Evidence-Based Practice and Nursing Care Plans

Evidence-Based Practice (EBP)

• EBP involves collecting, processing, and applying research to enhance clinical practice and patient outcomes
• Integration of available evidence, clinical knowledge, expertise, and consideration for patient preferences is EBP
• EBP aims to incorporate research, clinical experience, and patient preferences to inform nursing decisions

Nursing Care Plan

• A Nursing Care Plan guides the type of care a patient requires
• Care Plans support standardized, evidence-based holistic care

Computerized Nursing Care Plan

• A computerized plan is a digital method for writing care plans
• Manage large volumes of health information using the CNCP
• Nurses utilize computers to store client databases, update data, creating care plans, and track progress

Assessment

• Computer terminals are used to record admission information

Implementing

• Computers are leveraged to document interventions and their management
• Choosing interventions correctly can optimize the use of time

Evaluating

• During evaluation, computers can record observations, patient responses, and evaluation statements

Advantages of Computerized Nursing Care Plans

• Computerized plans prevent manual documentation
• They enable computerized prescriptions based on nursing diagnoses
• Import data from various areas of the system
• Ensure consistency in nursing diagnoses
• Provides intervention options based on diagnoses

Disadvantages of Computerized Nursing Care Plans

• Limited to the current HER system database
• Poses difficulties for less tech-savvy nurses
• Potential risk of data loss resulting from system crashes

Critical Pathway

• A critical pathway standardizes care processes
• Introduced in the US and UK in 1990
• Aids healthcare providers in coordinating patient care for specific conditions
• Serves as a guide for usual treatment patterns, providing a comprehensive overview
• Often recommends a comprehensive treatment regimen

Clinical Pathway Components: Timeline

• Clearly defines the coverage and timeframe for each step

Clinical Pathway Components: Categories of Care

• Assessment, diagnosis, diet and nursing care, and medical treatments are parts of it

Clinical Pathway Components: Outcome Criteria

• Pathways list clear expected health outcomes to help evaluate care/responses
• Outcome criteria help healthcare professionals decide on the next steps

Clinical Pathway Components: Variance Record

• Documentation of any inconsistency with the expected outcome is important
• Variance indicates divergence from the expected outcome

Benefits of Pathways

• Evidence-based pathways enhance teamwork, communication, and care planning
• Establish standards of care
• Improve clinical outcomes for patients
• Can optimize care and provide quality improvements
• Maximizes resource use
• Able to be integrated into EHR systems

Clinical Guidelines also called:

• Clinical Protocols
• Clinical Practice Guidelines (CPGs)
• Medical Guidelines
• Practice Guidelines

Clinical Guidelines Developed By

• Governing bodies or deputized authorities
• The AHA oversees cardiac-related conditions
• RITM oversees communicable diseases
• The WHO oversees global health

Clinical Guideline Definition

• Systematically developed statements aiding healthcare decisions for particular circumstances
• These guidelines reduce variations in practice and enhance evidence-based healthcare

Principles of Clinical Guidelines: Clarity

• All terminology is clearly defined
• There are no ambiguous areas that could confuse healthcare workers

Principles of Clinical Guidelines: Compatibility

• Components are expected to be met by concerned disciplines

Clear Rationale

• Good to give rationales for recommendations
• They must be evidence based

Sensitivity to Practical Issues

• The culture, economy, and other logistics are thought of

Purposes of Critical Guidelines

• Describe accepted approaches to diagnosis, management, and prevention of conditions
• Define practices meeting the needs of patients

Benefits of Critical Guidelines

• Improves health outcomes and reduces death and sickness
• Increases success of patient management
• Promotes standardization in care
• Helps reduce health costs

Limitations of Critical Guidelines

• Takes a general approach to the patient
• Requires understanding of scientific evidence
• Needs may not be correctly prioritized

E-journals

• E-journals are online journals with the most current research
• They allow clinicians to collaborate

Advantages of Electronic Documents include:

• Documents are more useful in electronic form because of enhanced searchability
• There is improved economy in space

Electronic Documents - Data

• Data is portable
• There are embedded links to supplemental reading
• Offer options to email the author
• Have search and filter tools

Limitations of Electronic Documents include:

• Not always free
• Requires connectivity
• Could lead to buld download of irrelevant material

Policies, Laws and Guidelines

• These are nursing informatics' basic concepts

Law

• Comprises standards, principles, and procedures society must follow
• Exists mainly to implement justice
• Systems of rules and guidelines are derived for the welfare and equity in society

Policy

• Policy outlines the goals and objectives of a government or organization
• Guides organizations, complying with the law

Guidelines

• Serve as recommendations applicable when specific standards don't
• Designed to streamline processes based on best practices
• Provides room for interpretation and revision

Laws in Nursing Informatics

• Intellectual Property Code of the Philippines, Copyright Law, and Data Privacy Act are crucial to consider in nursing informatics

Intellectual Property Code of the Philippines (RA 8293)

• Protects the rights of gifted citizens to their intellectual property
• divided into five sections

Intellectual Property Office

• Government agency responsible for intellectual property collection
• Handles conflicts

Law on Patents

• Branch of the Intellectual Property Office that addresses new inventions

Law on Trademarks

• It deals with symbols of an enterprise while trade names are associated with the name of an enterprise

Law on Copyright

• Pertains to illegal content distribution without recognition

Intellectual Property

• Refers to creations, including inventions, literary works, artistic items, symbols, designs, images and pictures

To be Patentable

• Creation must be novel, inventive, and industrially applicable

Trademark

• Differentiates goods and services
• The importance is with marketing
• Helps consumers and protects owners

Copyright

• Protects original work, covering literary works, music, art, and software
• Prevents unauthorized distribution and sales

Economic Rights

• Enable creators to profit from distribution of their work
• Includes replication, transformation, and public distribution.

Moral Rights

• Moral rights mandates authorship attribution and protects work integrity

Right to Resale

• Provides for creators to receive 5% of proceeds, lasting during and 50 years after their lifetime

Relates Rights

• Give specific privileges to rights of authors

Privacy

• Guarantees individual's right to keep their health information private

Confidentiality

• Entrusts and ensures that health information is private

Health Information

• This can be used is risky for unauthorized use, can involve theft, discrimination and other acts

Data Privacy Act of 2012

• Protects the right to privacy and promotes innovation (RA 10173)
• Kept to establishments for privacy

National Privacy Commission

• Endowed with rulemaking power
• Enforces law

Data Privacy Lifecycle

• Encompasses the rights/responsibilities of individuals/organizations regarding the handle of personal data (collection, storage, etc.)

RA 10173 Provisions

• If information regarding the client is confidential, it must be kept private

Personal Information

• Any data revealing individual identity is protected

Sensitive Personal Information

• Involves an individual's personal details, health, genetics, and legal proceedings

Privileged Information

• Refers to information established by an executive order or act Congress deems private

National Privacy Commission (NPC)

• Mandated to implement and oversee the Data Privacy Act

Data Sharing Agreement

• Requires specified purposes/consent before collecting personal data

Processing of Personal Data

• Requires subject content (as per law)

Personal Information Controller

• Controls the processing of personal data

Personal Information Processor

• Processes data as according to controller

Nurse Guidelines to Avoid Data Breach can:

• Breach and expose patients
• Refer to expert
• Remember hospital guidelines
• Never seek sensitive information

Classifications of Information

• Has personal/ sensitive/ privileged categories

Data Privacy Principles in the Philippines: Transparency

• Subjects must be aware of the nature, purpose, and extent of data processing

Data Privacy Principles in the Philippines: Legitimate Purpose

• Use of data should be specified and avoid conflicts

Data Privacy Principles in the Philippines: Proportionality

• Use of data should be relevant, not extensive, and in declared purpose

Principles of General Data Privacy Law:

• Process data within legal limits
• Retain to a minimum
• Keep secure

Privacy Notice contains:

• Statement of entity
• Types of generated data
• Purpose of data

Consent

• Means individual and free indication for collected personal data

Data Sharing agreement

• Includes the joint agreement with disclosed terms and conditions

The Personal Information Controller:

• Must implement reasonable measures that provides protection for personal information

Violations of Privacy of Data:

• Includes unauthorized alterations of disclosed data

E-Commerce Law (RA 8792)

• Recognizes and penalizes misuse of electronic transactions

Anti Wiretapping Law (RA 4200)

• Penalizes privacy violations of communication

Cybercrime Prevention Act of 2012 (RA 10175)

• Covers the imposition for criminalizing computer abuse and addressing legal issues online

Rules of Netiquette

• Guidelines for online communications

General Guidelines For Electronic Communication

• Must practice/ remember good habit and remember the human
• Keep the same manner and respect for others as in person
• Obey ethical manners and legal terms
• Be forgiving
• Share expertise
• Respect others' privacy
• Be helpful
• Remember that your power is limited in the digital age