits: Page 3 photo by Adrian Regeci; page 18 photo by Luke Chesser, Unsplash
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Innovate to Educate
The Good and Bad
of Wearable Health Technology
Emerging Technologies in Nursing Education
Calling for Bold Action to Address the Negative Impact of Technology on Nurses
14 14
10
Contents IN EVERY ISSUE
5 PRESIDENT’S NOTES You and Technology
6
ARTICLES AND FEATURES
8
21
TNA NEWS
DO'S AND DONT'S OF DEFENSIVE DOCUMENTATION
Remembering Elizabeth Sjoberg, JD, RN
Protect Patients and Your Practice Using These Tips
TNA MEMBER NEWS
Read on the Go: View this issue and past issues of Texas Nursing in the Texas Nurses app for iPhone and Android. Sign in with your TNA login for free access.
IS YOUR ONLINE PROFILE UP-TO-DATE? LOG IN AND CHECK!
Kudos
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I S S U E 4 , 2 0 23 | T E X A S N U R S I N G M AGA Z I N E
Join us in San Antonio May 30-June 1
Keynote speaker: Rebecca Love RN, MSN, FIEL
TRAIN TODAY. LEAD TOMORROW. SERVE ALWAYS.
BECOME AN AGGIE NURSE.
Keynote speaker: Kim Carpenter - Leadership Coach
Join hundreds of Texas nurses in San Antonio for TNA’s Annual Conference. We’ve already got great speakers lined up and continue to add more! We’ve also increased the number of poster and podium presenters - so be on the lookout for the call for abstracts. The discounted hotel rate is extended through the weekend, so bring your family and top off your excellent conference experience with a mini vacation!
Early Bird Registration is just $300 (Ends March 15, 2024) The 2023 event sold out. Reserve your spot today!
nursing.tamu.edu
@tamunursing
T E X A S N U R S I N G M AGA Z I N E | I S S U E 4 , 2 0 23
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President’s Notes Joyce Batcheller DNP, RN, NEA-BC, FAONL, FAAN
YOU AND TECHNOLOGY
Shaping the Future of Health Care EVERYWHERE WE LOOK nurses have opportunities to make change. If we capitalize on our past experiences and forecast what people need for care and what we can do best, imagine what is possible! I am going to focus on one aspect of future change—technology, by asking you three questions. What do YOU most commonly think of when you hear the word “technology?” From my experience, most nurses think about the electronic healthcare record and the overwhelming documentation requirements. This experience resulted in many of us being skeptical about other technological advances. The costs of implementing and sustaining the electronic healthcare record add to the financial pressures organizations are dealing with. Although companies are collaborating with clinicians to develop solutions to the problems, we have not seen effective and timely solutions. What do YOU need to know about technology? Obviously, most of us already know a lot about technology because most of our work involves complex equipment. Yet, we need to expand our knowledge and involvement as companies design innovative technologies. Nurses work across the continuum of care and can provide a comprehensive viewpoint of how to improve efficiencies, decrease costs, and improve outcomes. Without our voices, patients’ experiences may go unheard and their needs unmet. Nurses are adopting telehealth to provide healthcare remotely and improve access, communication and coordination of care, especially for people
Nurses work across the continuum of care and can provide a comprehensive viewpoint of how to improve efficiencies, decrease costs, and improve outcomes. who may live in areas underserved by various healthcare providers, including nurses. Many clinics provide virtual care visits because people only need a smartphone, computer or tablet and a comfortable, private place to sit. People are embracing virtual visits, including for mental health services, which might not be available otherwise. In an acute care setting, a nurse may work with someone virtually to provide nursing care in select processes, such as admissions and discharges. Some nurses work remotely with a nurse or a physically present nursing team to provide care. The remote nurse often is the most experienced, knowledgeable member of the team and is available to guide care or serve as a mentor or resource. Sometimes, a member of the nursing team is the technology. A robot may be a member of the nursing team, and depending on the robot, may simply provide services such as supply retrieval or may be the personal comfort “assistant” in the absence of a human. How can YOU help shape technology for the future of healthcare? The simple answer is get involved. Become curious about different technologies your organization may be investing in. Ask questions:
“How much can these investments help to decrease inefficiencies related to hunting and gathering and
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improve the work environment and staff satisfaction?” or
“What hospital care do you think will shift to being provided in consumers’ homes?”
“What impact are these changes having on patient outcomes, costs, and overall satisfaction?”
As consumers of healthcare, we can become early adopters of personal health apps and wearable devices and provide feedback on what is working, not working, suggest ways to improve a particular product, and volunteer to serve on an expert panel in the business. Currently, there is a lot of discussion and different viewpoints about the potential benefits, as well as the ethical, legal, and patient-privacy risks associated with artificial intelligence. At the same time, think about the possibilities artificial intelligence and other rapidly growing technologies could provide. No business is likely to stop moving forward. Our challenge is how to become engaged in the forward movement so we are most effective at working with technology to shape the future of health care. i
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TNA MEMBER NEWS SPOTLIGHT ON YOU KUDOS Kristin K. Benton, DNP, RN, has been announced as the Executive Director of the BON, effective September 1, 2023.
Dru Riddle Ph.D., DNP, CRNA, FAAN was appointed by Governor Greg Abbott to the Texas Board of Nursing for a term, effective September 1, 2023.
Sheranda Fesler PhD, RN, RNC-NIC, NE-BC, CPHQ, CPPS, FNAHQ was inducted as a Fellow in the National Association of Healthcare Quality. Bradley Goettl-Ng, DNP AGACNP-BC, ENP-C, FNP-C, CFRN, FAANP, FAEN, FAAN was inducted as a Fellow in the Academy of Emergency Nursing. Shawntay Harris, MBA, MSN, MBA RN, NEA-BC, TCRN, CPEN, CEN, CFRN, CTRN, FAEN was inducted as a Fellow in the Academy of Emergency Nursing.
Arturo Rodriguez, DNP, MPH, CPM, has been designated to serve as Chair of the Task Force of Border Health Officials. The Vietnamese University of Medicine and Pharmacy at Ho Chi Minh City (Saigon) conferred the title of Professor Honoris Causa on Dr. Kay Avant for her contributions in training, scientific research and community service. Congratulations to the following members for being named to Becker’s Hospital Review list of CNO’s to know:
Amber High DNP, CRNA, NC-BC, won the AACN’s Excellence in Advancing Nursing Practice Award for her project on peer support and QI.
C. Andrew Martin, DNP, MS, RN, CNE, ACRN, CHPN received the Peg E. Daw National League for Nursing Certification Star Award. Missam Merchant, MBA, BSN, RN, CENP, CCRN-K, PCCN, CV-BC, GERO-BC, MEDSURG-BC, NE-BC received the 2023 GLMA Achievement Award for improving health equity for LGBTQ+ communities.
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Jim Allard, DNP, RN, NEA-BC, FACHE is Vice President and Chief Nursing Officer at Medical City Arlington.
Kit Bredimus, DNP, RN, CPEN, CNML, NE-BC, CENP, NEA-BC, FACHE, FAONL, FNAP is Chief Nursing Officer at Midland Memorial Hospital. Steven BrockmanWeber, DNP, MSN, MSHSA is President at Ascension Seton Northwest, Southwest, Highland Lakes, Edgar B. Davis, Smithville, Bastrop and Shoal Creek Hospitals.
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Carol Porter, DNP, RN, FAAN is SVP and Chief Nursing Officer at UT MD Anderson Cancer Center.
Mary Robinson, PhD, RN is Chief Nurse Executive at Texas Health Resources.
Bryan Sisk, DNP, MPH, RN is SVP, Chief Nurse Executive at Memorial Hermann Health System.
Janice Walker DHA, MBA-HCM, NEA-BC, BSN, RN is System Executive Vice President and Chief Nurse Executive at Baylor Scott & White Health. Jackie Ward, DNP, RN, NE-BC is Chief Nursing Officer and Senior Vice President at Texas Children's Hospital. She was also named a 2023 Top 30 Influential Woman of Houston. Tammy Webb, PhD(c), MSN, RN, NE-BC is Chief Nurse Executive at Children’s Health.
Heidi Wolf, MSN, RN is Chief Nursing Officer at DeTar Healthcare Systems. i
ADVERTORIAL
ADVERTORIAL
Talk With Your Patients About Safe Rx Disposal Drug misuse continues to be a public health crisis in the U.S.—and right here in Texas. Help keep your community safe from potential misuse and overdose by talking with your patients about how to safely dispose of expired, unwanted or unused medications. Take-Back Days National Prescription Drug Take Back Day, held in April and October of each year, provides a free and confidential way for Texans to safely dispose of unused prescription drugs. Participants simply clean out their medicine cabinets and drop off medications at a drive-up location, where staff safely dispose of them. Encourage your patients to find a local collection site by visiting www.dea.gov/takebackday. Pharmacy Drug Disposal Resources Many Texas pharmacies offer free, year-round safe disposal methods, including: • On-site drop-off boxes that allow individuals to safely dispose of most prescription and over-the-counter drugs. • Mail-back programs that encourage customers to place unwanted medicines into a prepaid mailer, which is then sent to an environmental returns program for proper disposal. Advise patients to find a local disposal site by visiting the DEA Public Disposal Locations for Controlled Substances website. Single-Use Disposal System (SUDS) Pouches For a convenient at-home disposal method, the University of Houston Prescription Drug Misuse Education and Research Center offers two options: SUDS deactivation pouches and mail-back envelopes. • Deactivation pouches make it safe to throw away medication at home. They contain a powder that, when mixed with water directly inside a medication bottle,
For more information and resources, visit the txpmp.org Check the PMP Every patient. Every time.
renders the drug unusable and safe to dispose of in a trash receptacle. The pouches work effectively with pills, tablets, capsules, liquids and powders. • Mail-back envelopes allow patients to place unused medications into a prepaid envelope and mail it back to a treatment location for disposal. Patients can find a local SUDS distribution location to pick up free disposal materials by visiting the Texas Targeted Opioid Response Safe Drug Disposal Distribution Locations map. The Texas PMP: A Tool to Help Combat the Opioid Epidemic The Texas Prescription Monitoring Program (PMP) is another valuable tool in protecting your patients. By providing controlled substance prescription histories for your patients, it informs prescribing practices to prevent prescription drug misuse and overdose. The PMP can help end the opioid crisis, but it only works when we use it.
TNA NEWS WHAT'S NEW AND NEXT TNA REPRESENTS YOU
Texas Board of Nursing ›
REMEMBERING ELIZABETH SJOBERG, JD, RN AUGUST 25, 1949 - JUNE 4, 2023
BON Education Task Force Meeting
within THA, Elizabeth effectively articulated the important role of nursing and ensured nurses were front of mind within the association.
ANA ›
ANA Board Meeting
›
ANA ECHO Meeting
›
C/SNA Bi-Monthly
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C/SNA Lobbyist Monthly Meeting
›
Project MZ Stakeholder Meeting
From the onset of her role at THA, Elizabeth forged a strong working relationship with the Texas Nurses Association and other stakeholders—a relationship that very well may be unique across the country. Largely due to Elizabeth’s efforts, THA and TNA have enjoyed a productive, collaborative relationship, partnering on many legislative efforts.
Other ›
Workplace Violence Against Nurses Task Force
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State-Based Incubators Monthly Meeting
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Nursing Associations Committee Meeting
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Texas Society of Association Executives
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Texas Center for Nursing Workforce Studites (TCNWS) Advisory Committee mtg.
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North Texas Organization of Nursing Leadership Fall Forum
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Texas Women’s Healthcare Full Coalition Meeting
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Texas Health Steps Advisory Committee Meeting
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Texas Public Health Coalition Meeting
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12th Global Health Hub- Violence Against Nurses
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Healthier Texas Summit
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Aim Hire Texas Policy Coalition
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American College of Healthcare Executives: Legislative Panel
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Texas Association of Deans and Directors of Professional Nursing Programs
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Texas Nursing Students Association Conference
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Texas DNP Conference
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Elizabeth Sjoberg was one of three inhouse attorneys at the Texas Hospital Association (THA). Her specific areas of expertise spanned nurse licensure, practice and education; data collection; advance directives and endof-life care; children’s and women’s issues; EMS/trauma care; health information technology; and public health promotion and wellness. Following every legislative session, Elizabeth was tasked with updating THA’s New Health Care Law manual, so hospital leaders could develop appropriate policies to effectively implement new statutory requirements. Elizabeth was the consummate advocate for nurses working in hospitals —whether in a tertiary urban medical center or a small urban critical access hospital, whether a clinician at the bedside or a chief nursing officer, and whether a seasoned practitioner or a new graduate. She worked to create and safeguard a positive practice environment for nurses that would provide the highest quality and safety of patient care. The voice of nursing
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Elizabeth’s efforts to partner with TNA on workplace advocacy efforts didn’t stop with legislative sessions—she cared that nurses were informed and had the tools they needed to succeed. She traveled across Texas with TNA staff multiple times presenting workshops to ensure that nurses, especially nurse leaders, were fully aware of nursing peer review laws and how to implement them. She presented during the Legislative and Policy Update at every TNA Nursing Leadership Conference throughout her tenure at THA. Elizabeth’s contributions to nursing extended beyond TNA. She was an active participant on multiple state agency committees including the Board of Nursing’s Advisory Committees and task forces, the Center for Nursing Workforce Studies, the Higher Education Coordinating Board, and others. She championed support for the 2010 IOM Future of Nursing report by serving on the executive, practice, leadership, and education committees of the Texas Team Action Coalition. Elizabeth graciously gave of her time and expertise whenever TNA called. In addition to her professional accomplishments, Elizabeth was known for her fiercely independent spirit and love for animals. She cherished her cats,
dog, goats, and antelope, treating them as members of her family. Her nurturing nature extended to her personal relationships as well. Elizabeth had a strong bond with her son, Robert, and took great joy in the presence of her granddaughter, Alexandra Huddleston. She is also survived by her brother, Robert Newlin, a niece and nephew, as well as her dear friend, Mary
Romero, and Mary’s husband, Joe. The Texas Nurses Association sends our appreciation, gratitude as well as our condolences to all of those impacted by the loss of Elizabeth. As a dedicated nurse, she made an impact on nursing practice that will continuously positively impact nursing practice for years to come. i
THE UNIVERSITY OF TEXAS MEDICAL BRANCH
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UTMB SON’s teaching innovations have resulted in consistently high national rankings and alumni who have distinguished themselves as leaders throughout Texas and the United States. Today, informed by tradition, our vision continues to be our mission—to be the best in nursing education, research and practice in order to improve health for people around the world.
Programs Offered BACHELOR OF SCIENCE IN NURSING • BSN Traditional (on-campus) • RN-BSN (online) MASTER OF SCIENCE IN NURSING (ONLINE) • Family Nurse Practitioner • Adult-Gerontology Acute Care Nurse Practitioner • Adult-Gerontology Primary Care Nurse Practitioner • Neonatal Nurse Practitioner • Clinical Nurse Leader • Executive Nurse Leader • Nurse Educator CERTIFICATE (ONLINE) • Post MSN - Adult-Gerontology Acute Care Nurse Practitioner • Post BSN/MSN - Nurse Educator • Post Bachelors - Rural Telehealth (any health science)
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Learn more at To learn more about our programs, visit: https://nursing.utmb.edu
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Updated 5.10.22.indd 5/11/2022 PM I WF1225775 S S U E 4 ,TXNA 2 0 23 | TAd EX A S N U R2 S I N G M AGA Z I N2:59:27 E
Innovate to Educate
Emerging Technologies in Nursing Education By Jennifer Roye, MSN, RN, CHSE, CNE
NURSING EDUCATION has long relied on traditional learning methodologies like lectures, use of textbooks, and various hands-on clinical experiences. While these methods of delivery continue to serve as the cornerstone of nursing education, the landscape has rapidly evolved due to technological advancements. Online instruction in particular has acted as a catalyst for this transfor-
mation, significantly enhancing the role of technology in nursing curricula. This shift has not only made education more interactive but also more accessible, offering a variety of digital tools with seamless integration into existing teaching frameworks. These emerging technologies provide innovative approaches for learners to engage in clinical and interpersonal skills training, thereby modern-
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izing and enriching the overall learning experience. The purpose of this article is to explore the positive impact technology has on revolutionizing nursing education, from simulation-based learning to artificial intelligence, and to highlight some ways that the University of Texas at Arlington College of Nursing and Health Innovation (CONHI) has embraced and implemented new technology.
E-LEARNING PLATFORMS With the advent of digital tools and platforms, e-learning has become a significant part of nursing education. Numerous studies have shown that e-learning is as effective as traditional learning methods when it comes to knowledge acquisition and skill development (George et al., 2020). The flexibility offered by e-learning platforms allow learners to learn at their own pace and complete coursework asynchronously, leading to improved outcomes and increased learner satisfaction (Li et al., 2019). E-learning platforms allow for virtual delivery of content, improving access for remote learners and addressing geographic challenges (Elcullada Encarnacion, et al., 2021).
SIMULATION One of the most significant advancements in nursing education has been the use of simulation-based learning (SBL), which provides a controlled, safe space for learners to practice clinical skills. Evidence supports SBL as a modality to improve clinical decision-making and competency, while also promoting safe practices among nursing learners preparing for licensure (Hayden et al., 2014; Mancini et al., 2019). Simulation allows for experiential learning, which enables nursing learners to apply theoretical knowledge in practice, thus making them more prepared for real-world situations.
VIRTUAL REALITY When simulation is used to describe nursing education, manikin-based simulation or scenarios using simulated participants come to mind. However, advances in technology have expanded the possibilities. The use of virtual simulation, including screen based and virtual reality (VR) simulation, has revolutionized nursing education by providing a safe, risk-free environment for learners to practice a range of skills, from communication and prioritization to clinical procedures. At the University of Texas at Arlington CONHI, learners participate in VR simulation to learn to communicate with mental health patients, to perform assessments, and practice prioritization using multi-patient scenarios. The accessibility of these technologies has vastly
The experiential learning offered by VR not only supplements traditional education methods but also enhances the learners’ decision-making abilities, particularly in high-acuity, low frequency situations. Learner feedback has been favorable, especially in noting the opportunity to engage in clinical scenarios they may not have encountered otherwise, leading to positive outcomes. improved the integration into online curricula, offering virtual experiences that add depth and realism benefiting remote learners. Virtual reality simulation allows learners to engage in lifelike, immersive scenarios without the fear of causing harm. Furthermore, these digital platforms offer customizable scenarios that enable learners to build competence in various situations. The experiential learning offered by VR not only supplements traditional education methods but also enhances the learners’ decision-making abilities, particularly in highacuity, low frequency situations. Learner feedback has been favorable, especially in noting the opportunity to engage in clinical scenarios they may not have encountered otherwise, leading to positive outcomes. A recent technological advancement in virtual simulation is the use of holograms (Diaz et al., 2022). A hologram is a three-dimensional (3D) image that can be displayed and interjected into a virtual scenario (Mavrikios et al., 2019). This provides the experience of interaction with a lifelike simulated patient image without the actual presence of a human, increasing realism and learner engagement. However, the application of VR in nursing education isn’t without its challenges, such as costs for the learning platform and equipment, accessibility issues, and the learning curve for both educators and learners. Despite these hurdles, the potential benefits of VR are substantial, including its ability to augment traditional learning, facilitate
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skill development, reduce cognitive load, and offer comprehensive assessment tools. As technology continues to advance, the incorporation of VR into nursing education seems not only feasible but also increasingly necessary. In addition to this, integrating game-like elements into educational systems (gamification) enhances learner engagement and promotes knowledge retention (Vrabie, 2023). Overall, as we advance further into the era of digital medicine, VR and gamification stand as promising avenues in nursing education, aiming to prepare future nurses with the skills and confidence they require for successful careers.
ELECTRONIC HEALTH RECORDS Incorporating the Electronic Health Record (EHR) training into nursing education is increasingly essential to prepare learners for entry to practice in today’s healthcare environment. Training with an EHR has shown to be useful teaching learners how to think critically about their nursing documentation and the effect that accurate data has on patient care outcomes (Chung and Cho, 2017). At the University of Texas at Arlington CONHI, the integration of an academic EHR will begin in the spring of 2024. Learners will be introduced to the EHR in both the didactic and simulation settings, providing experience in both documentation and analyzing patient data. This training also boosts interdisciplinary teamwork and enhances awareness of ethical responsibilities, such as confidentiality and HIPAA compliance. While challenges like software costs and faculty training exist, the benefits of EHR education, including efficiency and reduced errors, make it a crucial of today’s nursing curricula.
TELEHEALTH Given the increasing role of telehealth in healthcare delivery, especially post-COVID-19, telehealth training has become indispensable in nursing education. Studies by Rutledge et al. (2017) show that telehealth training is essential for improving healthcare access and quality, especially in rural settings (Rutledge et
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AI can analyze individual learning patterns and adapt content delivery, accordingly, creating a tailored educational experience for each learner. Through machine learning algorithms, AI can identify weaknesses and strengths, guiding educators for individualized instruction. its role in enhancing access to care and managing diverse patient populations (AACN, 2021). Telehealth is also an important component in the field of Health Informatics. The University of Texas at Arlington offers both undergraduate and graduate certificate programs in Health Informatics. These certificate programs offer training to multiple disciplines, including nursing.
ARTIFICIAL INTELLIGENCE
al., 2017). Training nursing learners in this environment promotes interprofessional collaboration, a skill that is increasingly essential in today’s complex healthcare systems. Telehealth education serves as an excellent platform to teach learners about the ethical and legal considerations associated with remote healthcare, such as confidentiality, data security, and licensure across state lines. Nursing curriculums, both undergraduate and graduate, are now integrating telehealth modules to ensure that learners are well-versed in this mode of healthcare delivery. In 2021, the American Association of Colleges of Nursing (AACN) included guidelines that emphasized preparing nursing learners for telehealth competencies, highlighting
Artificial Intelligence (AI) is the newest emerging technology in the education environment, and nursing education is no exception. The integration of AI technology presents opportunities to enhance both teaching and learning experiences in nursing programs. AI can analyze individual learning patterns and adapt content delivery accordingly, creating a tailored educational experience for each learner. Through machine learning algorithms, AI can identify weaknesses and strengths, guiding educators for individualized instruction. AI-driven virtual simulations, including learner voice recognition and patient reaction, can offer realistic clinical scenarios that enable the learner to practice a skill in a safe environment. These scenarios can adapt in real-time, requiring learners to exercise critical thinking and make swift decisions, much
like they would in a real clinical setting. Immediate feedback from learner decisions can guide the scenario progression (De Gagne, 2023). AI can transform how we analyze medical data, diagnose, and improve patient outcomes. Software systems can use AI to automate some of the more tedious aspects of nursing education, such as grading assignments. Overall, AI is significantly impacting nursing education, providing new tools and methods to help promote learning and improve patient care. While AI promises significant advancements, concerns such as data privacy and the necessity for human oversight remain and are valid. Concerns from nurse educators over the use of AI and academic dishonesty have also been raised. Despite these challenges, there is exciting potential with the use of AI, providing both educators and learners with tools that make learning more efficient, immersive, and adaptive.
CONCLUSION Technology is equipping nursing faculty and learners with the skills and knowledge they need to advance education and allow learners to excel in their training. As educators and institutions continue to adopt these technological advancements as formal learning tools, it becomes crucial to keep abreast of the latest research and best practices
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in this area to ensure that nursing education remains both effective and relevant. The integration of technology in nursing education is not merely a trend but a necessity, given the rapidly evolving healthcare landscape. However, with technology integration must come pedagogical alignment. The bottom line is we should examine the needs of the learner and employ the appropriate strategy to deliver the content in an engaging manner, with the goal being to promote engagement, knowledge retention and improve learner outcomes. It offers a multi-dimensional approach to learning that better prepares learners for the challenges and opportunities in today’s healthcare environment. Nurses should remain at the forefront of this advancement working side-by-side with other innovators, developers, and organizations, leading the change one learning tool at a time. i
Elcullada-Encarnacion, R., Galang, A. A., & Hallar, B. J. (2021). The impact and effectiveness of e-learning on teaching and learning. International Journal of Computing Sciences Research, 5(1), 383–397. https://doi.org/10.25147/ ijcsr.2017.001.1.47
REFERENCES American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. Accessible online at https:// www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf
Mavrikios, D., Alexopoulos, K., Georgoulias, K., Makris, S., Michalos, G., & Chryssolouris, G. (2019). Using holograms for visualizing and interacting with educational content in a teaching factory. Procedia Manufacturing, 31, 404–410. https://doi.org/10.1016/j.promfg.2019.03.063
De Gagne, J. C. (2023). The state of artificial intelligence in nursing education: Past, present, and future directions. International Journal of Environmental Research and Public Health, 20(6), 4884. https://doi.org/10.3390/ijerph20064884
Rutledge, C., Kott, K., Schweickert, P., Poston, R., Fowler, C., & Haney, T. (2017). Telehealth and eHealth in nurse practitioner training: Current perspectives. Advances in Medical Education and Practice, 8, 399-409.
Díaz, D. A., Anderson, M., Hoffman, B., Alegre, J. V., Simon, E. G., Gomez, A. W., Villamizar, A., & Wade, A. (2022). Feasibility of using holograms as embedded participants (EP) in simulation-based education (SBE). International Journal of Healthcare Simulation. https://doi.org/10.54531/tdvf8904
Vrabie, C. (2023). Education 3.0 – AI and gamification tools for increasing student engagement and knowledge retention. Lecture Notes in Business Information Processing, 74–87. https://doi.org/10.1007/978-3-031-43590-4_5
George, P. P., Papachristou, N., Belisario, J. M., Wang, W., Wark, P. A. Cotic, Z., Rasmussen, K., Sluiter, R., Riboli-Sasco, E., Tudor Car, L., Musulanov, E. M., Molina, J. A., Heng, B. H., Zheang, Y., Wheeler, E. L., Shorbaji, N. A., Majeeb, A., & Car, J. (2020). Online eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes, and satisfaction. Journal of Global Health, 4(1), 010406. Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2). https://doi.org/10.1016/s2155-8256(15)30062-4 Li, C., He, J., Yuan, C., Chen, B., & Sun, Z. (2019). The effects of blended learning on knowledge, skills, and satisfaction in nursing students: A meta-analysis. Nurse Education Today, 82, 51–57. https://doi.org/10.1016/j.nedt.2019.08.004 PMID:31437783 Mancini, M. E., LeFlore, J. L., & Cipher, D. J. (2019). Simulation and clinical competency in Undergraduate Nursing Programs: A multisite prospective study. Journal of Nursing Education, 58(10), 561–568. https://doi.org/10.3928/0148483420190923-02
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Calling for Bold Action to Address the COMPASSIONomics An in-depth examination of technologies’ positive + negative impact on nurses
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Negative Impact of Technology on Nurses By Susan McBride, PhD, RN-BC, CPHIMS, FAAN and Mari Tietze, PhD, MSN, BSN, FAAN, FHIMSS
ELECTRONIC HEALTH RECORDS (EHRs), along with other technologies, have resulted in both positive and negative impacts on nurses in the U.S. According to the U.S. Census Bureau, 22.2 million people are considered healthcare and social assistance workers, 8.5% of the adult population [258.3 million]. Of those, one in four healthcare workers is a nurse [24.3%] (U.S. Bureau of Labor Statistics, 2020). In addition, nurses spend 40% of their time on EHR documentation activities which have demonstrated less than ideal workflow patterns (McBride et al., 2020, Schulte, & Fry, 2019). Of more significant concern is the trend that for the past 10 consecutive years, the suicide rate among nurses has been greater than that for the general U.S. population (Davidson et al., 2020). Although there is no direct relationship to documentation challenges, healthcare worker burnout, and associated “technostress,” these trends warrant bold action. Burnout is the topic of the newly released report from the U.S. Surgeon General and a substantive plan of action is provided to address burnout in healthcare providers (Office of the Surgeon General, 2022). The report represents the new normal for healthcare providers and healthcare leaders and includes an environment shaped by the costs of COVID-19, which has affected all healthcare organizations. As the price of care has risen and finances diverted, services, inclusive of staff education and technical support, have diminished. The resulting outcomes have influenced the quality of care, as well as the mental well-being of frontline staff and nursing leaders.
TEXAS STATEWIDE STUDIES [2015 AND 2020] In 2009, to address the impact of technology on nurses, the Texas Nurses Association (TNA) and Texas Organization of Nurse Leaders (TONL) established a
Health Information Technology Committee charged with examining how Texas nurses across the state were impacted by EHR use. The committee aimed to establish baseline measures of satisfaction to show the evidence, suggest improvement strategies that could be deployed and re-evaluate nurses’ satisfaction with EHRs in a subsequent study. The initial Texas Statewide Study Assessing the Experience of Nurses with their EHRs was conducted in 2015, and a follow-up study in 2020. While some progress has been made with the functionality of EHRs, findings in both Texas studies indicate that the maturity of the EHRs continues to be an essential factor for nurses, and textual qualitative data revealed an element of frustration that nurses need to be heard in order to improve the functionality of technology for nursing care. Further, the findings include interoperability, documentation, and usability challenges that result in dissatisfaction with EHRs. Other studies have found that these same challenges with EHRs contribute to clinicians experiencing burnout. (Boyle et al., 2019; McBride et al., 2018)
SCOPING REVIEW OF TECHNOLOGY IMPACT A scoping review conducted by four Expert Panels from the American Academy of Nursing was recently conducted, examining the evidence of technologies’ positive and negative impact on clinicians. The study collected and analyzed 101 articles, including research papers, systematic reviews, and quality improvement initiatives. (McBride et al., 2023) Key findings and categories of impact call for bold action to use interventions that improve clinicians’ satisfaction with technology. These key findings of the scoping review are summarized below and reveal evidence that can help inform strategies to improve nurses’ satisfaction:
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WORK + PSYCHOLOGICAL IMPACT: Cognitive workload, communication issues, inefficiency, and quality of care were some of the negative work impacts associated with HIT. Burnout, stress, and decreased satisfaction were common psychological effects of HIT on healthcare professionals. However, HIT was also found to improve accuracy, efficiency, and quality of care in some cases. There are indications that interventions can create positive impacts increasing satisfaction and reducing burnout when HIT systems are user-friendly, efficient, and aligned with workflow. EHR + PSYCHOLOGICAL FACTORS: Most studies in the scoping review found a negative association between EHRs and burnout, with excessive documentation requirements, high inbox volumes, and time constraints being common contributors. EHR + WORK ENVIRONMENT FACTORS: EHRs were associated with increased cognitive workload, inefficiency, time pressure, and communication issues. Despite the intention to improve efficiency, EHRs can increase the number of tasks for healthcare professionals. Some researchers found EHR training and focused documentation strategies improved documentation time and satisfaction. EHR INTERVENTION STUDIES: For providers, interventions such as medical scribes, EHR training, and clinical decision support redesign showed promise in reducing documentation time and burden, improving accuracy, and increasing satisfaction. These findings have implications for improvement strategies for nurse practitioners. EHRS + NURSING STUDIES: Reported studies on nurses’ experiences with their EHRs when well implemented reflect that EHRs can be helpful, easy to use, and contribute to care quality. Familiarity, knowledge, and confidence in using EHRs were associated with higher nurse
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workers such as nurses. A full scoping review of the literature on the topic of technology’s positive and negative impact on clinicians and associated recommendations has been discussed. For boldness, we believe executives should look to COMPASSIONomics. Informaticians and executive leadership cannot fix all the technology issues in the immediate future but COMPASSIONomics can make a difference now. Listening compassionately to nurses to inform negative impacts of technology on nurses is the path forward to improvement and is an important element of addressing burnout. i REFERENCES satisfaction. The review identifies a need for more robust research designs and emphasizes that while there is evidence of the downside of technology, there is a lack of evidence concerning how the stress of technology truly impacts clinicians. Additionally, it calls for careful consideration of policy and system changes that aim to reduce the documentation burden. The scoping review concludes by urging leaders to take bold action to balance the positive and negative aspects of technology while safeguarding clinical practice quality. It suggests considering the polarity between eustress and distress to understand that not all stressors are negative, especially in the context of technologyrelated challenges. For further details on the scoping review study details, the study can be accessed online. Scoping review: Positive and negative impact of technology on clinicians - Nursing Outlook (McBride et al., 2023)
COMPASSIONOMICS FOR BOLDNESS COMPASSIONomics is the act of being actively compassionate. In their book by this title, Trzeciak and Mazzarelli (2019) explain that compassion is more than caring or empathy; it is action-oriented, it is the desire to take action with an emotional response that is focused on helping a person in need. Even in the midst of moral injury, when there is little
that can be done medically, there are some things healthcare providers can do to deliver compassion for their patients. The patient benefits as well as the healthcare provider. Research shows that COMPASSIONomics for others activates the parasympathetic nervous system, resulting in a calming effect that counterbalances the stress response (Trzeciak, & Mazarelli, 2019). The typical COMPASSIONomics scenario can be transformed into interactions between healthcare administrators and the healthcare providers they lead. In fact, employees receiving more compassion in their workplace see themselves, their co-workers, and their organization in a more positive light, report feeling more positive joy and contentment, and are more committed to their jobs. Compassionate workplace culture is linked to less burnout, greater teamwork, and higher job satisfaction. Employees receiving more compassion in the workplace see themselves, their co-workers, and their organization in a more positive light, report feeling more positive joy and contentment, and are more committed to their jobs. Compassionate workplace culture is linked to less burnout, greater teamwork, and higher job satisfaction (Greater Good, 2022). We have described the state of healthcare delivery related to technology such as the EHR, and associated documentation and its impact on healthcare
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Boyle, D. K., Baernholdt, M., Adams, J. M., McBride, S., Harper, E., Poghosyan, L., & Manges, K. (2019). Improve nurses well-being and joy in work: Implement true interprofessional teams and address electronic health record usability issues. Nursing Outlook, 67(6), 791-797. https://doi.org/10.1016/j.outlook.2019.10.002 Davidson, J. E., Proudfoot, J., Lee, K., Terterian, G., & Zisook, S. (2020). A longitudinal analysis of nurse suicide in the united states (2005–2016) with recommendations for action. Worldviews on Evidence-Based Nursing, 17(1), 6-15. https://doi. org/10.1111/wvn.12419 Greater Good (2022). Compassion Definition | What Is Compassion (berkeley.edu) https://greatergood. berkeley.edu/topic/compassion/definition Hansa Bhargava, Stephen Trzeciak, Anthony Mazzarelli. (2022) Compassionomics in Defeating Burnout Episode 5. https://www.medscape.org/ viewarticle/942977 McBride, S., Alexander, G. L., Baernholdt, M., Vugrin, M., & Epstein, B. (2023). Scoping review: Positive and negative impact of technology on clinicians. Nursing Outlook, 71(2), 101918. https://doi.org/https://doi. org/10.1016/j.outlook.2023.101918 McBride, S., Tietze, M., Robichaux, C., Stokes, L., & Weber, E. (2018). Identifying and addressing ethical issues with use of electronic health records [Article]. Online Journal of Issues in Nursing, 23(1). https://doi. org/10.3912/OJIN.Vol23No01Man05 McBride S, Tietze M, Thomas L, Hanley MA. (2023) Electronic Health Record Maturity Matters! Texas Nurses Speak Out in Their Second Statewide Study. Comput Inform Nurs. doi: 10.1097/ CIN.0000000000000915. Schulte, F., & Fry, E. (2019, March 18,). Death by 1,000 clicks: Where electronic health records went wrong. www.khn.org. Retrieved September 28, 2019, from https://khn.org/news/death-by-a-thousandclicks/ Trzeciak, S., & Mazzarelli, A. (2019). COMPASSIONomics: The revolutionary scientific evidence that caring makes a difference. Studer Group. U.S. Bureau of the Census (2020). Quick Facts. U.S. Surgeon General report on Burnout in Healthcare Workforce (2022). https://www.hhs.gov/ surgeongeneral/priorities/health-worker-burnout/ index.html
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“My Apple Watch Says…”
The Good and Bad
of Wearable Health Technology A Nurse Practitioner Shares Her Experience With Tech-wearing Patients By Elizabeth Roberts, DNP, APRN, FNP-BC, CHFN HEALTHCARE HAS CONTINUED TO EVOLVE and become more complex. As this evolution continues, healthcare professionals will be required to maneuver in an increasingly competitive information marketplace (McGonigle & Mastrian, 2017).There has been considerable growth in the interaction of consumers with technology and artificial intelligence. Over the last decade, a technological revolution has occurred, resulting in what was once considered an accessory, such as a watch, now regarded as wearable technology. These wearables describe small electronic and mobile devices or computers with wireless communication capability incorporated into gadgets, accessories, or clothes (Ometov et al., 2021).Such devices are also known as biomedical monitoring devices (BMDs) (Tran, et al., 2019). Some contemporary examples of these gadgets are activity-tracking bracelets or smartwatches such as Fitbit, Apple, or Samsung Watch. These wrist-worn devices can monitor parameters such as heart rate (HR), energy expenditure (EE), steps taken, distance traveled, oxygen saturation, sleep patterns, cardiac arrhythmia, calories, etc. This literature review outlines wearable technology applications in healthcare, the perceptions of both patients and providers, the clinical implications, and concerns, while incorporating personal clinical anecdotes.
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WEARABLE TECHNOLOGY APPLICATIONS IN HEALTHCARE Wearable offers an assortment of solutions for a variety of healthcare problems. Wu and Luo (2019) outlined various healthcare applications of wearable technology in their literature review. These applications are identified as Prevention of Disease and Maintenance of Health, Patient Management, and Disease Management. Weight control and physical activity fall under disease prevention and maintenance of health applications (Wu & Luo, 2019). Some of these devices are your Fitbits and smart watches. These devices help people log their exercises and calories burned and count their daily steps. Sensors in some wearable technology can detect human physiological status, such as blood pressure, body temperature, and heartbeat, to monitor mental status changes for stress detection, a utility in mental health medicine. Coaches can use wearable devices to manage athletic training in sports medicine. Patient management applications use wearable technologies to assist in the early detection of health decompensations through point-of-care (POC) diagnostic devices. Activity monitoring can be used to manage chronic conditions by tracking sedentary vs. active lifestyles, and it is helpful in monitoring cancer survivors, stroke patients, chronic pulmonary patients
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(pulmonary rehabilitation exercises), and patients with brain and spinal cord injuries. (Wu & Luo, 2019). Wearable technology can help manage disease, such as cardiovascular monitoring with wearable ECG or implanted insulin pumps for diabetes.
One interesting problem is that no additional time is woven into the day to attend to the numerous messages from patients through MyChart or Secure Messaging applications. Though helpful, more work is generated for a provider because such inquiries can take as much time as a clinical visit, yet rarely is extra clinic time built into the provider schedule to accommodate the added responsibilities related to health technology.
WEARABLE TECHNOLOGY PERCEPTIONS A study called Community of Patients for Research (ComPaRe) was conducted by Tran et al. (2019) in 2018, looking at patients’ perceptions of using BMD and artificial intelligence (AI) in healthcare. The researchers recruited adult patients with chronic conditions in France from the ComPaRe. These participants “answered open-ended and quantitative questions about the new technologies’ dangers and potential benefits” (Tran et al., 2019, para. 1). Participants described the benefits of technology as the ability to improve the reactivity of care and reduce the burden of treatment. Twenty percent (20%) of the participants felt those benefits outweighed the dangers. Only 3% felt that negative aspects, such as misuse of private patient data, risks of hacking, and replacement of humans, vastly outweighed the benefits. Althobiani et al. (2023) completed a mixed-method study utilizing a survey working with patients with COPD. This study evaluated their perspectives on the extent of wearable technology utilization, perceived feasibility, utility of these devices, and hindering and facilitating factors. They found that 80% of the 118 clinicians included in the analysis did not use data from wearable devices in routine clinical care. Many did not have confidence in their effectiveness and impact on health outcomes. However, clinicians pointed out the potential value of wearables in delivering personalized care and quicker assistance. Some helpful factors were ease of use, technical support, and accessibility data. In contrast, factors contributing to a barrier to use included cost and lack of technical knowledge (Althobian et al., 2023).
ing its plan for guiding and regulating digital, health-related products (Liao et al., 2019).
Literature reviews have reported some concerns, such as the potential for inadequately replacing human intelligence in care, hacking risks, or misuse of private patient data by caregivers, insurance companies, etc.
PERSONAL ANECDOTES
WEARABLE TECHNOLOGY CONCERNS Literature reviews have reported some concerns, such as the potential for inadequately replacing human intelligence in care, hacking risks, or misuse of private patient data by caregivers, insurance companies, etc. (Tran et al., 2019). The cost of care and the effect of measures on health-related outcomes derived from wearable devices are not yet known and are still under investigation (Liao et al., 2019). Other concerning factors are interoperability and reliability. Some devices, like the Fitbit, are not approved or yet approved as medical devices. Because of this rising trend in wearable technology, the Food and Drug Administration (FDA) is updating and refin-
This following section illustrates some personal anecdotes as a clinician. As a Nurse Practitioner working in a busy cardiology practice at a Veterans Administration (VA) hospital in Central Texas, I can appreciate the usefulness of wearable technology that tells a patient when their heart is out of rhythm, such as atrial fibrillation (AF) or tachycardia, so I can follow up by ordering a formal EKG or other testing. That said, how many providers have not had the following experiences? A patient comes into the clinic at 8:00 a.m. with his usual walking cane and unsteady gait and tells you he had already walked 8,000 steps that morning, as evidenced by the information on his Fitbit, which he proceeds to show you. I have had a patient who is convinced he has insomnia and asks for a sleeping pill because his smart watch registered ‘poor sleep.’ Some patients who come in worried about an Apple watch notification have a false positive reading which can lead to anxiety (Wetsman, 2021). Some patients show up with their Excel spreadsheet of their heart rates and blood pressure downloaded from their Apple watch for a month for you to review. Mathew Ebben, a
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CONCLUSION In summary, there is a rising trend in the use of wearable health technology in the populace. Patients and providers have mixed views about the benefits or detriments of using such technology. Provider experience demonstrates that this technology can sometime create burden and lead to burnout. As the use of these devices grows, one must consider concerns such as patient privacy, data reliability, interoperability, and FDA approval for use in healthcare. Nevertheless, these technologies can help providers inform patient care. Information from BDMs, such as telehealth, can provide location independence, better care for rural areas, enhanced communication between patients and providers, and improved patient compliance (Cannon, 2018) while also being used to “predict patient outcomes and provide reactive guidance or proactive interventions” (Tran et al., 2019. Para. 3). i
As a provider, I may find myself pitting my knowledge against what a patient’s wearable device is telling them.
REFERENCES Althobiani, M. A., Khan, B., Shah, A. J., Ranjan, Y., Mendes, R. G., Folarin, A., Mandal, S., Porter, J. & Hurst, J. R. (2023). Clinicians’ Perspectives of Wearable Technology to Detect and Monitor Exacerbations of Chronic Obstructive Pulmonary Disease: Mixed-Method Survey. International Journal of Chronic Obstructive Pulmonary Disease, 1401-1412. https://www.tandfonline.com/doi/full/10.2147/COPD.S405386
sleep specialist at Weill Cornell Medicine in New York was quoted in Wetsman (2021, para 6) as saying “People come in and they have their device, and they’ve downloaded that data, and they want to show it to you...it happens all the time.” One interesting problem is that no additional time is woven into the day to attend to the numerous messages from patients through MyChart or secure messaging applications. Though helpful, more work is generated for a provider because such inquiries can take as much time as a clinical visit, yet rarely is extra clinic time built into the provider schedule to accommodate the added responsibilities related to health technology. Ye (2021) identified that integrating patient-generated health data (PGHD),such as patient-reported outcomes and mobile data, into electronic health records (EHR) can create a burden for clinicians, leading to burnout. Potential contributing factors were technostress, time pressure, and workflow related issues. Additionally, patients can become so reliant on these devices that they spend much time collecting data to report to the provider. For example, I have had a patient who would call daily about his heart rate and when he was in and out of AF. This patient chronically monitored his device to the extent of borderline obsession. I might give some advice, but it becomes strikingly more difficult when the patient comes back and counters with, “But my Apple Watch says…”So, as a provider, I may find myself pitting my knowledge against what a patient’s wearable device is telling them. “Patients who monitor their health with wearables can be prone to obsession and anxiety” (“Data Utility,” para 4). How does a provider reconcile the reported information with what is being seen? Many smartwatches can send false positive AF alerts which can lead to a decline in levels of disease self-management or self-perceived physical health (Tran 2023). Also, If wearable technology is not worn correctly, it can be imprecise which can send patients in for unnecessary tests (“Data Utility,” 2022).
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Cannon, C. (2018, May). Telehealth, mobile applications, and wearable devices are expanding cancer care beyond walls. In Seminars in Oncology Nursing (Vol. 34, No. 2, pp. 118-125). WB Saunders. https://www.sciencedirect.com/science/article/ abs/pii/S0749208118300159 Chesser, L. (2015, June 15). Unsplash (Image). https://unsplash.com/photos/ vCF5sB7QecM?utm_source=unsplash&utm_medium=referral&utm_ content=creditCopyText Data Utility and Accuracy Key to Physicians’ use of Wearable Tech for Healthcare. (2022, February 23). In Deloitte.https://action.deloitte.com/insight/1511/data-utilityand-accuracy-key-to-physicians-use-of-wearable-tech-for-healthcare Liao, Y., Thompson, C., Peterson, S., Mandrola, J., & Beg, M. S. (2019). The future of wearable technologies and remote monitoring in health care. American Society of Clinical Oncology Educational Book, 39, 115-121. https://ascopubs.org/doi/ full/10.1200/EDBK_238919 McGonigle, D., & Mastrian, K. G. (2017, March 17). Nursing informatics and the foundation of knowledge (4th ed.). Jones & Bartlett Learning. https://bookshelf. vitalsource.com/books/9781284142990 Ometov, A., Shubina, V., Klus, L., Skibinska, J., Saafi, S., Pascacio, P., Flueratoru, L., Quezada, Q. G., Chukhno, N., Chukhno, O., Ali, A., Channa, A., Svertoka, E., Qaim, W. B., Casanova-Marques, S.H., Torres-Sospedra, J., Casteleyn S., Ruggeri G., Araniti G., Burget, R., Hosek J., Lohan E.S. (2021). A survey on wearable technology: history, state of the art and current challenges. Computer Networks Journal (Vol. 193) 10.1016/j.comnet.2021.108074 Tran, K. V., Filippaios, A., Noorishirazi, K., Ding, E., Han, D., Mohagheghian, F.,Dao, Q., Mehawej,J.,wang, Z., Lessard, D., Otabil,E. M., Hamel, A., Paul, T., Gottbrecht, M. F., Fitzgibbons, T. P., Saczynski, J., Chon, Ki H., ... & McManus, D. D. (2023). False Atrial Fibrillation Alerts from Smartwatches are Associated with Decreased Perceived Physical Well-being and Confidence in Chronic Symptoms Management. Cardiology and cardiovascular medicine, 7(2), 97.Tran, V. T., Riveros, C., & Ravaud, P. (2019). Patients’ views of wearable devices and AI in healthcare: findings from the ComPaRe e-cohort. NPJ digital medicine, 2(1), 53. https://www. nature.com/articles/s41746-019-0132-y Wetsman, N. (2021, November 1). The unexpected health impacts of wearable tech. The Verge. https://www.theverge.com/22733073/smartwatch-wearablehealth-impact-doctors Wu, M., & Luo, J. (2019). Wearable technology applications in healthcare: a literature review. Online J. Nurs. Inform, 23(3). https://www.himss.org/resources/ wearable-technology-applications-healthcare-literature-review Ye J. (2021, April 23). The impact of electronic health record-integrated patientgenerated health data on clinician burnout. Journal of the American Medical Informatics Association. 28(5):1051-1056. https://academic.oup.com/jamia/ article/28/5/1051/6208286
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DO’S AND DON’TS
OF DEFENSIVE DOCUMENTATION By Cynthia Saver, MS, RN, President, CLS Development, Inc.
DOCUMENTING CARE is a basic nursing responsibility, but it’s one that nurses often struggle with because of time constraints and challenges associated with electronic health records (EHRs), such as poor user interfaces that leave nurses unclear as to where to document findings. However, taking time to document correctly and completely provides the first line of defense should you be named in a lawsuit.
CONSEQUENCES OF POOR DOCUMENTATION
Documentation issues can have serious legal consequences. The NSO/ CNA Nurse Liability Claim Report (4th Ed.) found that failure to document or falsifying documentation increased in frequency and severity in 2020, compared to 2015 and 2021. The average total incurred professional liability claims
by documentation allegations rose from $139,920 in 2015 to $210,513 in 2020. Documentation issues also can impact your license; the board of nursing may take disciplinary action or even rescind a license in the case of documentation maleficence. The NSO/CNA report noted that about half (49.6 percent) of all license protection matters related to documentation involved fraudulent or falsified patient care or billing records. Most nurses would not knowingly engage in these practices, but keep in mind that this category includes situations such as failing to document care as required by a regulatory agency. Thus, simply omitting information can lead to punitive action. Finally, deliberately falsifying documentation (such as submitting false claim to Medicare) can subject nurses to sanc-
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tions under the federal False Claims Act. Here are some strategies to follow to ensure your documentation is effective:
DO’S
Follow organizational policies and local, state, and federal regulations related to documentation. Failure to do so is a red flag to an attorney.
Ensure you are in the correct patient record.
Be accurate. This may seem obvious, but a 2020 study by Bell and colleagues found that 21 percent of patients who reviewed EHR ambulatory care notes about them reported an error, with 42 percent labeling the error as serious.
Use accepted abbreviations and medical terminology. One resource is The Joint Commission’s list of “do
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VALUE OF DOCUMENTATION It can be easy to focus on documenting in the healthcare record as an onerous task, but in addition to being a legal document, the record provides a tool to: Document services provided to patients, their responses to treatments, and caregiver decisions. Communicate information about the plan of care and outcomes to other members of the healthcare team.
not use” abbreviations, published in 2018. For example, it states to write out “unit” instead of using “U” or “u.” Another resource is the Institute for Safe Medication Practices’ “List of Error-Prone Abbreviations, Symbols, and Dose Designations.”
Document positive and negative findings. Negative findings may be overlooked. For example, nurses know to document signs and symptoms of infection, but they may forget to note the absence of them.
Record all care, even if it’s “routine.” For instance, regular checks for signs of skin injury around an endotracheal tube should documented.
Document in real time to help ensure accuracy. In some organizations, you can access the EHR from a secure mobile device you carry with you.
Note when you notified other healthcare providers of a change in a patient’s condition. You’ll also want to note the response. If the response is inadequate or not appropriate, document that you followed up with another person, such
Identify areas that need improvement; nurses can work with a team to address quality issues to enhance patient care. Provide evidence that an organization is meeting standards set by accrediting bodies that are protecting patients.
Demonstrate nurses’ contribution to patient care outcomes. It also helps nurses meet standards of professional practice. For example, to meet standards related to evaluating a patient’s progress towards
Provide information to ensure proper billing coding so that organizations receive the reimbursement they are entitled to. Proper reimbursement promotes an organization’s financial health, enabling it to deliver quality care to patients.
as your supervisor.
Review entries before submitting and sign and date each entry. In EHRs, signatures are generally automatic, but you should verify the information is correct.
Make documentation changes and corrections per organizational policy. It’s helpful to provide a reason for the change, if possible. Make changes and corrections as soon as possible.
Speak up about what’s not working. This is particularly important for the EHR. A well-designed EHR can save time, but one that is not well designed can rob you of time. Even the best EHRs can benefit from tweaking. In some cases, forms can be created or refined to make it easier to document care, or the number of false alerts can be reduced. The IT staff can sometimes make a simple adjustment such as including a new option for recording sputum findings. Although these simple changes may only save a few seconds, those seconds add up over the course of a day, week, month, and year.
Document communications with patients and their families/caregivers. This include providing education (both verbal and written): If a patient suffers harm as a direct result of not following instructions, this information can protect you. Use checklists appropriately. Checklists can save time, but it’s easy to move too quickly, accidentally selecting “yes” because several of the previous answers were “yes,” when “no” is correct. In addition, remember that checklists are not all-inclusive, so avoid relying too much on them. For instance, an assessment checklist doesn’t necessarily cover everything you need to check on a patient.
Be cautious of templates. Templates can help reduce missed care and save time, particularly for routine assessments; however, they are simply a starting point. You still need to ensure you completely assess patients and document care provided.
Pay attention to alerts. Over-riding a valid EHR alert can lead to practice errors.
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goals, the nurse and others on the healthcare team need to review past documentation.
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DON’TS
Don’t share your password for EHR records.
Don’t leave blanks in forms. Use N/A (not applicable) if something does not apply.
Don’t be subjective. State only the facts. For example, “patient slurring words, eyes bloodshot” rather than “drunk”. In addition to creating potential legal issues, keep in mind that many patients are now requesting their medical records and will see what you have written.
Don’t be judgmental. Avoid negative descriptors such as “noncompliant.” Be particularly sensitive to possible racial biases. For example, a 2022 study by Sun and colleagues found that Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical.
Don’t prechart (for example, entering information into the EHR before the start of a routine procedure). Situations can change and you may forget to amend the record. For example, during a procedure, a medical device different from what was originally planned may be used. In addition, the EHR keeps track of entries, so anyone reviewing the entry would know the timing was not correct. Don’t copy and paste text from one patient record to another. If you do decide to do this, be sure to carefully review the text and make changes as necessary. Otherwise, you may introduce errors. Don’t make late entries. If you must, be sure to make the late entry per your organization’s policy. Remember that the EHR will have a record of each entry, including date and time. Don’t assume you have to be the one to document something. When a new piece of information must be obtained on a regular basis, organizations often automatically turn to nurses. However, someone else in the organization may be able to collect the data, which helps avoid additional time demands on you, reducing the potential for documentation errors.
PROTECTION THROUGH DOCUMENTATION
Your documentation should include clinical information (such as assessments and responses to medications); patient education; and diagnostic tests, referrals, and consultations. Following the tips in this article will help ensure you cover these areas, thus protecting yourself from legal action and promoting optimal patient care. As you document, you may want to keep in mind some of the characteristics of high-quality documentation from the American Nurses Association: accurate, relevant, consistent, clear, concise, complete, thoughtful, timely, and reflective of the nursing process. i REFERENCES American Nurses Association. Principles for nursing documentation: Guidance for registered nurses. 2010 American Nurses Association. Nursing: Scope and Standards of Practice, 4th Ed. 2021. CNA, NSO. Nurse spotlight: Healthcare documentation. 2020. Bell SK, Elmore JG, Fitzgerald PS, et al. Frequency and types of patient-reported errors in electronic health record ambulatory care notes. JAMA Netw Open. 2020;3(6):e205867. Institute for Safe Medication Practices. List of error-prone abbreviations, symbols, and dose designations. 2021. https://www.ismp.org/ recommendations/error-prone-abbreviations-list Saver C. Easing the pain of electronic health records: Part 1. OR Manager. 2022;19-22. Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: Documenting racial biases in the electronic health record. Health Aff. 2022;41(2):2032011. The Joint Commission. Official “do not use” list. 2018. https://www.jointcommission.org/-/media/tjc/ documents/resources/patient-safety-topics/patientsafety/do_not_use_list_9_14_18.pdf Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation. This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.
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