Clinical Health Assessment

Clinical Health Assessment

Decision Making in the Nursing Profession

The nursing practice takes place in a setting of constant developments in technology and research. The undefined and active nature of a healthcare environment needs nurses to be experienced decision-makers to meet client’s needs. Nurses must be experienced in the proper use of health information technologies and patient valuation to ensure accuracy and make appropriate clinical decisions to ensure the safety of patients. The purpose of this assessment is to demonstrate the factors that influence decision making like a nurse and look into the impact of health information technologies on the quality of clinical decision making and patient health assessment.

Nursing education is the recognized training and learning in the science of nursing. It includes the duties and functions in the physical care of patients and a mixture of diverse disciplines that both hasten the health of a patient and how to maintain it. Nursing education plays a vital role in advance of the decision-making skills of a nurse (Johansen, & O’Brien, 2016). The type, manner, and levels of contribution of nurses in clinical decision-making depend on nursing education. Due to insufficient nursing education, there is a lack of experience with a large number of nurses. Academic training in the nursing profession does not prepare the nurses to be active decision-makers. Insufficient nursing education is a barrier for nurses in the form of clinical decision-making. According to nursing professionals, the best nurses are the ones with more medical information.

These nurses are equipped with a wide range of pharmacological, disease-related, and physiological information but lack information on nursing care. Many nurses have read the textbooks but have had little opportunity to apply them in practice.

Since nursing education is mostly theoretical and inapplicable, the nursing professions have played a significant role in the weaknesses and unwillingness of nurses to make independent clinical decisions. Moreover, since many nurse instructors are inexperienced, they lack the self-confidence to educate a new nursing generation. Routine-oriented actions and staff nurses act as role models for students taking the nursing profession, hence are barriers to clinical education and decision -making skills. Once nursing students join the nursing environment, they are faced with specific organizational behaviors that are concerned with tasks and hinder their independent decision making (Nehrir et al., 2016). Although the nurses have a considerable amount of knowledge, they are not able to apply it in practice; thus, they are limited to doing what doctors need them to do.

The National Electronic Health Record

The National Electronic Health Record (NEHR) is a safe patient data exchange system that allows healthcare professionals and clinicians to assess patient health records. It was designed with ideas from healthcare professionals from diverse sectors and vocations. It has been modified and enhanced over the years to improve its usability to better support clinical decision making and care provisioning to patients (Persaud, 2019). The NEHR has been gradually installed in both private and public healthcare establishments across Singapore to provide the healthcare records for patients. It is owned by the Ministry of Health and managed by the Integrated Health Information Systems. It accumulates the summary of patients’ health records across diverse healthcare providers; thus, enabling approved healthcare professionals to have a complete view of their patient’s healthcare history.

The NEHR has a vision of “one patient, one health record,” that is, after empowering safer, more efficient, and more modified care. The technology links healthcare professionals for combined patient care. This is because a summary of a patient’s healthcare records is safely kept in one place electronically for integrative healthcare professionals all over Singapore to work calmly to provide improved care. Furthermore, with better knowledge of a patient’s healthcare history via the NEHR, healthcare professionals are in a better position to make well-informed diagnoses and decisions for the best course of care. The technology also empowers patients to take control of their health through the access of their health records, therefore achieving better healthcare outcomes (Flattau et al., 2018). The doctors can also view, through the system, the patient’s allergies, prescriptions, diagnoses, and looked up results to carry out effective care and avoid any unnecessary hostile drug reactions. Moreover, the NEHR assists patients to move impeccably across the healthcare providers. It provides patients more ease, saving them time and money through lessening replication of tests and researches.

The NEHR has various benefits to both the patient and healthcare providers concerning the quality of clinical patient assessment and clinical nursing decisions. Firstly, technology assists healthcare providers to quickly assess their patients since they can easily trace patient records and get diagnoses given by other institutions (Abbasi, 2017). The NEHR assists clinicians to know what medicine and dosage need to be taken by patients, thus better decision making. The technology also helps healthcare professionals have a better understanding of their patients’ medical history through records. The system has reduced the amount of time needed by a clinician to assess a patient and make clinical decisions. Additionally, it has improved patient safety and provided better health outcomes, since the system facilitates retrieval of patient’s information through their history in the order. With a better understanding of the history of a patient through the NEHR, a healthcare giver can be able to deliver effective care to patients. The healthcare givers can also be able to improve the healthcare outcomes through an informed diagnosis and make an effective decision on the best course of treatment to improve a patient’s health.

Although the NEHR has numerous positive impacts on the quality of clinical patient assessment and clinical decision-making, it has also impacted the healthcare of patient safety negatively. For instance, the recent SingHealth cyberattack has ignited more nervousness in the healthcare sector. The cyberattack affected 1.5 million patients; hence patient safety and care are not reassured through the system. The data available in NEHR is not as comprehensive as it should be since there is very little input in the private and charity sectors. In case a patient from the private sector is transferred to the public sector, the doctors will not be able to acquire enough information due to a lack of medical history (Kinnunen et al., 2019). Therefore, the patient being treated is disadvantaged since the healthcare professional is not able to do a quality assessment and make appropriate clinical decisions. Moreover, installing the NEHR into a healthcare system is quite costly. It would be difficult for small clinics to install the system due to its costs, therefore affecting the decision making of nurses and the assessment of patients. The system does not also keep patient’s information confidential since the data can be breached and be a risk to a patient’s health.

Overall, nursing education plays a vital role in the decision making of a nurse in regards to patient care. Moreover, health information technologies such as NEHR considerably impact the quality of clinical patient assessment and clinical nursing decisions. Insufficient nursing education affects the decision-making process of a nurse hence delivery of poor services to a patient’s care. Being able to access a patient’s healthcare history through the NEHR can save the lives of patients since healthcare givers can make informed decisions on patient safety. Nurses must be competent in decision making by getting the right information of a patient to ensure patient care and safety.

References

Abbasi, R. (2017). A Study on the completeness of information communicated from hospital information systems to the national Electronic Health Record (SEPAS) and evaluation of its minimum data set in the first quarter of ۲۰۱۵ (Doctoral dissertation, School of Health Information and Management, Kerman University of Medical Sciences, Kerman, Iran).

Flattau, A., Gordon, H., Vinces, G., Ennis, W. J., & Minniti, C. P. (2018). Use of a National Electronic Health Record Network to Describe Characteristics and Healing Patterns of Sickle Cell Ulcers. Advances in wound care, 7(8), 276-282.

Johansen, M. L., & O’Brien, J. L. (2016, January). Decision making in nursing practice: a concept analysis. In Nursing forum (Vol. 51, No. 1, pp. 40-48).

Kinnunen, U. M., Heponiemi, T., Rajalahti, E., Ahonen, O., Korhonen, T., & Hyppönen, H. (2019). Factors Related to Health Informatics Competencies for Nurses—Results of a National Electronic Health Record Survey. CIN: Computers, Informatics, Nursing, 37(8), 420-429.

Nehrir, B., Vanaki, Z., Mokhtari Nouri, J., Khademolhosseini, S. M., & Ebadi, A. (2016). Competency in nursing students: a systematic review. International Journal of Travel Medicine and Global Health, 4(1), 3-11.

Persaud, N. (2019). A national electronic health record for primary care.