14: REFLECTIVE RESPONSE 1 ■ 349One of the key roles of the doctoral APN is to support evidence- based practice. As
the authors describe a paucity of articles on information mastery in nursing, there is also
a gap in the field of clinical decision support (CDS). As scientific knowledge continues
to grow at an amazing rate, it has become impossible for a clinician to keep up— not to
mention all the distractions occurring in the clinical environment. Use of clinical infor-
mation systems provides an opportunity to integrate knowledge and decision support
so that they are available to clinicians when needed. I would expect the doctoral APN
to make recommendations from the review of the standard of care and best evidence on
how CDS could be used to improve the care delivered. For example, are there compo-
nents of the assessment that are routinely being missed? If so, should the data elements
be rearranged on the form or reminders given when documents are submitted with miss-
ing data fields or creation of a display that illustrates critical missing data elements, to
ensure collection of complete and accurate information? How and where should data be
displayed that could prevent medication errors. What alerts and reminders are helpful?
Osheroff, Pifer, Teich, Sittig, and Jenders (2005) described six primary ways that decision
support can be provided to clinicians: documentation forms/ templates, relevant data
presentations, order/ prescription creation facilitators, time- based checking/ protocol
pathway support, reference information and guidance, and reactive alerts and remind-
ers. Excellent resources can also be found on the Agency for Healthcare Research and
Quality (AHRQ) website (AHRQ, n.d.a). The majority of this work to date relates to phy-
sicians. Mitchell et al. (2009) have found little research examining what CDS systems are
available to nurses or the characteristics the systems possess in comparison with physi-
cians. Dowding et al. (2009) found that nurses used CDS systems to record information,
monitor patients’ progress, or confirm a decision that they had already made. Use was
influenced by how well the nurse knew the patient, their experience, and how well it
fit in their workflow. These studies were, however, conducted in the National Health
Service in England. Dunn Lopez et al. (2016) performed an integrative review of quali-
tative and quantitative peer- reviewed original research studies focusing on use of CDS
by the bedside nurse. They summarized the 28 articles stating CDS had positive effects
on outcomes and substantiated there is much less research in nursing than in medical
decision making. We need the assistance of doctoral APNs to study, develop, and further
evaluate the use of CDS systems for nursing.
In the technological tools section, I would additionally suggest workflow and
mind- mapping software such as Smartdraw or Visio. In the technology drill- down
study, Burnes, Glassert, and Cipriano (2008) reported that 766 unique process issues
(out of 946) were required to improve and enable nurses to spend more time at the
bedside to address patient care needs. One of the most common reasons for lack of
adoption of clinical information systems is that the system does not support the cli-
nician workflow. Routine consistent use of these tools may decrease the number of
workarounds that evolve with implementations when changes in workflow patterns
are not adequately addressed preventing negative impacts to care of the patient or to
the business of the organization— for example, lost or delayed charges. Identifying cur-
rent practices and mapping out the new desired state workflows to use in education
and training facilitates adoption of new technology enabled best practices. Reference
management and report- writing tools are nice to know but suggest prioritization of
workflow tools higher in the chain of the skills required for advanced practice clini-
cians. A resource on workflow tools can be found at AHRQ HIT website (ARHQ, n.d.b;
Carayon et al., 2010).
It was interesting to read about informatics competencies in the different nurs-
ing professional groups. In addition to the nurse executive competencies, American
Organization of Nurse Executives (AONE) published a position paper on the role of the