Foundations of Practice

Question 1

Advanced practice nursing: Discuss ethical principals in practice (Nursing Code of Ethics).

Answer 1

The American Nurses Association developed the Nursing Code of Ethics. There are nine provisions, which are listed below:

• The nurse treats all individuals with respect and consideration, regardless of social circumstances or health condition.
• The nurse’s primary commitment is to the individual regardless of conflicts that may arise.
• The nurse promotes and advocates for the individual’s health, safety, and rights, maintaining privacy and confidentiality and protecting him or her from questionable practices or care.
• The nurse is r_esponsible for his or her own care practices_ and determines appropriate delegation of care.
• The nurse must retain respect for self and his or her own integrity and competence.
• The nurse participates in ensuring that the health care environment is conducive to providing good health care that is consistent with professional and ethical values.
• The nurse participates in education and knowledge development to advance the profession.
• The nurse collaborates with others to promote efforts to meet health needs.
• The nursing profession articulates values and promotes and maintains the integrity of the profession

Question 2

Compare electronic medical records and electronic helath records.

Answer 2

Although many in healthcare use the terms electronic medical record (EMR) and electronic health record (HER) interchangeably, there are major distinctions between the two. The electronic medical record is created by a hospital or other health care delivery organization (CDO). The CDO owns the information in the EMR. The EMR consists of clinical documentation, orders, medications, treatments, and other clinical decision support, and is a legal record. The EHR includes information from EMRs, likely from multiple health care delivery organizations. The EHR relies on the information from the EMR to complete it. The EHR is owned by the patient and stakeholders, which could include the government, insurance companies, and healthcare providers among others. Important to the EMR is using controlled medical vocabulary so that information will be comparable among providers and other interested stakeholders. Currently in the United States the use of EHRs is limited, mostly due to many healthcare delivery organizations not having an established EMR using decided predetermined standards. There may soon be an increase in the number of organizations using EMRs with standardized language conducive to EHRs, as organizations now receive financial incentives to install EMR and EHR systems from healthcare reform.

Question 3

Define the steps needed for workgroup formation.

Answer 3

A workgroup is a small number of people working together toward a common goal. An advantage of working in groups is that the environment allows for increased insight and creativity. A disadvantage is that workgroups sometimes fail because members of the group allow personal conflicts (in terms of personality and work styles) to interfere with the group’s goal. A popular concept identifies four stages in group development:

1. Forming: This is where a group is formed and the members begin to get to know one another. Typically, individuals are quiet and polite to one another.
2. Storming: This is the stage where conflicts normally arise. Effective communications must be occurring.
3. Norming: Typically, conflicting factions make peace and come together. Less communication is necessary.
4. Performing: This is the stage in which the group begins to really work well. Communication is free flowing.

Question 4

Describe some of the roles that informatics nurse plays.

Answer 4

The following are some of the roles that the informatics nurse must play:

• Developing informatics theories: Assemble what sort of information should be captured on the system and how the data should be analyzed.
• Analyzing the information needs of the organization: Sort through the large amounts of data collected to determine the best information for the organization.
• Helping the organization choose computer systems: Assist in the system requirements, both for now and in the near future.
• Customizing purchased computer systems: Work with IT to customize the system so that it will be the most useful.
• Designing computer information systems: Assist IT in the overall design of the system.
• Testing new or upgraded computer systems: Conduct robust tests of the system when changes or upgrades are performed.
• Teaching other people to use the computer system: Set up training and education programs to encourage the most effective use of the system.

Question 5

Describe the attributes that help to assure accuracy of information.

Answer 5

The following information attributes are important in assuring accuracy:

• Objective reporting - Information should be completely free from bias and reported accurately.
• Comprehensive - All the necessary information is available to complete reports and requests.
• Appropriateness - All users are able to access the information necessary to do their jobs.
• Unambiguous - The data is clearly defined in order to reduce errors.
• Reliability - When identical information is keyed in by different people, it should always be uniform in the system.
• Up to Date - The most recent information should be listed first.
• Convenience - It should not be difficult for users to locate the information they need.

Question 6

Describe the differences between clinical nurses and those nurses who specialize in informatics.

Answer 6

The focus of a traditional clinical nurse revolves around taking care of patients. Their use of computerized systems is limited to the user level (i.e., enough knowledge to operate the equipment and enter data). Their concentration is on the accuracy of the information that they are interpreting or giving to other caregivers. They are trained to handle malfunctions and are used as a feedback source for the informatics developers. Their opinion of the computerized systems is key as to whether or not the system is successful.

Nurses who specialize in informatics focus on the information systems. They worry about the security and stability of the systems installed at their facility. They are also very adept at troubleshooting problems (especially at the user level). They make sure the systems are as user friendly as possible and, more importantly, reduce the number of tasks the traditional clinical nurse has to perform in their routine day. Efficiency arid enhanced productivity are the key goals of the informatics nurse.

Question 7

Describe the essential elements in the practice of nursing informatics.

Answer 7

The essential elements within the practice of nursing informatics include traditional nursing aspects such as:

• Focus on the patient and their well-being.
• Healthcare in general. Keeping up to date on the latest state of the art in terms of nursing.
• Working environment. This includes how things are laid out (to avoid errors and make things as efficient as possible).
• Working with others. How to interact effectively with other healthcare practitioners and coworkers.

In terms of informatics, the related skills include:

• Knowledge of data structures (including metastructures)
• Knowledge of computer networking
• Knowledge of computer hardware
• Information system training skills

Formal education includes:

• A degree in nursing (Bachelor of Science)
• A minor (or second major) in a computer science program focused on computer systems in the healthcare industry

Question 8

Describe the factors necessary for information quality.

Answer 8

Quality information is defined by the following factors:

• Timeliness: The necessary data is available (and retrievable) as needed.
• Precision: System dictionaries shall describe uniform wording and clear definitions.
• Accuracy: The data should be as error-free as possible.
• Measurability: The information should be quantifiable so that comparisons can be made.
• Independently verifiable: The integrity of the information remains constant regardless of the individual reporting it.
• Availability: The information should be accessible where it is needed. In the hospital or clinic environment, the information should usually be available at the patient’s location.

Question 9

Describe the framework for nursing informatics as defined by the American Nurses Association.

Answer 9

The American Nurses Association (ANA) has laid out standards for the informatics nurse specialist. These standards are based on a “problem-solving framework” which includes both traditional aspects of nursing as well as those aspects more specific to the informatics nurse. The standards are:

• Assessment
• Diagnosis
• Identification of outcomes
• Planning implementation
• System planning

The ANA has also set standards for the performance that informatics nurses should attain. The performance issues include quality assurance, review of performance evaluation methods, and ensuring that the practice of nursing informatics is effective. The informatics nurse should also work to create guidelines for research, ethics, peer cooperation, allocation of resources, and effective communication. Finally, they should be willing to help other nurses who want to improve their skills in informatics and computer science.

Question 10

Describe the history of the Health Insurance Portability and Accountability Act (HIPAA).

Answer 10

The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 to protect patient privacy rights. This is especially important given the large amount of sensitive data that is now handled electronically through large databases. Some key compliance dates for HIPAA are listed below (for large health plans):

• October 16, 2002: Electronic transactions and code sets are to be identified.
• April 14, 2003: Privacy standards are to be set.
• July 30, 2004: Standards for employer identification are to be set.
• April 21, 2005: Standards for system and data security are to set.
• May 23, 2007: Standards for provider identification are to be set.

These uniform standards will allow the data repositories of large healthcare systems to be efficiently monitored for adherence to the HIPAA regulations, thus assuring patient rights to privacy are honored.

Question 11

Describe the informatics nurse responsibilities.

Answer 11

The following is a list of responsibilities that are required of the informatics nurse:

• Teaching the policies involved with information systems including the standard operating procedures and system security features.
• Deciding the effectiveness of the computer system based on overall performance (e.g., system response time) and how well the system design is working.
• Making sure the system works as it was designed to by verifying that the system produces results that are expected and troubleshooting problems.
• Deciding when computer systems need to be upgraded based on gauging the obsolescence of the hardware and system compatibility with modern software.
• Finding new ways to use technology in nursing by looking for new and novel applications of technolow.
• Ensuring compliance in regulations regarding patient information including the patient privacy regulations.
• Managing projects as needed.
• Conducting research into the field of nursing informatics.

Question 12

Describe the International Council of Nurses (ICN) Code of Ethics for nurses in regards to patients.

Answer 12

The following is an outline of the ICN (International Council of Nurses) Code of Ethics for nurses in regards to patients:

• Foremost, the nurse’s responsibility is to the patient. The patient must receive the best possible care and their rights and well-being are respected and maintained.
• Respect and support patient rights, religious beliefs, values, and customs. The patient should be able to live their way of life while under care. This means that they should be allowed to follow their culture and traditions as best as possible.
• Make sure the patient gives informed consent for any treatment. The patient has the ultimate say as to whether or not they receive treatment. The right of the patient to accept or refuse a given treatment through the informed consent process is essential.
• Keep patient information confidential. The patient’s right to privacy is protected under law and should be respected.

In addition, nurses should be proponents for community health and act to promote environmentalism.

Question 13

Describe the International Council of Nurses (ICN) Code of Ethics for nurses in regards to coworkers.

Answer 13

The International Council of Nurses (ICN) has developed a Code of Ethics for nurses in regards to coworkers. Healthcare is a team oriented process with all attention focused on the well-being of the patient. Effective interaction with other team members (coworkers) is a key to success in this environment. The following bullet points are key areas that need attention:

• Keep relationships with coworkers cooperative and professional
• Make sure that patients are safe and promptly deal with unprofessional or dangerous conduct on the part of coworkers
• Take care not to delegate more work than the individual is able to handle
• Promote continuing education in the workplace
• Keep the lines of communication open between departments, management, etc.

This is an area that needs constant monitoring by workers and management. Any drift from optimal conditions should be addressed before the patient is exposed to any negative effects of poor teamwork.

Question 14

Describe the role of chief information officer, chief privacy officer, and chief e-health officer.

Answer 14

There are three management level positions that deal with the functioning of an organization’s information system:

1. Chief Information Officer: The chief information officer (CIO) is the head of the information services department. This individual is in charge of hiring information systems staff budgeting for maintenance of the system, and designing and implementing new systems as needed. Generally, the CIO holds a masters or doctorate degree in computer science.
2. Chief Privacy Officer: The chief privacy officer (CPO) is a federally mandated position at any facility that treats patients. This individual is responsible for all forms of patient information. The title of CPO is generally bestowed on an employee already working for the organization rather than being an entirely separate job.
3. Chief E-health Officer: The e-health officer is a relatively new position created by the onset of interactive health websites. The e-health officer is generally in charge of promoting and enabling the use of online interactive patient services.

Question 15

Describe the role of network administrator and trainer.

Answer 15

Network administrators and trainers are two types of support personnel needed primarily when an organization implements a new information system. They perform the following functions:

Network administrator: Network administrators are given access to all areas of the system and must be held to high standards of ethical accountability. These individuals take on the bulk of managing existing systems and planning new systems. They should also help the organization make hardware decisions and manage the lower level information systems employees such as PC specialists and programmers.

Trainer: Trainers teach the organization’s staff how to use computer systems. Trainers may be full-time employees of the organization, provided by the software vendor as part of the system contract, or temporary workers. They need to be up to date regarding healthcare information systems and the functions they support.

Question 16

Describe the role of security officer for information systems.

Answer 16

Since there are many regulatory patient privacy requirements (e.g., HIPAA), security officers are essential members of the healthcare information system team. It is important that confidential information is not accessible to unauthorized users or abused by employees. The security officer is responsible for assigning system access codes, making sure passwords are kept secret (and updated), and monitoring the overall use of the system. They may also be in charge of the physical security of the computers and peripherals. A stolen hard drive or laptop computer could contain sensitive information and be a target for information thieves. It is important that the security officer work with the information systems department and the organization’s management to create enterprise wide policies and procedures, which describe the proper and ethical use of equipment andinformation. These standards should apply to all staff members.

Question 17

Describe the roles of analysts, liaisons, and programmers.

Answer 17

There are three types of support personnel that are typically involved in information systems:

1. Analyst: Analysts must have a background in healthcare information systems. Healthcare information system analysts usually have degrees in the medical field with certificates in computer studies. Their primary job is to define the way in which clinical data is entered into and processed by the information system.
2. Liaison: Liaisons are hospital employees chosen to work with the information system team while remaining at their primary clinical post. Liaisons act as a conduit between the clinical and information systems staff.
3. Programmers: Programmers may be full-time hospital employees, but are most likely contract workers or employees of the software vendor. These individuals write the machine language code necessary for system functions. They often work with the analyst and liaison in order to accomplish their tasks.

Question 18

Discuss acquiring recommendations form national quality organizations: National Quality Forum.

Answer 18

The National Qualify Forum (NQF) has endorsed a set of safe practices that can be used to assess and develop the organization’s patient safety culture. Practices encompass creating a safe culture as well as specific steps to ensure safe practices throughout the organization. According to NQF, the four elements needed to create and sustain a patient safety culture include the following:

• Leadership must ensure structures are in place for organization-wide awareness and compliance with safety measures, including adequate resources and direct accountability.
• Measurement, analysis, and feedback must track safety and allow for interventions.
• Team-based patient care with adequate training and performance improvement activities must be organization-wide.
• Safety risk must be continuously identified and interventions taken to reduce patient risk.

Question 19

Discuss acquiring recommendations from national quality organizations: Leapfrog initiatives related to safe practices.

Answer 19

Leapfrog has developed a number of specific initiatives related to safe practices, including:

• Implementation of a computerized physicians order entry system that includes software to detect and prevent errors with a goal of decreasing prescribing errors by more than 50%.
• Evidence-based hospital referral, requiring referral to hospitals that demonstrate the best results with high-risk conditions and surgeries; these are assessed, according to the number of procedures or treatments done each year and outcome data with a goal of reducing mortality rates by 40%.
• Intensive care unit physician staffing requiring specially trained specialists (intensivists) with a goal of reducing mortality rates by 40%.

Leapfrog Safe Practices Score, which assesses the progress a health care organization makes on thirty safe practices that Leapfrog has identified as reducing the risk of harm to patients.

Question 20

Discuss acquiring recommendations from national quality organizations: Leapfrog initiatives related to preventing medical errors.

Answer 20

Leapfrog is a consortium of health care purchasers/employers providing benefits to millions of Americans. The focus initially was on reducing health care costs by preventing medical errors and “leaping forward” by rewarding hospitals and health care organizations that improve safety and quality of care. Leapfrog has developed a number of initiatives to improve safety. These initiatives can be valuable tools in assessing and developing a patient safety culture. Leapfrog provides an annual Hospital and Quality Safety Survey to assess progress, releases regional data, and encourages voluntary public reporting. Leapfrog has instituted the Leapfrog Hospital Rewards Program as a pay-forperformance program to reward organizations for showing improvement in key measures. One initiative includes preventing medical errors. Purchasers of health care agree to the base purchase of health care based on four principals:

1. Educating enrollees about patient safety and providing comparative performance data
2. Recognizing and rewarding health care organizations that demonstrate improvement in preventing errors
3. Making health plans accountable for implementing these principles
4. Advocating for these principles with clients by using benefits consultants

Question 21

Discuss acquiring recommendations from national quality organizations: Quality indicators from the Agency for Healthcare Reasearch and Quality.

Answer 21

The quality indicators (QIs) from the Agency for Healthcare Research and Quality are distributed as a software tool free of charge to health care organizations to help them identify adverse events or potential adverse events that require further study. This software is an invaluable aid in assessing and developing the organization’s patient safety culture. Current quality indicators include the following:

• Prevention QIs use patient discharge data to determine conditions that require ambulatory care to prevent rehospitalization.
• Inpatient QIs measure quality of care through types of procedures, use of procedures, and mortality rates associated with procedures or conditions.
• Patient Safety QIs use data regarding adverse events and complications related to surgeries, medical procedures, and childbirth.
• Pediatric QIs use patient discharge data to screen for problems related to pediatric exposure to health care and analyze system changes that may prevent problems.

The data indicators may also be used to assess safety factors at an area (e.g., county) level per 100,000 population.

Question 22

Discuss acquiring recommendations from national quality organizations: Agency for Healthcare Research and Quality and evidence-based practice centers.

Answer 22

The Agency for Healthcare Research and Quality promotes evidence-based practice through funding of evidence-based practice centers (EPCs) to develop evidence-based practice guidelines for dissemination and use in development of patient care plans, establishing insurance coverage, and development of educational materials. These centers issue research reports, including meta-analysis of all relevant research, on a wide range of topics, such as “Pain Management Interventions for Elderly Patients with Hip Fracture,” which include morbidity/mortality rates and cost-effectiveness associated with different treatments and procedures. Research focuses on areas of significance to people receiving Medicaid and Medicare. For example, five EPCs are engaging in research on technology for the Centers for Medicaid and Medicare, which focuses on topics related to the U.S. Preventive Services Task Force. Partners, such as insurance companies, professional associations, patient advocacy groups, and employers, nominate topics. Guides are available for both consumers and clinicians.

Question 23

Discuss acquiring recommendations from national quality organizations: Institute of Medicine and National Committee for Quality Assurance safety issues.

Answer 23

The Institute of Medicine called for accrediting agencies to ensure organizations focus on patient safety. In response, the National Committee for Quality Assurance has addressed safety issues as part of its accreditation standards. Guidelines directed at managed care organizations provide useful information for other organizations as well. Organizations should:

• Educate staff regarding clinical safety by providing information.
• Provide collaborative training within the network related to safe clinical practice.
• Combine data within the network (organization) on adverse outcomes and polypharmacy.
• Make improving patient safety a priority for quality improvement activities.

Provide and distribute information about safe practices that includes information about computerized pharmacy order systems, physicians trained in intensive care, best practices, and research on safe clinical practices.

Question 24

Discuss acquiring recommendations from national quality organizations: Institute of Medicine.

Answer 24

The Institute of Medicine (lOM), founded in 1970 under the charter of the National Academy of Sciences, is a nonprofit organization that serves an advisory role on health care issues to governmental and nongovernmental decision-makers. The lOM advises the government but is outside of the governmental structure to ensure lack of bias. The lOM issues guidelines based on research and evidence, conducts studies for Congress and other organizations, and conducts a number of epidemiological studies. The lOM is involved in a broad range of activities, issues regular reports, and provides workshops and forums about a health care issues (e.g., obesity]. The lOM has standing committees to focus on specific issues and provide forums for general discussion. Additionally, the lOM provides fellowships to help professionals gain experience and expertise in health-related fields.

Question 25

Discuss acquiring recommendations from national quality organizations: **National Quality Forum's safe practices.**

Answer 25

**National Quality Forum's safe practices** include: * Considering _patient's rights/responsibilities_, providing informed consent, respecting advance directives, making full disclosure of medical errors, managing information and care by documenting care properly, providing prompt accurate test results, using standard procedures for labeling diagnostic studies, & providing discharge planning. * _Managing medications_ by implementing a computerized prescriber order entry system, standardizing abbreviations, maintaining updated medication lists for patients/pharmacists in medication management, identifying high-alert drugs, and dispensing drugs in unit doses. * Providing adequate well-trained and well-supervised staff and resources, including critical care physicians. * To _prevent HCA infections_: ventilate properly, central lines, wash hands, immunize, & surgical care procedures. Providing safe practices for surgery, i.e., informing patient of risks, taking measures to prevent errors, and using prophylactic treatments to prevent complications. Providing procedures/ongoing assessment to prevent adverse events, such as pressure ulcers, thromboembolism/DVT, allergic reactions, or anticoagulation complications.

Question 26

Discuss adult learning theories: **Theory of adult development** developed by **Robert Peck.**

Answer 26

In his **theory of adult development**, **Robert Peck** expanded on Eric Erikson's stages of adult development, believing that there were seven important tasks required during the last two stages of life. **In middle age:** * Mental flexibility vs. mental rigidity * Valuing wisdom vs. physical powers * Socializing vs. sexualizing * Cathectic (libidinal energy) flexibility vs. cathectic impoverishment **Negative** outcomes lead to weak relationships, inflexibility, and resistance to change. **Positive outcomes** lead to strong relationships, flexibility in lifestyle, and adaptability to change. **In older adulthood:** * Ego differentiation vs. work role preoccupation * Body transcendence vs. body preoccupation * Ego transcendence vs. ego preoccupation **Negative** outcomes lead to loss of identity after retirement, depression, inability to accept bodily or functional changes, and fear of death. **Positive** outcomes lead to meaningful life after retirement, acceptance of bodily or functional changes, acceptance of death, and feeling that life has been good.

Question 27

Discuss adult learning theories: **Theory of adult development** developed by **Robert Havighurst.**

Answer 27

**Robert Havighurst**, in his **theory of adult development**, stated that there were a number of _tasks that needed to be accomplished during each stage of development_ and that remaining active is important. His adult stages reflect stereotypical roles to some degree related to the 1960s when marrying young was more typical than now. **Early adulthood**: Tasks include finding a mate, marrying, having children, managing a home, getting started in an occupation or profession, assuming civic responsibility, and finding a congenial social group. **Middle age**: Tasks include achieving civic & social responsibility, maintaining an economic standard of living, raising teen-agers & teaching them to be responsible adults, developing leisure activities, accepting physiological changes related to aging, & adjusting to aging of parents. **Older adulthood**: Tasks include adjusting to a decrease in physical strength and health, death of a spouse, life in retirement, and reduced income. Other tasks include establishing ties with those in the same age-group (senior citizen's groups/retirees), meeting social and civic obligations, and establishing physical living arrangements that are satisfactory.

Question 28

Discuss adult learning theories: **Theory of andragogy** developed by **Malcolm Knowles.**

Answer 28

**Malcolm Knowles** developed the **theory of andragogy** in relation to _adult learners, who are more interested in process than in information and content_. Knowles outlined some principles of adult learning and typical characteristics of adult learners that an instructor should consider when planning strategies for teaching parents, families, or staff. **Practical & goal-oriented:** * Provide overviews or summaries and examples, * Use collaborative discussions with problem-solving exercises. * Remain organized with the goal in mind **Self-directed:** * Provide active involvement, asking for input. * Allow different options toward achieving goals. * Give them responsibilities **Knowledgeable:** * Show respect for their life experiences or education. * Validate their knowledge and ask for feedback. * Relate new material to information with which they are familiar. **Relevancy-oriented:** * Explain how information will be applied, * Clearly identify objectives **Motivated:** • Provide certificates of achievement or some type of recognition for achievement.

Question 29

Discuss adult learning theories: **Bloom's taxonomy** developed by **Benjamin Bloom**.

Answer 29

**Bloom's taxonomy** developed by **Benjamin Bloom** outlines _behaviors that are necessary for learning_, and this can apply to health care. The theory describes three types of learning: **Cognitive**: (Learning and gaining intellectual skills are used to master six categories of effective learning.) * Knowledge Comprehension * Application * Analysis * Synthesis Evaluation **Affective**: (Recognizing five categories of feelings and values from simple to complex is slower to achieve than cognitive learning.) * Receiving phenomena: accepting the need to learn * Responding to phenomena: taking an active part in care **Valuing**: under-standing the value of becoming independent in care * Organizing values: understanding how surgery or treatment has improved life * Internalizing values: accepting condition as part of life; being consistent and self-reliant **Psychomotor**: (Mastering six motor skills necessary for independence follows a progression from simple to complex.) * Perception: uses sensory information to learn tasks * Set: shows willingness to perform tasks * Guided response: follows directions * Mechanism: does specific tasks * Complex overt response: displays competence in self-care * Adaptation: modifies procedures as needed * Origination: creatively deals with problems

Question 30

Discuss adult learning theory: **Theory of social learning** developed by **Albert Bandura.**

Answer 30

In the 1970s, **Albert Bandura** proposed the **theory of social learning**, in which l_earning develops from observation, organizing, and rehearsing behavior that has been modeled_. Bandura believed that people were more likely to adopt the behavior if they valued the outcomes, if the outcomes had functional value, and if the person modeling had similarities to the learner and was admired because of status. Behavior is the result of observation of behavioral, environmental, and cognitive interactions. There are four conditions required for modeling: 1. **Attention**: The degree of attention paid to modeling depends on many variables (e.g., physical, social, environmental}. 2. **Retention**: A person's ability to retain models depends on symbolic coding, creating mental images, organizing thoughts, and rehearsing (mentally or physically). 3. **Reproduction**: The ability to reproduce a model depends on physical and mental capabilities. 4. **Motivation**: Motivation may derive from past performances, rewards, or vicarious modeling.

Question 31

Discuss applying current research findings to practice: **Model of integration**.

Answer 31

Integrating the results of data analysis and research into performance improvement or best practice guidelines varies from one organization to another, depending on the **model of integration** that the organization uses: * **Organizational**: Processes for improvement are identified, and teams or individuals are selected to participate in different areas or departments, reporting to one individual, who monitors progress. * **Functional/coordinated**: While staff specialties, such as risk management and quality management, are not integrated, they draw from the same data resources to determine issues related to quality of care and efficiency. * **Functional/integrated**: While staff specialties remain, there is cross-training among specialties. A case management approach to individual care is used so that one person follows the progress of a patient through the system and coordinates with the various specialties, such as infection control and quality management.

Question 32

Discuss benchmarking: **External benchmarking** and **internal trending**.

Answer 32

**External benchmarking** involves _analyzing data from outside an institution, such as monitoring national rates of hospital-acquired infection, and comparing them to internal rates_. In order for this data to be meaningful, the same definitions must be used as well as the same populations or effective risk stratification. Using national data can be informative, but each institution is different; thus, relying on external benchmarking to select indicators for infection control, for example, can be misleading. Additionally, benchmarking is a compilation of data that may vary considerably if analyzed individually; it can be further compromised by anonymity, making comparisons difficult. **Internal trending** involves _comparing internal rates of one area or population with another_, such as infection rates in intensive care units and general surgery; while this can help to pinpoint areas of concern within an institution, making comparisons is still problematic because of inherent differences. Using a combination of external and internal data can help to identify indicators.

Question 33

Discuss benchmarking: **Xerox Corporation's 10-step benchmarking model**.

Answer 33

Benchmarking is an ongoing process of measuring practice, service, or product results against competitors or industry standards. The **Xerox Corporation** developed the **10-step benchmarking model**. This model _compares an organization's efficiency with that of others and searches for improvements_. The 10-step process moves through four phases: planning, analysis, integration, and action. The steps include the following: * Identify benchmark targets. * Identify organizations/units/providers with which to compare data. * Determine and initiate methods of data collection. * Evaluate current performance level and deficits. * Project vision of future performance. * Communicate findings and reach group agreement. * Recommend changes based on benchmark data. * Develop specific action plans for objectives. * Implement actions and adjust as necessary based on monitoring of process. * Update benchmarks based on latest data. This basic benchmarking model is often modified to a 7 to 11 step process, depending on the needs of the organization. _Benchmarking is often used to improve cash flow as health care becomes more competitive or to compare infection rates_.

Question 34

Discuss **cloud computing** and its implications for healthcare.

Answer 34

Cloud computing is using the internet to store and access files as opposed to a business network or a computer hard drive. Cloud computing has dramatically increased by healthcare organizations in the past years, likely associate with health care reform giving financial incentives for providers and organizations that use electronic medical records and electronic health records (EHR). Health care organizations are also using the cloud to store information that is not EHR related at rapidly increasing numbers. The benefits to using the cloud include multiple providers being able to access the records at the same time from many different locations, increasing collaboration and decreasing healthcare costs. The major disadvantages focus on privacy concerns, as patient's personal health information is being stored on the internet, making it susceptible to cybercriminals. As the health care industry moves to new and alternative solutions to satisfy the "meaningful use" clause given by the Centers for Medicare and Medicaid Services, cloud providers are coming up with new agreements to protect private information, thereby becoming more attractive to healthcare organizations.

Question 35

Discuss **communication skills** needed for leading **intra-** and **interdisciplinary teams**.

Answer 35

A number of communication skills are needed to lead and facilitate coordination of intra- and interdisciplinary teams, such as the following: * _Communicating openly_ is essential with all members encouraged to participate as valued members of a cooperative team. * _Avoiding interrupting or interpreting the point another_ is trying to make allows free flow of ideas. * _Avoiding jumping to conclusions_ as this can effectively shut off communication. * _Active listening_ requires paying attention and asking questions for clarification rather than challenging the ideas of others. * _Respecting the opinions and ideas of others_, even when they are opposed to one's own, is absolutely essential. * _Reacting and responding to facts rather than feelings_ allows one to avoid angry confrontations or diffuse anger. * _Clarifying information or opinions_ stated can help avoid misunderstandings. * _Keeping unsolicited advice out of the conversation_ shows respect for others and allows them to solicit advice without feeling pressured.

Question 36

Discuss communication theories: **Communication accommodation theory** developed by **Howard Giles** and **cultivation theory** developed by **George Gerbner**.

Answer 36

**Howard Giles** developed the **communication accommodation theory (CAT)** to _explain why people alter their communication styles_. Individuals may practice convergence, modeling the communication style (i.e., accent, dialect, vocabulary) after the other if seeking approval, or may practice divergence, intentionally using differences in communication to emphasize social differences. Components of CAT include the following: * Context (social and historical) influences communication. * Accommodative orientation includes three factors: personality, positive or negative feelings, and understanding areas of conflict. * Immediate communication is affected by social and political states, motivations, goals, convergence, divergence, linguistic choices, and attributions. **George Gerbner** developed the **cultivation theory** to explain the _effect media, primarily television, have on cultivating ideas and beliefs related more to the media than to the real world_. Gerbner believed that media cultivate beliefs that already exist but spread these beliefs through society, thus affecting people's belief systems and perceptions of reality.

Question 37

Discuss **documentation of quality indicators**.

Answer 37

The Agency for Healthcare Research and Quality (AHRQ) provides software (current version 4.4) that allows tracking and **documentation of quality indicators (QIs)**; this software and focus on QIs can be integrated into the information system so that data can be easily accessed. The QI software programs of AHRQ include: * SAS, which uses SAS/STAT statistical software (which is commercially available). * Windows, which has a GUI and uses a SQL Server (which has a free version). MONAHRQ, which facilitates development of a website for health care reporting, including data regarding quality of care, use, preventable hospitalizations, and rates for different conditions and procedures (free to federal, state, and local organizations). MONAHRQ is especially valuable for documenting QIs and providing access to consumers and health care providers because it is easy to use by downloading, inputting the organization's data, selecting options related to websites, and creating a website.

Question 38

Discuss implications of **health care reform.**

Answer 38

**Health care reform** initiatives are spurring the _switch from paper to electronic health records and sharing of health care information_ among health care providers, increasing the demand for health information technology and people with expertise in informatics. New programs have been developed to _focus on wellness with an increased emphasis on cost-effective measures because of increases in health costs_. Internal data analysis and research are becoming important means by which to identify waste, institute best practices, and reduce costs. Increasing numbers of people are covered by health plans, even those with preexisting conditions, placing more demand on health care providers for services. There is an _increased need for health literacy_ so that people are better informed about the services available, especially those newly insured. Medicaid costs have increased, resulting in some cutbacks in care. _Early transfer from acute care facilities to extended care or home health care_ is also increasing.

Question 39

Discuss **integrating the results of data analysis**

Answer 39

**Integrating the results of data analysis** is necessary; attempting performance improvement and developing practice guidelines without data can be problematic. These data should be used not only as the basis for long-term strategic planning but also for identifying opportunities for performance-improvement activities on an ongoing basis. Integration of information includes: * Identifying issues for tracking. * Reviewing patterns and trends to determine how they impact care. * Establishing action plans and desired outcomes based on the need for improvement. * Providing information to process improvement teams to facilitate change. * Evaluating systems and processes for follow-up. * Monitoring specific cases, criteria, critical pathways, and outcomes. The integration of information should assist with case management, decision-making about individual care, improvement of critical pathways related to clinical performance, staff performance evaluations, credentialing, and privileging.

Question 40

Discuss integration of key quality concepts within the organization.

Answer 40

There are a number of **key concepts** related to quality that must be communicated to ail members of an organization through inservice, workshops, newsletters, fact sheets, and team meetings. Quality care/performance should be: * **Appropriate** to needs and in keeping with best practices. * **Accessible** to the individual despite financial, cultural, or other barriers. * **Competent**, with practitioners well-trained and adhering to standards. * **Coordinated** among all healthcare providers. * **Effective** in achieving outcomes based on the current state of knowledge. * **Efficient** in methods of achieving the desired outcomes. * **Preventive**, allowing for early detection and prevention of problems. * **Respectful** and caring with consideration of the individual needs given primary importance. * **Safe** so that the organization is free of hazards or dangers that may put patients or others at risk.

Question 41

Discuss interpersonal communication skills: **Team building**.

Answer 41

Leading, facilitating, and participating in performance improvement teams require a thorough understanding of the dynamics of team building: * Initial interactions: This is the time when members _define their roles and develop relationships_, determining if they are comfortable in the group. * Power issues: The members observe the leader and determine _who controls the meeting and how control is exercised_; alliances begin to form. * Organizing: Methods to achieve work are clarified, and _team members begin to work together_, gaining respect for each other's contributions and working toward a common goal. * Team identification: Interactions often become less formal as _members develop rapport_, and members are more willing to help and support each other to achieve goals. * Excellence: This develops through a combination of good leadership, committed team members, clear goals, high standards, external recognition, spirit of collaboration, and a shared commitment to the process.

Question 42

Discuss issues related to the **fair distribution of health information access**.

Answer 42

The **fair distribution of health information access** information specific to the individual (e.g., electronic health records), data (both aggregate and comparative), and knowledge-based information (e.g., journals, websites). While people should have access to health information, considerations must include the right to privacy, regulations regarding intellectual property, and equitable access to information. One problem with access is that many people are unaware of their rights or lack the training or tools to access information, so an important element of fair distribution must include providing public means of access, such as in libraries and through public health agencies and education (e.g., posters, handouts, videos) to educate the general public. People in rural or isolated areas may lack access to basic care and health information but may be served by telehealth services, using telecommunications to provide information and Internet health resources.

Question 43

Discuss legal implications: **Malpractice and negligence**.

Answer 43

Risk management must attempt to determine the burden of proof for acts of **negligence**, including compliance with duty, breaches in procedures, degree of harm, and cause as a finding of negligence can lead to a **malpractice** suit. Negligence indicates that proper care, based on established standards, has not been provided. State regulations regarding negligence may vary, but all have some statutes of limitation. There are a number of different types of negligence. * Negligent conduct indicates that an individual failed to provide reasonable care or to protect/assist another, based on standards and expertise. * Gross negligence is willfully providing inadequate care while disregarding the safety and security of another. * Contributory negligence involves the injured parties contributing to the harm done . * Comparative negligence attempts to determine what percentage of negligence is attributed to each individual involved.

Question 44

Discuss legal implications: **Liability**.

Answer 44

With the marked increase in use of electronic health records (EHRs) has come increased concern regarding **liability** because the EHR documents all actions in real time. For example, if there is a delay between the time a patient event occurs and when the health care provider responds, the duration of time is documented in the record and cannot be altered. This can give the appearance of negligence even if the delay was unavoidable. Additionally, errors tend to increase with any major change, and there is a learning curve in adjusting to new technology, so information may be entered into EHRs incorrectly and a facility may be liable if it did not provide adequate staff education. Providers used to reports on paper may not access electronic reports in a timely manner. Hardware or software incompatibilities may cause information, such as medicine orders, to be altered or deleted. If health care providers provide patients access to them via e-mail or messaging and do not respond promptly to those messages, then they may be liable for malpractice.

Question 45

Discuss legal implications: **Patient data misuse**.

Answer 45

**Patient data misuse** is an increasing problem with the rapid proliferation of electronic health records (EHRs). Types of misuse include: * **Identity theft**: Health records often contain identifying information, such as Social Security numbers, credit card numbers, birthdates, and addresses, making patients vulnerable. * **Unauthorized access**: Although EHRs and computerized documentation systems are password protected, providers sometimes share passwords or unwittingly expose their passwords when logging in, inadvertently allowing access to information about patients. * **Privacy violations**: Even professionals authorized to access a patient's record may share private information with others, such as family or friends. * **Security breaches**: Data are vulnerable to security breaches because of careless, inadequate security, especially when various business associates, such as billing companies, have access to private information.

Question 46

Discuss methods to maximize reimbursement : **Do-not-pay list**.

Answer 46

As a means to control quality of care and to cut costs. Medicare instituted a **do-not-pay list** for serious, preventable, hospital-acquired conditions and complications for which Medicare will not reimburse hospitals; thus, avoiding these complications is a critical element in maximizing reimbursement and requires ongoing monitoring of quality care and staff education. Additionally, some insurance companies are following suit, so this has the potential to impact reimbursement seriously. For example, if surgery is done on the wrong side or botched. Medicare will not pay the costs. If a blood clot occurs after hip replacement surgery. Medicare will not pay for treatment. There are currently over forty categories on the do-not-pay list, including the following: * Fall or other trauma that causes serious injury * Stages III and IV pressure ulcers * Vascular catheter-associated infections * Catheter-associated urinary tract infections * Transfusion reaction from blood incompatibility * Postoperative dehiscence * Surgical deaths associated with treatable serious complications

Question 47

Discuss **methods to maximize reimbursement**: Overiview.

Answer 47

**Methods to maximize reimbursement** include: * Recording of information and sending of claims in a timely manner. * Using care managers to determine the most cost-effective care plan. * Using standardized billing codes (Current Procedural Terminology, International Classification of Diseases [ICD]). * Ensuring that the health care provider's National Provider Identifier is present on all claims. * Updating systems promptly when new coding (e.g., ICD-10) and billing regulations (e.g., pay-for-performance) are issued rather than waiting for the end of the grace period so that problems can be identified and corrected early. * Ensuring that the presentation on admission (Medicare severity diagnosis-related group code) diagnosis is correct to avoid a different discharge diagnosis. * Monitoring quality of care to prevent complications and reduce costs related to the do-not-pay list. * Sending claims in the correct form and to the correct address for different entities: insurance companies. Medicaid, and Medicare.

Question 48

Discuss methods to maximize reimbursement: **Pay-for-performance** or **value-based purchasing**.

Answer 48

A reimbursement system called **pay-for-performance (P4P)** or **value-based purchasing**, one element of the Affordable Care Act of 2010, is an alternative to standard pay-for-care reimbursement. Some states, such as California, have P4P plans in effect, and Medicare also has a number of P4P initiatives and demonstration projects. The primary objective of P4P programs is to reward health care providers when patients have good results (e.g., discharge within a defined period without complications), although there remains some controversy regarding measuring quality performance. Payment is related to quality rather than quantity of service, so ongoing quality improvement processes must be in place to maximize reimbursement. In some cases, bonus incentives may be provided. Disincentives, such as reduced payment for never events (inexcusable outcomes), are also considered. There are both hospital-based P4P plans and physician-based P4P plans.

Question 49

Discuss methods to maximize reimbursement: **Present-on-admission Medicare severity diagnosis-related group.**

Answer 49

On admission to acute hospitals under the Medicare Inpatient Prospective Payment System (IPPS), patients must be given a **present-on-admission (POA) Medicare severity diagnosis-related group (MS-DRG)** diagnosis. The MS-DRG should include primary and secondary diagnoses present during the admission process. This is a concern regarding maximizing reimbursement because hospital acquired conditions may not be covered if there is a change at discharge from the POA diagnosis. A POA indicator must be on all claims: * Y: Medicare pays for a condition if a hospital-acquired condition (HAC) is present on admission. * N: Medicare will not pay for condition if a HAC is present on discharge but not on admission. * U: Medicare will not pay for condition if a HAC is present and documentation is not adequate to determine if the condition was present on admission. * W: Medicare will pay for condition if a HAC is present and if the health care provider cannot determine if the condition was present on admission.

Question 50

Discuss methods to promote an **environment for ethical decision-making** and **patient advocacy**.

Answer 50

**An environment for ethical decision**, making and patient advocacy does not appear when it is needed; it requires planning and preparation. The expectation for the institution should clearly communicate that nurses are legally and morally responsible for assuring competent care and respecting the rights of patients and other stakeholders, Decisions regarding ethical issues often must be made quickly with little time for contemplation; therefore, ethical issues that may arise should be identified and discussed, Clearly defined procedures and policies for dealing with conflicts, including an active ethics committee, in•seflice training, and staff meetings, must be established, Patients and families need to be part of the ethical environment, which means empowering them by providing patient/family information (e.g., print form, video, audio) that outlines patient's rights and procedures for expressing their wishes and dealing with ethical conflicts. Respect for privacy and confidentiality and a nonpunitive atmosphere are essential.

Question 51

Discuss organization accreditation standards: **Centers for Medicare and Medicaid Services.**

Answer 51

The **Centers for Medicare and Medicaid Services (CMS)** maintain a list of approved accreditation organizations for health care providers, as providers and suppliers who have been accredited by one of these national accrediting agencies are exempt from state surveys in determining if they are in compliance with Medicare-mandated conditions. Approved organizations include the Joint Commission, Community Health Association Program, and the Accreditation Commission for Health Care. The CMS has established an incentive program for adoption, upgrade, or use of electronic health records (EHRs). Those applying for incentive programs must use certified EHR systems that demonstrate that they can store and share patient data securely. Health care providers who are eligible for incentive pay from Medicare or Medicaid can receive up to $44,000 over a 5-year period, while eligible hospitals and critical access hospitals can receive a beginning base payment of $2 million. Medicare eligibility guidelines and Medicaid eligibility guidelines vary for both eligible professionals and eligible hospitals.

Question 52

Discuss **team buildlng**.

Answer 52

Leading, facilitating, and participating in performance improvement teams requires a thorough understanding of the dynamics of **team building**: * **Initial interactions**: This is the time when members begin to _define their roles and develop relationships_, determining if they are comfortable in the group. * **Power issues**: The members observe the leader and determine _who controls the meeting and how control is exercised_, beginning to form alliances. * **Organizing**: Methods to achieve work are clarified and team members _begin to work together_, gaining respect for each other's contributions and working toward a common goal. * **Team identification**: Interactions often become less formal as _members develop rapport_, and members are more willing to help and support each other to achieve goals. * **Excellence**: This develops through a combination of goodleadership, committed team members, clear goals, high standards, external recognition, spirit of collaboration, and a shared commitment to the process.

Question 53

Discuss the **American Nurses Association** definition, scope, and functional areas of the **informatics nurse specialist**.

Answer 53

The informatics nurse is one who works in informatics because experience or interest in the field but has not received formal training; an **informatics nurse specialist (INS)** has completed graduate studies in informatics and may also have certification. According to the American Nurses Association, nursing informatics is a nursing specialty integrating nursing, computer sciences, and information sciences, which support professionals and patients in decision-making through information processes and technology. INS functions include: * Providing tools for standardized documentation. * Managing information and analyzing data. * Re-engineering information processes and promoting standardization. * Participating in research and collection of data. * Providing nursing management and administration. * Serving as a consultant in the field of informatics. * Promoting and providing professional development activities, including training of human-computer interaction systems. * Advocating for changes in policies. * Serving as advocate for staff and patients. * Ensuring implementation of electronic health records and computerized physician order entry systems. * Providing support to clinical applications.

Question 54

Discuss the **International Medical Informatics Association Code of Ethics**

Answer 54

The **International Medical Informatics Association Code of Ethics** was developed in 2002 and recently revised. Part 1, the introduction, includes the six primary ethical principles: autonomy (selfdetermination), equality and justice (equal treatment), beneficence (promoting good), nonmalfeasance (preventing harm), impossibility (predicated on possibility), and integrity (honesty and diligence). General principles in the introduction include the following: * The right to privacy, regarding sharing of personal information and control of collection, methods of collection, and storage * Open process of data collection with patient informed * Security of all data collection and protection from data manipulation * Right to access of personal data * Legitimate infringement or the consideration for greater good of society in regard to individual's right to privacy * Infringement of right to privacy with minimum interference * Accountability for infringement Part II, rules of ethical conduct, includes subject-centered duties, duties toward health care professionals, duties toward institutions and employers, duties toward society, self-regarding duties, and professional duties.

Question 55

Discuss the **synergy model**: **Advocacy** and **moral agency**.

Answer 55

Nurse competencies under the **synergy model** include **advocacy and moral agency**. Advocacy is working for the best interests of the patient/stakeholders despite personal values in conflict and assisting patients to have access to appropriate resources. Agency is openness and recognition of issues and a willingness to act. Moral agency is the ability to recognize needs and take action to influence the outcome of a conflict or decision. The levels of advocacy and moral agency include: * **Level 1**: The nurse works on behalf of the patient/stakeholders, assesses personal values, has awareness of patient's rights and ethical conflicts, and advocates for the patient/stakeholders when consistent with the nurse's personal values. * **Level 2**: The nurse advocates for the patient/stakeholders, incorporates their values into the care plan even when they differ from the nurse's, and can use internal resources to assist patient/stakeholders with complex decisions. * **Level 3**: The nurse advocates for patient/stakeholders despite differences in values and is able to use both internal and external resources to help empower patients and their families to make decisions.

Question 56

Discuss **updating documentation requirements based on changes to regulatory or accreditation standards**.

Answer 56

The nursing informatics specialist must **update documentation requirements based on changes to regulatory or accreditation standards**. This means that the nurse must be cognizant of accreditation standards, such as those by the Joint Commission, and current regulations, such as those related to the Centers for Medicare and Medicaid Services (CMS) or the Health Insurance Portability and Accountability Act, which must be monitored closely to determine if current documentation is adequate and what changes must be made. Accreditation standards require huge amounts of paperwork to demonstrate compliance, so building requirements into the system can save time when reports are due; thus, the nursing informatics specialist must consider the need to retrieve data as well as document necessary information when updating. While CMS provides updates regarding most federal regulations, states may have additional requirements that must be accommodated. Changes should be done well in advance of required compliance so that staff members can become familiar with changes, and problems with changes can be evaluated.

Question 57

Explain the factors that are important for information systems in the **accreditation process.**

Answer 57

**The Joint Commission** outlined factors it believes are important for **information standards**: * Measures must be adopted that are designed to protect an individual's personal health information. This may be accomplished by limiting access to information based on a user's need to know, having strict policies regarding the removal of records, and making sure data is physically and electronically safeguarded. * A national standard for data entry should be created and followed. All users should be trained both in system use and information management. Educational courses may include lectures on how information that is entered into a computer system is transformed into data that can later be used to perform statistical analysis and support decision-making. * All information should be available both on the computer and in print form.

Question 58

Give a general definition for each of the terms associated with maintaining quality programs in nursing (or other areas).

Answer 58

Programs to assess and maintain quality measures in nursing and many other areas revolve around a number of concepts. One is QA, or quality assurance, which a method to evaluate the degree of excellence by monitoring, evaluating and correcting problems if detected. Another term, less used perhaps in health care than in other fields, is total quality management, or TQM, which involves the formulation of an organizational mission statement encompassing the goal of satisfying the client. Total quality improvement (TQI) and continuous quality improvement (CQI) are concepts involving a continuous process of improvement. Nursing (and healthcare) tends to focus more on the last concept, which is performance improvement (PI). PI is a leadership- driven, organizational-focused process. For healthcare professionals, this typically means developing a process to design, measure, assess, and improve performance that can have a positive effect on patients.

Question 59

List **standards** related to computerized systems used in healthcare, as outlined by The Joint Commission.

Answer 59

The Joint Commission has described the need for computer system **standards** in the following areas: * Access to databases that are located outside the organization and used to compare information, need to be supported and secured. * Patient confidentiality related to personal health information (PHI) and data security must be ensured. * Knowledge-based systems should be developed and promoted to allow resident organizational expertise to be used throughout the organization. * A means to link physician information systems while protecting patient privacy and data security. * Projects that are designed to achieve quality improvements should be supported. * Data integrity and overall system security must be ensured. * Procedural controls that are currently in place for documentation should be integrated into the new computerized standards. * A regular assessment of needs and system capacity for growth should be supported.

Question 60

Outline the factors that **The Joint Commission** has identified as important to patient information **security**.

Answer 60

The Joint Commission outlined many factors that it believes are important to the security of patient information. The two major factors are: 1. Information should be transmitted accurately and quickly: This factor may be fulfilled by: * Supplying information within 24 hours in whatever format the user needs. * Orders should be put in place with as little delay as possible and test results should be entered into the system quickly. * Errors should be minimized. This could be achieved with the implementation of a computerized system such as a pharmacy system. * Methods of communication should be evaluated for efficiency. 2. Clinical and non-clinical systems should be fully integrated: * Records should be customizable to the patient and their individual needs. * The system should be able to create reports based on the user's demands. * Comparisons between healthcare organizations should be fully supported.

Question 61

Outline the International Council of Nurses (ICN) **Code of Ethics** for nurses in regards to **practice and profession**.

Answer 61

The following is an outline of the International Council of Nurses (ICN) **Code of Ethics** for nurses in regards to **practice and profession**: * Keep up to date with the practice of nursing through continuing education. This entails taking continuing education courses and adding certifications to one's resume. * Look after one's own health in order to maintain quality of care to the patient It is very easy to forget about taking care of yourself while working with sick patients on long shifts. The importance of keeping healthy is a key to providing excellent care to patients. * Do not take on more than can be reasonably handled. In the current cost cutting healthcare environment, nurses are being asked to do more with less. This can lead to burn out and high staff turnover. * Uphold a high standard of personal conduct * Make sure that all new applications of technology are safe for use in treatment and do not compromise the dignity of the patient. * Develop and put in place ethical standards in clinical, management, education, and research.

Question 62

Discuss systems theory: **Complex adaptive theory.**

Answer 62

**Complex adaptive theory** holds that complex systems are interdisciplinary systems with multiple components or agents that depend on interaction and adaptation as part of learning. Adaptive systems are open systems that are able to adapt readily to changes and problems. The original adaptive theory referred to biology, but the model has expanded to encompass families, communities, and organizations. Interactions tend to be rich and nonlinear with close associates and with much feedback. Interactions are often random rather than planned. Change is often mutual: Agents change, causing the system to change, and the system changes, causing the agents to change. Adaptive systems are dynamic by nature with interdependent agents acting together to bring about change. Adaptive systems that are selfadjusting are able to avoid chaos even though changes may bring them to the brink. Adaptive systems tend to favor effectiveness over efficiency and are less rule-governed than nonadaptive systems.

Question 63

Discuss change theory: **Theory of reasoned action** developed by **Martin Fishbein** and **Icek Ajzen**.

Answer 63

The **theory of reasoned action**, developed in 1975 by **Martin Fishbein** and **Icek Ajzen**, is based on the premise that the actions people take voluntarily can be predicted, according to their personal attitude toward the action and their perception of how others will view their doing the action. There are three basic concepts to the theory: 1. **Attitudes**: These are all of the attitudes about an action, and they may be weighted (i.e., some may be more important than others). 2. **Subjective norms**: People are influenced by those in their social realm (e.g., family, friends) and their attitudes toward particular actions. The influence may be weighted (e.g., the attitude of a spouse may carry more weight than the attitude of a neighbor). 3 . **Behavioral intention**: The intention to take action is based on weighing attitudes and subjective norms (opinions of others), resulting in a choice to either take an action or avoid an action.

Question 64

Discuss communication theories: **Social exchange theory** by **George C. Homans, John Thihaut, and Harold Kelley**; **social penetration theory** by **Irwin Altman and Dalmas Taylor**; **spiral of science theory** by **Elisabeth Noelle-Neuman**; and **face-negotiation theory** by **Stella Ting-Toomey**.

Answer 64

**Social exchange theory developed by George C. Homans, John Thibaut, and Harold Kelley**, describes communication as an exchange system in which people attempt to negotiate a return on their "investment" in much the same way that people engage in commerce. Those involved in communication seek a balance between investment and return. **Social penetration theory, developed by Irwin Altman and Dalmas Taylor**, describes the manner in which people use communication to develop closeness to others, proceeding from superficial communication to more explicit self-disclosure, which causes vulnerability but allows for a closer relationship. **Spiral of science theory, developed by Elisabeth Noelle-Neuman**, looks at the role mass media has in influencing communication and suggests that people fear isolation so that they conform to public opinion as espoused by mass media and mute dissent. **Face-negotiation theory developed by Stella Ting-Toomey** assumes that all cultures are concerned with maintaining face, and this affects conflict resolution. The theory encompasses the concepts of "positive face" and "negative face" and suggests that people in individualistic cultures are likely to be less compromising than those in collectivist cultures.

Question 65

Discuss systems theory: **Family systems theory** developed by **Murray Bowen**.

Answer 65

**Murray Bowen's family systems theory** suggests that one must look at the person in terms of his or her family unit because the members of a family have different roles and behavioral patterns; thus, a change in one person's behavior affects the others in the family. There are eight interrelated concepts: 1. **Triangle theory**: Two people comprise a basic unit, but when conflict occurs, a third person is drawn into the unit for stability with the resulting dynamic of two supporting one or two opposing one. This, in turn, draws in other triangles. 2. **Self-differentiation**: People vary in their need for external approval. 3. **Nuclear family patterns**: Marital conflict, one spouse dysfunctional, one or more children with problems, and emotional distance constitute some familiar nuclear family patterns. 4. **Projection within a family**: Problems (emotional) are passed from parent to child. 5. **Transmission (multigenerational)**: There are small differences in transmission from parent to child. 6. **Emotional isolation**: Reducing or eliminating family contact results in emotional isolation. 7. **Sibling order**: Sibling order can have a profound influence on behavior and development. 8. **Emotional process (society)**: Interactions in society result in regressive or progressive social movements.

Question 66

Discuss **change theory** developed by **Kurt Lewin** and modified by **Edgar Schein**.

Answer 66

**Change theory** was developed by **Kurt Lewin** and modified by **Edgar Schein**. This management theoiy is based on three stages: 1. **Motivation to change (unfreezing)**: Dissatisfaction occurs when goals are not met, but as previous beliefs are brought into question, survival anxiety occurs. Sometimes, however, anxiety about having to learn different strategies causes resistance that can lead to denial, blaming others, and trying to maneuver or bargain without real change. 2. **Desire to change (unfrozen)**: Dissatisfaction is strong enough to override defensive actions. The desire to change is strong but must be coupled with identification of needed changes. 3. **Development of permanent change (refreezing)**: The new behavior that has developed becomes habitual, often requiring a change in perceptions of self and establishment of new relationships.

Question 67

Discuss change theory: **Theory of planned behavior** developed by **Icek Ajzen**.

Answer 67

The **theory of planned behavior**, developed by **Icek Ajzen**, evolved from the theory of reasoned action in 1985 when studies showed that behavioral intention does not necessarily result in action. The theory of planned behavior is more successful in predicting behavior. To the basic concepts of attitudes, subjective norms, and behavioral intentions encompassed by the earlier theory, Ajzen added the concept of perceived behavioral control, which relates to the individual's attitudes about self-efficacy and outcomes. Ajzen's theory shows that beliefs are central: * Behavioral beliefs lead to attitudes toward a behavior or action. * Normative beliefs lead to subjective norms. * Control beliefs lead to perceived behavioral control. All of these beliefs interact to influence intention and action. Basically, this theory relates to the person's confidence, based on beliefs and social influence of others, that he or she can actually do an action and that the outcome of this action will be positive. This theory considers the power of emotions—such as apprehension or fear—when predicting behavior.

Question 68

Discuss cognitive science: **Cognitive flexibility** developed by **Rand J. Spiro, Paul J. Feltovitch, and Richard L. Coulson**.

Answer 68

The **theory of cognitive flexibility**, focusing on the use of interactive technology, such as computerized programs, was developed by **Rand J. Spiro, Paul J. Feltovitch, and Richard L. Coulson**. The theory recognizes the complexity and flexibility of learning and suggests that information must be presented in a variety of perspectives and that materials and presentations must be context specific. According to this theory, the primary factor in learning is the ability of the person to construct knowledge. Basic concepts include: * Providing multiple and varying presentations of content, including technological presentations (computerized) as well as input from instructors or experts, who can facilitate learning. * Avoiding oversimplification of content and ensuring that information relates to context. * Building knowledge rather than transferring information. Learners must interact with the material, such as responding to questions or formulating hypotheses based on information presented, to construct their own conclusions. * Interconnecting instructional sources.

Question 69

Explain the term: **systems theory**.

Answer 69

**Systems theory** is a method to detect ways to connect seemingly unrelated ideas or functions. An underlying principle of systems theory is that all systems have common ways of processing information. By understanding the basic principles of systems theory an individual can detect, understand, and predict most systems environments. This theory is effective since a system is not just a grouping of individual parts, but also an entity of its own. There are two types of systems: natural and designed. Natural systems are those that have not been created by human intervention. Designed systems, however may contain hybrids of human created and natural systems. An important factor of any system is complexity. Complexity refers to the number of parts that are connected, embedded, and entangled with one another. Embedded is defined as one system being completely housed inside another system. Entangled is defined as one system existing only as a part of another system.

Question 70

Discuss **systems theory** developed by **Ludwig von Bertalanfly**.

Answer 70

**Systems theory**, developed by **Ludwig von Bertalanfiy** in the 1940s, is an approach that considers an entire system holistically rather than focusing on component parts. Bertalanffy believed that all of the elements of a system and their interrelationships need to be understood because all interact to achieve goals; a change in any one element impacts the other elements and alters outcomes. There are five elements in a system: 1. **Input**: This is what goes into a system in terms of energy or materials. 2. **Throughput**: These are the actions that take place in order to transform input 3. **Output**: This is the result of the interrelationship between input and processes. 4. **Evaluation**: This is monitoring success or failure. 5. **Feedback**: This is information that results from the process and can be used to evaluate the end result. To achieve desired outcomes, every part of the process must be considered. The individual parts added together do not constitute the whole because viewing the parts separately does not account for the dynamic quality of interaction that takes place.

Question 71

Discuss cognitive science: **Attribution theory** developed by **Bernard Weiner**.

Answer 71

**Bernard Weiner** developed the cognitive theory known as **attribution theory**, which focuses on explaining behavior. Weiner suggested that people attempt to attribute cause to behavior, based on three-stages, which include: 1 . Observing behavior. 2. Determining that the behavior is intentional. 3. Attributing the behavior to internal or external causes. According to this theory, there are four factors to which achievement can be attributed: 1 . Individual effort 2 . Ability 3. Difficulty of task 4 . Good or bad luck People often view their own achievement as the result of effort and ability and the achievements of others as the result of luck. By the same token, people may view personal failures as the result of bad luck and the failure of others as the result of lack of effort or ability. Attributions are classified according to three factors: 1. Locus of control (internal/external) 2. Stability of causes for behavior 3. Ability to control causes

Question 72

List the questions that should be asked when evaluating an information system's **Health Insurance Portability and Accountability Act (HIPAA) compliance**.

Answer 72

In order for a healthcare organization to comply with the **Health Insurance Portability and Accountability Act**, they should evaluate their system's **compliance** on a frequent basis. The following is a list of questions that should be asked during the evaluation procedure: * Where is patient data stored? * Does each user have a unique sign-on that must be entered before gaining access to the system? * Are workstations physically secured (e.g., in a locked room)? * Does the system have an auto-log off function? * Is the system safe from unauthorized users? * Is all hardware and software up to date? * Where are backup devices kept? * Are print copies of information disposed of properly (e.g., shredded)?

Question 73

Explain a **review of informatics policies and procedures**.

Answer 73

**Review of informatics policies and procedures** should be done in response to surveillance/evaluation reports, as policies and procedures should be written with clear goals and outcomes in mind. A comprehensive review should include: * **Analysis of achievement of goals**: If goals are met or exceeded, then new goals may need to be set. If goals are not met, then policies, procedures, or training were either inadequate or unrealistic. * **Analysis of variances and assessing risk factors**. * **Staff input**: Meetings to discuss adequacy or problems with current policies and procedures can be held to gather opinions of staff. In addition, cross-sectional questionnaires regarding compliance, knowledge, and training can be used * **Training review**: Training should be ongoing and coupled with clear expectations of staff compliance.

Question 74

Discuss **downtime forms**.

Answer 74

**Downtime forms** are used for record-keeping when the information system has scheduled or unscheduled downtime. Policies should be in place stating when use of downtime forms should begin (often after 1 hour). Downtime forms should be readily available at the point of care and correspond as much as possible to the screen presentations in the information system so that information can be easily entered when the system is back up. Screenshots may provide helpful guides when creating downtime forms but are usually not flexible enough for accurate record-keeping. Each department may have different downtime forms, depending on functions. Some systems have print options for forms, and these should be preprinted and ready for use. Forms should be up-to-date and contain correct coding (e.g., current procedural terminology codes) when applicable. Print medication records should contain allergy information.

Question 75

Discard system security and integrity: **Time-out.**

Answer 75

Once a person has logged in and gained access to a computer, the computer is vulnerable if that user leaves the computer and fails to log out, so computers connected to a secure system routinely have a **time-out** feature (automatic log off) that locks the system after a prescribed period (usually 10-15 minutes) in which there is no mouse or keyboard activity. Some software programs and applications also have time-out features. Once the time out is initiated, a person must log in again in the prescribed manner to gain access. Time out/automatic logoff is one of the security procedures that must be addressed for part of the Health Insurance Portability and Accountability Act's security rule. The users' workflow and type of use of devices should be considered when scheduling automatic log off.

Question 76

Discuss **development of policies**

Answer 76

The **development of policies** must be based on best practices and conform to state, federal, and accreditation regulations and guidelines. Empowerment includes encouraging participation of all staff in policy making. Objectives for policies should be clearly outlined. In some cases, policies may be broad and cover all aspects of an organization, but in other cases, policies may be much more specific, such as a policy regarding use of computer equipment. Conflict of interest policies should be in place to ensure that those involved in review activities should not be primary caregivers or have an economic or personal interest in a case under review. Policies should ensure that access to protected health information be limited to those who need the information to complete duties related to direct care or performance improvement review activities. Policy and procedure manuals should be readily available organization-wide in easily accessible format, such as online. Policy issues may include cost-effectiveness, insurance coverage, criteria for qualified staff, and legal implications.

Question 77

Discuss administrative computer related **policies.**

Answer 77

A healthcare facility must have a **policy** regarding computer system use. This policy should be discussed during the orientation process and before the employee is allowed to access the computer system. The policy should outline the regulations pertaining to client confidentiality, ethical use of computers, and the disciplinary actionS that will be taken against employees who do not adhere to the policy. Many organizations insist that staff members sign an agreement (which states that system misuse can result in disciplinary action) before system access instructions. System access is usually achieved by entering a user name and password. Security measures may include setting the complexity of the password and the password change intervals.

Question 78

Discuss **audit trails.**

Answer 78

**Audit trails** are records of activity related to systems and applications, users' access, and use of systems and applications. One system may employ a number of different audit trails. Audit trails are a security tool that allows administrators to track individual users, identify the cause of problems, note data modification and misuse of equipment, and reconstruct computer events. Audit trails can also indicate penetration or attempted penetration. Audit trails include event records and keystroke monitoring, which shows each keystroke entered by a user and the electronic response. * Audit trails at the system level generally record any logins, including identification, date, and time, devices used, and functions. * Audit trails at the application level monitor activity within the application, including opened files, editing, reading, deleting, and printing. Audit trails for users include all activities by the user, such as commands, accessed files, and deletions.

Question 79

Discuss system security and integrity: **Security failures.**

Answer 79

**Security failures** may occur as the result of a number of different problems. * **System penetration**: Penetration can result from undetected vulnerabilities. Penetration tests should be conducted to identify vulnerabilities. Perpetrators may be cyberhackers, hackers, computer specialists, authorized users, unauthorized users, and opportunists. * **Destruction/sabotage**: This includes physical damage to the system or purposeful alterations in applications. Perpetrators may be anyone who has access to the computer system or who has issues with management or other aspects of the organization. * **Mistakes/errors**: Errors may result from poor design; incorrect entries; system changes; poorly trained personnel; and absence of adequate procedures, policies, and education. * **Password management**: Poor management procedures, such as sharing passwords or posting user names and passwords where they can be accessed by unauthorized persons, can allow unauthorized people to access a system. * **Device compromise**: Handheld devices, such as personal digital assistants and smart phones, are vulnerable to theft and can easily transmit viruses and worms .

Question 80

Discuss system security and integrity: **Device access control.**

Answer 80

**Device access control** can encompass a wide range of technologies and procedures. The first step is to determine what class of users has access to different devices and then what method of authentication (e.g., password, biometrics) for role and entity-based access is required. Clear policies and procedures must be in place for both access and use of devices. Role and entity-based access should be determined by the individual role and function within the organization rather than on hierarchy. Networked medical devices and information technology devices may be on the same network, and handheld devices may connect to multiple networks; thus, these situations pose additional security risks. All handheld devices, which pose the most risk, must be password protected. Security of access control must be strictly enforced, and those who violate security policies and procedures should have restricted use. Each potential device user must be correctly identified and access controlled. Commercial access control programs are available for health care organizations.

Question 81

Discuss Federal regulations pertaining to security and privacy: **Health Information Technology for Economic and Clinical Health Act.**

Answer 81

The American Recovery and Reinvestment Act of 2009 included the **Health Information Technology for Economic and Clinical Health Act (HITECH).** HITECH provides incentive payments to Medicare practitioners (usually physicians] to adopt electronic health records (EHRs). EHRs must be certified and meet the requirement for "meaningful use." Additionally, HITECH provides penalties in the form of reduced Medicare payments for those who do not adopt EHRs, unless exempted by hardship (e.g., rural practices). Security provisions include the following: * Individuals and Health and Human Services must be notified of a breach in security of personal health information. * Business partners must meet security regulations or face penalties. * The sale or marketing of personal health information is restricted. * Individuals must have access to electronic health information. * Individuals must be informed of disclosures of personal health information. HITECH also provides matching grants to institutes of higher education and funding for training for health information technology, promotes research and development of health information technology, and provides grants to the Indian Health Services for adoption of health Internet technology.

Question 82

Discuss user security: **Tokens.**

Answer 82

**Tokens** are items used to authenticate a person's identity and allow access to a system. They commonly require the use of not only the token but also a personal identification number or user name and password. Some devices, such as the SecurelD token by RSA generate one-time passwords. Tokens may be in the form of access cards, which may use different technologies: photos, optical-coding, electric circuits, and magnetic strips. They may also be contained in common objects, such as a key fob. Some tokens must be plugged directly into the computer. Different types of tokens include: * **ID cards**: These include driver's licenses and employee badges but provide very little security as they can easily be falsified or stolen. * **Challenge-response tokens**: These combine use of the token with user information, such as user name and password. * **Smart cards**: These contain microchips with information that can be programmed to allow access, like a debit card. Typically, databases track who is accessing a system and the duration of access.

Question 83

Discuss system security and integrity: **Physical security**.

Answer 83

**Physical security** is essential for computer systems. The first step is to determine who has access to different types of equipment and then to apply methods to limit access to only those authorized through use of user names and passwords or tokens. Servers should be rack-mounted in locked, climate-controlled rooms that have regular surveillance. Vulnerable devices should remain in the locked room. Data should be backed up routinely and stored or archived in a secure remote location. Workstations should be secure, including printers. Cable lock systems should be used to secure equipment, including laptops, to furniture. Operating systems should be locked when not in use, and encryption software should be used to secure routers that are used for wireless transmission. Equipment should be in restricted areas. Remote access should be done with secure modems and encryption. Public access to the Internet should be on a different network from that used to transmit healthcare information.

Question 84

Describe the fundamentals of computer **security mechanisms**.

Answer 84

Keeping computer systems safe entails a mixture of both physical and electronic **security**. This consists of: * Physical security may be maintained by placing computers or servers in restricted areas. Laptop and other portable computers should be fitted with locks or alarms and have extensive password protection in place. * Since many systems are open to remote access, it is important that even if they are physically secure that they have electronic protection also. Firewalls help protect systems from unauthorized access by presenting an electronic barrier between the system and the remote user. A firewall is able to look at incoming information and only let through that which is approved. Firewalls may also be placed within a system to keep parts of it off limits to individuals who are authorized users of the system in general. It is a good practice to use a firewall to protect such things as payroll, personnel data, and client information.

Question 85

Outline the three levels of user **authentication security.**

Answer 85

There are three levels of user **authentication security** scaled to the amount of security offered (e.g., Level Three offers the most security): 1 . Level One * Once an individual is logged into the system (using their name and password), their name appears on the screen and their access is tracked as they use the system. * Users are automatically logged out after some period of inactivity and must login again to continue using the system. * Must update their password (set to a specific level of complexity) on a regular basis (e.g., monthly). 2 . Level Two * Encrypted key-based authentication. * User must present computer access card (CAC) to the system before they can log on. * Automatic log out if CAC is too far from the computer. 3 . Level Three * Biometric authentication: Uses something unique to the individual such as: fingerprint, retinal scan, or face recognition. Some newer laptops now come with a fingerprint scanner built-in. * Cannot be lost or stolen.

Question 86

List the recommendations for **secure passwords** on a computer system.

Answer 86

The following is a list of recommendations for creating **secure passwords** on a computer system: * All passwords should be at least six characters in length and use a combination of symbols, numbers, upper case and lower case numbers, and punctuation marks. * Each application should have its own password. That is, a separate password for each application that the user is authorized to access. * Use a password security tester to be sure the password is strong enough. This program will attempt to "break" a given password and determine how effective it is. * Never save passwords on the Internet browser. Disable the "save form data" option in the privacy settings. Also, never access the computer system from a public computer (such as those found in a library). * Do not use personal identifiers such as social security numbers, birthdays, or names. * Do not write passwords down. * Have a set expiry time limit for passwords and do not allow them to be repeated.

Question 87

Describe the terms: **antivirus software** and **spyware**.

Answer 87

Two types of programs are essential to the security of today's computers: * **Antivirus software**: New computer viruses are being developed and detected all the time, making it necessary to have antivirus software that is completely updated. Many vendors of antivirus software allow the user to purchase updates for a small fee. These updates are generally downloaded from the company's website using an Internet connection. The software then should be scheduled to check for viruses on a regular basis (typically daily). * **Spyware detection software**: Spyware is a type of software that implants itself into a computer system and sends information back to its maker. Spyware is typically attached to many "free" software programs available for download on the Internet. All computers connected to the Internet are at risk to spyware. Therefore, updated spyware detection software should be run regularly to find and eradicate these programs.

Question 88

Describe **encryption methods** designed to protect confidential information.

Answer 88

Patient information that is stored in databases is of a sensitive and confidential nature. Therefore, it is a requirement to use **encryption** when transmitting this information to other locations. Encryption is the process of using mathematical formulas to code data so that it is unrecognizable if it is intercepted by someone outside of the system. There are three distinct ways that encryption can be handled by a company: at the desktop, administrated, or server-wide. When an employee encrypts messages at their desktop, it protects the message, but unfortunately may also hide information (such as viruses) from detection by the system administrator. A company may also assign an encryption administrator to handle the coding and decoding of messages. With today's computer systems, the most effective way to encrypt messages is to have the central server encrypt every outgoing message automatically. This requires no manual procedures whatsoever.

Question 89

Discuss four **major threats** to computer systems.

Answer 89

There are four main categories of **threat** to a computer system. These threats can incapacitate a computer system for a short or very long time, depending on their severity: * **Environmental disasters** can be either natural or man-made. Natural disasters include blizzards, earthquakes, epidemics, floods, tornadoes, and hurricanes. Man-made environmental disasters include: chemical contamination, power outages, accidents when hardware is being transported, and toxic fumes. * **Human error** is one of the major causes of problems with a computer system. Human error includes overwriting files, accidentally deleting files, and overloading the system with unnecessary programs. * **Human mischief** includes theft, malicious programs, terrorism, and cybercrime. Since the attacks of September 11, 2001, organizations have also had to include potential loss of large numbers of information system employees in their disaster planning scenarios. * **Equipment failure** includes disconnected wiring, CPU crashes, and monitor failure.

Question 90

Define the terms **privacy** and **confidentiality** and how they relate to informatics.

Answer 90

Patient **privacy and confidentiality** are two main concerns especially as they apply to the collection and storage of computer records. Patients have a right to privacy and that any information they choose to share is only accessible to authorized personnel. * **Privacy** is defined as "freedom from intrusion, or control over the exposure of self or personal information." In healthcare, an individual's right to privacy includes remaining anonymous by request, deciding what information is collected, and how that information is used. * **Confidentiality** is the careful sharing of private information to people who have a valid interest in helping the individual. The ethical duty of confidentiality requires the information to be stored or transferred in a secure way. The individual's right to decide how information is shared is known as information privacy. This includes the right to accurate information being collected and stored. Information security includes the measures taken to ensure that records are kept accurate and are not accessible to unauthorized people.

Question 91

Describe the **unauthorized user** and what threat they pose to system security.

Answer 91

While system access by an external hacker is a valid concern, the biggest security problem for health database systems is the **unauthorized user**. An unauthorized user is an employee of the company that has legitimate access to the database system, but access of information beyond what is needed for their job or task. This type of individual purposefully or inadvertently views data that they should not, creates a disruption in the availability of information, or corrupts the integrity of the stored data. Under HIPAA regulations, all healthcare facilities must guarantee patient information privacy under penalty of law. Because healthcare databases may be very large and fragmented, it is sometimes difficult to restrict an employee's access to only those patients (or specific patient test results) to which they have a valid need to access.

Question 92

Outline the different types of **malicious programs** that may be a threat to an information system.

Answer 92

There are five types of **malicious computer programs**: 1 . Viruses * Can damage data, but may only be an annoyance. * Computer must be running in order for these to spread. 2 . Worms * Named after the pattern of damage they perform. * Use LAN and WAN practices to spread and reproduce. 3. Trojan horses * Appear to be performing a legitimate task, but actually do something else. * May look like a regular system login, but in fact records information, which it then sends back to its creator for malicious reasons. * Do not self-replicate. * Easily confined once found. 4. Logic bombs * Triggered by a specific bit of data. * Can be hidden in a normal program. * Type of virus. 5 . Bacteria * Type of virus. * Are not attached to existing programs.

Question 93

Explain the term: **system penetration**.

Answer 93

**System penetration** occurs when someone other than the authorized system personnel access a private computer system. System penetration can lead to lost time and money in addition to negative public relations. Losing private information has become a regular headline in the news. In today's world of cyber criminals, the robbery of personal information from a computer system is a far larger threat than physical breaking and entering. There are typically three types of people who attempt system penetration: opportunists, hackers, and information specialists. Opportunists are those individuals who have valid access to a computer system and use the information stored there for nefarious purposes. Hackers may see system security as a challenge to rise to and attempt system penetration for the thrill. Similar to hackers, an information specialist is someone who has been trained to work with computers on a professional level, but then uses this training to commit crimes.

Question 94

Explain the significance of **sabotage, errors, and disasters** on an information system.

Answer 94

**Sabotage**: The willful destruction of computer equipment (or database records) is defined as sabotage. The majority of these types of acts are committed by angry or unhappy employees. The others are caused by external hackers to the system who destroy (or erase) records for their own notoriety. **Errors**: There are several ways that errors occur in computer systems: poor design, incorrect data entry, or retrieval of an incorrect entry. It is important that when errors are found, they be reported to the system administrator immediately. **Disasters**: A disaster may cause the system to be shut down entirely for an undefined length of time. For this reason, it is important to have backup procedures (both manual and at a remote site) in place and to conduct practice drills regularly so that the entire operation will not be put at risk.

Question 95

Describe the methods to avoid the installation of **malicious software**.

Answer 95

In order to avoid **malicious software** (such as viruses or Trojan horses), use the following proven methods: * Monitor and verify that only licensed software is uploaded into the system. * Make sure that all network computers have updated virus detection software installed and that it is set-up to make daily scans of the entire system. * Be wary of e-mail and never open a file attachment from an unfamiliar source. * Keep copies of computer start-up files, original software, work flies, and directory structure in case problems arise. Keep a list of where each piece of hardware or software was purchased, the date of purchase, and all serial numbers in a secure location separate from the system. * Update software regularly to fix security vulnerabilities. * Finally, be sure that all staff members are familiar with the appropriate use of software, hardware, and e-mail.

Question 96

Discuss legal implications: **Privacy and security rules**.

Answer 96

The Health Insurance Portability and Accountability Act of 1996 mandates privacy and security rules (Code of Federal Regulations, Title 45, part 164) to ensure that health information and individual privacy are protected. * **Privacy rule**: Protected information includes any information included in the medical record (electronic or paper), conversations between the physician and other health care providers, billing information, and any other form of health information. Procedures must be in place to limit access and disclosures. * **Security rule**: Any electronic health information must be secure and protected against threats, hazards, or nonpermitted disclosures, in compliance with established standards. Implementation specifications must be addressed for any adopted standards. Administrative, physical, and technical safeguards must be in place as well as policies/procedures to comply with standards. Security requirements include: limiting access to those authorized, use of unique identifiers for each user, automatic logoff, encryption and decryption of protected health care information, authentication that health care data have not been altered or destroyed, monitoring of logins, and security of transmission. Access controls must include a unique identifier, procedures to access the system in emergencies, time out, and encryption/decryption.

Question 97

Describe the **Health Insurance Portability and Accountability Act** (HIPAA).

Answer 97

The **Health Insurance Portability and Accountability Act** (HIPAA) was created by Congress in 1996 to establish standards for computer based record keeping in the healthcare industry. Timetables were established that included fines for noncompliance by certain dates. This legislation required the Director of Health and Human Services (DHHS) to create: * Rules regarding how electronic transactions are processed. * A unique identification code for all providers, health plans, and employers. * A way to keep patient information secure and private. The Health Insurance Portability and Accountability Act also granted certain rights to patients including the right to view their own medical records and request that corrective changes are made to their medical files. A key attribute of HIPAA is that healthcare providers may not keep personal health information (PHI) unprotected on their computer systems.

Question 98

Describe the **Accredited Standards Committee** and the **Pharmacy Standards Association.**

Answer 98

These organizations have created universal standards for healthcare computerized tasks in the United States. The goal is to create records that are more accurate, avoid duplication, and ensure communication between computer systems. * **The Accredited Standards Committee (ASC)** created the standards associated with administrative medical insurance tasks. The current version, X12N, is used nationwide. X12N helps with claims, enrollment, and determining insurance eligibility. * The **National Council for Prescription Drug Programs (NCPDP)** develops pharmacy standards for the U.S. Electronic claims processing under this standard was first introduced in 1992 and has gone on to make up nearly 100% of retail pharmacy claims being processed in real-time. Healthcare providers send EDI (electronic prescriptions} messages to the pharmacy directly. Another NCPCP set of standards, HL7, focuses on the communication of information within and between different healthcare facilities. Collaboration between X12N and HL7 has resulted in the EHR-S (electronic health record system) standards as a way to solidify all aspects of patient healthcare under a single system.

Question 99

Discuss legal implications: **Proprietary data**.

Answer 99

**Propriety data** derive from proprietary software that has been developed internally or used under contract with a company, such as Cisco, which developed the software. Proprietary software should be protected by patent or copyright and use restricted to protect intellectual property, such as patient lists, financial reports, or details about an organization. Those who use proprietary software should require that all those working with the data, including third parties, sign a nondisclosure agreement to prevent information regarding the software or data from being stolen or misused. Stealing proprietary data is common when people leave an organization and is often used to benefit a new employer; however, stealing legally protected information is an act of fraud. Security experts should constantly monitor software and data to ensure that they have not been invaded by malware (malicious software), which can steal information, damage systems, or disrupt operations.

Question 100

Discuss cognitive science: **Theory of multiple intelligences** developed by **Howard Gardner.**

Answer 100

**Howard Gardner** developed the **theory of multiple intelligences**, which states that there are at least seven categories of "intelligence" that people use to comprehend the world and to learn. Gardner proposed that teaching that engages multiple intelligences is more effective than teaching focused primarily on linguistic or logical and mathematical intelligences (those most commonly addressed in education). Students should be assessed to determine the strengths of their personal intelligence, and teaching should address the student's preferences. * **Linguistic intelligence** is the ability to use and understand written or spoken language. * **Logical/mathematical intelligence** is the ability to use deductive and inductive reasoning, numbers, and abstract thinking. * **Spatial intelligence** is the ability to visualize and comprehend spatial dimensions. * **Bodily/kinesthetic intelligence** is the ability to control physical action. * **Musical intelligence** is the ability to create and appreciate musical forms. * **Interpersonal intelligence** is the ability to communicate and establish relationships with others. * **Intrapersonal intelligence** is the ability to use self-knowledge and to be self-aware.

Question 101

Describe the **organizational development (OD) model of change**.

Answer 101

The **organizational development model (OD) of change** within an organization works by focusing on the entire culture of the organization rather than trying to change individual behaviors. OD encourages management-worker cooperation and free flowing communication. Its primary goal is to make the whole workplace an excellent environment for everyone to work towards common goals. There are several steps that must take place in order for OD to be beneficial: * First, the dynamics of the organization are studied and accurately described in a written document. * Next, a comprehensive strategic plan for problem solving should be carried out. * Finally, the necessary resources are obtained and the plan is put into place and carried out. These three comprehensive steps can be further broken down into the following: initial diagnosis, data collection/confrontation, action planning/problem solving, team building, intergroup development, evaluation and follow-up.

Question 102

Discuss cognitive science: **Theory of cognitive development** developed by **Jean Piaget—Sensorimotor Stages III and IV (4 months to 12 months of age).**

Answer 102

**Jean Piaget's theory of cognitive development** discusses how children assimilate new experiences and deal with them through accommodation. Piaget believed children go through stages of development beginning with sensorimotor, which has six substages. Stage: III Age: 4-8 months of age Description: There is an intensification of stage II, with children developing a sense of causality, time, and personal separateness. They begin to imitate and show different affects. They develop a sense of object permanence between 6 and 8 months (secondary circular reactions). Stage: IV Age: 9-12 months of age Description: This is a transitional stage with age further intellectual development, including understanding that a hidden object is not gone. Children begin to behave with intention, to associate words and symbols (bye-bye) with events, and attempt to climb over obstacles.

Question 103

Discuss cognitive science: **Theory of cognitive development** developed by **Jean Piaget—Preoperational, concrete, and formal operational, 2 years of age to adult**.

Answer 103

Jean Piaget's theory of cognitive development includes sensorimotor stage (0-24 months of age) and three additional stages: Stage: Preoperational Age: 2-7 years Description: From 2-4 years of age, during the preconceptual substage, chlidren use language and symbols, have poor logical ability, and show egocentrism. From 4-7 years of age, during the intuitive substage, children establish a concept of cause and effect, but it may be faulty because of transductive reasoning. They may engage in magical thinking, centration, and animism. Stage: Concrete operational Age: 7-11 years Description:Cause and effect is better understood, and children understand concrete objects and the concept of conservation. Stage: Formal operation Age: 11 years of age to adult Description: Children exhibit mature thought processes and the ability to think abstractly. Children and young adults can evaluate different possibilities and outcomes.

Question 104

Discuss cognitive science: **Theory of cognitive dissonance** developed by **Leon Festinger.**

Answer 104

**Leon Festinger's theory of cognitive dissonance** states that individuals attempt to escape dissonance and try to avoid inconsistencies between their beliefs and actions. If dissonance occurs, then beliefs and ideas are more likely to change than actions or behavior. Dissonance can be resolved by understanding and attaching less importance to dissonant beliefs, seeking beliefs that are more consonant to outweigh those that are dissonant, or changing beliefs to avoid inconsistencies. Dissonance is especially a concern when the individual is faced with choices and decision-making. Because people want to avoid dissonance, they may avoid individuals or situations in which dissonance occurs. A cognition is considered a piece of knowledge. When faced with dissonance, the person can: * Change one cognition to match others, or change all to bring them in line. * Eliminate one cognition, or add more to bring about consonance. * Alter the importance of cognitions

Question 105

Discuss cognitive science: **Theory of cognitive development** developed by **Jean Piaget—Sensorimotor Stages I and II (birth to 4 months of age).**

Answer 105

**Jean Piaget's theory of cognitive development** discusses how children assimilate new experiences and deal with them through accommodation. Piaget believed children go through stages of development, beginning with sensorimotor, which has six substages. Stage: I Age: 0-1 month Description: Reflexes (sucking, rooting, grasping, crying) are primary. Stage: II Age: 1-4 months Description: Reflexive behavior is replaced by voluntary behavior, recognizing a stimulus and a response (primary circular reactions).

Question 106

Discuss cognitive science: **Theory of cognitive development** developed by **Jean Piaget—Sensorimotor Stages V and VI (13 months to 24 months of age).**

Answer 106

**Jean Piaget's theory of cognitive development** discusses how children assimilate new experiences and deal with them through accommodation. Piaget believed children go through stages of development, beginning with sensorimotor, which has six substages. Stage: V Age: 13-18 months of age Description: Newly acuqired motor skills allow children to experiment and demonstrate the beginning of rational judgment and reasoning. children further differentiate themselves from objects, understand cause and effect, but have little transfer ability. Children gain spatial awareness (tertiary circular reactions). Stage: VI Age: 18-24 months Description: Preparation for more complex intellectual activiities. Children understand object permanence, begin to use language, and engage in domestic mimicry and sex-role behavior. They have some sense of time, but time is exaggerated.

Question 107

Discuss cognitive science: **Psychosocial development model** developed by **Eric Erikson.**

Answer 107

Eric Erikson's psychosocial development model covers the life span, focusing on conflicts at each stage and the virtue that is the outcome of finding a balance in the conflict. The first five stages relate to infancy and childhood and the last three stages to adult-hood, but childhood development affects later adult development:

Question 108

Discuss nursing theories: **Philosophy of human caring** developed by **Jean Watson**.

Answer 108

**Jean Watson** developed the **philosophy of human caring** in 1979. Watson focused on transpersonal caring, which views the individual holistically from the perspective of the interrelationship among health, sickness, and behavior with a nursing goal to promote health and prevent illness. Watson's theory encompasses ten caritas (methods of caring) the nurse can employ during opportunities to provide care and caring moments. The ten caritas include: 1. Having loving kindness and equanimity. 2. Being present and sustaining the spiritual beliefs of patient and self. 3. Cultivating personal spiritual practice. 4. Developing and maintaining a caring relationship. 5. Supporting both negative and positive feelings of the patient. 6. Being creative in caring. 7. Providing teaching-learning experiences within the patient's frame of reference. 8. Creating a physical and spiritual healing environment 9. Providing for basic human needs. 10. Being open to spiritual concepts related to life and death of self and the patient.

Question 109

Discuss nursing theories: **Crisis theory** developed by **Lee Ann Hoff**.

Answer 109

**Lee Ann Hoff** developed the **crisis theory of nursing**. Crisis theory considers those stress-related events that are turning points in a person's life and can lead to danger or to opportunity. These may be health issues (e.g., cancer), environmental issues (e.g., an earthquake), criminal issues (e.g., rape), or any other issues that precipitate a crisis reaction. During a crisis, people are overwhelmed with anxiety and are unable to function effectively. Crisis management helps the person and those in hi s or her soc ial networ k to deal wi th the crisis issues and reach resolution. The nurse and others, such as police, social workers, physicians, and ministers, depending on the type of crisis, are in the position to provide crisis intervention. Crisis care comprises a number of steps, including assessing the situation, making plans to resolve the crisis, implementing actions, and following up to ensure that the crisis has been resolved.

Question 110

Discuss Information science: **Information theory** developed by **Claude Shannon**.

Answer 110

**Claude Shannon** devised the **information theory** in 1948, which is used to determine the effectiveness of communication systems, especially related to compressing, transmitting, and storing data. Shannon identified problems that required solutions. The essential factors in a system of communication include the source of power, the bandwidth, the noise, and the decoder/receiver. Information is carried by symbols, such as words or codes. The three steps involved in communication include encoding a message (e.g., bits, words, icons), transmission through a channel of communication (e.g., voice, radio, computer), and decoding when reaching a destination. Note that signal-to-noise indicates the ratio between a signal's magnitude and interfering "noise" magnitude. Another element is channel capacity, which determines the amount of information that can be transmitted with the smallest rate of error. Entropy refers to the amount of energy, code, or bits, required to communicate or store one symbol in the communication process. The lower the entropy, the more efficient the process of communication.

Question 111

Discuss nursing theories: **Nursing process theory** developed by **Ida Jean Orlando**.

Answer 111

**Ida Jean Orlando** developed the **nursing process theory** in the late1950s and published them in 1961 in The Dynamic Nurse-Patient Relationship, based on her observations of what comprises good or bad nursing care. She theorized that the nursing process includes the following: * **Behavior of the patient**: Behavior is an indication of need, which may be expressed directly or through actions. * **Nurse's reaction**: The nurse must evaluate the needs of the patient based on perception and evaluation of this perception, exploring with the patient the meaning of the patient's behavior. * **Subsequent nursing actions**: Actions are based on the nurse's determination of the patient's real needs, which may be different from expressed needs, and then finding the appropriate action to meet these needs. When the patient's needs are met, the patient's distress is decreased and his or her sense of well-being is improved.

Question 112

Discuss nursing theories: **Transcultural theory of nursing** developed by **Madeline Leininger.**

Answer 112

**Madeline Leininger** developed the **transcultural theory of nursing** in 1974, based on anthropological concepts. Transcultural nursing considers cultural issues as central to providing care and promotes study of cultural differences as they pertain to people's beliefs about illness, behavioral patterns, and caring behavior as well as nursing behavior. Leininger recognized that response to illness is often rooted in cultural beliefs and traditions. Based on research, the goal is to identify and provide care that is both culture-specific (i.e., fitting the needs of a specific cultural group based on their belief systems and behavior) and universal (i.e., based on belief systems and behavior that hold true for all cultures). Nurses are expected to determine the most appropriate approach to care, considering not only the needs of ethnic or minority populations but also gender issues. Transcultural theory tries to find ways to accommodate traditional belief systems with modern medicine and to prevent cultural conflict.

Question 113

Discuss nursing theories: **Stages of clinical competence** developed by **Patricia Benner.**

Answer 113

**Patricia Benner** developed the **stages of clinical competence** for nurses based on the Dreyfus Model of Skill Acquisition in 1984. There are five stages of clinical competence for nurses: 1. **Novice**: The novice has little experience, depends on rules and learned behavior, and is not able to adapt easily. 2. **Advanced beginner**: The advanced beginner has some experience in coping with new situations and is able to formulate some principles of action. 3. **Competent**: The competent nurse has 2-3 years of experience, has some mastery of new situations and goals, and can cope well but may require time for planning and lack flexibility. 4. **Proficient**: The proficient nurse looks at situations holistically, relies on experience to determine goals and plans, can adapt plans to changing needs, and can make decisions based on the understanding of maxims. 5. **Expert**: The expert nurse has a wealth of experience from which to draw and can provide care intuitively rather than relying on rules and maxims. The nurse is able to understand needs and determine quickly the most effective focus for providing care.

Question 114

Discuss nursing theories: **Science of unitary human beings** developed by **Martha E. Rogers.**

Answer 114

**Martha E. Rogers** developed the **science of unitary human beings** in the 1980s and 1990s. The individual is viewed as a unitary energy source within the larger universe, constantly interacting with the environment The four primary characteristics of this theory include the following: 1. **Energy field**: This is basic to all living and nonliving things. 2. **Openness**: The individual and the environment exist together with an openness that allows a continuous exchange of energy. 3. **Pattern**: This energy wave distinguishes and identifies the source of energy. 4. **Pan-dimensionality**: This domain is nonlinear and not constrained by time or space, which are arbitrary means that people use to describe events. Basic concepts derived from the above characteristics include the following: * **Unitary human being**: Humans are energy fields that can be identified by patterns and characteristics. The holistic human cannot be predicted by parts but only by being viewed as a unified whole. * **Environment**: The environmental energy field is integral to that of the human energy field. * **Homeodynamics**: Good health and illness constitute part of the same continuum.

Question 115

Discuss nursing theories: **General theory of nursing** developed by **Dorothea Orem**.

Answer 115

**Dorothea Orem** developed a **general theory of nursing** in 1959. Orem believed that the goal of nursing was to serve patients and assist them to provide self-care through three steps: identifying the reason a patient needs care, planning for delivery of care, and managing care. Orem's theory is actually a collection of three theories: 1. **Self-care**: There are two agents, the self-care agent (i.e., the individual) and the dependent-care agent (i.e., the other caregiver). There are three categories of needs, consisting of universal needs (i.e., food, air), developmental needs (i.e., maturation or events), and health needs (i.e., illness, injury). 2. **Self-care deficit**: This occurs if the self-care agent cannot provide for his or her own care. Nursing assists through five means: providing care, guiding, instructing, and adjusting the environment to help the patient in self-care. 3. **Nursing systems**: Actions to meet the patient's self-care needs may be completely compensatory (i.e., patient is dependent), partly compensatory (i.e., patient provides some self-care), or supportive (i.e., patient needs assistance to provide self-care).

Question 116

Discuss nursing theories: **Florence Nightingale, founder of modern nursing**.

Answer 116

**Florence Nightingale** (1820-1910), **founder of modern nursing**, created one of the first training schools for nurses. Nightingale observed that the disciplined care provided to the sick by nuns was superior to the haphazard and untrained care of nurses in England. Based on her experiences in the Crimean War, Nightingale set standards for patient care that included sanitary conditions (e.g., cleanliness, improved ventilation, less crowding), adequate nutrition, and kindness. She used statistical analysis to show the number of deaths related to poor sanitation. Nightingale reformed the ways in which hospitals provided care for patients. She set standards for nursing and developed the Nightingale pledge, which is still recited by nurses at graduation ceremonies. Reciting this pledge, nurses swear that they will practice the profession faithfully, do no harm, maintain and elevate the standards of the nursing profession, maintain confidence in personal matters, aid the physician, and devote themselves to the welfare of the patient.

Question 117

Define the term: **management science**.

Answer 117

**Management science** is the study of business decision-making using various analytical methods. There are several elements used in management science to help organizations make practical decisions: * Strategic planning: Strategic planning is based on an organization's goals and mission. * Morphological analysis: Morphological analysis looks at many different possible solutions in an attempt to come up with the most appropriate one. * Influence diagrams: Influence diagrams use mathematical representations and graphs to solve problems. * Problem structuring: A method used in management science is problem structuring, sometimes known as "soft-operations research". Management science may also be called operations research. Some experts consider operations research primarily academic in nature (focusing only on making operations more productive and efficient) while management science is regarded to be more related to the process of making business decisions that effect more than operations.

Question 118

Discuss nursing theories: **Interpersonal relations model of nursing** developed by **Hildegard Peplau**.

Answer 118

**Hildegard Peplau** developed the **interpersonal relations mode! of nursing** in 1952, focusing on the quality of the nurse-client interaction. Peplau believed that patients deserved humane care by educated nurses and that they should be treated with dignity and respect. She also believed that the environment (i.e., social, psychosocial, physical) could affect health in a positive or negative manner. Peplau viewed the nurse as a person who could make a substantial difference for the patient and who acts as a "maturing force." The nurse can focus on the way in which patients react to their illness and can help patients to use illness as an opportunity for learning and maturing through the nurse-client interactions. The nurse helps the patient to understand the nature of his or her problem and to find solutions. Peplau's theory stresses the importance of collaboration between the patient and the nurse. The nurse-client relationship is viewed as a number of overlapping phases: orientation, identification of the problem, explanation of potential solutions, and resolution of the problem.

Question 119

Discuss nursing theories: **Total-person systems model** developed by **Betty Neuman**.

Answer 119

**Betty Neuman** developed the **total-person systems model of nursing** in 1972. The concentric circle of variables (e.g., physiological, psychological, sociocultural, spiritual, developmental) provides defenses for the individual; these defenses should be considered simultaneously for the individual, who directly interacts with and is influenced by the environment. This model focuses on how the individual reacts to stress, using defense mechanisms and resistance, and how this feedback affects the individual's stability. Stressors are environmental forces that may provide negative or positive reactions, affecting the individual's stability. Stressors may be intrapersonal, interpersonal, or extrapersonal. The nurse intervenes to help the individual maintain stability and prevent negative effects. Interventions include the following: * **Primary (health promotion, education):** Preventive steps are taken before a reaction to a stressor develops. * **Secondary**: The goal is to prevent damage of the central core by facilitating internal resistance and by removal of stressors. * **Tertiary**: Efforts are made to promote reconstitution and reduce energy needs, supporting the client after secondary interventions.

Question 120

Discuss developing teaching materials and resources: **Hospital information system**.

Answer 120

The **hospital information system (HIS)** can provide real practice for students and trainees using hardware and software programs that they will need when caring for patients. Nursing students can use HIS to generate care plans and do mapping rather than doing this in the traditional time-consuming paper method. The students and trainees should be able to access fictitious patient files and retrieve and enter information, but security must be in place to prevent access to actual patient files for training purposes as this violates the Health Insurance Portability and Accountability Act (HIPAA) regulations. Additionally, existing staff, such as nurse managers, should be taught how to access data from patient census records and electronic health records (EHRs) to plan staffing, organize care, and promote patient safety. Any training involving HIS and EHR must review HIPAA regulations as well as methods to ensure data security and patient confidentiality.

Question 121

Discuss developing teaching materials and resources: **Help tools**.

Answer 121

A variety of **help tools** are available for education, including the following: * **Learning aids**: Questions, guides, maps, pictures, charts, illustrations, outlines, or diagrams can be used to support lecture or computer-based training. * **Web tools**: These can include websites that provide specific .educational content and information updates, such as the Skin Care Network at NursingCenter.com (Lippincott), and interactive websites. Additionally, chat tools and message boards may provide valuable support for students. * **Software applications**: Software is available for training on almost every health care topic and usually includes interactivity and audiovisual presentations. Many applications are available for portable devices as well. * **Books:** Many books are now available in electronic versions, making access less expensive and more easily transported. * **Multimedia:** Compact discs, DVDs, and streaming videos combine sound and images with hardware/software to deliver educational content.

Question 122

Define the term: **computer science.**

Answer 122

**Computer science** is often misunderstood to be solely the study of computers. Computer science began long before modern computers were ever created. Computer science is the study of how information is manipulated to solve problems or answer questions. In essence, computational science has been automated by the technology of modern computers. There are many subfields within computer science including computer graphics, computational complexity theory, programming language theory, computer programming, and human/computer interaction or interface. The history of computer science is founded in mathematics and the two fields continue to influence one another. The first modern computers were designed to perform complex mathematical calculations related to projectile trajectories for the battlefield. Computer science may be thought of as the study of computation and its associated principles. More commonly, however, the education that computer scientists often receive focuses more on programming and the specific computational problems found in association with software engineering.

Question 123

Discuss developing teaching materials and resources: **Videos, videoconferencing, and teleconferencing.**

Answer 123

**Videos** are a useful adjunct to teaching as they reduce the time needed for one-on-one instruction (increasing cost-effectiveness). Good-quality videos can be expensive to produce, although commercial products are available. Passive presentation of videos, such as in a waiting area, has limited value, but focused viewing in which the educator discusses the purpose of the video presentation before viewing and then is available for discussion after viewing can be very effective. Videos are also effective tools for demonstrating patient care techniques, such as wound care. Additionally, videos can be placed on course or learning management systems for anytime access. Providing focused questions for use during the video presentation helps increase retention by keeping active involvement. **Videoconferencing and teleconferencing** allow for audiovisual collaboration at a distance and can be a valuable tool for education, providing access to experts without the transportation costs. In teleconferencing, students may be at multiple sites while interacting with each other and an instructor.

Question 124

Discuss developing teaching materials and resources: **Classroom response systems**.

Answer 124

**Electronic classroom response systems (CRS)** include the use of clickers to respond to questions or educational content. For example, if an instructor asks the class a question, all students can answer with the clicker, which beams responses wirelessly to a computer, so the instructor can immediately determine if the students understood the question and responded appropriately. This is especially valuable in large groups where quiet students [or those in the back) may have little input into discussions. Additionally, responses can be projected from the computer onto a screen and, in some cases, graphed, so that students are able to see the results of the questions visually. One major advantage to the clicker is that those who might be afraid to answer or unsure can do so privately. Students using clickers often remain more actively engaged in the learning process.

Question 125

Discuss **developing informatics competencies: End-users and informatics staff**.

Answer 125

**Developing informatics competencies** among end-users and informatics staff requires intensive and comprehensive training and institutional support. A variety of different training procedures, such as one-on-one or instructor-led classrooms, may be used. Training should include the following: * Policies regarding computers, including privacy issues, penalties, and failure to comply with policies * Access policies and issues regarding misuse (e.g., viewing nonauthorized materials) * Preimplementation steps to prepare end-users for changes and to inform and educate informatics staff * Basic computer literacy information * Workflow diagrams outlining changes occurring with transition from manual to automatic systems * Scenarios with step-by-step instructions * Access and use of help documents and online tutorials * Generation of error messages, including avoidance and error correction * Causes of screen & system freezing and troubleshooting methods * Elements specific to the organization's system * Maintenance and troubleshooting for hardware and software * Methods of information retrieval * Managing downtimes (both scheduled and nonscheduled) and backup systems

Question 126

Discuss teaching strategies and methodologies: **Teaching models**.

Answer 126

**Audiovisual tutorials**: These are very effective for supplementary material and independent study. **Independent study**: This is geared toward the needs of the individual who can self-pace; materials may be Web-based or paper-based and may include audiovisual materials. **Goal-focused**: Learners are presented with a goal, and all materials and activities are aimed at achieving that goal. **Guided focus**: Learning takes place outside a formal classroom with materials provided or recommended by the instructor. **Anchored:** Activities are based on problem-solving in relation to realistic case studies. **Collaborative**: Learners work together to complete a learning activity. **Project-based**: Learners develop materials (e.g., videos, Web pages, pamphlets) regarding a topic. **Problem-based**: Learners work in teams to solve problems. **Cognitive apprenticeship**: Instructors model, and learners analyze and apply processes. **Simulations**: Learners actively participate in simulated activities. **Direct instruction**: This is an instructor-focused presentation. **Cooperative:** Small teams work together through a variety of activities to master a subject, with each member responsible for self-learning and learning from others on the team.

Question 127

Discuss developing **teaching materials** and **resources: Selection.**

Answer 127

It is impractical to believe that the nurse can produce all **teaching materials** and **resources**, but careful consideration must be given to the **selection** process. * **Price** ranges from free to hundreds or even thousands of dollars for educational materials, which may be handouts, videos, posters, or entire courses or series of courses available online. The nurse must first consider the budget and then look for material within those monetary constraints. Government agencies, such as the Centers for Disease Control, often have posters and handouts as well as PowerPoint presentations and videos available for download online at no cost. * **Quality** varies considerably as well. The nurse should consider the goal and objectives before choosing materials, and the materials should be evaluated to determine if they cover all needed information in a clear and engaging manner. * **Currency** must be considered as well. If material will soon be outdated because of changes in regulations, then it will have to be replaced.

Question 128

Discuss developing teaching materials and resources: **Electronic and audiovisual materials.**

Answer 128

There are a number of issues that must be considered when teaching a course and determining the appropriate audiovisual and handout materials. The physical environment is a major consideration, especially when using **electronic and audiovisual materials.** * First, everyone in the room must be able to **hear and see**. In a small room, a television or computer screen may suffice, but in a large space, a projection screen must be used. * Another issue is **lighting**. Some projectors have low resolution and the lights need to be turned off, dimmed, or windows covered. Turning lights on and off a dozen times during a presentation can be very distracting. A small portable light at a speaker podium or an alternate presentation can be used. * **Text size for presentations** is another issue: PowerPoint or other presentations that include text must be of a sufficient font size to be read from the back of the room.

Question 129

Discuss teaching strategies and methodologies: **Problem-based lear**ning.

Answer 129

**Problem-based learning** was developed by McMaster University in the 1960s. It is learner-centered with the instructor serving as facilitator rather than lecturer. The learners are presented with a problem and must search for the solution. Problem-based learning focuses on promoting the learners' ability to use critical thinking and problemsolving skills, increasing motivation. This process of problem-solving is believed to enhance transfer so that information learned in one context is internalized and can be used in other contexts as well. While effective, this method requires more preparation time and may require an extended learning period while the learners identify the problem and attempt to formulate a solution. The teacher/facilitator can guide the learners by helping them to ask questions that lead to solutions.

Question 130

Discuss teaching strategies and methodologies: **Blended/hybrid learning**.

Answer 130

**Blended/hybrid learning** encompasses a wide range of teaching methodologies. Blended/hybrid learning combines traditional lecture-type, instructor-focused delivery with more modern approaches, such as computer-based instruction. With blended/hybrid learning, the instructor often balances classroom learning with out-of-classroom learning, using various technologies, such as smart phones, IPods, and IPads to access Web-based, computerized modules or applications. When designing a blended/hybrid course, the instructor must consider the expected outcomes and competencies the learners must master, the size and nature of the audience, the location of learners or classrooms, and the available resources. A typical blended/hybrid class begins with an introduction by the instructor and then moves to other formats, such as computer-based learning, while the instructor assumes the role of facilitator, using just-in-time presentations and combining over-theshoulder, one-on-one, and group instruction as necessary to meet the class goals.

Question 131

Discuss developing teaching materials and resources: **Written handouts and paper materials.**

Answer 131

**Written handouts or other paper materials** are a fixture in classes, but many end up in the wastebasket without ever being used; thus, thought should be given to what useful information should be in the handouts: * Handouts that simply copy a PowerPoint presentation or repeat everything in the presentation are less helpful than those that summarize the main points. * Giving out handouts immediately before a discussion ensures that most of the class will be looking at the handout instead of the speaker. Thus, handouts should be placed in a folder or binder and passed out before the class meets so students can peruse them in advance; for example, handouts can be passed out at the end of class in preparation for the next class. * Handouts can be used to provide guidance or worksheets for smallgroup discussions. * Posters (with drawings or pictures) that can be placed on bulletin boards are useful. * Handouts should be easily readable and not smudged copies of newspaper articles or small print text.

Question 132

Discuss educational technologies: **High- and low-fidelity simulations**.

Answer 132

**High-fidelity simulations** are those that use real or realistic equipment and materials as part of learning. This can include electroencephalogram machines, mannequins, or specialized equipment used in the work environment, so that learners can actually practice the tasks or procedures that they will carry out as part of their job. High-fidelity simulations are often the most helpful for the learner but are also the most costly because equipment may need to be dedicated for learner use. Additionally, training that involves practice and assessment of performance is often more time-consuming. **Low-fidelity simulations** rely on verbal, print, video, or audio descriptions and often involve discussion of potential actions rather than actual practice. Thus, learners may be presented with a case study or scenario with specific problems and asked to describe the process for dealing with the problems. Lowfidelity simulations are less expensive and can usually be completed more quickly, but evaluation may not adequately measure clinical expertise.

Question 133

Discuss teaching strategies and methodologies: **Over-the-shoulder instruction**.

Answer 133

**Over-the-shoulder instruction** is a learner-centered strategy in which the instructor moves about the classroom monitoring the learner's progress rather than standing at the front of the classroom and lecturing or providing instructor-focused teaching. Most instruction is computerized learning, so student attention is often focused on technology. Advantages are that this strategy allows for one-on-one instruction with individual learners as the instructor observes a need or the learner requests assistance, and the instructor is better able to monitor individual progress. However, disadvantages are that many learners may have the same questions so the instructor may waste time answering the same questions multiple times to individual students. Additionally, if the group of learners is large, the instructor may not be able to address the needs or questions of all students. In some cases, the learning environment may seem impersonal because of less interaction with the instructor.

Question 134

Discuss teaching strategies and methodologies: **Just-in-time presentations**.

Answer 134

**Just-in-time presentations** are used when learners need to use the information immediately. For example, if teaching learners to access data in a new computerized system, a supportive overview of the system and its purpose may be given right before hands-on practice and basic instruction about use. However, only when the learners need to access data is the presentation about data access provided. This allows learners to draw on what they have learned immediately without the typical memory loss that occurs when people try to retrieve information they learned at an earlier time. Just-in-time presentations are especially useful with procedural information that is not very complex and that helps people master a specific task. A training session may include both supportive information given immediately before practice and just-in- time presentations interspersed throughout the session.

Question 135

Discuss **conflict resolution**.

Answer 135

Conflict is an almost inevitable product of teamwork, and the leader must assume responsibility for **conflict resolution**. While conflicts can be disruptive, they can produce positive outcomes by forcing team members to listen to different perspectives and opening dialogue. The team should make a plan for dealing with conflict resolution. The best time for conflict resolution is when differences emerge but before open conflict and hardening of positions occur. The leader must pay close attention to the people and problems involved, listen carefully, and reassure those involved that their points of view are understood. Steps to conflict resolution include: * Allow both sides to present their side of conflict without bias, maintaining a focus on opinions rather than individuals. * Encourage cooperation through negotiation and compromise. * Maintain the focus, providing guidance to keep the discussions on track and avoid arguments. * Evaluate the need for renegotiation, formal resolution process, or third party. * Utilize humor and empathy to diffuse escalating tensions. * Summarize the issues, outlining key arguments. * Avoid forcing resolution if possible

Question 136

Discuss educational technologies: **Virtual reality.**

Answer 136

**Virtual reality** involves participation in computer-simulated environments in which the participant often has an avatar, a visual representation of the person. Virtual-reality systems may be only viewed on the screen or may require use of special equipment, such as a wired glove or special stereoscopic goggles. Tactile information (force feedback) is also available in some applications, such as those used in medicine. The virtual reality simulation allows the person to interact and have a life-like experience in a learning environment. Virtual reality may be used to practice medical techniques, such as dissection or insertion of intravenous lines or catheters. Virtual reality systems are also used as part of therapy in some instances, such as for treatment of phobias. Second Life is a virtual online world that has been incorporated into health care educational programs, allowing students to interact in medical communities. For example, the Centers for Disease Control (CDC) have a Second Life site that provides information to "visitors" about the CDC.

Question 137

Discuss teaching strategies and methodologies: **One-on-one instruction versus group instruction.**

Answer 137

Both **one-on-one instruction and group instruction** have a place in patient/family education. * **One-on-one instruction** is the most costly for an institution because it is time intensive. However, it allows more interaction with the instructor and allows learners to have more control over the process by asking questions or having the instructor repeat explanations or demonstrations. One-on-one instruction is especially valuable when learners must master particular skills or if confidentiality is important. * **Group instruction** is less costly because the needs of a number of people can be met at one time. Group presentations are more planned and usually scheduled for a particular time period (e.g., an hour), so learners have less control. Questioning is usually limited and usually only at the end of a session. Group instruction allows learners with similar needs to interact. Group instruction is especially useful for general types of instruction, such as managing diet or other lifestyle issues.

Question 138

Describe the role of **compliance officers, planning and recovery officers, and interface engineers.**

Answer 138

Three information system support roles that are typically held by fulltime employees in addition to working under their normal clinical role: 1. **Compliance officer**: A compliance officer keeps track of state and federal regulations and accrediting requirements to make sure that the organization is in compliance. This job may be held by someone from the information systems department or by one of the clinical staff members. 2. **Planning and recovery officer**: The planning and recovery officer must be sure that disaster plans are up to date and that they are integrated between departments. They must also be aware of what would be required to recover the full functionality of the information system in the event of a disaster. 3. **Interface engineer**: The interface engineer should be an employee from the information system department who is capable of making sure that information integrity is maintained when data is exchanged between different systems.