Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast jo u r n al ho m e p a g e :w w w . i j m i j o u r n a l . c o m
Nurses’ experiences of using an interactive tailored patient assessment tool one year past implementation
Elin Børøsund
a,∗, Cornelia M. Ruland
a,b, Shirley Moore
c, Mirjam Ekstedt
a,daCentreforSharedDecisionMakingandCollaborativeCareResearch,OsloUniversityHospital,Oslo,Norway
bDepartmentofMedicine,UniversityofOslo,Norway
cFrancesPayneBoltonSchoolofNursing,CaseWesternReserveUniversity,Cleveland,OH,USA
dSchoolofTechnologyandHealth,KTH,RoyalInstituteofTechnology,Stockholm,Sweden
a r t i c l e i n f o
Articlehistory:
Received29April2013 Receivedinrevisedform 24September2013 Accepted24October2013
Keywords:
Implementation
Tailoredsymptomassessment Patient–providercommunication Patient-centeredcare
Cancercare Nursesexperiences Focusgroups
a bs t r a c t
Background:Despiteevidenceofbenefits,integrationofpatient-centeredcommunication inclinicalpracticeischallenging.Interactivetailoredpatientassessment(ITPA)toolscan contributetoamorepatient-centeredcareapproach.However,littleresearchhasexamined theimpactofsuchtoolsonnursingcareoncetheyhavebeenimplemented.
Objective:Toexplorenurses’experiencesofthebenefitsofandbarrierstousinganITPA calledChoice,incancercareoneyearafteritsimplementation.
Methods:ThisinvestigationisapartofalargerstudyexaminingtheuseofChoiceincancer care.Fourfocusgroupinterviewswereconductedwith20nursesexperiencedinusingthe Choiceapplication.Thedatawereanalyzedusingqualitativecontentanalysis.
Results:Threethemesandninesub-themesemerged:(1)“Choiceasfacilitatorforshared understanding andengagementinpatients’owncare,”withthreesub-themes: prepar- ingbothpatientandnurseforcommunication,sharedengagementincareplanning,and givingthepatientsavoice;(2)“enhancingthepatients’strengths,”withtwosub-themes:
releasingpatient’sinternalstrengthsandconfirming“normalcy”forthepatient;and(3)
“new challengesforthenurse,”withfoursub-themes: organizationalchallenges,inter- actions withtechnology, a needfortrainingin communicationskills,and new ethical challenges.
Conclusions: Findings suggestthat,fromnurses’perspectives, integrationofITPAssuch asChoiceinclinicalpracticeoffersmanybenefitsthatcancontributetopatient-centered care. However, toreap thesebenefits,use ofsuchtools mustreceiveequalpriority as otherroutines,andrequiresufficienttime,spaceandcompetence.Choicealsochallenged nurses’professionalrolesandcreateddilemmassuchasnurses’ambivalenceregarding patients’ levels of disclosureof sensitive issues and the nurses’ ability to respond to them. Although patient-centeredcareis advocatedas modelforgoodclinicalpractice, this is not always internalized. Tools such as Choice may help to make such a shift happen.
©2013ElsevierIrelandLtd.Allrightsreserved.
∗ Correspondingauthorat:CentreforSharedDecisionMakingandCollaborativeCareResearch,OsloUniversityHospital,Pb4950Nydalen, 0424Oslo,Norway.Tel.:+472307545;fax:+4723075450.
E-mailaddress:Elin.borosund@rr-research.no(E.Børøsund).
1386-5056/$–seefrontmatter©2013ElsevierIrelandLtd.Allrightsreserved.
http://dx.doi.org/10.1016/j.ijmedinf.2013.10.010
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast
1. Introduction
Patients with cancer oftenexperience multiple symptoms, problemsandconcernsduringtheirtreatmentandrehabili- tation[1,2].Toeffectivelyhelppatientsmanagetheirillness, cliniciansneedtounderstandhowpatientsexperiencetheir diseaseandsymptoms,aswellasanyproblems,concerns,and carepreferencestheymay have.TheQualityChasmreport fromtheInstituteofMedicinedefinedpatient-centeredcare as care that is “respectful ofand responsive to individual patients’ preferences,needs andvalues, and ensuringthat patientvalues guide all clinicaldecisions” [3] (p6).Patient- centeredcareimprovesdiseaseoutcomesandqualityoflife [4].Patient-centeredcommunicationisacriticalelementof patient-centered care [4–6], and essential for knowing the personbehindthepatient,inordertoreachasharedunder- standing ofthe patients’ problems, preferencesand needs [6,7]. Through patient-centered communicationthe patient is activated and the foundation is laid for a partnership thatincludessharingofinformation,shareddeliberation,and shareddecisionmaking[6].
Despiteevidenceofthebenefitsofpatient-centeredcare and communication[4,8,9], thereare significant challenges to integrating patient-centered communication in clinical practice[5,6].Althoughcareprovidersmayendorsethenotion ofpatient-centeredcareasawaytoengagethepatientasan activepartnerinhis/hercareandtreatment,careisstilloften basedonroutinesandoffersfewopportunitiestoestablish meaningful patient–provider relationships [5,6]. Frequently, cliniciansalsohaveincompleteunderstandings ofpatients’
needs,andthusareunabletoprovidetheinformationandcare thatpatientsfinduseful[5].Patients,ontheotherhand,may havepoorknowledgeabouttheirdiseaseanditssymptoms, orbe unabletoarticulate theirbeliefs,values, information needs and preferences. Investments in infrastructure and informationtechnologyaredescribedasimportanttofoster anenvironmentthatenablespatient-centeredcare[4].
1.1. TheChoiceapplication
Choice is an interactive tailored patient assessment and communication (ITPA) toolfor cancerpatients designed to overcome these pitfalls. Itspurpose istwofold: (a) to help patientsreporttheirexperiencedsymptoms,problems,and prioritiesforcareand(b)tosupportclinicians inproviding individuallytailoredsymptommanagementsupport[10].The content of the Choice intervention is based on a thorough reviewoftheliteratureonsymptoms,problemsandsymp- tommanagementinpatientswithcancer,ononcologyexpert focusgroupsandoninterviewswithpatients[10].
UsingChoice,patientsreporttheirsymptomsand health problemsalongphysical,functional,andpsychosocialdimen- sions, note downtheir degreeof distress or affliction,and prioritizetheirneedforcarefortheirsymptoms.Theassess- mentisindividuallytailoredtoeachpatientbasedonhis/her initialresponse.Itallowspatientstobranchintothoseaspects that are personally relevant while skipping those that are not. For example, patients first select from problem cate- goriesthosethatapplytothem,andthisopensupasubset
Fig.1–ScreenshotshowingtheChoicesummarysheet.
of more specific symptom descriptions in lay terms from whichpatientsagainselectthosethatapply.Theythenrate degreeofdistressoftheirselectedsymptomsonascaleof 0–4 (nottroublesome toextremelytroublesome)and priori- tizeneedsforsupporttomanagetheirsymptomsonascale of0–10(receivingsupportnotimportanttoextremelyimpor- tant).Whenthepatienthasfinished,thesystemimmediately createsanassessmentsummarythatdisplayspatients’selected symptomsanddistress,inrank-orderofprioritizedneedfor care(Fig.1,summary),therebydirectingtheclinician’satten- tion totheproblemsthatmattermosttoeachpatient.The summary istransferredtothehospital’selectronic system, from whichitcanbeaccessed.Thepatientreceivesacopy.
Becausepatientscancompletetheassessmentontheirown attheirownpacepriortobeingseenbyaclinician,theassess- ment itselfdoes nottake upclinician time.Resultscanbe usedtoassistcareproviderstobettertailorsymptomman- agementandcareindividuallytoeachpatientandtosupport person-centeredcommunication.DevelopmentoftheChoice applicationforcancerpatients[11,12],andademonstration ofitsvalidityandreliabilityarepresentedindetailelsewhere [13].
TheChoiceITPAhasbeenshowninclinicaltrialstosignif- icantlydecreasecancerpatients’symptomdistressoverthe courseoftheirillness,reducepatients’needsforcare,increase disclosure of patients’ cues and concerns in communica- tion withclinicians,andincreasethe numberofsymptoms andqualityoflifeissuesaddressedinpatientconsultations [10,14–16]. Thesystem received high ratingson usefulness bypatients,nursesandphysiciansinasurveyafterthetrial period[17].PatientswhohadusedChoicereportedincreased
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast self-awareness and knowledge about the illness, improved
communication and information sharing with health care providersandincreasedsenseofcoherenceandcontrol[18].
Theclinicians atthe hospitalunits who participated in therandomizedcontrolled trialthat demonstratedpositive effectsofChoiceinterms ofreduced symptomdistressand needforcare[10]decidedtousetheapplicationaspartofrou- tinepractice.However,tobesuccessful,interventionsfound tobeeffectiveinclinicaltrialsmustalsobepossibletoimple- mentandmaintaininroutinecare.Puttingnewcomputerized toolstouse inclinical practice isdescribed aschallenging [19–22].Forexample,astudydoneatapalliativeunitwherean electronicassessmenttoolwasbeingimplementedreported perceived difficulties related to establishing new routines, increasedworkload,technologyissues,increasedburdenfor patients,andethicalissuesduetoconcernsaboutwhether or notthe systemwould actually benefitthe patients[21].
Functional and technological issues, the users’ desire for morein-depthinformation,userprivacyconcerns,andlimited patientuseareotherchallenges notedwhenimplementing newsystemsinclinicalpractice[23].However,whileanumber ofstudieshaveaddressedaspectsofsystemimplementation, lessresearchhasexaminedthechallengesthatmayemerge overtimeortheimpactofnewinterventionsaftertheyhave beenimplemented[24].
After the Choice ITPA was implemented into regular practice,themainclinicaluserswerenurses.Therefore,the currentstudyexploresnurses’experiencesofbenefitsofand barrierstomaintaininguseofChoiceincancercareoneyear afteritsimplementation.
1.2. Theoreticalperspective
TheintroductionofasystemsuchasChoiceincancercarecan beviewedas implementinganewinnovationinto existing routines. According to Roger’s theory ofdiffusion of inno- vations[25],users’willingnesstoimplementaninnovation dependonfiveattributesoftheinnovation:(1)relativeadvan- tage,thedegreetowhichtheinnovationisperceivedasbeing betterthanwhatitsupersedes,(2)compatibilitywithexisting values,experiencesandneeds,(3)complexity,(4)abilitytobe tested,and(5)visibilityofresults.Thefindingsinthisstudy willbediscussedinlightoftheseattributes.
2. Methods
Thisstudyisapartofalargerstudy,inwhichtheChoiceITPA wastestedamongcancerpatientsinthreeinpatientandtwo outpatientwardsin2003–2006[10].
2.1. Context
Basedonevidenceofitseffectiveness[10],theunitsrequested touseChoiceinroutinepatientcareafterthestudyperiod.
Thiswassupportedbythenursingandmedicalleadership.
Thenurses werefamiliarwithuseoftheassessmentsum- maryfromthetrialperiod,buthadneveradministratedChoice themselvesasapartofroutinepractice,asthiswasdoneby theresearchassistantsduringtheearlierstudy.
AnimplementationplanforChoicewasdeveloped,inwhich dedicatedpersonsattheunitswereinvolvedascollaborators intheimplementationprocess.Theplanincluded:1)informa- tionfoldersaboutthetool,2)kick-offmeetingsforthestaffat eachunit,3)individualtrainingforthenursesonhowtooper- atetheapplication,4)trainingonhowtointroduceChoiceto thepatients;and5)andguidanceonhowtousetheassess- mentsummaryofthepatients’symptomsinclinicalpractice.
Thetrainingprogramandcoursesforthecliniciansstartedin autumn2006,andChoicestartedtobeusedinroutineclini- calpracticeearlyin2007.Inthetrainingsessions,physicians andnursesweregiventhoroughinformationabouttheback- ground,purpose,anddevelopmentoftheChoiceITPAbythe projectdirector(CR).Theywerealsogiventrainingsessionsin smallgroupsledbytwotrainedresearchassistants.Thetrain- ingsessionswereslightlydifferentforphysiciansandnurses, mainlyowingtotimerestrictionsamongphysicians.Allnurs- ing staffattended training sessionswithhands-ontraining withtheChoiceITPAandwereencouragedtouserole-playing topracticeintroducingittopatientsandintegratinginforma- tionfromthesummarysheetintotheconsultations.
2.2. Design
Inthisexploratoryretrospectivestudywecollecteddatausing focusgroupdiscussionstoobtainanin-depthunderstanding ofnurses’experiences whenusing Choice[26]. Focus group discussionshavequalitiesofbothinterviewsanddiscussions [27],andbenefitfromgroupdynamics[28]bystimulatingpar- ticipantstoreactto,rejectorconfirmstatementsfromother participants’.Thegoalwithusingfocusgroupswastoelicitas widearangeofparticipantexperiencesaspossible.
2.3. Sampleandsetting
Thefocusgroupsincludednursesfromthreeinpatientand one outpatient cancer ward at two teaching hospitals in Norwaywhohadbeenpartoftheimplementationprocessand hadusedChoice.Headnursesidentifiedpotentialparticipants, andnursesreceivedinformationleafletsaboutparticipation.
Twentynursesagreedtoparticipate.Theiragerangedfrom 23to55years(mean34),andtheirnursingexperienceatthe unitrangedfrom1to25years(mean5.9).Eightnurseshada clinicalspecialisteducation,suchasoncology,mentalhealth, intensivecareoramasterofnursingscience.Twomaleand 18femalenursesparticipatedinthefocusgroups.
2.4. Procedures
An interview guide was developed by the research team accordingtoKruegerandCasey[28]tofosterconsistencyin thequestionsaskedacrossgroups.Theopeningquestioncon- cernedtheparticipantsandtheirinitialthoughtsaboutbeing inthestudy.Afterabriefintroductiontothe areaofinter- est, participantswere asked about their experiences using Choiceintheirdailywork.Thereafterkeyquestionswereposed concerningChoice’s abilitytoelicitthe patient’s symptoms, problemsandprioritiesforhelp,possibilitiesandchallenges and perceived barriersto usingChoice.Theinterview guide
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast Table1–Examplesofmeaningunits,condensedmeaningunits,sub-themesandthemefromcontentanalysisoffocus groupinterviews.
Meaningunits Condensedmeaningunits Sub-themes Themes
“I’mmentallypreparedfortheconversation,..Ihavetime tothinkthingsthrough,bothwhatanswersIcan provide,whatfeedbackandsupportIcanoffer.”
Havingtimetothinkthrough, preparesthenursefor communication
Preparesboth patientandnurse
forcommunication Facilitatorforshared understandingand engagementinpatients’
owncare
“It’sprobablyawayforthemaspatientstobecomemore aware,writingthoughtsdownandbeingableto organizeandbettersortthingsthrough.”
Becomingawareof,and structuringthoughts
“Thepatientiswellprepared.Heknowsthathehas alreadycheckedsomethingoff,ratherthansuddenly beingaskedaboutit.Oriftheycometous,theyare morepreparedwhentheyknowtheyhavealready checkedsomethingoff“
Knowingwhatproblemstheyhave checkedinChoicepreparesthe patientsforcommunication.
”It’sactuallyeasiertopreparetreatmentplansthrough theuseofChoice.Problemsandissuesaremore evidentthere,theneedsofthepatientmoreclear,and ratherthanguessingit’seasiertodeterminewhat needstobedonepointingtoChoiceandChoiceresults”
InformationrevealedinChoicewas usedasabasisforcareplanning
Sharedengagement incareplanning
”WhenyouuseChoiceyouask‘whatdoyouthinkifthis couldhelplikethisorthat?’Thatwayheparticipates inthedecisionmakingabouthisowntreatment,we createaplanbasedonourdiscussions,andhehas indirectlyparticipatedinmakinghisowntreatment plan”
Thepatientindirectlyparticipates inowncareplanningthroughuse andcommunicationaboutChoice results
“Withthequietones,wefindoutaboutproblemswe didn’tthinktheyhad...”
Healthcareprofessionalsget insightintotheworriesofmore quietpatients.
Givesthepatientsa voice
“AndIthinkthere’ssomethingintreatingpeopleequally butdifferently.Thatthetoolallowseveryonetospeak onanequalfooting”
Eachpatienthasanequal opportunitytobeheard.
“Atthesametime,itwillbeuptothepatientshowmuch theywanttorevealabouttheirthoughts,concerns, andstruggles”
Thepatientsdecidehowmuch theywanttoshare.
endedwithaninvitationforparticipantstocommentonthe assistantmoderator’soralsummaryofthediscussion.
Theinterviewguidewasfirsttestedinapilotfocusgroup consistingofexperiencednurses.Sincethegroupdiscussions capturedissues ofinterest,theresultsfrom the pilotwere includedinthestudy.
Fourfocusgroupdiscussionswereconductedinahospital meetingroomwith4–6respondentsineachgroup.Tocircum- ventthe risk thatexperienced nurseswould dominate the discussioninthegroups[29],therespondentsweredivided intotwogroupsofexperiencednurses(twoormoreyearsat theunit)andtwogroupsoflessexperiencednurses(lessthan twoyearsattheunit).
Thediscussionslastedbetween56minand123min;they were audio-taped and transcribed verbatim by the first author.Duringallthediscussionsthefirstauthorandacol- league(bothexperiencednurses)werepresentandalternated between being moderator and assistant moderator in the differentfocusgroupdiscussions.Themoderatoraskedques- tionstogetparticipantstoelaboratewhentheirstatements werevague.Theco-moderatortooktheroleofanobserverand recordedfieldnotesduringthefocusgroups.Directlyafterthe focusgroups,themoderatorandco-moderatormetanddis- cussedtheirimpressionofthediscussions,andnotedthese impressionsinanobservationlog.
Thisstudywasplannedandperformedincompliancewith theprinciplesoutlinedintheDeclarationofHelsinki[30],and wasapprovedbytheRegional CommitteesforMedicaland
HealthResearchEthicsinNorwayandthePrivacyProtection Committeeatthehospital.
2.5. Analysis
Theanalyticalprocesswasguidedbyqualitativecontentanal- ysisasdescribedbyGraneheimandLundman[31].Content analysisisamethodofsystematicallyanalyzingwrittenor verbalcommunication,withcontexttakenintoaccount[32].
Aslittle isknown abouthowcommunication toolssuchas Choicearereceivedintoanorganization,aninductiveapproach was chosen [33]. This approachinvolves identification and condensationofthemeaningunits(seeexplanationbelow), and identification ofsubthemes andthemes (Table1).The analysiswasperformedbythefirst(EB)andthelastauthor (ME) in an interactive process in several steps. First, the interviews were thoroughly readthrough toobtain a com- prehensiveunderstanding aboutthenurses’experiencesof using Choice. Secondly, meaning units, i.e. sentences and paragraphs containing aspects related tothe same central meaningthroughcontentorcontext[31],wereextractedfrom the text. Themeaning unitswere condensed and summa- rized,andwherepossibledescribedintermsoftheunderlying meaning,preservingthecorecontent.Thecondensedmean- ingunitswere abstractedinto sub-themes.Bycontinuously examiningpartsaswellastheentiretext,wewereableto abstractthreemainthemesandninesub-themesdescribing thenurses’experiences(Table2).Toensuretrustworthiness,
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast Table2–Overviewofthemesandsub-themesfrom
contentanalysisoffocusgroupinterviewswithnurses usingChoice.
Themes Sub-themes
Facilitatorforshared understandingand engagementinpatients’
owncare
Preparesbothpatientandnurse forcommunication
Sharedengagementincare planning
Givesthepatientsavoice Enhancementofthe
patients’personalstrengths
Releaseofinternalstrengths Confirming“normalcy”
Newchallengesforthe nurse
Organizationalchallenges Interactionswithtechnology Aneedforcommunicationskills training
Newethicalchallenges
thesub-themesandthemeswerediscussedbetweenthefirst and last author aswell aswithin theresearch groupuntil agreementwasreached.Toincreasethetransparencyofthe interpretation,themes and subthemes are illustrated with quotations.
3. Findings
MainfindingsinthisstudyindicatethattheuseoftheChoice ITPA,asexperiencedbynurses,canbecategorizedintothree themes; (1) Choice as facilitator for shared understanding and engagementinpatients’owncare,(2)enhancementofthepatients’
personalstrengths;and(3)newchallengesforthenurse.
3.1. Facilitatorforsharedunderstandingand engagementinpatients’owncare
ThenursesexperiencedChoiceasafacilitatorforcommuni- cation.Nursesreportedthatitenabledpatientstoreportand sharetheirsymptomsandprioritiesforcarewiththenurses, whichmadeboththepatientandthenursebetterpreparedto communicateandtoplanthecare.
3.1.1. Preparesbothpatientandnurseforcommunication Choicewasdescribedasadooropenertoaddressdifficulttop- ics.Informationaboutthepatient’sproblemsmadeiteasier forthenursestofollowupmoredirectlyincommunication.
Thenursesexperiencedthatcommunicationatthewardshad changed.Topicssuchasdeathandpsychologicalproblems, whichhadseldombeenraisedearlier,werenowaddressed, andthecommunicationwithpatientswasregardedasmore effective.
“Ithinkthepatientsarebetteroff,thattheygethelpfor preciselytheproblemstheyhave. Andwedon’t haveto askasmanyquestionsandtheydon’thavetoansweras many.”
Thenurses’experiencewasthatbyusingChoice,andread- ingthe reportpriortoseeingthepatient, bothpatientand nursewerebetterpreparedfortheirconversation.Onenurse expressed:
“I’mmentallypreparedfortheconversation,...Ihavetime tothinkthingsthrough,bothwhatanswersIcanprovide, whatfeedbackandsupportIcanoffer.”
Asthenursesdescribedit,patientsknewthattheproblems theyhadmarkedinChoicewouldberaisedintheconversation, andevenifthetopicsweresensitive,thepatientswereusually willingtotalkaboutthem.
3.1.2. Sharedengagementincareplanning
Sincethepatientshadidentifiedtheirsymptomsandhadan opportunitytoreflectonthem inadvance,nursesreported thatthepatientsweremoreengagedintheconversationand thetimewasputtobetterusetodeterminehowtroublesome theproblemswereforthepatientsandwhattodoaboutthem.
“WhenyouuseChoiceyouask;‘whatdoyouthinkifthis couldhelplikethisorlikethat?’Thatwayheparticipates inthedecisionmakingabouthisowntreatment,wecre- ateaplanbasedonourdiscussions,andhehasindirectly participatedinmakinghisowntreatmentplan.”
Therichnessofinformationrevealed inChoicewasused asabasisforcareplanning,nursingassessmentsandasan information supplement in interdisciplinary rounds.Choice wasconsideredtoimprovecareplans;problemsthepatients rankedhighintermsofdistressorpriorityforcarecouldbe transferredtothecareplanandthusfollowedup.Accessto thisinformationenablednursestoprovidebettercare.
3.1.3. Givesthepatientsavoice
ThenursesverbalizedthatChoicegaveeachpatientanequal opportunity to be heard and to express their feelings and needsforhelpfromhealthcareproviders,independentofthe careprovider,shynessorverbalskills.Onenursesaid:
“Withthequietones,wefindoutaboutproblemswedidn’t thinktheyhad.”
Nursesdescribedthattheyoftenweresurprisedwhenthey readtheChoicesummaryaboutwhatthepatientshadbeen dealingwith.Somereportedmoreproblemsthanthenurses expected judgingfrom their condition, somereportedless.
Thenursesalsoexperiencedthatitwasthepatientsthem- selveswhodecidedwhattheywantedtosharewiththehealth carepersonnel. When thepatient initiatedcommunication aboutunexpectedthemesthroughChoice,theygavenursesa betteropportunitytobeinvolvedinandprovideindividualized care.
“AndIthinkthere’ssomethingintreatingpeopleequally butdifferently.Thatthetoolsalloweveryonetospeakon anequalfooting”
3.2. Enhancementofthepatients’personalstrengths
WhenusingChoicethepatientsthoughtthroughmanyoftheir problems,andthenursesperceivedthatsomehealingtook placeasa“side-effect”.
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast 3.2.1. Releaseofinternalstrengths
Nurses experienced that, for the patients, merely going throughtheproblemsavailableinChoiceandmarkingtheones thatappliedtothemstartedaprocessofreflection.
“TheadvantageofChoiceisthatitsetsthingsinmotion.It’s awaytoorganizethoughts,thinkabouttheirsituation.It isn’tnecessarilyimportanttogethelpwithit.Theyhave thesolutionthemselvesandtheyalsoknowwecan’thelp themwithit,butthat’showitis.That’sthewayitis.”
Thenurses’experienceswerethatthepossibilitytotalk about theproblem wasconsidered helpfulbythe patients.
Since the tool helped to identify the problems, nurses perceivedthat itwaseasierforthe patienttoaskforhelp, andthepatientscouldgethelpwiththoseproblemsthatwere mostimportanttothematthetime.Inadditionitwasnot necessarytobringupalltheproblemsduringthediscussions.
Ifthepatientgothelpwiththoseheorsheconsideredmost important,thenursesexperiencedthatotherproblemsoften wereresolvedaswell.Justbeinglistenedtocouldsometimes beenoughhelp.
“It’sasiftheburdenisabitlighterafterthey’veputitin writing.SoIthinkit’sagreathelpforsomeofthem...”
3.2.2. Confirmingnormalcy
By seeingasymptomlisted inChoicethepatients gotcon- firmationthat their symptoms could be“normal” fortheir condition.Thenursesdescribedhowthisseemedtomakethe problemslessfrighteningandthatthepatientsometimesfelt relieved,evenwithoutafollow-upconversation.Puttingthe problems“onthetable”couldbeawaytoacceptthatthiswas somethingtheyhadtodealwith.
“Ithinkit’sanimportantconfirmationforthepatients;they seethatit’sactuallycompletelynormaltofeelthistired or...”
3.3. Newchallengesforthenurse
UsingChoicealsoraisednewchallengesforthenurses.
3.3.1. Organizationalchallenges
The nurses expressed challenges related to organizational constraintsintermsoftime,routinesandworkorganization.It couldbedifficulttofindtimetogiveapatienttheChoiceappli- cationforanassessment,forthefollow-upconversationand todocumentthepatient’sidentifiedproblemsinthecareplan.
Havingtimeandspaceforanundisturbedconversationwas highlightedasakeyprerequisitewhenthepatientneededto talkaboutsensitivetopics.TofitChoiceintotheregularwork- flow,thedailyroutineshadtobechanged,butanentireyear afterimplementationChoicehadstillnotbecomeanentirely well-establishedroutine.
“MaybepartofitisthatChoiceisfairlynewandthereare somanyfamiliaroldroutinesyousortofhavetorearrange ifyou’regoingtomakethisagoodpartofthoseroutines.”
EventhoughmostnursesrecognizedthevalueofChoice,on busydaystheadministrationofChoicewasoflowerpriority.
“Itmightendupprettyfardownonthelistofpriorities.
First you dowhatyou havetodo, thethings you know absolutelymustdo,andthenthatstuffcomesinlater.”
Somenursesexperiencedmoralstressaboutnotbeingable toofferChoiceasplannedwhentheyrealizedtheydidnothave timeforfollow-upconversations.Someregardeditimportant todothefollow-upconversationthemselves,ratherthanhand itovertoothernursesatthenextshift.Theyalsoregardedit asveryimportanttoletthepatientknowiftheycouldnotfind timeforconversationuntillater.
3.3.2. Interactionswithtechnology
Severalsystemsforplanningpatientcarewereinuseatthe hospital.TotransferinformationfromChoiceintoelectronic careplansthenursesthereforehadtologontodifferentcom- puterizedsystems.Thislackofcoherencebetweensystems wasconsideredveryinconvenient.Choicewasregardedasrel- ativelysimpleforthepatientstomanage,butsomenurseshad heardsomepatientsdescribetheprogramascumbersome.
Patients who were unaccustomed to computers expressed uncertaintyatfirstaboutwhetherornottheywouldbeable touseChoice.Althoughthiscouldbeachallenge,forexample, amongtheelderlypatients,theywereabletouseitwhenthey tried.
Somenurses highlightedthatthe patient’sfirst meeting withthehospitalwasimportantandthatChoicecouldgivea cold,impersonalimpression.
“Wehavetothinkaboutthehumanrelationshipsbetween caregiverandpatient,and ourfirstmeeting,howimpor- tant that is. [...] This thing is obviously a computer, it canfeelcoldandabitmechanical.Itmightdosomething withyouasthevulnerablepatientthatyouare.It’sabit problematic...”
Someofthenursesexpressedthatiftheirownexperiences withtheuseofChoicewerepoor,theywerelesslikelytoprior- itizegivingChoicetotheirpatients.Somenursesemphasized that itwas criticaltobeaware ofthebenefitsChoicecould provideforthepatients,andthatnursesthemselveshadto haveapositiveattitudeinordertogetthepatientinvolved.
“You’vegottoplanwhatyou’regoingtosay,andhavea positiveattitudetowardityourself,ifyouwantthepatient togetinterestedanduseit.”
3.3.3. Aneedforcommunicationskillstraining
Somenurses describedthatthe greatestchallengewasnot inofferingtheChoiceapplicationtothepatient,butinmaking useofthefullpotentialofChoiceforconstructivecommunica- tionandcare-planning.Someexpressedaneedforguidance frommoreexperiencednursesbeforeenteringconversation withpatients.Beingpreparedandfeelingsecureintheirpro- fessionalroleasnurseswasimportant,andtheyexpresseda needforguidanceandtimetocarryoutameaningfulpatient- centeredcommunication.
“We’vereceivedabitofguidanceonwhatwecandotohan- dleanextremereaction.Formypart,I’vefiguredoutthat itcanbeagoodidea–ifit’saboutthingsyouhavetrouble talkingabout,andI’llnevergetusedtotalkingaboutdeath
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast andsexuality–itcanbeagoodideatochatwithsomeof
theotherpeopleatwork,kindofaskwhataboutthis,he sayshe’sthinkingalotaboutthesethingsand‘what’sa goodwaytoexpressit’.”
Thenurses expressed that unless theyfelt comfortable enteringintocommunicationwiththepatient,itwouldmost likelynothappen.Unconsciously,communicationaboutsen- sitivetopicswasputatthebottomofthelistofdailytasks ifnursesdidnotfeel confidentabouttheircommunication skills.Itwas easier todothe never-ending practicaltasks.
Nursesdescribed how a courseincommunication training theyhadreceivedearlier,whenChoicewasintroducedtothem, hadbeenveryhelpfulinovercomingtheseissuesand they expressedaneedforfurthercommunicationtraining.
3.3.4. Newethicalchallenges
Choice also implied new ethical challenges. The ethical demandwasthetrustthepatientliterallyputinthenurse’s handsandthenurse’sfeelingabouttheirabilitytorespondto thattrust.NursesdescribedthateventhoughChoicecontained onlycommonsymptomsandproblemsreportedintheliter- ature,patientsshared informationtheyperhapshad never revealedtoanyonebeforeandbroughtupnewintimatetop- icsforconversation.Nursesperceivedthepatientstobemore vulnerablethanever,withanexpectationofbeingheardand respondedto.Conversely,thepatientresponsesfromChoice weredescribedasoverwhelmingbysomenurses,especially iftheydidnotknow thepatientwell.Theinformationthe patientsharedwasregardedassensitive,personalanddiffi- culttorespondto.
“That’savulnerablepartofChoice,preciselythattheyhand overalltheirproblems,andthenmaybeyoudon’tdoany- thingaboutthem.That’smorehurtfulthannothingatall.
I’vealwaysthoughtthataboutChoice.”
Thenursesfeltresponsibleforthetrustthepatientshad putin their hands.They experienced that the most nega- tivefeedbackfrompatientswasrelatedtolackofafollow-up conversation after the assessment; that as a bare mini- mum,nursesneededtoacknowledgethattheinformationthe patientsharedhadbeenreceived.
When introducing Choice to the patients, some nurses informedthepatientsaboutwhattheycouldexpectinterms offollow-upfromthenursetoavoidunrealisticexpectations.
Somenursesexperiencedthatpatientsdidnotwanttoopen uptonursestheydidnotknow,eveniftheyhadindicated theirproblemsinChoice.Nursesdescribedthatitwaseasier forpatientstotalkwithnursestheyknewwell,andimportant thatnurses perform follow up conversationswithpatients theypersonallyhadintroducedtoChoice.Notallnursesshared thisopinion.Somenursesthoughtthatpatientscoulddecide forthemselveswhotheywantedtotalkto,oriftheydidnot wanttotalkatall.
“It’shappenedtometoo,gettingsomeoneIdidn’tknow.
Iwouldwishsomeoneelsecoulddoit,ifthetopicswere sensitive.Butthenhehastoviewmeasanurse,andnot asapersonhemaybehasn’tmetbefore.”
Somenursestooktheroleofanadvocateonthepatients’
behalfbyclaimingthattheyknewintuitivelyifpatientswere reluctanttofillinChoice.Lackofchemistrybetweenpatient andnursewasmentionedbysomenursesasareasonnotto giveChoicetothepatient.Thenurse’sjudgmentconcerning whetherornottoofferChoicetopatientswasdrivenbyawish toprotectsomepatientsfromunnecessaryburden.
Anotherethicaldilemmaraisedbysomenurseswasthe accessibilityofinformation.Onceapatientlistedaproblem, itwasdocumentedintheirrecordandavailableforeveryoneto read.Thenursesthoughtthatthepatientssometimesmight feel exposed, sincetheyhad no controlover the accessto this information.Intraditionalpatientinterviews,sensitive informationisgiveninacaringpatient–nurse relationship, whereaswithChoicethepatientconfidedtoadeviceandhad littlecontroloverwhotheywouldtalkwithlater.
“Yousortofdivein,insidealltheboundariespeopleraise aroundthemselveswhentheymeetnewpeople.Andhere Icomewithadocumentwherethispersonhasopenedup.
Soyoujumprightinwithoutreallyhavinganinvitation.”
4. Discussion
TheuseofChoicewasexperiencedbynursesasbothafaci- litatorformutualengagementincommunicationandasan initiatorofnewchallenges.Ontheonehand,Choicegavethe patientavoice,enhancedthepatient’sstrengthsandprepared bothnursesandthepatientforcommunicationandpromoted anengagementinsharedcareplanning.Ontheotherhand, Choiceposedorganizational, technical,ethicaland commu- nicationalchallenges(Table2).Thesefindingsareconsistent withfourofRogers’attributesofinnovations[25],andwewill discuss thefindings inlight ofthese attributes; (1)relative advantage,thedegreetowhichtheinnovationisperceivedas beingbetterthanwhatitsupersedes,(2)compatibilitywith existing values, experiences and needs, (3)complexity, the degree to which the innovationis perceived as difficultto understandanduse,(4)observability,thedegreetowhichthe results ofthe innovationsare visibletoothers. Trialability, thedegreetowhichuserscantryouttheinnovationsbefore use, wasrarelydiscussedinthe focusgroups,asthisstudy wasconductedoneyearpastimplementation.Trialabilitywill thereforenotbeincludedinthediscussion.
4.1. Relativeadvantage
TherelativeadvantagesofChoicewerethatitaddressedthe patients’ perspectives,madepossibleasharedunderstand- ing of the patients’ problems and prepared both patients and nurses for communication. This is in line with find- ings reportedbypatients thatusedChoiceinanotherstudy [18],whereChoiceincreasedtheirself-awarenessandknowl- edge,improvedcommunicationandinformationsharingand increasedtheirsenseofcoherenceandcontrol.Assuch,Choice contained severalofthe core elementsin patient-centered communication[7],andthuscanbeavaluabletooltoenhance patients’participationintheirowncareanddecisionsrelated to their health. Similar findings were reported in a study of the EdmontonSymptom Assessment System (ESAS),an
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast assessmenttoolwithsomesimilaritiestoChoice[34].Inthe
studymostofthenursesandalliedhealthprofessionsfound theESAStoenhancepatientcare,helppatientstoarticulate theirsymptomissues,andfacilitatefollow-upwithpatients withpastsymptomissues.Similarly,inastudyofanelectronic versionofESAS,cliniciansreporteditasuseful[35].
Some of the nurses noted, however, that even though theyknewtheadvantagesandpossibilitiesthatChoicecould bring,theystilldidnothave“goodexperiences”usingit.This affectedbothhowoftenthepatientsweregiventhepossibility toreportsymptomsusingChoiceandthefrequencyoffollow- upconversationsbasedontheassessment.Thisisconsistent withRogers’theorythatit istheindividuals’perceptionof therelativeadvantageofaninnovation(inthiscase,whatthe usersbelievetherelativeadvantagetobe)thatmatters,not theexperts’objectiveevidence[25].Thegreatertheinnova- tion’sperceivedadvantagetotheuser,theeasieritistoadopt andsustain[25].
Thestudyrevealed thatnurses’confidenceintheirpro- fessionalrolesandwhattheyperceivedasappropriatecare planningwerekeyfactorsinhowtheyperceivedtheadvan- tagesofChoice.Systematicassessmentisseenasnecessary toprovideprofessionalcare[36].Choicewasperceivedassup- portinthisassessmentbycapturingthepatients’perspective andwasusedasabasisforacareplan.However,bybecoming awareofallofthepatients’problemsandneedsinabusyward and simultaneouslyfeelinguncomfortable withperforming patient-conversationsaboutsensitivetopics,reluctancetouse Choiceseemedtooccur.Intraditionalinterviewsthenursehas morecontroloverwhatquestionstoask,andcaninsomeways adjustthisinformationtofittheconstraintsofbothtimeand personalperceivedcompetence.
Accordingto Rogers [25], the disseminationofan inno- vation is dependent on to what degree it is perceived as betterthantheproceduresitsupersedes.Inbusyperiodsin thewards,the nurses founditinconvenient toofferChoice as planned due to lack of time to communicate with the patientsaftertheassessment.Ontheotherhand,nursesalso experiencedChoiceasenhancingpatients’personalstrengths without any follow-up conversation.In lightof this,Choice maybeofferedtopatientsasaself-managementtool,also inperiodsofhigh work-load. However,inthis casenurses shouldclearlyinformthepatientthattheycannotfollow-up theassessmentsindetail,andencouragethepatienttoiniti- ateconversationaboutwhattheywanttotalkabout.Assuch, Choicewouldstillbeatooltocommunicatepatient’ssymp- tomsand preferences,but patients’ expectations would be differentandthemoralstressonnurseswoulddecrease.
4.2. Compatibility
AccordingtoRogers[25],aninnovationhastobecompatible withexistingvaluesandexperiencestopreventamismatch betweentheprofessional’sidealsandreality,whichisabasis forburnoutandturnoveramongnurses[37].
The use of Choice posed organizational and new ethi- calchallenges. Onechallenge wasto makefull use ofthe informationacquiredthroughChoiceincommunicationwith thepatientsinthedailyworkflow.Situationswherenurses wereunabletotalktopatientsabouttheinformationshared
throughChoicegaverisetomoralstress,becausetheycould notmeettheexpectationscreated.
Manynursesregardedgooddeliveryofcaretoentaila“con- tinuous caringrelationship” between an individual patient andanidentifiedhealthcareprofessional[38]andexpressed reluctancetohandovertaskstothenextshift,ortofollow up on anassessmentinitiatedbycolleagues. However,the complexitythatcharacterizescancercare,withamultitudeof professionalsandstakeholdersinvolvedindeliveryofasafe and coordinatedcare[39], callsfornewmodelsofcommu- nication.Patient,orperson-centricmodelsofcommunication that givethepatientsand familycaregivers avoicewillbe increasingly importantas advanced care moves more and moreintothepatient’shome.OurstudysuggeststhatChoice mightserveasafacilitatorofteamwork,linkteamsofprofes- sionalstogether,andpromote“teamcontinuityofcare”[38].
Assuch,Choicemightchallengeexistingvaluesandroutines abouthowtoperformandorganizepatientcare.
The“normalization”ofanewtechnologyintodailyworkis inpartdependentonhowwellthetoolfitswithexistingskill sets[40].Lackofcommunicationsskillswashighlightedasa barriertotheuseofChoicebysomeofthenurses.Issuesrelated todeathanddying havebeendescribedintheliteratureas areas wherenurseshavethe leastskillsincommunicating withcancerpatients[41].Thenursesinthecurrentstudyalso mentioned that these issues were difficult todiscuss with thepatients.Trainingofthestaff’scommunicationsskillsis highlightedasacrucialpointininterpreting feedbackfrom thepatientsthroughelectronicsystems[42,43].Heavenetal.
pointout thatclinicalsupervisionisessentialtoeffectively transfer skills learnedduring communication training into clinicalpractice[44].Iftrainingandsupervisionincreasethe possibilityofofferingandfollowinguptheChoiceITPA,this canmakeadifferenceonpatients’outcomes,asthepositive resultsintherandomizedcontrolledtrialdemonstrate[10].
Onthe otherhand,itcouldbearguedthatChoicewascon- sistentwith existingvalues andneeds forcommunication.
PatientswhohadusedChoicereportedittoenhancecommu- nicationwithhealthcareproviders[18],andourstudyindicate thatpatient-centeredcommunicationwasimproved.Forthe patientsitissometimesenoughthatsomeonelistens.They donotnecessarilyneedhelptosolvealltheirproblems.ITPAs have significantadvantagesforeliciting patients’ strengths andillnessexperiences,andfortailoringcareindividuallyto eachpatient.Theprocessofselectingaspectsthatareperson- allyrelevantisapowerfulinterventionitself,asitactivates the patient’sownreflectionandawarenessandencourages patients to take amore activerole [18]. Self-reflection has beensuccessfullyusedasaninstrumentforimprovinglearn- ing skills inprofessionals [45], and hasbeen viewed asan instrument forinterpretingand handlingthe situation and an approachto learning[46]. However it hasto befurther evaluatedandtestedinpatientcare.
4.3. Complexity
Innovations that are perceived as easy to use and under- standaremoreeasilyadopted[25].Althoughnursesinthis study described Choiceas beingoverall easy tomanagefor the patients andthe nurses,it was challengingto makeit
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast fit inthe dailyroutines. This isin line with other studies
describingintegrationofcomputertechnologyinhealthcare aschallenging[20,22].Challengesarenotnecessarilydueto technicaldifficultiesorlimitationswithinthee-healthappli- cation,butalsotoanunderstandabledown-prioritizationof qualityimprovementandresearchprojectsinfavorofurgent clinicalcareanddemands[47].Eventhoughthenursesinthe currentstudyexperiencedthattheuseofChoicehadseveral advantages,theycouldstillmanagetheirjobwithoutinclud- ingpatientsintocarebyusingChoiceand Choicewashence reportedtobeputonthebottomofthedailytasklistonbusy days.ThismightrelatetothefactthatChoicecameinaddition toexistingsystemsandthattherewasnopronouncedneed foratoolthatassessesthepatients’concerns,preferences, andknowledge.
Anunexpectedfinding wasthat Choicechallengedskills relatedtoethical issuesmorethan technicalones. Achal- lengethatarosewasnurses’feelingsofbeingoverwhelmedby patients’problemswithoutbeingabletohelp.Beingunableto liveuptoexpectationsanddemandsatworkfostersfeelings ofpowerlessnessandthreatensaprofessional’sself-imageas acompetentandresponsiblenurse.Incompatibledemands, stress of conscience and lack of support from managers andcolleaguesarestronglyassociatedwithburnoutandjob turnover[48].Thishighlightsthecomplexity ofintroducing anewtechnicaltoolintopractice,sinceitchangesformsof interactionbetweenpeople[49].Leadershavetobeprepared forunexpectedchanges,suchasneedforsupporttotheusers thatmayariseaftertheintroductionofanewtoollikeChoice.
Inaddition,nursesneedtobeawarethatitmaynotbepos- sibletohelppatients withall theirsymptomsandconcern whentime is shortand/or the patientis tired.It could be arguedthatsomeproblemsare andshould remainoutside thehospital’ssphereofresponsibility[50],orcouldbehanded overtootherprofessionals(e.g.socialworkers)orcaregivers.
Someoftheseself-expectationsmaybeduetohownursesare trainedtointervene,andnursinginterventionsareseenasa keyfunctioninthenursingprocess.Furthermore,nursesare notnecessarilyawareoftheirfacilitatorrole,suchashelping patientstomobilizetheirownstrengths.Educatingnursesin theseimportantrolesmayhelpfosterprofessionalconfidence, despitethefactthattheycannotalwayssolvetheproblemfor thepatient.
4.4. Observability
Observabilitydealswiththedegreetowhichtheresultsofthe innovationare visibletousers [25]. Inthis study the sum- maryassessment was available in the hospitalselectronic system.Itcouldbeprintedandthereforewasvisibleforboth patientsandhealthcarepersonnel.Inaddition,information fromChoicewasusedincareplanning.However,Choicewas notintegratedintheelectronichealthrecord,andonecould notdirectlytransferinformationtoacareplan.Assuch,itwas notpossibleforotherstoseewhetherinformationfromChoice hadbeenusedornot.
ThepositiveeffectofChoicedemonstratedinanRCT[10]
wasarationaleforimplementingChoiceinthisstudy,andwas initiallypresentedtothenurses.Inthefocusgroups,nurses describedpositiveeffectsofChoice.Forexample,thenurses
reportedthattheChoiceinformationallowedbothpatientsand nursestobebetterpreparedtodiscussthepatients’needsand thatitstrengthenedthepatients’personalresources.These benefitswere,however,notnecessarilyvisibletoothernurses or healthcare personnelona dailybasisunless discussed amongthestaff.
Itisessential thatkey professionals andadministration understand thevalueofaprogram beforeimplementing it [51].Howeverthefindingsfromthisstudyclearlyunderscore that, tosuccessfullyimplementandsustaine-health appli- cations in daily practice, the users must recognize that it isbeneficialintheirdailyworkandforthepatients[52,53].
Understandingatool’sutilityaffectsthemotivationbothto use thesystemand toencouragethepatient toparticipate [54].Further,resultsfromthe focusgroupdiscussionswith thenursessupportthatthisunderstandingofusabilityamong users isimportantforsustainingaprogramuntilit isfully integratedintodailyroutines.Choicepromotesashifttoward morepatient-centered carebyinviting thepatients totake activepart intheirowncarebyassessingtheir symptoms, preferencesandneeds.Sinceitisnaturaltoturnbacktoold routinesduringperiodsoftimepressure,onemustestablish routinesthatinitiate,integrateandprotectpatient-centered careindailypractice[6].
4.5. Studystrengthsandlimitations
Strengthsofthestudyincludethattheparticipatingnurses hadexperienceswithuseofChoiceinroutinecareand,assuch, gaveusinsightintoreallifeuseoftheapplication.Credibility wasreachedbytheparticipants’opportunitytochallengeand verifyeachother’sopinionsduringthefocusgroupdiscussion.
Transferability,however,isprobablysomewhatlimited,given theintervention,participants,settingandcontext.
As for limitations, the interview guide and the focus groups were developed and conducted by personnel who knewtheunitsandtheimplementationprocessoftheChoice application, which mighthave influenced the interviewer’s pre-understanding and mayhaveaffected the participants’
willingnesstodiscusschallengingissues.Ontheotherhand, this knowledgeprovided insightinto what questions were importanttoask,andwhichstatementsneededelaboration.
Asthenursesraisedseveralsensitivetopicsduringthefocus groups,thiscouldbeconsideredbothastrengthandalimita- tion.
Sincethefindingsinthisstudyarecontextspecificanddif- ferentapplicationshavedifferentcharacteristics,theseresults arenotnecessarilytransferabletoothercontextsandapplica- tions.Thestudyfindingsarelimitedtonurses’experiencesof use.Patients’viewsarereportedelsewhere[18].AsChoiceis alsousedbyphysicians,theviewfromthisgroupwouldgive amorecomprehensivepictureofclinicians’experiences.In addition,theleadersoftheunitsmighthaveadditionalexperi- ences.Moreover,asatextneverimpliesjustonemeaning,but ratherthemostprobablemeaningfromaparticularperspec- tive[32],ourinterpretationofthefindingsshouldbeseenas onepossibleunderstandingofuseofChoiceinclinicalcancer practice.Nevertheless,thisstudyhighlightssomeimportant
Pleasecitethisarticleinpressas:E.Børøsund,etal.,Nurses’experiencesofusinganinteractivetailoredpatientassessmenttooloneyearpast issuesthatdevelopersandimplementersofotherapplications
mayfindhelpful.
4.6. Conclusionandimplications
Ourfindingssuggestthat,fromthenurses’perspectives,inte- grationofITPAssuchasChoiceinclinicalpracticehasmany benefitsintermsofelicitingpatients’symptoms,promoting patients’ownparticipationincareandgivingpatientsavoice.
It can make communication between the patient and the nursemorepurposeful,allowinghelptobeofferedforwhat mattersmosttothepatient.Aswehaveseenfromourearlier clinical trial, it improves outcomes in terms ofless symp- tomdistressandbetterpatient–providercommunication[10].
However,toobtain thesebenefits,theorganizationmustbe awareoftheusers’viewofbothadvantagesandchallenges theusesuchadevicemayentail.Inadditiontofocusingon thebenefitsofsuchsystems,onemusttaketheusers’beliefs andconcernsintoaccountandunderstandhowitaffectstheir dailyroutines.Tomakefulluseofthesystem’spotential,man- agershavetoenablethestafftoprioritizethesetoolsamong otherroutines(i.e.ensuresufficienttime,spaceandcompe- tence).Nurses havetobeoffered supporttoincreasetheir communicationskillsandbegivenopportunitytoreflecton ethicalissuesregardinguseoftheITPA.
Theuncertaintythenursesexpressedconcerningtheirpro- fessionalrolesintermsofcommunication,andtheirwishfor moretrainingandsupervisioninthecommunicationcontext, suggestsaneedformoreeducation,whichagainmaycon- tributetofosterprofessionalconfidencedespitethefactthat theycannotalwayssolvetheproblemforthepatient.
Theshiftstowardmorepatient-centeredcommunication andcarewillimpacthealthcareorganizationandheightenthe needforcompetencetointegratepatients’ preferencesinto care.Ourfindingsrevealedaneedforbettertraininginpatient communicationinordertomakefulluseofthepossibilities offeredbytoolslikeChoice.
Finally,thisstudyshowsthatnewtoolschallengetheexist- ing routines, and do not automatically fit in the ordinary workflow.To facilitatea sustainable implementation of an innovationintodailyworkroutines,theinformaticsfieldmust tocollaboratecloselywiththeusers inordertodesignsys- temsthatareperceived asuseful,compatiblewithexisting valuesandneeds,andeasilyintegratedintoroutinecare.On theotherhandpeopleinhealthcareorganizationsmustbe willingtochangesomeoftheirroutinesandinvestigatethe needfornewskillsandcompetences.Inconclusion,inorder tomovetowardmorepatientcare,grasping thenewpossi- bilitiesofferedbyelectronicassessmentsofsymptomsand integratingthemintoroutinepracticehastobeafocusofthe future.
Authors’ contributions
EB:Design and conduction ofthestudy. Transcribing, cod- ing,analysisandinterpretationofdata.Draftingthearticle, andrevisingitforimportantintellectualcontent.CR:PIofthe study.Designandconductionofthestudy.Analysisandinter- pretationofdata.Contributiontomanuscriptforimportant
Summarypoints
Whatisalreadyknownaboutthetopic?
• Theimplementation of patient-centeredcare appli- cations in clinical practice is challenging despite evidenceofthebenefits.
• Interactive Tailored Patient Assessment(ITPA) tools can contribute to a more patient-centered care through eliciting patients’ experienced symptoms, problems,and prioritiesforcareandsupportingcli- nicians in providing individually tailored symptom managementsupport.
• While a number of studies have addressed issues relatedtoITimplementation,lessresearchhasexam- inedthechallengesthatcanemergewhenusingand maintainingnewsystemsovertime.
Whatthisstudyaddtoourknowledge
• From the nurses’ perspectives, integration ofITPAs suchasChoiceinclinical practiceoffersmanybene- fitsthatcanimprovepatient-centeredcommunication andcare.
• Toobtainthesebenefits,suchtoolsneedtogetorga- nizational support at an equal level as other daily routines,suchascompetencytraining,anddedicated time.
• Such toolscan challenge professional nursing roles and assumptions about patient-centered care and bring ambivalence such as discrepancies between patients’ levels of disclosure and nurses’ ability to respondtothemappropriately.
• Usershavetofeelconfidenceintheircommunication skillsandthebenefitsofuseiftheyarenottoputthe toolsatthebottomoftheirprioritylist.
intellectualcontent.SM.Designofthestudy.Contributionto themanuscriptforimportantintellectualcontent.ME.Design andconductionofthestudy.Coding,analysisandinterpreta- tionofdata.Draftingpartsofthemanuscriptandcontribution tothemanuscriptforimportantintellectualcontent.
Competing interest
ThisworkwassupportedinpartbytheSouth-EastRegional Health Authority of Norway, grant number: 2009051 and OsloUniversityHospital,Norway.Findings,opinions,conclu- sionsandrecommendationsexpressedinthispaperarethe authors’.
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