Module 6
What did you like or dislike about taking an online course?

I liked the pace of this course even though I should have started a little sooner on some things. Once I got use to how the modules worked things went smoother. I would try to be more interactive with the instructors. Sometimes that is a draw back of an online class, the feeling you are teaching yourself the class.


What topic did you learn the most about and what was your favorite topic?

Making the Blog site was fun. I think that my favorite topic was learning about evidence based practice and the CDSS. I really liked the you tube videos ("Pay Attention" and "A Vision of Students") and shared them with my sons. My least was the Wiki doc., but I did like the idea behind it and see that it is a unique way to collaborate online. I feel that I learned, more than I ever have, how to use the Internet more proficiently to find reliable resources . I never thought I would like Endnotes, but I do, and hope to get even better at using it. I feel that I still have a lot to learn about gathering data.


If you were the instructor, and this being the first course for all DNP and Master students, what would you do the same or different?

I'm not sure that I would do anything different. It was all very new for me and I don't know that I can suggest changes. I am still quite a ways away from feeling computer savvy. Maybe I would tell students to interact more with the instructors. I know that for myself taking 13 credit hours at once makes for a ton of information to keep track of and digest, as well as people to keep in touch with. I think that this class has a large amount of reading, but he text for the course was well worth buying.

The AHRQ Website

Well, once again I was enlightened. That seems to be happening a lot lately. The U.S. Department of Health & Human Services Agency for Healthcare Research and Quality was something that I had not looked at. I have gone to the U.S. Department of Health & Human Services, but never linked into this site. This is definite a place to get more familiar with. This is a huge site that is a little intimidating.
In looking for regulatory information, the AHRQ has a link that leads to “State and Local Policymaker” which in turn gives information about The Users Liaison Program (ULP). Their purpose is to, “disseminates health services research findings for State and local health policymakers in easily understandable and usable formats through interactive onsite workshops, teleconferences, distance learning programs, and research syntheses”. There are links for quality, cost and financing, information and data systems, and ethical subjects such as behavioral health, special populations and racial and ethnic disparities (AHRQ, 2008). What a great way to see what's happening in your state.
I used the AHRQ search to see what putting in the word “accreditation” would link me to and it brought me to a new window titled “Health Care Report Card Compendium” there were many links to reports for information on accreditation status of health care organizations(AHRQ, 2008).
In searching this site for reimbursement issues there is again a lot of information. An example of what was available was I looked at the information that the AHRQ gave as far as Pay for Performance (P4P) programs that are designed for health care providers and offer incentives to them when their care meets a certain quality of care is met. The AHRQ give resources for finding research information they have conducted concerning P4Ps (AHRQ, 2006).

I first smiled when I noticed the link to Evidence-Based Practice under the Clinical Information Menu but, the first link I went to was AHRQs “Knowledge Transfer Initiative” which was listed under “Special Interest”. Here I saw one of the goals listed as: “Enhance awareness and increase knowledge among users about available tools, research, and products of AHRQ” (AHRQ, 2008, n. p.). I felt that the information offered here were very applicable in considering the acquisition, use, and management of a healthcare information system. There was so much information available, but this statement is an example of what they suggest in using a system to help manage their data and make it assessable and usable:
"To administer care management programs, States can contract with an external organization, undertake in-house operations, or use a hybrid of the two. As a result, care management models lie on a continuum, with three general categories—often referred to as buy, build, and assemble—as shown…The majority of States use a model between the two ends of the continuum or adopt a combination of these models" (AHRQ, 2008, n. p.).
Another link I found in looking for ethical considerations on this website was the National Guideline Clearinghouse or NCG. This is a database originally started by the AHRQ, the American Medical Association (AMA) and the America's Health Insurance Plans (AHIP). It is a data base for guidelines for using EBP and has a wealth of documents related to this.
In my humble opinion I feel that this is a wealth of information availble to both healthcare providers and the general public. The intention is to provide informations that has been found to be best practice. They state their mission as “to improve the quality, safety, efficiency, and effectiveness of health care for all Americans”(AHRQ, 2008, n. p.).
The only problem may be in getting those who need this information the most, access.
References
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Retreived April 17, 2009 from http://www.guideline.gov/about/about.aspx

AHRQ's Knowledge Transfer/Implementation Program. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ktint.htm

AHRQ Resources on AHRQ Resources on Pay for Performance (P4P) (P4P). March 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pay4per.htm

The National Guideline Clearinghouse. 2009. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Retreived April 17, 2009 from http://www.guideline.gov/about/about.aspx

Module 4 Question # 2

How does nursing data quality relate to decision support?
The quality of nursing data in relationship to decision support is critical. As Mollie Poynton related in her Captivate presentation much of the data that is collected by nurses ends up on notes in the pockets of their scrubs. Nurses need to have a place that they can import data as well as extract it in a timely manner. According to the chapter 10 reading by Androwich and Kraft, when making critical clinical decisions, clinicians depend on the reliability, accuracy, and timeliness of the information. I see that one of the area that would be a benefit for the quality of nursing care would be an interdisciplinary support in medication orders. Medication errors are a major problem. When a nurse has several patients, who each have multiple medications, it can be very time consuming to make sure all of the medications are the right dosage and often the original orders by the physicians are terribly written. I know when I worked as a floor nurse, medications were checked against several paper check lists: the cardex, the pharmacy printout, the physicians orders. A med would be added, one would be discontinued, a subtle dosage change would take place. Having a CDSS that was used by physicians, pharmacy, nursing etc. would help track changes, alert to any problems, and possible medication discrepancies. According to Androwich and Kraft, "Nurses need access to current knowledge at the point-of-care delivery where it is useful: in clinics, at the bedside, in homes, offices, and in research that makes contribution to evidence based practice." Having access to a CDSS for medications alone would help in all these areas. I know that larger health care facilities probably are already doing this, but it needs to be something that any nurse in any location can have access to when caring for patients.

Module 4 Question # 1 part 2

How do we reconcile the value of nursing experience with known heuristics and biases used in human decision making?
I think the first step is to realize that we as humans make mistakes. Making mistakes in the health care profession can unfortunately have irreversible effects. Anything that can enhance our decision making quality must be considered. I think the next step is in analyzing our own tendencies in using heuristics and biased practices. It is easy to have something work for you and therefore feel comfortable in using it again, and again, without realizing what evidence you really base your use of it on or if another technique would work better. Treating patients take the ability to make quick decisions, but the quality of these decisions must be best practice. I can see that in today's information explosions that tapping into EBP is essential in supporting our profession. The use of a CDSS does not take the place of experience and intuition, and the ultimate decision of care, but having access to electronic libraries, medical dictionaries, drug formularies, expert opinions and patient databases as discussed in chapter 10 (Androwich and Kraft) in real time is an advantage that our patients deserve. Nursing practice must be on the cutting edge of technology and our own EBP must be made available to other health care entities.

Module 4 Question # 1 part 1

How did the readings influence your perception of your own clinical decision-making?
The readings gave me a new perception of how I make my clinical decisions. I definitely need to get the support that Computer-based Clinical Decision Support System can offer. In reading the material I first had to understand the full meaning of the term Heuristics. After understanding it more clearly as being defined as: Educated guesses, optimal solutions, problem solving, trial and error, and rules of thumb; I felt I could understand the Captivate presentation and the readings. In the Captivate presentation that Mollie gave, I realized that I am one of those nurses who has felt that if I didn't know the answers I felt less than adequate and unsure of my education. Depending on intuition and experience, or asking a more experienced health care provider has been the way I have primarily done things. I have always attended re- certification classes and gone to seminars yearly and the fact that I have always continued my education has helped my practice as well. I also subscribe to several journals, but as much as I use the Internet, I do not have a CDSS. This may be due to my non-traditional clinical setting in occupational health where I am the only health care provider and the company I work for is very tight in spending money. They feel that having just the Internet is enough and I do use it extensively, but not as efficiently as I could with a CDSS. Since my company pays for my tuition I plan to present what I have learned to my employer and request we get a CDSS. I feel that I can help them see the importance of this.


In the Thompson article, I found the information on Combating overconfidence interesting. I have a physician who come once a month and I look forward to interacting with him, but he tends to ignore the detailed knowledge that I have concerning a patients I am having him see and often jumps to his own conclusion before giving me a chance to have input. He is not interested in consulting with me or teaching me from his more advanced knowledge base. For example, I see a particular patient several times a week and he may see him twice a year, but he jumps to a quick diagnosis upon seeing one elevated blood sugar for example and then leaves, disregarding the other signs and symptoms I present for his opinion. I ended up sending this patient out for a neurological consult. He has Meniere's disease. When my opinions and research has been disregarded because "I am just a nurse " it certainly undermines my confidence. I would like to be treated more professionally.


I also enjoyed the material on Hindsight that Thompson (2003) gives. I felt it was important advice to make sure that as nurses we make sure we do the work-up before we come up with our prognosis. If a patient has already been diagnosed with diabetes for example, we tend to look at everything from that point of reference having priori knowlege as Thompson (2003) explains.

Module 3 Question 1

The strengths that were highlighted in my multiple intelligent test were Intrapersonal and Spatial-Visual. These were tied for first place with musical, logical-mathematics coming in second. As far a my intrapersonal strength, I thought that my interpersonal scores would be higher, although they weren't too far behind. I do spent time reflecting and thinking. One of the reasons becoming a FNP is that I like the idea of having more autonomy and I do think about being self employed often. When I have time alone I feel it energizes me. I don't feel I am an extreme introvert, but I do have some of those qualities such as preferring small groups and having a few close friends. I am a private person and when I have conversations with others I try to get them to talk about themselves, rather than talk about myself.

As far as my visual-spatial skills I feel that this is something I come by quite honestly because their are many artists in my family. I love art and wish I could spent more time drawing. I love to read and I visualize what I am reading easily in my head, but I do love picture books. One of my favorite artists is James Joyce who has wonderful children's books. I love to go to art museums and try to understand the story behind the paintings or sculpture. One of the funnest trips I have ever been on was an art tour I went on with my sister to Washington, DC.

Technologies that might augment my personal learning style would be the use of the Internet to find visual images that wouldn't be available to me because of where I live. Being able to search online libraries is such invaluable tool to someone like me who lives so far away form any cultural centers. I am inserting a picture from one of my favorite artists-Gustav Klimt. It is called "The Kiss." For my intrapersonal learning style keeping an online journal might be worthwhile.

Module 2 Question #3

Electronic and guideline indexes are very useful when you take the time to learn the best way to perform a search. I learned to strengthen my searching abilities after reading "How to Search" on the National Guideline Clearinghouse sight and using other tutorials. Many terms such as Boolean, wildcard and truncation, use of double quotations, were not familiar in my information searching experience. I discovered how primitive my searching techniques really were. Becoming a proficient Internet user from an educative perspective takes time and perseverance. Using a web search engine, such as Google, has always been the way I do most of my Internet searches. It seems easier when compared to electronic and guideline indexes, but often it does not carry the quality of searches (peer reviewed and best practice). In the isolated area in which I live, the resources brought via the Internet are invaluable. I can see that I need to develop my ability to utilize them. There is a lot of information that is irrelevant and of questionable authority on the world wide web. Buy using heath care specific electronic indexes the access of quality information is more likely. One alternative strategy that would be helpful is to participate in online live lectures given on specific health care topics that are offered for CME hours by belonging to organizations such as the American Heart Association.

Module 2 Question #2

The software that I am using is EndNote. I'd never used or even heard of it before starting my classes. I was very impressed by what I heard it was capable of doing. EndNotes allows searches of bibliographic databases. It can retrieve selected references directly into EndNotes and can attach the full text to articles. When searching for specific articles you can build a "library" which helps to manage them into specific folders. In trying to import the citations I found in Pub Med into EndNotes, I had difficulties. In reading the EndNote instructions that we were given by the librarian, I discovered that importing from PubMed works best if you are not at your own computer which I was. I read that exporting is not available for PubMed, so I will have to remember this for future use. My favorite feature of EndNotes is that it helps with citations while you are writing a paper and can automatically put your references into the correct APA format. I have heard many praises of the EndNote software with the caveat of being patient in learning how to use it effectively. I hope that it will become the support it is said to be throughout my career.

Module 2 Question #1

Functional capacity testing and return to work was the clinical problem that I chose to search for. The electronic index that I used was PubMed which I accessed through the Eccles Library after taking the tutorial. I am not very confident with my knowledge in searching and Pub Med was the second index I tried. I first tried the Cochrane Library and felt like I was getting too much information all at once even thought I plan to return and try again. It was rather time consuming for me. When I tried Pub Med I watched two short videos: Simple Subject Search and Search by Author. I decided to jump in and first did a simple search that gave me too many citations (1331). By adding a "and operator" I was able to narrow my search to a much smaller, manageable citation collection. Yes, I felt that this process was time intensive, but I know that part of that is due to my learning curve. As for using this in a daily practice, I feel that barriers would be patient load and available time to search, sort, identify and make appropriate selections for application. Not all software is user friendly and many I noticed have subscriptions that must be purchased. I feel these are valuable resources and my goal is to become more savvy about them and understand which would be the most effective for my clinical setting.

Introduction and IT in my current clinical setting

Hello Nursing 6004 classmates! My name is Leslie Rasch. I live in Leamington, Utah. I am married and have four sons. I work at Intermountain Power Service Corporation as a Registered Nurse. My specialty is Occupational Health. As a graduate nurse I feel I need to improve my knowledge about information management so that I can transition into the role of Family Nurse Practitioner more proficiently and effectively. I am the only health care professional where I work and it is often difficult to stay on top of new technologies. Since I do not work in a traditional setting, I rely heavily upon my own skill and in the relationships I have built with outside health care providers when making referrals. I am hoping to change our current clinic into a primary care facility. I can see that I will need to embrace the use of information systems and technology resources to be able to provide quality care and make administrative decisions.
As far as the structured documentation that I use at work, I am in charge of all documentation for about 500 employees. This is done by old fashioned charting (SOAPIE notes) by hand. I do have two computerized programs that I use in testing employees hearing and pulmonary function. We do have our own "social network" where I work. I have tried to get my company to consider computerized charting, but so far they have not been convinced. I hope that as I learn more about IT I can educate myself, as well as my supervisors, to the benefits it could bring to our clinic.

Arrival

Hello! I have finally arrive! Another first for me! I am now the proud, yet timid, owner of my own blog site. I don't know how I have live for half a century and not partaken of this technological treat! But here I am finally, and it is a good time of day right now because I am nearly caught up with my NURS 6004 assignments. I know most of the rest of my classmates are probably light-years ahead, but I am just so thankful to finally find a server (Verizon) so that I can view the Polycom classes while sitting here in little old Leamington, Utah, population 200 souls. Leamington is the definition of rural and we are on the edge of outer darkness when it comes to technology. We have no businesses except for the post office ,which is only open from 10 am to 12am. There isn't a stop light in town, and even though the speed limit through town is 45 mph, most have left town before they slow down. Tonight I am being serenaded by my neighbor's cows who are waiting for dinner very noisily. Enough of my ruralness. It is good to have this blog set up and I will enjoy seeing how it grows and develops (that sounds like a nurse doesn't it). Anyway, I also look forward to seeing my classmates blogs and discovery the advantages of having a bolg. Thanks for looking in, Leslie Rasch