Far Eastern University

INSTITUTE OF NURSING
N. Reyes St., Sampaloc Manila 1008

Nursing Informatics
Concept IV - Informatics – Applications in Evidence-Based Nursing Practice

I. MODULE INTRODUCTION
Evidence-Based Nursing Practice refers to the process of collecting, processing, and
implementing research findings for the improvement of patient outcomes, clinical nursing
practice, and/or work environment. It helps in providing the highest possible quality of care at
the most cost-efficient manner. The practice also enables nurses to incorporate clinical expertise
and current research to the data and turn it into a useful basis in the decision-making process.
The use of information technology allows a more efficient facilitation in the applications in
Evidence-Based Nursing Practice such as the computerized nursing care plan, use of clinical
pathway, clinical practice guidelines, and e-journals that provide the latest and up-to-date
accessible literatures that can be used as support for new evidence-based nursing practice
projects. This module will provide you an overview of the above-mentioned applications and its
intended purpose.

II. PURPOSE AND OBJECTIVES

Objectives:
At the end of this module, you will be able to:
1. Provide evidence-based nursing care using nursing informatics and technology system.
2. Apply guidelines and principles of evidence-based nursing practice utilizing
information technology.

III. Computer Generated Nursing Care Plans

Nursing care plans or NCPs as we use them in our conversations with our colleagues, have been
introduced to us during our stay in the nursing school. It has been used extensively inside the academic
institution as an essential teaching tool to present the value of planning patient care, which has been also
reinforced by the Joint Commission on Accreditation for hospitals (JCAH). But in actual clinical settings,
it is difficult to find completely written nursing care plans. If in any case that a written care plan is found,
they can be incomplete, outdated, rarely used for determining care and infrequently relied upon as a
means of communicating problem management from one shift to another. The nurses view the care plan
burdensome, as it is time-consuming paperwork, preparation or revision of the plan is low in practice
settings (Dharmarajan and Gangadharan, 2013). It is with this practice that the initiation of a computer-
generated nursing care plan was done.
The computer-generated nursing care plans promotes the value of planning care but at the same
time addresses the burden of the workload NCPs can consume from the nurses. It works by providing a
template that nurses can work on and modify based on the individual cases of their clients.

IV. Critical Pathways

Care pathways are considered to be one of the best tools hospitals can use to manage the quality
in healthcare concerning the standardization of care processes, since they promote organized and
efficient patient care based on evidence. It has been proven that their implementation reduces the
variability in clinical practice and improves outcomes.

Care pathways are also known as Clinical or Critical pathways. A care pathway is a
multidisciplinary healthcare management tool based on healthcare plans for a specific group of patients
with a predictable clinical course, in which the different tasks or interventions by the professionals
involved in the patient care (physicians, nurses, pharmacists, physical therapists, social workers etc.)
are defined, optimised and sequenced either by hour (ED) or day (acute care). Outcomes are tied to
specific interventions.

The care pathway concept appeared for the first time in 1985 inspired by Karen Zander and Kathleen
Bower at the New England Medical Center in Boston (Massachusetts, USA). Care pathways are
usually represented as a Gantt chart (Figure 1).
So far, different systematization tools were being used for clinical processes. The oldest and most
known are medical and nursing protocols. Over the last years other tools were introduced, such as
clinical practice guidelines and standardized nursing care maps. Care pathways are care protocols that
embrace all of these tools (Figure 2).

Scope of clinical pathways

The main goal of care pathways is based on the improvement of the following areas: quality in
healthcare, coordination / cooperation among professionals, efficiency and patient satisfaction. Thus,
the purpose of pathways is the enhancement of care processes in three areas: quality, safety and
efficiency.

Care pathways are a powerful tool for care process management, since they permit to check the
compliance of all the interventions included in the healthcare plan, fix care standards and introduce
clinical audits as a part of the process. Likewise, pathways are very useful to identify improvement
areas in these standardized care processes, under the umbrella of the culture of Continuous Quality
Improvement (CQI).

The development and implementation of a care pathway involves a change in the organizational culture
at any setting. This process may involve overcoming of some hurdles in its way of implementation.
Following are some of the activities to be done to develop and implement a care pathway:
• Preparing multidisciplinary documents
• Reviewing the process by all the concerned staff
• Holding care pathway meetings to facilitate the exchange of opinions about patient care by different
professionals
• Conducting periodic reviews to monitor some defined indicators
• Analyzing variances or deviations
• Preparing common record documents for all the staff

Some barriers in developing and implementing a pathway are identified: the heterogeneity of patients
and diagnosis, the common reluctance among organizations and professionals to change. Hospital
managers must consider these barriers since they may threaten a successful implementation of care
pathways.

Methodology
 The methodology of any project for care pathways implementation is divided in four phases: selection,
development, implementation and evaluation.

V. Clinical Guidelines
Clinical practice guidelines are statements that include recommendations intended to optimize
patient care. They are informed by a systematic review of evidence, and an assessment of the benefits
and harms of alternative care options. CPGs should follow a sound, transparent methodology to
translate best evidence into clinical practice for improved patient outcomes. Additionally, evidence-
based CPGs are a key aspect of patient-centered care.

Clinical practice guidelines should be developed using rigorous evidence-based methodology with the
strength of evidence for each guideline explicitly stated.
▪ Clinical practice guidelines should be feasible, measurable, and achievable.
▪ Clinical performance measures may be developed from clinical practice guidelines and used in
quality improvement initiatives. When these performance measures are incorporated into public
reporting, accountability, or pay for performance programs, the strength of evidence and
magnitude of benefit should be sufficient to justify the burden of implementation.
▪ In the clinical setting, implementation of clinical practice guidelines should be prioritized to those
that have the strongest supporting evidence, and the most impact on patient population morbidity
and mortality.
▪ Research should be conducted on how to effectively implement clinical practice guidelines, and the
impact of their use as quality measures.

Below is a sample of the clinical practice guideline for pneumonia by the Philippine College of Chest

Physicians:

The differences between Critical Pathway and Clinical Guidelines (Kumar, 2020)
Clinical Guideline Clinical Pathway Practice Protocol

Focuses on Specific clinical The quality and co- Treatment.

circumstances. ordination of care.
What is it? Systematically developed Structured, A suggested course of
statements to assist multidisciplinary plans of treatment and/or treatment
practitioners and care. service for a specific diagnosis,
patient make decisions functional deficit or problem
about appropriate health area.
 care.
What does it do? Makes specific Supports the Highlights major therapeutic
recommendations on implementation of clinical intervention points.
health care and links these guidelines and protocols. Identifies choices of difference
to research evidence. courses or paths of treatment.
Suggests other diagnosis that
could be considered as
treatment progresses.
How does it Provides a summary and Provides detailed guidance Provides a logical flow of
work? appraisal of the best for each stage in the interventions. Provides
available research management of a patient. detailed recommendations that
evidence or expert build on those made in
consensus. guidelines.
Highlights the strength of
the evidence underlying
each recommendation.
Who uses it? Clinicians/ Medical Doctor, A multidisciplinary clinical Specific clinicians./ Medical
patients and third parties. team. Doctors with specializations

Also known as.... Guidelines Integrated Care Pathways Protocol

Clinical Practice Guidelines Multidisciplinary Pathways Best Practice Treatment
of Care Protocol
Pathways of Care
Care Maps
Collaborative Care
Pathways.
What are its 1) Appraisal of literature 1) Timeline 1) List of major therapeutic
components? (research evidence or 2) Categories of care/ interventions.
expert consensus). intervention. 2) Goals: When interventions
2) Summary of 3) Intermediate and long should be achieved.
recommendations. term outcome criteria. 3) Options for different choices
3) An outline of how 4) A variance record. of treatment.
guideline should be 4) Differential diagnoses and
implemented and how treatments based on the
adherence monitored. achievement of these goals.

Important Note:
In a nutshell, the computerized nursing care plan and the clinical guidelines of physicians can be found
on the clinical pathway as it promotes multi-disciplinary collaboration and coordination of patient care.

What happens when the clinical guidelines or critical pathways did not go as expected?
This is where the term variance takes place. Variances are the unexpected events that occur
during patient care - events that are different from what is predicted on the clinical pathway. As part of
quality improvement and to maintain the cost benefit analysis in the organization. It is a practice to
perform variance analysis. This practice helps providers of health care services to detect deviations in the
clinical pathways such as increased overhead costs and lack of proper training amongst care personnel,
thus enabling the health care providers to redirect their efforts and make realistic and sensible adjustments
within the clinical pathways. The reporting and practice of variance analysis differs from one institution to
another. Refer to the sample provided in the RLE activity portion.

Variance is documented by using the letter V. The V indicates that a variation from the pathway
has occurred on that day. When applicable flag it in the “Variance Column”, then document in the free
text area as instructed. (The free text area is also known as free text / clinical events/variance page). If this
variance occurs more than once daily, document the additional times of the variance in the variance free
text area and in the patient’s progress notes as applicable. The treating clinician is then expected to go to
the variance page to complete the entry. Document the relevant Code; describe the Variance (V), any
Actions (A) taken and Outcomes (O) as they occur.

For example write

• V Patient states they are nauseated
• A Antiemetic given as ordered, medical officer notified
• O Medical officer reviewed patient, medication order changed, patient placed on clear fluids
only

VI. E-journals
E-journals or electronic journals are scholarly publications in digital form, which are accessible
on the web. In the Philippines, we have the Philippine E-journals ([Link]) where you can
find an online bibliographic database & repository of academic journals in different disciplines
from various resources. These are often used as acceptable review of related literatures for
research projects and evidence-based nursing practice. (See Module 8 – Informatics application
in Research for the reliable search engines that you can use for research)

VII. SUMMARY
In this module you have learned the following:
1. What is evidence-based nursing practice.
2. The list of common information technology applications of evidence-based nursing
practice
3. The significance of evidence-based nursing practice applications

Module Questions:
1. What are the commonalities of computerized nursing care plan, clinical pathway, and clinical
guidelines have in common? Expound your answer
2. Can we have differences in the implementation of a standardized clinical pathway? Explain your
answer.

Answers:
1. Computerized nursing care plans, clinical pathway and clinical guidelines have one thing in
common and that is standardization of care and treatment to promote quality of care yet a cost
effective one as well.
2. Yes. This is in a form of variance. Variance analysis can be performed so that later on we can
incorporate this as part of the pathway.
 VIII. REFERENCES

Babu Dharmarajan, [Link] Gangadharan "Applying Technology Acceptance (TAM) model to

determine the acceptance of Nursing Information System (NIS) for Computer Generated Nursing Care
Plan among nurses"International Journal of Computer Trends and Technology (IJCTT),V4(8):2625-
2629 August Issue 2013 .ISSN [Link]. Published by Seventh Sense Research
Group.

Philippine College of Chest Physicians

Philippine E-jounals

Rosique, Ricard (2020). The Basics of Care Pathways. [Link]

management/care-pathways-basics Date Accessed: July 30, 2020