Communication experiences of healthcare students whilst managing adults with communication disorders

Background

Research has found that people with communication disabilities are three times more likely to encounter medical mishaps. Almost a third of patients with speech-language therapy (SLT) diagnoses have other medical conditions across more than one of the burden of disease categories. Fifty per cent of these patients present with communication disorders. Student healthcare curriculums focus on patient dynamics and field-specific diversities. It does not often include the skills and knowledge required to effectively communicate and treat those with communication disorders.

Objectives

This study aims to describe the communication challenges and strategies employed by a group of final year Nursing, Medicine, Dietetics and Human Nutrition, Physiotherapy and Occupational Therapy students when managing adults with communication disorders.

Method

A qualitative, phenomenological study design was used. Questionnaires were electronically distributed, and results were analysed thematically.

Results

The most significant challenges whilst managing adults with communication disorders were patients’ receptive and expressive language difficulties. Further challenges included lack of knowledge surrounding communication disorders, lack of training in the use of appropriate communicative assistive devices, factors within the physical environment and gaps in students’ clinical performance. Strategies used to facilitate communication included caregiver assistance, gestures and written language.

Conclusion

This study revealed that there is a need to develop healthcare students’ skills in managing adults with communication disorders. This is because of the challenges faced and inefficiency of the strategies used. Future research should focus on determining solutions for improved communication with adults with communication disorders. The study highlights the need for further education and training to address students’ communication needs with patients.

When interactions are interruptions: an ethnographic study of information-sharing by speech and language therapists and nurses on stroke units

PURPOSE

To explore how the information-sharing context influences how speech and language therapy (SLT) and nursing staff interact on stroke units and what they discuss.

METHODS

Ethnographic methodology was used, with data collected during 40 weeks of fieldwork across three inner city stroke units in the UK. Data comprised field notes collected during 357 h of participant observation and 43 interviews. Interviews were conducted with 14 SLTs, 1 SLT assistant, 24 registered nurses and 4 nursing assistants.

RESULTS

This paper is focused on informal information-sharing. SLTs and nurses had different experiences of time and space (the temporal-spatial context) with respect to ward presence and proximity to patients, influencing how they interacted, the content of their talk and their relationships. Most interactions had the quality of interruptions, in which SLTs seized moments in between nursing tasks. Conditions were less suited to sharing information about communication than swallowing and SLTs felt more allied to other therapists than nurses.

CONCLUSION

The temporal-spatial context impeded information-sharing, particularly about patients' communication needs. Consideration should be given to developing relationships between SLTs and nurses as key partners for patient care and raising the profile of communication information in ways that are relevant and useful to nursing work.Implications for rehabilitationStrategic waiting for opportunities to interrupt nurses and gain their attention is central to how speech and language therapists manage their need to share information informally with nurses.The small "windows in time" available for interaction influence information-sharing, with a limiting effect on information about patients' communication.There is potential to improve information-sharing between speech and language therapists and nurses by considering how the relevance of information for patient care could be made clearer.

Examining the impact of an asynchronous communication platform versus existing communication methods: an observational study

Background

Healthcare systems revolve around intricate relations between humans and technology. System efficiency depends on information exchange that occur on synchronous and asynchronous platforms. Traditional synchronous methods of communication may pose risks to workflow integrity and contribute to inefficient service delivery and medical care.

Aim

To compare synchronous methods of communication to Medic Bleep, an instant messaging asynchronous platform, and observe its impact on clinical workflow, quality of work life and associations with patient safety outcomes and hospital core operations.

Methods

Cohorts of healthcare professionals were followed using the Time Motion Study methodology over a 2-week period, using both the asynchronous platform and the synchronous methods like the non-cardiac pager. Questionnaires and interviews were conducted to identify staff attitudes towards both platforms.

Results

A statistically significant figure (p<0.01) of 20.1 minutes’ reduction in average task completion was seen with asynchronous communication, saving 58.8% of time when compared with traditional synchronous methods. In subcategory analysis for staff: doctors, nurses and midwifery categories, a p value of <0.0495 and <0.01 were observed; a mean time reduction with statistical significance was also seen in specific task efficiencies of ‘To-Take-Out (TTO), patient review, discharge & patient transfer and escalation of care & procedure’. The platform was favoured with an average Likert value of 8.7; 67% found it easy to implement.

Conclusion

The asynchronous platform improved clinical communication compared with synchronous methods, contributing to efficiencies in workflow and may positively affect patient care.

Secure smartphone application-based text messaging in emergency department, a system implementation and review of literature

BACKGROUND

The utilization of smartphone-based technology and applications to streamline patient care provides an exciting opportunity for quality improvement research. As traditional communication methods such as paging have repeatedly been shown to be susceptible to errors and inefficiency that can delay patient care, smartphones continue to be investigated as means of improving inter-hospital communication and patient outcomes.

METHODS AND MATERIALS

We conducted a systematic literature review in PubMed, MEDLINE using the keywords Health Insurance Portability and Accountability Act (HIPAA) Compliant Group Messaging (HCGM), text paging communication, secure hospital text message, HIPAA text message, and secure hospital communication. The search considered studies published until January 2018. Only English-language studies were included. We reviewed the reference lists of included articles for additional studies, as well. Abstracts, unpublished data, and duplicate articles were excluded.

RESULTS

569 studies were screened and assessed for eligibility with 35 meeting the inclusion criteria. 15 of these studies are data-driven with topics of investigation ranging from facilitation of communication (40%), security (33%), provider/patient satisfaction with communication (26%), diagnostic assistance (20%), demographics of use (13%), time spent in communication (13%), and finances (7%). Sample size per study varied from 30 to 10,000 encounters.

CONCLUSIONS

The use of smartphones can positively impact patient care; however, these benefits must be balanced with the responsibility to protect patient privacy and confidentiality. In order to continue to support HCGM's expansion and integration into daily practice, further data-driven studies into HCGM-specific interventions must be pursued.

Using the Electronic Medical Record to Enhance Physician-Nurse Communication Regarding Patients' Discharge Status

The fast-paced environment of hospitals contributes to communication failures between health care providers while impacting patient care and patient flow. An effective mechanism for sharing patients' discharge information with health care team members is required to improve patient throughput. The communication of a patient's discharge plan was identified as crucial in alleviating patient flow delays at a tertiary care, academic medical center. By identifying the patients who were expected to be discharged the following day, the health care team could initiate discharge preparations in advance to improve patient care and patient flow. The patients' electronic medical record served to convey dynamic information regarding the patients' discharge status to the health care team via conditional discharge orders. Two neurosciences units piloted a conditional discharge order initiative. Conditional discharge orders were designed in the electronic medical record so that the conditions for discharge were listed in a dropdown menu. The health care team was trained on the conditional discharge order protocol, including when to write them, how to find them in the patients' electronic medical record, and what actions should be prompted by these orders. On average, 24% of the patients discharged had conditional discharge orders written the day before discharge. The average discharge time for patients with conditional discharge orders decreased by 83 minutes (0.06 day) from baseline. Qualitatively, the health care team reported improved workflows with conditional orders. The conditional discharge orders allowed physicians to communicate pending discharges electronically to the multidisciplinary team. The initiative positively impacted patient discharge times and workflows.

The critical managerial capabilities of medical and nursing managers in an Israeli hospital

Purpose

– The purpose of this paper is to determine the managerial capabilities that are required of medical and nursing managers, in a Christian-affiliated hospital in Israel, in order to promote the job satisfaction of their subordinates.

Design/methodology/approach

– Data were gathered via questionnaires, administered to 107 doctors and nurses of a small Christian-affiliated hospital in Israel, regarding the job satisfaction of the respondents, and their evaluation of the managerial capabilities of their medical and nursing superiors. Correlations and regressions were carried out on the data.

Findings

– Overall managerial capabilities of medical and nursing managers were shown to be significantly related to how their subordinates felt about their teams and about their work. The results suggest differences between nurses and doctors. When analyzed for the two dimensions of managerial capabilities and the two dimensions of job satisfaction, the results were significant for the nurses, but not significant for the doctors. When tested for Christians vs non-Christians, the results for the nurses were the same as in the sample as a whole; whereas for the doctors, there were differences between the two religious groups.

Research limitations/implications

– The sample is small and culturally specific, thus limiting the generalization potential of this study.

Practical implications

– Findings of this research may have practical implications regarding hospitals’ recruitment, promotion, instruction and follow-up policies.

Originality/value

– This study sheds light on the issue of hospital management and leadership within a specific cultural-religious setting, which has not been previously investigated.

Comparing the information seeking strategies of residents, nurse practitioners, and physician assistants in critical care settings

OBJECTIVE

Critical care environments are information-intensive environments where effective decisions are predicated on successfully finding and using the 'right information at the right time'. We characterize the differences in processes and strategies of information seeking between residents, nurse practitioners (NPs), and physician assistants (PAs).

METHOD

We conducted an exploratory study in the cardiothoracic intensive care units of two large academic hospitals within the same healthcare system. Clinicians (residents (n=5), NPs (n=5), and PAs (n=5)) were shadowed as they gathered information on patients in preparation for clinical rounds. Information seeking activities on 96 patients were collected over a period of 3 months (NRes=37, NNP=24, NPA=35 patients). The sources of information and time spent gathering the information at each source were recorded. Exploratory data analysis using probabilistic sequential approaches was used to analyze the data.

RESULTS

Residents predominantly used a patient-based information seeking strategy in which all relevant information was aggregated for one patient at a time. In contrast, NPs and PAs primarily utilized a source-based information seeking strategy in which similar (or equivalent) information was aggregated for multiple patients at a time (eg, X-rays for all patients).

CONCLUSIONS

The differences in the information seeking strategies are potentially a result of the differences in clinical training, strategies of managing cognitive load, and the nature of the use of available health IT tools. Further research is needed to investigate the effects of these differences on clinical and process outcomes.

Understanding the nature of information seeking behavior in critical care: implications for the design of health information technology

OBJECTIVE

Information in critical care environments is distributed across multiple sources, such as paper charts, electronic records, and support personnel. For decision-making tasks, physicians have to seek, gather, filter and organize information from various sources in a timely manner. The objective of this research is to characterize the nature of physicians' information seeking process, and the content and structure of clinical information retrieved during this process.

METHOD

Eight medical intensive care unit physicians provided a verbal think-aloud as they performed a clinical diagnosis task. Verbal descriptions of physicians' activities, sources of information they used, time spent on each information source, and interactions with other clinicians were captured for analysis. The data were analyzed using qualitative and quantitative approaches.

RESULTS

We found that the information seeking process was exploratory and iterative and driven by the contextual organization of information. While there was no significant differences between the overall time spent paper or electronic records, there was marginally greater relative information gain (i.e., more unique information retrieved per unit time) from electronic records (t(6)=1.89, p=0.1). Additionally, information retrieved from electronic records was at a higher level (i.e., observations and findings) in the knowledge structure than paper records, reflecting differences in the nature of knowledge utilization across resources.

CONCLUSION

A process of local optimization drove the information seeking process: physicians utilized information that maximized their information gain even though it required significantly more cognitive effort. Implications for the design of health information technology solutions that seamlessly integrate information seeking activities within the workflow, such as enriching the clinical information space and supporting efficient clinical reasoning and decision-making, are discussed.

Development of a prototype continuity of care record with context-specific links to meet the information needs of case managers for persons living with HIV

OBJECTIVES

(1) To develop a prototype Continuity of Care Record (CCR) with context-specific links to electronic HIV information resources; and (2) to assess case managers' perceptions regarding the usability of the prototype.

METHODS

We integrated context-specific links to HIV case management information resources into a prototype CCR using the Infobutton Manager and Librarian Infobutton Tailoring Environment (LITE). Case managers (N=9) completed a think-aloud protocol and the Computer System Usability Questionnaire (CSUQ) to evaluate the usability of the prototype. Verbalizations from the think-aloud protocol were summarized using thematic analysis. CSUQ data were analyzed with descriptive statistics.

RESULTS

Although participants expressed positive comments regarding the usability of the prototype, the think-aloud protocol also identified the need for improvement in resource labels and for additional resources. On a scale ranging from 1 (strongly agree) to 7 (strongly disagree), the average CSUQ overall satisfaction was 2.25 indicating that users (n=9) were generally satisfied with the system. Mean CSUQ factor scores were: System Usefulness (M=2.13), Information Quality (M=2.46), and Interface Quality (M=2.26).

CONCLUSION

Our novel application of the Infobutton Manager and LITE in the context of case management for persons living with HIV in community-based settings resulted in a prototype CCR with infobuttons that met the majority of case managers' information needs and received relatively positive usability ratings. Findings from this study inform future integration of context-specific links into CCRs and electronic health records and support their use for meeting end-users information needs.

Use of a health information exchange system in the emergency care of children

BACKGROUND

Children may benefit greatly in terms of safety and care coordination from the information sharing promised by health information exchange (HIE). While information exchange capability is a required feature of the certified electronic health record, we known little regarding how this technology is used in general and for pediatric patients specifically.

METHODS

Using data from an operational HIE effort in central Texas, we examined the factors associated with actual system usage. The clinical and demographic characteristics of pediatric ED encounters (n = 179,445) were linked to the HIE system user logs. Based on the patterns of HIE system screens accessed by users, we classified each encounter as: no system usage, basic system usage, or novel system usage. Using crossed random effects logistic regression, we modeled the factors associated with basic and novel system usage.

RESULTS

Users accessed the system for 8.7% of encounters. Increasing patient comorbidity was associated with a 5% higher odds of basic usage and 15% higher odds for novel usage. The odds of basic system usage were lower in the face of time constraints and for patients who had not been to that location in the previous 12 months.

CONCLUSIONS

HIE systems may be a source to fulfill users' information needs about complex patients. However, time constraints may be a barrier to usage. In addition, results suggest HIE is more likely to be useful to pediatric patients visiting ED repeatedly. This study helps fill an existing gap in the study of technological applications in the care of children and improves knowledge about how HIE systems are utilized.

Information requisition is the core of guideline-based medical care: which information is needed for whom?

RATIONALE, AIMS AND OBJECTIVES

It is mandatory for the design of an efficient software product to know the different groups of users of a software tool, the tasks the users want to perform with it, and the information that is required for it. Our goal is to establish a comprehensive information source for the development of a consistent software environment supporting all tasks emerging from the creation to the execution of a computerized clinical practice guideline (CPG) for different user groups.

METHODS

We conducted a comprehensive literature review to investigate the different user groups of a computerized CPG as well as their specific information needs.

RESULTS

We provide a complete catalogue of every single aspect that may be related to information needs of any party concerned. In particular, we give detailed information on the tasks of guideline modellers on the one hand, and clinical information needs (i.e. information needs of physicians, nurses, nurse practitioners and patients) on the other hand.

CONCLUSION

By providing categorized information from several studies and publications, we establish an exhaustive information basis for the design of a useful software tool facilitating the formalization and the execution of a CPG.

A simulation framework for mapping risks in clinical processes: the case of in-patient transfers

OBJECTIVE

To model how individual violations in routine clinical processes cumulatively contribute to the risk of adverse events in hospital using an agent-based simulation framework.

DESIGN

An agent-based simulation was designed to model the cascade of common violations that contribute to the risk of adverse events in routine clinical processes. Clinicians and the information systems that support them were represented as a group of interacting agents using data from direct observations. The model was calibrated using data from 101 patient transfers observed in a hospital and results were validated for one of two scenarios (a misidentification scenario and an infection control scenario). Repeated simulations using the calibrated model were undertaken to create a distribution of possible process outcomes. The likelihood of end-of-chain risk is the main outcome measure, reported for each of the two scenarios.

RESULTS

The simulations demonstrate end-of-chain risks of 8% and 24% for the misidentification and infection control scenarios, respectively. Over 95% of the simulations in both scenarios are unique, indicating that the in-patient transfer process diverges from prescribed work practices in a variety of ways.

CONCLUSIONS

The simulation allowed us to model the risk of adverse events in a clinical process, by generating the variety of possible work subject to violations, a novel prospective risk analysis method. The in-patient transfer process has a high proportion of unique trajectories, implying that risk mitigation may benefit from focusing on reducing complexity rather than augmenting the process with further rule-based protocols.

Factors motivating and affecting health information exchange usage

OBJECTIVE

Health information exchange (HIE) is the process of electronically sharing patient-level information between providers. However, where implemented, reports indicate HIE system usage is low. The aim of this study was to determine the factors associated with different types of HIE usage.

DESIGN

Cross-sectional analysis of clinical data from emergency room encounters included in an operational HIE effort linked to system user logs using crossed random-intercept logistic regression.

MEASUREMENTS

Independent variables included factors indicative of information needs. System usage was measured as none, basic usage, or a novel pattern of usage.

RESULTS

The system was accessed for 2.3% of all encounters (6142 out of 271,305). Novel usage patterns were more likely for more complex patients. The odds of HIE usage were lower in the face of time constraints. In contrast to expectations, system usage was lower when the patient was unfamiliar to the facility.

LIMITATIONS

Because of differences between HIE efforts and the fact that not all types of HIE usage (ie, public health) could be included in the analysis, results are limited in terms of generalizablity.

CONCLUSIONS

This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act.

Addressing dysfunctional relations among healthcare teams: improving team cooperation through applied organizational theories

Previous research has demonstrated that communication failure and interpersonal conflicts are significant impediments among health-care teams to assess complex information and engage in the meaningful collaboration necessary for optimizing patient care. Despite the prolific research on the role of effective teamwork in accomplishing complex tasks, such findings have been traditionally applied to business organizations and not medical contexts. This chapter, therefore, reviews and applies four theories from the fields of organizational behavior (OB) and organization development (OD) as potential means for improving team interaction in health-care contexts. This study is unique in its approach as it addresses the long-standing problems that exist in team communication and cooperation in health-care teams by applying well-established theories from the organizational literature. The utilization and application of the theoretical constructs discussed in this work offer valuable means by which the efficacy of team work can be greatly improved in health-care organizations.

What can we learn from patient dissatisfaction? An analysis of dissatisfying events at an academic medical center

BACKGROUND

Patient satisfaction is typically measured by quantitative surveys using predetermined domains. However, dissatisfaction may be an entity distinct from satisfaction, may have different determinants, and may better reflect problems in healthcare delivery.

OBJECTIVE

The aim of this study was to describe domains of dissatisfaction experienced by patients during hospitalization.

SETTING

The setting was a U.S. urban academic medical center.

PATIENTS

The patients were adults discharged between July 1, 2007 and June 30, 2008

INTERVENTION

The intervention was a postdischarge telephone interview: "If there was one thing we could have done to improve your experience in the hospital, what would it have been?"

MEASUREMENTS

The measurements were standard qualitative analysis of suggestions for improvement.

RESULTS

We randomly selected 976 of 9,764 interviews. A total of 439/976 (45.0%) included at least one suggestion for improvement. We identified six major domains of dissatisfaction: ineptitude (7.7%), disrespect (6.1%), waits (15.8%), ineffective communication (7.4%), lack of environmental control (15.6%), and substandard amenities (6.9%). These domains corresponded to six implicit expectations for quality hospital care: safety, treatment with respect and dignity, minimized wait times, effective communication, control over physical surroundings, and high-quality amenities. Some of these expectations, such as for safe care, effective communication between providers, and lack of disrespect, may not be adequately captured in existing patient satisfaction assessments.

CONCLUSIONS

The results represent patient-generated priorities for quality improvement in healthcare. These priorities are not all consistently represented in standard patient satisfaction surveys and quality improvement initiatives. Patient input is critical to assessing the quality of hospital care and to identifying areas for improvement.

Multi-professional patterns and methods of communication during patient handoffs

OBJECTIVE

Health information technology has been shown to influence the communication patterns of healthcare providers. The goal of this study was to learn more about how healthcare providers communicate and exchange patient clinical information during patient handoffs (transfers) between units in an acute care setting.

METHODS

Convenience sampling was used to select five patient handoffs. Questionnaires were distributed to providers identified through observation and snowball sampling. Social network analysis methodology was used to develop sociograms of the emergent communication patterns and identify the role of individual providers in the handoff process based on the number of contacts with other providers and incoming and outgoing communication activity. Individual handoff network size ranged from 11 to 20 providers. Participants were asked to describe the method of communication they used to access or share clinical information with other providers, their preferred method of communication; their satisfaction with the available options; and their suggestions for how the process could be improved.

RESULTS

The network patterns that emerged uncovered the overlapping use of synchronous and asynchronous communication methods (verbally via phone or in person; or written via paper charts and/or an electronic records). No particular professional group dominated or coordinated information flow; instead each handoff network exhibited unique communication patterns and information coordination by two or more influential providers from nursing, medicine, or pharmacy. Most (84%) participants preferred verbal communication. Overall satisfaction with the current communication process varied by unit: 82% of emergency department providers and 54% of the providers working in the admitting units stated they were satisfied or very satisfied. Recommendations for improvement included converting all units to the electronic health record, electronic handoff communication modules and asynchronous multi-professional communication logs.

CONCLUSIONS

The results of this exploratory study provide a foundation for future research examining how network structure and communication principles can be used to design health information technology that compliments the non-linear information gathering and dissemination behaviors of providers from multiple professions.

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety

PURPOSE

Clear and complete communication between health care providers is a prerequisite for safe patient management and is a major priority of the Joint Commission's 2008 National Patient Safety Goals. The goal of this study was to describe nurses' perceptions of nurse-physician communication in the long-term care (LTC) setting.

METHODS

Mixed-method study including a self-administered questionnaire and qualitative semistructured telephone interviews of licensed nurses from 26 LTC facilities in Connecticut. The questionnaire measured perceived openness to communication, mutual understanding, language comprehension, frustration, professional respect, nurse preparedness, time burden, and logistical barriers. Qualitative interviews focused on identifying barriers to effective nurse-physician communication that may not have previously been considered and eliciting nurses' recommendations for overcoming those barriers.

RESULTS

Three hundred seventy-five nurses completed the questionnaire, and 21 nurses completed qualitative interviews. Nurses identified several barriers to effective nurse-physician communication: lack of physician openness to communication, logistic challenges, lack of professionalism, and language barriers. Feeling hurried by the physician was the most frequent barrier (28%), followed by finding a quiet place to call (25%), and difficulty reaching the physician (21%). In qualitative interviews, there was consensus that nurses needed to be brief and prepared with relevant clinical information when communicating with physicians and that physicians needed to be more open to listening.

CONCLUSIONS

A combination of nurse and physician behaviors contributes to ineffective communication in the LTC setting. These findings have important implications for patient safety and support the development of structured communication interventions to improve quality of nurse-physician communication.

Social network analysis of medication advice-seeking interactions among staff in an Australian hospital

PURPOSE

To examine the medication advice-seeking network of staff in a hospital ward.

METHODS

Social network analysis was carried out in a renal ward of an Australian metropolitan teaching hospital. The medication advice-seeking interactions of doctors, nurses, allied health professionals (including a pharmacist) and a ward clerk were examined using data from questionnaires administered to staff. The questionnaire listed all staff who worked in the ward and sought information from respondents regarding their interactions with each staff member. Data were analysed using social network software, UCINET. Analyses performed included geodesic distance, network density, strength of ties, reciprocation of relations, and centrality of individuals. NetDraw was used to produce social network diagrams.

RESULTS

A very high response rate of 96% was achieved with 45 of 47 staff returning the questionnaire. On average, there is little interaction between each of the staff members in the medication advice-seeking network, with even less interaction between staff from different professional groups. Nurses are mainly located on one side of the network and doctors on the other. However, the pharmacist is quite central in the medication advice-seeking network as are some senior nurses and a junior doctor.

CONCLUSIONS

When hospital clinical staff seek medication advice from other members of a ward it tends to be sought from those in their profession. However key individuals in the ward are relied upon for the provision of medication advice by staff from all professions. Social network analysis can be used to examine the complex medication advice-seeking interactions amongst staff in a hospital ward, providing useful quantitative baseline data against which to compare the effect of interventions, such as an electronic medication system, on interactions.

Development and psychometric evaluation of the Impact of Health Information Technology (I-HIT) scale

OBJECTIVE

The use of health information technology (HIT) for the support of communication processes and data and information access in acute care settings is a relatively new phenomenon. A means of evaluating the impact of HIT in hospital settings is needed. The purpose of this research was to design and psychometrically evaluate the Impact of Health Information Technology scale (I-HIT). I-HIT was designed to measure the perception of nurses regarding the ways in which HIT influences interdisciplinary communication and workflow patterns and nurses' satisfaction with HIT applications and tools.

DESIGN

Content for a 43-item tool was derived from the literature, and supported theoretically by the Coiera model and by nurse informaticists. Internal consistency reliability analysis using Cronbach's alpha was conducted on the 43-item scale to initiate the item reduction process. Items with an item total correlation of less than 0.35 were removed, leaving a total of 29 items.

MEASUREMENTS

Item analysis, exploratory principal component analysis and internal consistency reliability using Cronbach's alpha were used to confirm the 29-item scale.

RESULTS

Principal components analysis with Varimax rotation produced a four-factor solution that explained 58.5% of total variance (general advantages, information tools to support information needs, information tools to support communication needs, and workflow implications). Internal consistency of the total scale was 0.95 and ranged from 0.80-0.89 for four subscales.

CONCLUSION

I-HIT demonstrated psychometric adequacy and is recommended to measure the impact of HIT on nursing practice in acute care settings.

Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science

Complexity science teaches that relationships among health care providers are key to our understanding of how quality care emerges. The authors sought to compare the effects of differing patterns of medicine-nursing communication on the quality of information flow, cognitive diversity, self-organization, and innovation in nursing homes. Two facilities participated in 6-month case studies using field observations, shadowing, and depth interviews. In one facility, the dominant pattern of communication was a vertical "chain of command" between care providers, characterized by thin connections and limited information exchange. This pattern limited cognitive diversity and innovation in clinical problem solving. The second facility used an open communication pattern between medical and frontline staff. The authors saw higher levels of information flow, cognitive diversity, innovation, and self-organization, although tempered by staff turnover. The patterns of communication between care providers in nursing facilities have an important impact on their ability to provide quality, innovative care.

The influence of information technology on patient-physician relationships

Interpersonal relationships and information are intertwined as essential cornerstones of health care. Although information technology (IT) has done much to advance medicine, we are not even close to realizing its full potential. Indeed, issues related to mismanaging health information often undermine relationship-centered care. Information technology must be implemented in ways that preserve and uplift relationships in care, while accommodating major deficiencies in managing information and making medical decisions. Increased collaboration between experts in IT and relationship-centered care is needed, along with inclusion of relationship-based measures in informatics research.

Incorporating the International Classification of Functioning, Disability, and Health (ICF) into an electronic health record to create indicators of function: proof of concept using the SF-12

OBJECTIVE

The purpose of this proof-of-concept study was to assess the feasibility of using a generic health measure to create coded functional status indicators and compare the characterization of a stroke population using coded functional indicators and using health-related quality-of-life summary measures alone.

DESIGN

Multiple raters assigned International Classification of Functioning, Disability, and Health (ICF) codes to the items of the 12-Item Short Form Health Survey (SF-12). Data for comparing the information from the SF-12 and from ICF codes were derived from the Montreal Stroke Cohort Study that was set up to examine the long-term impact of stroke. Available for analysis were data from 604 persons with stroke, average age 69 years, and 488 controls, average age 62 years.

MEASUREMENT

The SF-12 provides two summary scores, one for physical health and one for mental health. Domains of the ICF are coded to three digits, before the decimal; specific categorizations of impairments, activity limitations, and participation restrictions are coded to four digits before the decimal.

RESULTS

Persons with stroke scored, on average, approximately 10 points lower than controls on physical and mental health. The ICF coding indicated that this was attributed, not surprisingly, to greater difficulty in doing moderate activities including housework, climbing stairs, and working and was not attributed to differences in pain. Differences in mental health were attributed most strongly to greater fatigue (impairment in energy), but all areas of mental health were affected to some degree.

CONCLUSION

The ICF coding provided enhanced functional status information in a format compatible with the structure of administrative health databases.