Ebook: Connecting Health and Humans

The Finnish Nurses Association is pleased to host this major event in health informatics, the 10th International Congress on Nursing Informatics, NI2009, entitled Connecting Health and Humans. This special event, which has been held every three years since 1982 in collaboration with the International Medical Informatics Association Nursing Informatics Special Group (IMIA-SIG NI), advances nursing and nursing informatics by bringing together experts from all over the world to share their knowledge and skills.

It is particularly auspicious that the 2009 gathering occurs in Helsinki. The host country Finland is well known for advances in mobile information technology as well as eagerness among citizens to access the internet. The current development of a national health information system will also serve as a basis for active information exchange among conference participants.

Following the western continental bloc represented by Rio de Janeiro, Brazil (2003) and Seoul, South Korea (2006) from the eastern, the meeting in Finland offers an opportunity to better and more easily engage Europeans to participate and share their experiences and knowledge with colleagues from around the world.

The theme for the conference, Nursing Informatics – Connecting Health and Humans, reflects not only the importance of European Union eHealth initiatives but also highlights global activities to strengthen the role of consumers in health information management. Finnish health care authorities, like those in many other countries, are committed to putting in place strategies that in the near future will permit citizens to access their health data stored in health records and national data archives. This conference will offer significant guidance to governments, while also deliberating issues important to citizens such as privacy, ethics, and education.

The Scientific Programme Committee received in all more than 400 submissions. Each submission was evaluated by at least two reviewers selected from the panel of more than 80 experts. The SPC selected 130 papers and 120 posters for presentation during the conference. The conference programme follows ten themes: Clinical Workflow and Human Interface; Consumer Health Informatics and Personal Health Records; Health Information Technology; Terminology, Standards and NMDS's; Patient Preferences and Quality of Care; Patient Safety; Evidence Based Practice and Decision Support; Consumer and Professional Education; Strategies and Methods for Training and National eHealth Initiatives across the Globe. All in all the presenters represent more than 35 countries. Thus each theme will have a wide scope of discussions in the sessions.

The result of the SPC activity is reflected in the proceedings and the Conference programme. The printed version of the proceedings has sufficient space to permit printing of papers and posters. The full contents of the conference, including panel, workshops and scientific demos, are included in the electronic version of the proceedings. The Congress Proceedings will be indexed in MEDLINE, and thereby be accessible world wide on the web.

NI-congresses have been important and unforgettable events. We also hope that these proceedings will disseminate the knowledge and experiences presented at the congress long after the oral presentations.

We would like to thank all those who have made the printed volume and the electronic version possible, especially the authors, the Scientific Programme Committee, the Organizing Committee, the reviewers as well as Sami Suominen in the Finnish Nurses Association, Virpi Jylhä from Kuopio University and Jussi Saari from the Blue and White Congrex Management.

Kaija Saranto, Patricia Flatley Brennan, Hyeoun-Ae Park, Marianne Tallberg, Anneli Ensio

IMIA-NI's past achievements are reflected upon in the context of its current strategic directions. Two key historical milestones are described in some detail, the ISO Reference terminology model for nursing and the International Nursing Minimum Data Set development project, as this work is continuing to influence future directions in health and nursing informatics. Current features of our health care environment are explored noting the current desire of most nations to implement electronic health records (EHRs) and its relationship with IMIA-NI's strategic directions. Nurses can play their part by working collaboratively, converting their knowledge into computer processable formats, establishing the necessary professional knowledge governance infrastructure and lobbying key decision makers to establish national infrastructures that will enable the adoption and optimum use of EHRs.

The development of methods to improve the quality of services provided at hospitals has been essential owing to the inadequacy of arrangements for standard procedures and the inadequacy of work instructions based on such procedures. In this paper, we propose a method that involves the following steps: description of the job process, analysis of the causes of incidents, and the planning of improvements for the relevant job process. This method describes a healthcare process using a set of unit process flow charts (UPFCs), which are structured and standardized modules represented in the form of flow charts that elucidate the elements of jobs. Describing a job in this manner allows for an appropriate and in-depth analysis of the causes of incidents that occur during a job process, owing to the fact that the structure and description of the characteristics of relevant unit processes are properly designed. In this paper, we provide a detailed explanation of how this method was developed. Lastly, we apply the method to actual cases at a hospital to illustrate its effectiveness in comparison with the systems that are currently in place.

This study aimed to compare the use of clinical information systems, particularly for nursing, in Austria and Germany. In 2007, all acute care hospitals in both countries received questionnaires with identical questions. 12.4% in Germany and 34.6% in Austria responded. The surveys revealed a consistent higher usage of clinical IT in Austrian than in German hospitals. It also included a significant difference in the percentage of electronic nursing records in use. These findings correspond with a significantly higher number of PC workstations on the wards. Despite these differences, Austrian and German hospitals reported a nearly identical IT budget. Factors which might have influenced the wider use of clinical IT are a re-focus on clinical matters after rigorous organisational changes, legal constraints and a general IT-friendly climate in Austria.

The overall aim of the RAFAELA system is that the personnel resources should be in balance with the patients' caring needs, i.e. when the nursing intensity per nurse is on the optimal level of the unit. The RAFAELA system consists of three parts: the OPCq (Oulu Patient Classification Qualisan) instrument for measuring the nursing intensity, registration of the daily nursing resources and the PAONCIL (Professional Assessment of Optimal Nursing Care Intensity Level) method. The aim of this paper is (1) to describe the structure of benchmarking with the RAFAELA system and (2) to present comparisons of optimal nursing intensity levels in Finnish hospitals by using data from RAFAELA benchmarking reports in 2001. Totally 86 wards from 14 different hospitals in Finland took part in the study, the optimal nursing intensity had been decided for 53 wards. Data was analyzed using descriptive statistics. The average workload was on adult wards 25.2 NCI points per nurse. The optimal NCI was exceeded during 48% of the days and under during 22% of the days. An imbalance between nursing intensity and personnel resources clearly affects the care quality and the results. Benchmarking with the RAFAELA system provides nurse managers with many opportunities in their decision processes in human resource management.

As patients have become older their care needs have increased, and this has consequences for the working conditions within primary health care. Objectives: The aim of this study was to evaluate, whether the OPC instrument, which has been developed for hospital care, is valid and useful within primary healthcare for older people. Materials and Methods: Reliability and validity testing of the OPC instrument was carried out at a health care centre in Eastern Finland spring 2004. A total number of 92 questionnaires were handed out, and the response rate was 67% (n=61) in order to test the validity. The inter-rater reliability was tested through parallel classification. A total number of 860 patient's were classified; in total 1722 classifications ware done. Cohens Kappa was chosen as the measurement for the consensus between the nurses' classification. Resultat: The consensus of the NI scores in total (OPC points) was 71%. The consensus measured with Kappa (k) showed a strong (0.65) consensus degree. Discussion: It can be said that the OPC instrument achieved a high enough reliability and validity in order to be seen as a reliable and useful instrument to measure the NCI within primary healthcare for the elderly. Conclusion: The OPC instrument can be seen as providing a fairly comprehensive view of the patient's caring needs, without claiming to be covering everything.

The automated linkage of nursing assessment, nursing interventions, nursing workload measurement, and outcomes supports the user in practice and increases the explanatory power of nursing data, e.g. in DRG systems. Practice relevant data should therefore be available for the different needs for information by policy, management, research and training. To this end, two projects have gradually linked the outcome-oriented nursing assessment instrument AcuteCare (ePA-AC) and the nursing intervention and workload measurement system LEP^® Nursing 3 with each other.

Given the definition if nursing informatics it should be a core activity for all nurses, and seen as a tool to support high quality care giving. Three studies reported in this paper show that this is not the case. Qualified nurses are perceived as having poor skills and knowledge, and as being resistant to IT as it takes them away from patient care. Educators share this lack of knowledge, and neither academics nor students consider nursing informatics to be a clinical skill. In order to use computers while on placement students were found to need confidence in their skills, and to feel that the use of computers was encouraged. Socialisation into the profession is an important part of nurse education, and currently students are being socialised into a professional role where they are not encouraged to use computers, or to consider their use to be a key nursing task. If nursing informatics is to truly become a way of improving patient care this needs to be changed, and pre-registration education is a key place to start to bring this change about.

The Managed Knowledge Network (MKN) for Nurses, Midwives and the Allied Health Professions (NMAHPs) in NHS Scotland was launched in November 2007. The online portal supports the NMAHP network to manage its knowledge and information sources that facilitate engagement with the national eHealth programme and realisation of benefits that eHealth offers to improve healthcare and service delivery. It is an integrated change management and knowledge management initiative. Web2 technologies support the social networking side of knowledge management and learning, allowing people to contact each other and collaborate. MKN resources are managed within the e-Library also giving access to over 5000 online journals and over 500 bibliographic databases.

The aim of the study was to identify key elements of successful care process of patients with heart symptoms from the nursing management viewpoint in an emergency care. Through these descriptions, we aimed at identifying possibilities for using enterprise resource planning (ERP) systems to support decision making in emergency care. Hospitals are increasingly moving to process-based workings and at the same time new information system in healthcare are developed and therefore it is essential to understand the strengths and weaknesses of current processes better. A qualitative descriptive design using critical incident technique was employed. Critical Incidents were collected with an open-ended questionnaire. The sample (n=50), 13 head nurses and 37 registered nurses, was purposeful selected from three acute hospitals in southern Finland. The process of patients with heart symptoms in emergency care was described. We identified three competence categories where special focus should be placed to achieve successful process of patients with heart symptoms: process-oriented competencies, personal/management competencies and logistics oriented competencies. Improvement of decision making requires that the care processes are defined and modeled. The research showed that there are several happenings in emergency care where an ERP system could help and support decision making. These happenings can be categorized in two groups: 1) administrative related happenings and 2) patient processes related happenings.

Human computer interaction (HCI) equates nurses using voice assisted technology within a clinical setting to document patient care real time, retrieve patient information from care plans, and complete routine tasks. This is a reality currently utilized by clinicians today in acute and long term care settings. Voice assisted documentation provides hands & eyes free accurate documentation while enabling effective communication and task management. The speech technology increases the accuracy of documentation, while interfacing directly into the electronic health record (EHR). Using technology consisting of a light weight headset and small fist size wireless computer, verbal responses to easy to follow cues are converted into a database systems allowing staff to obtain individualized care status reports on demand. To further assist staff in their daily process, this innovative technology allows staff to send and receive pages as needed. This paper will discuss how leading edge and award winning technology is being integrated within the United States. Collaborative efforts between clinicians and analyst will be discussed reflecting the interactive design and build functionality. Features such as the system's voice responses and directed cues will be shared and how easily data can be documented, viewed and retrieved. Outcome data will be presented on how the technology impacted organization's quality outcomes, financial reimbursement, and employee's level of satisfaction.

The field of ambulatory care nursing is rapidly growing due to rising health care costs and the demographic development. Against this background, the VitaBIT project started in 2007 with the objective of designing an ICT platform for the safe application of mobile information services in ambulatory care nursing. Communication and secure information exchange between all parties involved in the care process are also guaranteed. The article explains the project's current approach to develop a user-oriented solution using the design steps implied by ISO 13407. Even if a technology is developed and formally tested to be highly usable there exists no guarantee that this will lead to acceptance. That is the reason why end users are involved in all the project stages and serve as testers of prototypes in VitaBIT.

Software is often designed based on the designer's mental model rather than the user's. To correct this, we created personas (archetypes) of nurses using observations and semi-structured interviews. We developed and evaluated patient monitoring display prototypes for each persona. Among 11 ICU nurses, we found that the majority of nurses preferred a parsimonious data representation with large numbers and waveforms allowing all relevant data to be visible. Using personas and paper prototypes is an inexpensive and effective way to assess nurses' requirements and design preferences.

Introduction: Health care organizations and providers are under constant pressure to do more with less. On the other hand, users of health care services are faced with problems due to errors in communication between professionals, fragmentation of care and gaps in the continuum of care. Objectives: The aim of this study was to explore the meaning of the term ‘integration’ with reference to health, and underscore the need for integration of the healthcare systems. Methods: The literature study approach was employed. The first part underlines the conceptualizations of integration and methods for healthcare integration in practice. In the second part, the current situation in Slovenia in this field is outlined. Results: Activities are currently underway for laying down the fundamental normative infrastructure and legal bases for implementation of the eHealth projects, establishing a common health information network, and creating the bases for a standardized electronic health medical record. Conclusions: In the ‘top-down’ method, we concentrate mainly on general organizational changes for the purpose of achieving coherence and optimization. Projects that focus on the needs of individual patient groups belong under the ‘bottom-up’ process of integration. To achieve an optimal degree of integration, all health professionals have to play a key role in formulating the strategy of integration at all levels of healthcare.

Using observational and interview approaches, we evaluated the usability of a web-based communication tool that allows managers to announce open work shifts and staff to request work shifts. We used Morae^™ software to record screen shots and study participants' (4 Nurse Managers, 3 Registered Nurses and 3 Patient Care Technicians) utterances during system use. Although features and functions used and patterns of use varied by role and individual, all participants found the system easy to use. Use of a particular function depended upon how effective the user perceived the function to be for the task that they wished to accomplish. User satisfaction was achieved when an effective function also allowed them to meet their task goal efficiently.

The aim of this study is to describe nurse managers' perceptions of the strategic management of information systems in health care. Lack of strategic thinking is a typical feature in health care and this may also concern information systems. The data for this study was collected by eight focus group interviews including altogether 48 nurse managers from primary and specialised health care. Five main categories described the strategic management of information systems in health care; IT as an emphasis of strategy; lack of strategic management of information systems; the importance of management; problems in privacy protection; and costs of IT. Although IT was emphasised in the strategies of many health care organisations, a typical feature was a lack of strategic management of information systems. This was seen both as an underutilisation of IT opportunities in health care organisations and as increased workload from nurse managers' perspective. Furthermore, the nurse managers reported that implementation of IT strengthened their managerial roles but also required stronger management. In conclusion, strategic management of information systems needs to be strengthened in health care and nurse managers should be more involved in this process.

As nurses around the world prepare to celebrate the centenary of the death of Florence Nightingale in 2010 this paper reviews her work on using information, especially statistics, to analyze and manage patient care and links that to current developments in informatics. It then examines assistive technologies and how they may impact on nursing practice in the future and links these developments to the writings of Florence Nightingale. The paper concludes by suggesting that in progressing towards sustainable and ubiquitous healthcare informatics we need to study history in order to learn from the lessons of Florence Nightingale and other healthcare pioneers.

In 2007 the Rostering Project Team (RPT) completed an audit of nursing managers using computerised rostering system. This audit highlighted the overall lack of rostering experience among the participants and the need for formalised education in this area.

This paper describes that the nurses attitudes, using and motivation towards the computer usage significantly influenced by area of nursing/health care service. Today most of the nurses traditionally document patient information in a medical record using pen and paper. Most nursing administrators not currently involved with computer applications in their settings are interested in exploring whether technology could help them with the day-to-day and long – range tasks of planning and evaluating nursing services. The results of this investigation showed that respondents (nurses), as specialists and nursing informatics, make their activity well: they had “positive” attitude towards computers and “good” or “average” computer skills. The nurses overall computer attitude did influence by the age of the nurses, by sex, by professional qualification. Younger nurses acquire informatics skills while in nursing school and are more accepting of computer advancements. The knowledge about computer among nurses who don't have any training in computers' significantly differs, who have training and using the computer once a week or everyday. In the health care services often are using the computers and the automated data systems, data for the statistical information (visit information, patient information) and billing information. In nursing field often automated data systems are using for statistical information, billing information, information about the vaccination, patient assessment and patient classification.

A major event, such as a nursing informatics conference or course has been used successfully as an impetus to gather nurses interested in informatics together. This paper reflects on a 2008 nursing informatics event held in Singapore and the author's previous experiences with initiatives to support the emergence of nursing informatics in countries without a strong nursing informatics presence. Possible next steps and potential barriers are identified. It is hoped that countries new to informatics, and without an established nursing informatics group may gather ideas on how to better support nursing informatics involvement.