NR 541 Week 3 Consultation Write-Up Example

Consultation Write-Up: Eleven Conversations With the People a Single Isolation Status Would Land On, What Each Needed From It, Where They Disagreed and the Four Changes the Requirement Took On as a Result

Student Name

College of Nursing, Chamberlain University

NR 541: Practice of Nursing Informatics

Instructor Name

Month Day, Year

Consultation Write-Up: Eleven Conversations With the People a Single Isolation Status Would Land On, What Each Needed From It, Where They Disagreed and the Four Changes the Requirement Took On as a Result

Why Consult

The first draft of the isolation status requirement was written in a week from an event report, a walk through the record and one meeting. It was coherent, and it was mine. Before it went to the build queue, I spent two weeks asking the people it would affect what they actually needed. Requirements are not found lying around; somebody has to go and ask. A sociotechnical model of health information technology emphasizes that people, workflow and organizational policy interact with the software itself (Sittig & Singh, 2010), and the only way to learn the workflow and the policy in a given hospital is to ask the people who live in them.

I held eleven conversations, each about 20 minutes, most at the place the person works: a pair of charge nurses, three bedside nurses split between days and nights, a pair of unit clerks, the transport supervisor and one transporter, the infection preventionist and a hospitalist. I also spent 30 minutes with a radiology technologist at the scanner. In each conversation I asked the same four questions: When do you need to know a patient's isolation status? Where do you look now? What goes wrong? What would you need from a single status to trust it?

What Each Group Needed

Staff nurses needed to start precautions immediately when they suspected infection, often at night, without waiting for a provider to answer a page. The existing nurse-initiated isolation protocol allows this, but the draft requirement did not make clear that a nurse's order takes effect before co-signature. Night nurses also said they look at the door sign, not the header, when entering a room.

Charge nurses needed to see isolation status for every patient on the unit at once, for bed assignments. The patient list column met this need, but they asked that it sort to the top, since isolation affects which rooms can be used.

Unit clerks filled in transport and procedure requests and wanted the isolation field to be automatic. One clerk explained the habit of copying from an older screen: it was the only screen that showed isolation on the request workflow. The requirement removed that screen, and the clerks welcomed it.

Transport staff needed to know not only that a patient was in contact precautions but whether soap and water hand hygiene was required, since alcohol hand rub does not work against C. difficile spores. The draft's six precaution types included "Contact, enteric," but the transport request showed only the first word. The transporter said, "If it says contact, I use the gel."

The infection preventionist needed to control discontinuation, because precautions for some organisms continue after symptoms resolve, and staff often remove them early. The preventionist also needed a report of all active isolation orders each morning.

The hospitalist wanted to be notified when a nurse started isolation, so the medical team could order appropriate tests, and wanted isolation discontinuation not to require a separate visit to the record for each patient.

Radiology wanted isolation status on the request so that isolated patients could be scheduled at times when the room could be cleaned afterward.

Conversations were short on purpose. Twenty minutes at a workstation fits a shift in a way that an hour in a conference room does not, and people describe their work more accurately where they do it. I took notes in the same four headings each time and read them back at the end so the person could correct them.

Where They Disagreed

Two disagreements emerged. The first was about who may end isolation. The infection preventionist wanted sole authority. The hospitalist argued that providers should be able to discontinue it when criteria are clearly met, especially at weekends when infection prevention is not on site. The draft allowed both, and the consultation confirmed that both views were reasonable. The compromise, agreed in a joint meeting, allows providers to discontinue isolation for three listed conditions with clear criteria, while discontinuation for C. difficile, multidrug-resistant organisms and tuberculosis requires the infection preventionist.

The second disagreement was about the door sign. Night nurses wanted signs printed automatically. The unit clerks warned that automatic printing to a shared printer at night could leave signs uncollected. The resolution was to print automatically and add a task to the nurse's worklist to post the sign, which disappears only when the nurse confirms it.

What Changed in the Requirement

The consultation produced four changes. First, the transport request now displays the full precaution type, including "enteric," with the hand hygiene instruction in words: "Soap and water required." Second, the patient list column sorts isolated patients first by default. Third, discontinuation rights now differ by reason, as agreed. Fourth, printing a door sign creates a nursing task to post it, and a hospitalist notification is sent when a nurse starts isolation.

One requested change was declined. A charge nurse asked for the header band to flash. Flashing elements can distract and are an accessibility concern, and the clinical informatics group had already rejected them for other alerts. I explained this to the charge nurse and noted the request for the next review.

What the Consultation Showed About Requirements

The most important finding was one I would never have found by drafting alone: the transporter's rule that "contact" means gel. That rule was reasonable given what the transporter could see, and it would have survived the draft requirement unchanged. Researchers studying errors linked to patient care information systems have described how systems can present information in ways that are technically complete but misread in the context of work (Ash et al., 2004). The consultation found such a case before it caused harm. It also showed that each group looks at a different place for the same information, which is why the requirement insists that all places show the same status from one source. The American Nurses Association's standards for nursing informatics include collaborating with stakeholders and incorporating their input into design (American Nurses Association [ANA], 2022). This write-up is the record of that collaboration for one requirement.

The consultation notes, with names removed, are filed with the requirement so that the reasoning behind each change can be traced later.

References

American Nurses Association. (2022). Nursing informatics: Scope and standards of practice (3rd ed.). American Nurses Association.

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11(2), 104-112. https://doi.org/10.1197/jamia.M1471

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68-i74. https://doi.org/10.1136/qshc.2010.042085