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VOLUME
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Tabbner’s
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Nursing Care
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THEORY AND PRACTICE 8E

Gabrielle Koutoukidis & Kate Stainton

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 Tabbner’s
Nursing Care

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THEORY AND PRACTICE 8E

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Volume 1

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Gabrielle Koutoukidis
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MPH, BN(Mid), DipAppSci(Nur), AdvDipN(Ed), DipBus,

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Voc Grad Cert Business (Transformational Management), MACN,

International Specialised Skills Institute Fellow, Candidate EdD (Research),
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Dean, Faculty Health Science, Youth & Community Studies, Holmesglen,

Melbourne, Victoria, Australia
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Kate Stainton
MA HlthSci(Nurs), GDipNurs(Ed), BN(Mid), DipAppSci(Nurs), Cert IV TAE,
Industry Relationship Lead, Health, Wellbeing and Community Services,
SkillsPoint, TAFE NSW, New South Wales, Australia
 iii

SHORT
CONTENTS

Volume 1 Unit 5 Critical thinking and

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reflective practice
Unit 1 The evolution of the nursing

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Chapter 17 Critical thinking, problem-based
profession learning and reflective practice in nursing
Chapter 1 Nursing: the evolution of a

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care 396
profession 2 Chapter 18 Nursing process: framework 407

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Chapter 2 Professional nursing practice:
legal and ethical frameworks 27 Unit 6 Health assessment
Chapter 3 Nursing research and Chapter 19 Health assessment frameworks:
evidence-based practice 56 initial and ongoing 420

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Chapter 20 Vital sign assessment 455
Unit 2 The contemporary Chapter 21 Admission, transfer and

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healthcare environment discharge processes 494
Chapter 4 Australia’s healthcare delivery
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system 80 Unit 7 Basic healthcare needs
Chapter 5 Nursing informatics and Chapter 22 Infection prevention and
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technology in healthcare 99 control 528

Chapter 6 Health information: nursing Chapter 23 Maintenance of health: hygiene
documentation and clinical handover 126 and comfort care 577
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Chapter 7 Understanding and promoting Chapter 24 Medication administration

health 162 and monitoring 621
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Chapter 8 Quality and safety in healthcare 193

Chapter 9 Communication and nursing
Volume 2
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practice 207
Chapter 10 Models of nursing care,
management and leadership 241 Unit 8 Health promotion and
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psychosocial and physiological

Unit 3 Health beliefs, cultural nursing care
diversity and safety
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Chapter 25 Nursing care of an individual:

Chapter 11 Cultural competence and safety 254 cardiovascular and respiratory 714
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Chapter 12 Australian Indigenous health 289 Chapter 26 Nursing care of an individual:

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fluid and electrolyte homeostasis 789

Unit 4 Nursing care throughout Chapter 27 Promotion of health and
the lifespan
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wellbeing: rest and sleep 826

Chapter 13 Nursing care across the
lifespan: conception to late childhood 308
Chapter 14 Nursing care across the
lifespan: late childhood to adolescence 337
Chapter 15 Nursing care across the lifespan:
younger adulthood to middle adulthood 357
Chapter 16 Nursing care across the
lifespan: older adult 376
Chapter 28 Promotion of health and
wellbeing: movement and exercise 845
Chapter 29 Maintaining and promoting
skin integrity and wound care 878
Chapter 30 Promotion of health and
wellbeing: nutrition 943
Chapter 31 Nursing care: urinary
elimination and continence 984
iv Short contents

Chapter 32 Nursing care: bowel Chapter 40 Nursing care in rehabilitation 1286

elimination and continence 1023 Chapter 41 Nursing care: chronic illness
Chapter 33 Nursing assessment and and disability 1304
management of pain 1048 Chapter 42 Nursing in the acute care
Chapter 34 Nursing assessment and environment 1330
management of sensory health 1068 Chapter 43 Nursing in the perioperative
Chapter 35 Nursing assessment and care environment 1353
management of neurological health 1099 Chapter 44 Nursing in the emergency
Chapter 36 Nursing assessment and care environment 1387
management of endocrine health 1151 Chapter 45 Nursing care: maternal and

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Chapter 37 Nursing assessment and newborn 1415
management of reproductive health 1184 Chapter 46 Nursing in the community 1444

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Chapter 47 Nursing care in rural and

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Unit 9 Healthcare in specialised remote areas 1458
practice areas

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Chapter 38 Nursing care in palliation 1222

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Chapter 39 Mental health and mental
health conditions 1238

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Louise Alexander RN, BN, GCPMHN, GCPET, MEd,
PhD (Psychology)
Senior Lecturer in Mental Health Nursing & Post Graduate
Course Coordinator—Master of Mental Health (Nursing)
Australian Catholic University, St Patrick’s Campus,
Melbourne, Victoria, Australia
Ai Tee Aw RN, BN, OND, MRN
Deputy Director of Nursing, Singapore National Eye
Centre, Singapore
Lindsay Bava RN, BHlthSc(Nur), Cert IV TAE, Cert
IV TESOL, MEd, GDipIndEd, DipVET
se
Manager, Bourke Street Campus, Holmesglen Institute,
Melbourne, Victoria, Australia
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Vicki Blair Drury RN, RMHN, OND, PhD, MClNsg,
PostGradDipMentHlthNurs, GradCertMensHlth,
BHlthSc(Nsg), BA(Ed)
©
Adjunct Associate Professor, Curtin University, Perth,
Western Australia
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Independent Scholar, Educare Consulting, Australia
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Ann Bolton RN, BN, MCN, GDipAdNurs, GDipMid,
GDipVET, GDipCritCare, Cert IV TAE
Educator, Partners in Training, Shepparton; GOTAFE,
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Seymour, Victoria; Batchelor Institute of Indigenous
Tertiary Education, Batchelor, Northern Territory,
e
Australia
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Marie Casamento RN, BN, GradCert Clinical
Education Certificate in Wound Management, Cert IV in
m
Training & Assessment
Nurse Educator, Holmesglen Institute, Victoria, Australia
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Colin Cassells MGeront, PG DipAdvNsg (Community
Health), Cert Cont Prom, BSc, RN, MCNA
Continence Nurse Specialist (private practice), Melbourne,
Victoria, Australia
Kym Davey RN, RM, BN, Cert IV TAE
Lecturer in Midwifery, Monash University
Lecturer in Nursing, TAFE-Holmesglen,
Victoria, Australia
ix
Contributors
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Shannon Forsyth RN, GradCert Advanced Nursing
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Reproductive and Sexual Health Nurse, Australia
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Meagan Gaskett RN, BN, BHSc, Cert IV TAE Grad
st
Dip VET (Adult Ed), MNursSci
TAFE Trainer & Assessor Nursing
Au
Clinical Nurse Educator/Clinical Support Nurse, Northern
Health, Melbourne, Victoria, Australia
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Jasmine Gunaratnam (née Alagappan) RN, MN,
GradDip, Peri Op Nurs, GradCert TAE, GradCert BusMgt
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Lecturer Bachelor of Nursing, Holmesglen Institute,
Benetas—Quality Business Improvement Advisor
Melbourne, Victoria, Australia
Michelle Hall RN, BN, Cert IV TAE, Grad Cert Health
Professional Education, MHPE
Education Manager—Diploma of Nursing, Holmesglen
Institute, Victoria, Australia
Jodie Hughson MPH, GCHP, Cert IV TAE, RN
Quality and Risk Manager, Healthecare Australia,
Woolloongabba, Queensland, Australia
Yangama Jokwiro RN, MPH, MSc Physiology
Senior Lecturer, La Trobe Rural Health School,
La Trobe University, Victoria, Australia
Taryn Kellerman RN, BN, MAdvNsg, GradDip Adult
Educ, DipVET, DipTDD
Lecturer, School of Nursing and Health Sciences,
Chisholm Institute, Dandenong; Swinburne University,
Victoria, Australia
Toni Kennison RN, Bachelor Nursing Practice,
Emergency Nursing Cert IV TAE
Lecturer in Nursing TAFE, Gilles Plains, South Australia,
Australia
Rehana Khan Master Clinical Education, RN, BSN,
DipCounselling, Cert IV TAE
NSW Health Workforce Development Consultant,
Centre for Education & Workforce Development
(SLHD), Sydney, New South Wales, Australia
x Contributors
Gabrielle Koutoukidis MPH, BN(Mid), DipAppSci(Nur),
AdvDipN(Ed), DipBus, Voc Grad Cert Business
(Transformational Management), MACN
International Specialised Skills Institute Fellow, Candidate
EdD (Research)
Dean, Faculty Health Science, Youth & Community
Studies, Holmesglen, Melbourne, Victoria, Australia
Anne MacLeod ME (Adult), GC (Flexible Learning
& Simulation for Health Professionals), GCEd (Adult),
GDip (Adult), BN, DipAppSci(Nur), DipVocEd,
CertNero, CertAcCare
Teacher, Health Wellbeing and Community Services,
TAFE NSW North Region
Nurse Educator, Quality, Risk Manager, Toronto Private
Hospital, Toronto, New South Wales, Australia
Auxillia E Madhuvu RN, BN (Hons), MN, DipVET,
Dip Training Design & Development, PhD Candidate
Associate Lecturer, School of Nursing and Midwifery,
Monash University, Melbourne, Victoria, Australia
Renee McBride RN, BN, Cert IV TAE, Grad Cert
Clinical Nursing & Teach, MAdEd
TAFE Teacher Nursing and Aboriginal Health
St Leonards, New South Wales, Australia
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Michelle McKay BN, BVoc ED, Grad Cert (Paeds &
Oncology), DipAppSc (Nurs), Dip TAE, Cert IV TAE
Teacher-Nursing, Health, Wellbeing & Community
©
Services, Hunter TAFE, Newcastle, New South Wales,
Australia
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Andrea Miller, RN, BN (Hons), Grad Dip Health
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Science, MCN, MEd
Lecturer, School of Nursing, University of Tasmania,
Hobart, Australia
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Sally Moyle BN, MClinNursTeach, Cert IV TAE
Clinical Nurse Educator, Epworth Health Care,
e
Melbourne, Victoria, Australia
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Goetz Ottmann BA/Hons, PhD, MSWQ
m
Associate Professor Social Work, Australian College of
Applied Psychology,
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Sydney, New South Wales, Australia
Kylie Porritt RN, GradDipNursSc(Cardiac), MNSc, PhD
Senior Research Fellow, Joanna Briggs Institute, University
of Adelaide, South Australia, Australia
Kalpana Raghunathan RN, PhD student, MNursEd,
MHRM, MDevStudies, GradDip DevStudies, BNurs, BA
Sociology, Dip ComDev, Dip BusMgt, CertIV TAE
Education Development Consultant, Carramar
Educational Design, Victoria, Australia
Heather Redmond RN, BN, MN, BNHon, GradDip
CritCare, GradCert HDU Nursing, DipVET
Program Manager, TAFE Gippsland, Victoria, Australia
Bob Ribbons RN, ICCert, BAppSc (Nur), MEd
(Computing), FACHI
Lecturer, Bachelor of Nursing, School of Nursing, Faculty
of Health Science, Youth and Community Studies,
Holmesglen Institute, Holmesglen, Victoria, Australia
ia
Desiree Rodier RN (Emergency), BNurs
Teacher, Nursing Health, Wellbeing and Community
l
Services Skills Team, TAFE NSW, New South Wales,
ra
Australia
st
Bianca Rohlje RN, MEd, BNurs, DipVET
Lecturer in Nursing and Health Sciences, Latrobe
Au
University and Latrobe College, Victoria, Australia
Juanita Sherwood PhD, RN, DipT(Primary),
PGCertCollabRes
er
Professor, Academic Director, National Centre for
Cultural
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Competence, University of Sydney, Sydney, New South
se
Wales
Adjunct Professor of Indigenous Health, Public Health,
James Cook University, Townsville, Queensland, Australia
Patricia Sinasac, RN, STN, MASc (Research), GradDip
AdvNrsg Educ, GradCert Stomal Therapy, BN
Clinical Nurse Consultant, Wound Management &
Stomal Therapy, Community and Oral Health, MNHHS,
Chermside, Queensland, Australia
Kate Stainton MA HlthSci(Nurs), GDipNurs(Ed),
BN(Mid), DipAppSci(Nurs), Cert IV TAE
Industry Relationship Lead, Health, Wellbeing and
Community Services SkillsPoint, TAFE NSW, New South
Wales, Australia
Andrea Steele RN, BN, GradDip AdvNsg Rural
Critical Care, MHSM GradCert Tertiary Teaching, Dip TAE
Coordinator, South Nursing and Aged Care, GOTAFE,
Victoria, Australia
Kim Louise Strachan MPH, BN, DipHlthProm,
DipPM
Nursing Teacher, TAFE Queensland, Brisbane, Queensland,
Australia
Karren Taber BNurs, RN (Anaesthetics and Recovery),
GradCert Anaesthetic and Recovery Room Nursing,
GradCert Perioperative Nursing, Cert IV TAE
Registered Nurse, Operating Theatres, John Hunter Hospital
Casual Teacher, Nursing, TAFE NSW, Hunter Institute,
Newcastle, New South Wales, Australia
 Contributors xi

Melissa Taylor RN, PhD, MHlthSci,
GrDipHlthProm(Dist)
Senior Lecturer, Coordinator (Post Graduate—Leadership
& Management in Health), School of Nursing and
Midwifery, Faculty of Health, Engineering and Sciences,
University of Southern Queensland, Ipswich, Queensland,
Australia
Denise B Tomaras BA(Psych), RN, PostGrad(Nsg Crit
Care), DipEd, DipSci, DipFP
Glenda Verrinder PhD, MHSci, GradDip Public &
Community Hlth, GradCert Higher Education, GradCert
Community Nsg, RN, Midwife
Honorary Associate, La Trobe Rural Health School,
La Trobe University, Australia
Heather Wakefield PostGradDip Advanced Clinical
Nursing (Crit Care), GradDip Clinical Nursing Education
Dip VET, Cert IV TAE, RN, BN
Senior Teacher, Diploma of Nursing, Department of

ia
Education Manager—Department of Nursing, Holmesglen Health, Science and Community, Swinburne University,
Institute, Melbourne, Victoria, Australia Melbourne, Victoria, Australia

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xii

Reviewers

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Bronwyn Bennett RN, BA of Health Science (Nursing) Janice Martin RN, MEd, GradDipAdvNsg(ClinEd),

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Cert IV TAE, TAE50216 Diploma of Training Design GradCertAcuteClinNsg(IntensCare), Cert IV TAE

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and Development, TAE50116 Diploma of Vocational Education Manager, Health and Community Centre of
Education and Training Excellence, Kangan Institute, Victoria, Australia

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Nurse Lecturer, CRTAFE, Northam, Western Australia,
Australia Rosemary Mitchell RN, BN, Grad Dip (Leadership),

Au
MEd
Sue Ganley RN, Dip VET, Dip App Sci Senior Academic Lecturer, Department of Health Practice,
Lecturer, Enrolled Nursing, TAFE SA, South Australia, Ara Institute of Canterbury Ltd, Christchurch, New

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Australia Zealand

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Morag MacKenzie NZCpRN, PGDip HSci, PG Cert Mike Shearsmith RN, BNSc, AdvDip Nursing
TDR, CAT, CATE (perioperative)
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Senior Academic Staff Member, Wintec, Hamilton, Course Coordinator, Open Colleges School of Health,
New Zealand Western Australia, Australia
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xiv
Preface
The eighth edition of Tabbner’s Nursing Care is contempo-
rary, includes informatics to assist Enrolled Nurses to work
within the digital world, and reflects the enrolled nursing
scope of practice, assisting graduates to be competent, safe
and able to work flexibly to adapt to changing and challeng-
ing healthcare environments. This new edition retains, and
builds on, the strengths of previous editions that have made
Tabbner’s Nursing Care an essential resource for enrolled
nursing students and their educators.
THE ROLE OF THE ENROLLED
NURSE
The Enrolled Nurse is an essential member of the healthcare
team, providing person-centred, safe and competent nurs-
ing care. Enrolled Nurses’ responsibilities also include pro-
El
viding support and comfort, assisting with activities of daily
living to enable individuals to achieve their optimal level
of independence, and providing for the emotional needs
©
of people. Where state and territory law and organisational
policies allow, Enrolled Nurses may administer prescribed
fs
medicines or maintain intravenous fluids, in accordance
with their educational preparation.
oo
Enrolled Nurses are required to be information-
technology literate, with specific skills in the application
of healthcare technology. Enrolled Nurses demonstrate
pr
critical- and reflective-thinking skills in contributing to de-
cision making, including reporting changes in health and
e
functional status and individual responses to healthcare in-
terventions. Enrolled Nurses work as part of the healthcare
pl
team to advocate for, and facilitate, the involvement of indi-
viduals, their families and significant others in planning and
m
evaluating care and progress towards health outcomes. The
role also requires them to act as preceptors for students and
Sa
other healthcare workers.
Career opportunities for Enrolled Nurses are expanding
and include acute care; perioperative, emergency, intensive
and coronary care; aged care; rehabilitation; community and
mental health nursing; and general practice settings. In
ia
addition, Enrolled Nurses work in specialty areas such
l
as nursing education, diabetes education, continence man-
ra
agement, dementia management, lactation consultancy,
workplace safety and wound care. There are also increasing
st
opportunities for Enrolled Nurses to move into manage-
ment positions.
Au
EIGHTH EDITION OF TABBNER’S
NURSING CARE
er
Person-centred care is the approach used throughout the
vi
textbook, allowing students to appreciate the skill and scope
required to be a safe and competent Enrolled Nurse. All
se
chapters have been completely revised with a focus on criti-
cal thinking and problem solving, quality and safety and
evidence-based practice, with national registration require-
ments addressed where appropriate.
The full-colour internal design enhances photographs
and illustrations to provide clear and meaningful visual aids
to learning.
The eighth edition has been carefully developed to align
with the Diploma of Nursing in the HLT Health Training
Package for the enrolled nursing student. It provides a con-
temporary approach to nursing practice and is an invaluable
teaching resource. The text provides the theoretical knowl-
edge on the care that individuals may require in a range
of healthcare settings and offers special features to enhance
student learning of the material.
This edition is a culmination of the efforts of many
nursing academics and professionals who are passionate
about the education of Enrolled Nurses and the important
role they play in healthcare settings. We are grateful for their
enthusiasm and support throughout the writing process. In
addition, we would like to thank the team at Elsevier for
their hard work and perseverance in ensuring the publica-
tion of this edition.
Gabby Koutoukidis
Kate Stainton
 CHAPTER
5 technology in healthcare
KEY TERMS
big data
browser
business analyst
central processing unit (CPU)
clinical informatics
clinical information system
(CIS)
computer literacy
convergent technology
database
data standards
digital health
electronic health record (EHR)
email
hardware
health informatics
health information technology
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(HIT)
hospital information system
(HIS)
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informatics
informatics competency
information and communication
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technology (ICT)
information literacy
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information management
information technology (IT)
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Internet of Things (IoT)
local area networks (LANS)
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management information
system (MIS)
medical informatics
mobile technology
nursing informatics
nursing minimum data sets
picture archiving and
communication system (PACS)
protocol
random access memory (RAM)
read only memory (ROM)
shared electronic health record
(SEHR)
Nursing informatics and
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Bob Ribbons and Kalpana Raghunathan
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ra
st
LEARNING OUTCOMES
Au
At the completion of this chapter and with further reading, students should be
able to:
er
΄ Define informatics, health informatics and nursing informatics
΄ Describe the nursing informatics standards for nurses in Australia
vi
΄ Discuss the fundamentals of information technology including concepts of
hardware and software
se
΄ Discuss the role of the internet and the web in contemporary healthcare
΄ Demonstrate a beginning understanding of how specific software
application (e.g. word processing, spreadsheet, database, presentation
El
and statistics) may be applied to nursing practice, administration,
education and research
΄ Describe the role of database, communication and network technology in
©
the development, implementation and utilisation of information systems
΄ Understand issues related to informatics ethics, privacy and confidentiality
΄ Demonstrate a beginning understanding of the role of computer and
fs
network security in maintaining health information system integrity
΄ Describe the need for data standards and nursing minimum data sets
΄ Discuss contemporary health information technologies and their role in
improving delivery of healthcare
΄ Demonstrate an understanding of current trends in digital health including
the use of social media and how they influence the development,
implementation and utilisation of information systems
΄ Discuss specific clinical, administration, education and research
information systems and determine their role in improving nursing care
social media telehealth
social network telenursing
software universal serial bus (USB)
spreadsheet world wide web (WWW)
100 UNIT 2 | The contemporary healthcare environment

CHAPTER FOCUS
Today, the provision of effective healthcare by multidisciplinary teams requires access to timely, accurate health
information data. As the electronic health record (EHR) becomes the source of health information and aids in the
planning of individual care, it is essential that any health data generated can be collected, exchanged, stored and
retrieved from healthcare information systems. In this increasingly technology-driven healthcare environment, nursing
professionals will be required to possess not only computer literacy but, more importantly, information literacy and
information management skills.
This chapter examines the relationships between computers, information technologies and the provision of
nursing care. Nursing graduates, both enrolled and registered, need to be cognisant of contemporary issues in nursing
informatics and possess skills in the use of information technologies in healthcare settings.

l ia
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LIVED EXPERIENCE

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I went to a seminar recently about digital hospitals. In this talk they discussed that individuals being admitted to a

Au
digital hospital will have a bar code on their identification band. Nurses will have smartphones and will scan the
barcode and up on the phone will come all the individual’s details, care plan, medications, medical and nursing history!
These hospitals will be silent, with all messages and alerts coming up on the smartphones. Nurses will be able to
find equipment—by searching on the phone—which will inform the nurse where the piece of equipment is, instead of

er
looking everywhere for it in the hospital and phoning around wards. It sounded like something out of a James Bond
movie. The emerging technologies in health are amazing!
Siobhan Robbie, Enrolled Nurse, Acute Care Facility

vi
se
AN INTRODUCTION TO Informatics is described as the science of using data,
El

INFORMATICS information and knowledge to improve human health and

healthcare service delivery (American Medical Informat-
It is hard to imagine conducting a transaction with a bank, ics Association 2011). Informatics is used in clinical and
©

purchasing an airline ticket or doing the grocery shopping non-clinical applications to manage the different aspects
without some involvement of computers or information of healthcare services. An example of non-clinical activities
fs

technology (IT). IT refers to all forms of technology used to is rostering or allocations; common clinical applications in-
create, store, exchange and use data, information and knowl- clude medication administration system and EHRs.
oo

edge (Hebda et al 2018). IT essentially provides the infrastruc- The interdisciplinary specialty health informatics is
ture for a networked economy and in doing so forms a highly part of informatics focusing on the use of health informa-
widespread component of modern society. It is so ubiquitous tion technologies (HIT) to manage and communicate data,
pr

that often individuals are unaware of their interaction with the information, knowledge and wisdom in the provision of
technology. In many respects, IT is not only taken for granted, healthcare. Health informatics integrates the health, com-
it is expected. IT has made life easier and more convenient. puter and information sciences as well as other analytical
e

At the same time, some might say it has made our lives more sciences to assist healthcare delivery (Nelson & Staggers
pl

complex. One only needs to think how email has impacted the 2018). Health informatics involves a wide collection of
workplace. We are now inundated with information, much of health professionals including doctors, nurses, radiogra-
m

it superfluous, but all of it requiring some form of attention. phers, pharmacists, physiotherapists, health information
The use of computers and information technology as a managers, clinical researchers, administrators and comput-
Sa

way of managing health information is also becoming almost
ubiquitous (Roehrs et al 2017) and has been the impetus for
the rapid evolution of nursing and health informatics in the
past few years. We are now witnessing increased implemen-
tation of electronic records, the use of medication adminis-
tration technology, clinical mobile devices, patient portals,
wearable technologies and the potential for increased use of
internet-enabled devices (Booth 2016). The development
of these technologies in healthcare usually involves a range
of health professionals and their different practices such that
we often see a number of healthcare professionals involved
in the development of information systems.
ing professionals. Clinical informatics is a narrower term
that addresses the use of information systems specifically
related to individual care by nurses as well as medical and
other health professionals (Masters 2018).
Nursing informatics works within the broader con-
text of health informatics and is both an area of nursing
study and a field of nursing specialisation (Masters 2018).
In other words, nursing informatics is a sub-group of health
informatics that deals with nursing-specific issues. Medical
informatics is another sub-group largely comprising doc-
tors and dealing with health data from a medical perspec-
tive. Nursing informatics is a relatively new specialty and

Health
information
Informatics
Science/
technology/ People
analytics
Figure 5.1 Health informatics
(K. Raghunathan)
was first recognised as a specialty by the American Nurses
Association in 1992 (Hebda et al 2018). See Figure 5.1 for
an illustrated overview of health informatics.
El
NURSING INFORMATICS
©
Graves and Corcoran (1989) first defined nursing infor-
matics as ‘a combination of computer science, information
fs
science, and nursing science designed to assist in the man-
agement and processing of nursing data, information and
oo
knowledge to support the practice of nursing and the deliv-
ery of nursing care’ (p. 227). In essence, nursing informatics
is an amalgam of nursing science, information science and
pr
computer science for the purpose of managing health infor-
mation to enhance the provision of quality healthcare.
Nursing informatics has had a somewhat difficult be-
e
ginning and although it has been recognised as a nursing
pl
specialty for the past three decades, many nurses still do not
understand the nature of this discipline. The definitions of
m
nursing informatics have changed over time to reflect the
developments in nursing practice and technologies. The
Sa
most widely accepted definition now comes from the Inter-
national Medical Informatics Association—Nursing Infor-
matics (IMIA-NI) group who defined nursing informatics
as ‘science and practice (that) integrates nursing, its infor-
mation and knowledge, with management of information
and communication technologies to promote the health of
people, families, and communities worldwide’ (American
Medical Informatics Association 2018).
In their various roles and specialty areas, nurses handle
large volumes of data; nursing informatics is concerned with
all aspects of this. For example, it encompasses all aspects
of access, retrieval and efficient use of data, information
Nursing informatics and technology in healthcare | CHAPTER 5 101
Biomedical
informatics
Pharmacy Medical
Clinical
informatics informatics
informatics
Health
informatics Nursing
informatics
ia
Medical
informatics
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Nursing
ra
informatics
Clinical
st
informatics
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and knowledge to support decision making, which in turn
se
enhances the quality, effectiveness and efficiency of nursing
care. While information and communication technology
(ICT) is essential to nursing practice to support the devel-
opment and dissemination of new knowledge, it can also
support and empower an individual’s decision making and
healthcare choices (Conrick 2006). Nursing informatics
offers a range of tools that assist in advancing nursing as a
professional research-based discipline (Hebda et al 2018).
Improved database technology enables the timely collec-
tion, storage and analysis of vast amounts of data. This is
made available and retrievable as information in a manner
that nurses require it to support their practice. It also allows
nurses to critically review their practices based on the
evidence that can be provided by these systems.
The role of nurses in an informatics context can vary from
the routine user at the clinical interface, to a super user assist-
ing in the implementation of systems, to application special-
ists, system administrators and business analysts. In the USA,
suitably credentialled nurses holding postgraduate qualifica-
tions in informatics are able to take on the role of informat-
ics nurse specialist (Hebda et al 2018). Recently, the Health
Informatics Society of Australia, the Health Information
Management Association of Australia and the Australasian
College of Health Informatics have established an Australian
informatics certification program in order to address the
lack of formal recognition of health informatics knowledge
and skills in Australia. The Certified Health Informatician
Australasia (CHIA) certification ensures candidates are able
to demonstrate the application of a number of health infor-
matics core competencies to perform safely and effectively as
a health informatics professional in a broad range of practice
settings (Health Informatics Society Australia 2018).
102 UNIT 2 | The contemporary healthcare environment
NURSING INFORMATICS
COMPETENCIES
In Australia, the national digital health agenda is evident
through increasing adoption of information and commu-
nication technologies (ICT) such as EHR and telehealth
systems to integrate and improve delivery of healthcare and
services. Healthcare providers depend on the digital systems
such as EHR for data collection, communication and clini-
cal decision support, and nurses have an integral role in this
process (Herbert & Connors 2016; Jenkins et al 2018; Miller
et al 2014). This technology-integrated healthcare environ-
ment makes informatics knowledge and skills, and the ability
to use the ICTs in the context of practice efficiently, an absolute
essential for all healthcare professionals today. It is vital for pro-
viding effective, efficient, safe and integrated care, leading to
positive health outcomes (Nelson & Staggers 2018).
The shift to digital healthcare has a significant impact on
everyday nursing practice and the educational preparation
of nurses. As we rapidly move to technology-enabled health-
care, proficiency in technology skills and ability to utilise
information systems to support clinical decision making,
and deliver high-quality and safe care, are core to the prac-
tice of nursing (Gardner & Jones 2012; Huston 2013).
It is expected that nurses at all levels have fundamental
se
computer skills, as well as informatics capabilities to man-
age and use the health technology and data applications in
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the healthcare environment. Equally, there is also an expec-
tation that beginning-level nurses entering the workforce
are adequately prepared to use health informatics and the
©
ICT in the work environment, and basic informatics edu-
cation is addressed within the entry to practice curriculum
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(Australian Nursing & Midwifery Accreditation Council
2014; Australian Nursing and Midwifery Federation
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(ANMF) 2015; HISA- ACN-NIA 2017).
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e
Informatics competencies include the psychomotor
skills to confidently use computers and ICT devices, and
specific informatics knowledge and skills to support prac-
tice, which involves working with health data, processing
information and contributing to knowledge development
for nursing practice (Schleyer et al 2011). Examples of how
nurses use informatics skills in everyday practice include
using ICT to:
t
Access data, record, retrieve and manage health data
t
Share and communicate health data
t
Interpret and organise information for decision sup-
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port and care interventions
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t
Synthesising health data to generate new knowledge
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for nursing practice.
(Hebert 2008)
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Figure 5.2 illustrates the continuum and application of
informatics in nursing practice.
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At present there are informatics standards for nurses
in Australia, which identify the level of IT knowledge and
skills required of all nurses for practice. See National Infor-
matics Standards for Nurses and Midwives—there are three
er
domain areas of focus for nursing informatics education
and competence: computer literacy, information literacy and
vi
information management skills (ANMF 2015). The do-
mains involve technical, cognitive and application-based
competencies necessary to support routine daily nursing
practice activities and processes in the technology-enabled
work environment. These standards serve as a detailed
resource and a valuable tool for practising nurses, educa-
tors and nursing students to build informatics capability
to support practice and improve health outcomes (Reeves
2016). (See Clinical Skill 5.1, Clinical Interest Boxes 5.1
and 5.2). In addition, there is the Australian National
Nursing and Midwifery Digital Health Capabilities Frame-
work, a guide for individuals and organisations towards
Wisdom


  
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Knowledge b


 
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Information  ing
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or 

 
 
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Figure 5.2 Nursing informatics application in practice

(K. Raghunathan)

developing digital health knowledge and skills in the in-
creasingly digitised work environment (AIDH 2020). Five
key domains viewed within the context of roles, workplace
settings and the professional practice standards are identi-
fied: digital professionalism, leadership and advocacy, data
and information quality, information-enabled care, and
technology. Three progressive achievement levels, from
novice to expert, are also described for each capability
area: formative, intermediate and proficient, which relate
to the role and practice setting of the professional (AIDH
2020). Nurses should evaluate their own individual abili-
ties against the informatics standards and digital health
capability framework, which can then be used to inform
continuing professional development needs.
In healthcare, a range of health technologies and in-
formation systems are utilised. There is multidisciplinary
input and engagement with these systems. In reality,
it would not be possible to learn about all the different
systems in use. What is necessary and important is learn-
ing the fundamentals around navigating computers, and
being aware of digital care technologies or devices and
CLINICAL SKILL 5.1 Nursing informatics competency
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Review and carry out the standard steps for all clinical skills/interventions; these steps must be performed
consistently with each individual to ensure safe nursing care is provided
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NMBA Decision-making Framework considerations
(refer to NMBA Decision-making framework for nursing
©
and midwifery 2020):
1. Am I educated?
2. Am I authorised?
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3. Am I competent?
If you answer ‘no’ to any of these, do not perform that
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activity. Seek guidance and support from your teacher/a
nurse team leader/clinical facilitator/educator
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Digital literacy
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Skill activity
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Application of basic knowledge and skills in information and communication technology (ICT) to support work practice
m
Understand basic ICT terminology
Sa
Basic use of ICT to support work, includes:
΄ Computer system
΄ Computer and device security
΄ Electronic devices
΄ Intranet, internet, the world wide web and WiFi
΄ Electronic communication tools
΄ Electronic file management
΄ Word processing
΄ Spreadsheets
΄ Databases
΄ Presentation
Nursing informatics and technology in healthcare | CHAPTER 5 103
data management systems used in the healthcare environ-
ment. A foundational understanding of informatics skills
and knowledge will assist in preparation for the clinical
environment and professional practice as a nurse. Dur-
ing clinical rotations, students will gain more knowledge
and become familiar with specific workplace technologies
through work experience placements and on entry to the
nursing profession.
A BRIEF HISTORY OF
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COMPUTERS AND INFORMATION
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TECHNOLOGY
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The history of computing can be traced back to around 5000
st
BCE with the use of Persian clay boards. The abacus has
been in use in China since around 2000–3000 BCE (and
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is still in use today). However, the genesis of the computer
as we know it today originates in 1642 with the invention
of Pascal’s mechanical counter. This device was able to
add, subtract, multiply and divide much like a modern day
er
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Equipment:
Computer
Tablets and handheld devices
ICT external devices, multimedia tools
Telecommunication tools
Smartphones
Internet web access
Healthcare records
Learning software/applications
Information databases/educational platforms
Educational learning technologies
Rationale
Knowledge of common ICT terminology such as web browser,
website, cloud based, internet, intranet, interoperability,
operating systems, home page, hypertext link, bookmark, URL
(Uniform Resource Locator) address, encryption, backing up
Demonstrates psychomotor skills as well as knowledge to
use the software and device applications optimally
Able to use hardware (e.g. mouse, screen, workstation)
and the software (primary operating systems, programs
and applications) relevant to work; knows basic
troubleshooting for checking power, rebooting and printing
Understands and respects legal and organisation policy
guidelines to protect data privacy and confidentially, login
and logging out, suspending sessions and password
protection
Continued
104 UNIT 2 | The contemporary healthcare environment

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Protects against computer viruses and malware
Reports unauthorised use or breach to appropriate
personnel
Knows how to use external/peripheral devices such as
USBs, tablets and handheld devices, smartphones apps
and point-of-care (POC) digital devices, wearables
Able to use internal organisational (intranet, private networks,

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shared file servers); and external web-based (world wide
web, cloud computing, internet browsers) systems

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Able to use remote communication tools such as emails,

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facsimile, skype, online discussion forums, chat or other
messaging applications and telehealth apps and tools

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Able to navigate the computer operating systems to
access installed applications such as Microsoft Windows

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to organise and manage information files and data
Able to use basic desktop software Microsoft Word and
Excel to create, access, categorise and store reports and

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documents. Able to save, cut, copy, paste and delete
information

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Able to locate online search engines and electronic
collections of data to research and search information
se
Able to use basic desktop software Microsoft PowerPoint
and other web-based multimedia tools, e.g. videos,
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podcasts, You Tube, slideshow, etc

Consider the workspace design, the environment and Understands workplace health and safety requirements,
workstation safety to protect self and others in relation to equipment, body
©

mechanics and safe work practices, and minimise risk

of injury or harm. Includes bedside, workstation and
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portable technology
Professional practice
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Skill activity Rationale

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Work in accordance with the legal and regulatory requirements, professional standards and ethical principles for
all uses of ICT in work practice
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Uphold the legal, regulatory and ethical standards related Understands and respects legislation and policies.
to the use of digital health information E.g. data security, storage, disposal, protection of health
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information, privacy, confidentiality, individual’s rights,

impact on individual and community, harmful content,
m

safety, social media, professional boundaries, passwords,

information sharing, unauthorised or illegal use and
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breaches in data security

Follow requirements for intellectual property, copyright
and fair use of copyrighted material
Standards for safe and appropriate use of ICT in health.
E.g. the Australian Council on Healthcare Standards
(ACHS) (EQuIP) Information Management Standard
includes: criteria for Health Records Management;
Corporate Records Management; Collection, Use
and Storage of Information; and Information and
Communication Technology
Understands and respects legislation and policies
pertaining to patents, design, trademarks, authorship,
publications, ownership of material, etc
Aware of Australian Copyright Act, statutes, fair dealings,
provisions and exceptions
 Nursing informatics and technology in healthcare | CHAPTER 5 105

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Consider cultural, ethical and socioeconomic issues
related to accessing and using the information
Proactive use of ICT to improve health outcomes, support
professional practice and lifelong learning
Understands and respects legislation and policies.
E.g. protection of privacy and confidentiality, impact on
individual and community, human rights, cultural safety,
access and equity issues
Actively promotes and engages in the use of educational,
informatics and other ICT tools to build on digital
capability to support work, professional development
and ongoing learning

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Information literacy

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Skill activity Rationale
Application of fundamental knowledge and skills to identify, locate, access, evaluate and apply information

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to support work practice

Use the internet to search, locate and download relevant
information
Plan and use online search strategies for scholarly
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Able to use basic online searching options through a
search engine to locate organisations, services, websites
etc (e.g. Google, Ask.com, Bing)
Knows how to conduct literature search and locate

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literature evidence-based resources and websites to support
informed and safe practice

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Knows how to use available proprietary search databases
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such as CINAHL, EBSCO, JBI, etc
Use multiple sources of data to retrieve information to Able to use various and additional services such as
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support work library resources, professional associations, government

websites, research institutes, peak bodies, community
resources, relevant experts and practitioners to obtain or
retrieve information needed to support clinical judgment
©

and evidence-based decision making

Use ICT and informatics tools to obtain information Able to use electronic records, POC databases, clinical
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applications and communication tools to assist workflow,

evidence-based decision making and care planning, and
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for health teaching

E.g. digital systems for care plans, admission and
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discharge, clinical information systems (CIS), handovers,

medication management and proprietary clinical decision
solutions such as Clinical Key and UpToDate
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Evaluate various sources of information Ensures information is evidence-based, best practice,

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current and supports safe and informed high-quality

practice. Analyses and understands the available
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information, by critically evaluating reliability, currency,

validity, accuracy, authority, timeliness and point of view
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or bias in information for determining its suitability and

appropriate use
E.g. guidelines, policies, procedures and protocols,
scholarly and best practice literature
Recognises specific cultural, physical or other context of
information. Understands the background and specific
nature or type of information, including its range and
limitations, when interpreting and applying it to practice
E.g. population health, demography, cultural safety,
gender, specific health needs, etc
Continued
106 UNIT 2 | The contemporary healthcare environment

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Manage information collected or generated
Information management
Organises and documents data and information using
ICT tools
Appropriate use of POC digital tools and CIS (e.g. vital
signs, measurements, observations, progress notes,
care plans, medication management), electronic record
systems (e.g. EMRs, EHRs and personal health records
(PHRs)) and other ICT tools used in healthcare

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Skill activity Rationale

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ra
Application of fundamental knowledge and skills in collection, use, management and storage of data, information
and ICT to support safe and informed practice

st
Recognise digital data storage methods and formats Knowledge of EHRs, EMRs, PHRs (e.g. My Health
Records), including levels and types of POC applications

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E.g. practice management systems, patient administration
systems, bed management systems, hospital
management systems, aged care and long-term care
systems, clinical portals and patient acuity systems,

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digital monitoring systems, prescribing and medication
administration systems, order entry systems, health and

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safety reporting, quality and audit systems, and clinical
data repositories and POC decision tools
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Distinguish between data and information and how it can Understands that data is raw, unorganised and
be used to support work unprocessed individual information (facts) which may
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not be useful by itself. When this data is organised,

processed and given context to make it meaningful it
becomes information
©

E.g. by itself, a person’s vital signs, measurements,

pathology or diagnostic test results are raw data. When this
data is organised and presented to obtain a picture of the
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person’s health it is information about the individual

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Use of digital records and information systems Knows how to use digital health records, clinical
appropriately databases and other informatics tools for accessing and
investigating information to support safe and informed
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practice as per organisation policy (e.g. use of EMR,

EHRs, PHRs, CIS, and other data systems)
Integrate and use digital communication Communicates remotely with other healthcare
e

professionals, services, colleagues and healthcare

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recipients/their families/carers in delivery and

management of timely care
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Knows how to use networks, intranets, and internet

for emails, messaging, referrals, reports, handovers,
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transfers, telehealth, etc

Recognise embedded decision support systems and
clinical workflows to guide work
Responds to safety alerts, reporting and workflow triggers
and parameters
Reviews POC clinical data to guide timely decisions,
interventions and workflow
Knowledge of system-generated administrative, clinical
and safety workflows and reporting prompts and
requirements
E.g. electronic applications used for admissions and
discharge, bed management, patient care activities,
medication safety alerts, best practice alerts,
credentialling, etc
 Nursing informatics and technology in healthcare | CHAPTER 5 107

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Use data and statistical reports for quality improvement
Recognise common informatics classifications, coding
systems and languages
Understands value and link between quality nursing care
and health outcomes, which has the ability to influence
policy, budgets, practice, allocation of resources,
research and education
E.g. episode of care outcomes and activities can be
evaluated for improvements
Aware of technical and IT specific coding systems,
classifications, terminology and language used to

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describe, standardise and collate the computer data or
common set of data to make it meaningful

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E.g. application of data standards, minimum data sets,

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clinical dictionaries and clinical language system such
as Systemised Nomenclature of Medicine (SNOMED)

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International Classification of Diseases (ICD-10) and the
North American Nursing Diagnosis Association (NANDA)

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Maintain accurate and up-to-date records and Accurate, comprehensive, timely and up-to-date
documentation information enhances quality of data and increases
reliability and validity of information to guide timely
decisions and improve safety and health outcomes

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Interdisciplinary and stakeholder engagement relating to Demonstrates interprofessional interdisciplinary and

vi
digital records individual/family/carer collaboration for effective and
efficient holistic and person-centred model of care
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Uses digital applications and information methods for
health teaching
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Note: There are several different digital health and ICT systems in the clinical environment. How each facility and
healthcare agency uses these information management and clinical support systems varies. With rapid technology
developments and ICT constantly evolving, new POC and information management solutions to improve health
©

services and delivery of care continue to emerge. In reality, it is not practical to learn the use of each and every
individual ICT tool in the work environment. Therefore, the emphasis for developing nursing informatics competencies
among nursing students is an understanding of the core principles and essential skills that can be built upon with
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ongoing exposure to health IT and professional experiences.

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Due to liability for data entry errors, confidentiality and data security concerns, some facilities may restrict or only allow
limited access to the digital data systems during clinical placement for students. At some clinical facilities, students may
be required to complete an orientation module before being allowed access to the system. In the clinical environment,
pr

all staff are required to complete user training modules before being allowed to use the health IT systems.
It is recommended that students optimise opportunities to master ICT and informatics skills through educational and
communication technologies used in the course and the institution.
e

(AIDH 2020; ANMF 2015; Honey et al 2018; Nagle et al 2014; Nursing Informatics Learning Centre 2010–2012; Rahman 2015; Sun & Falan 2013)
pl
m
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CLINICAL INTEREST BOX 5.1 National Informatics Standards for Nurses

and Midwives
The three domains for nursing informatics education and competence for nurses and midwives in Australia are:
΄ Computer literacy
Understand the basic concepts of computers, electronic devices, operating systems, intranets, hardware, software
and peripheral devices
΄ Information literacy
Use fundamental knowledge and skills to identify, locate, access, evaluate and apply information
΄ Information management
Use knowledge and skills to ensure safe, legal and ethical management of health information for professional
practice and lifelong learning, appropriate to context of practice.
(Australian Nursing and Midwifery Federation 2015)
110 UNIT 2 | The contemporary healthcare environment

TABLE 5.2 | Different types of point-of-care computing devices used in healthcare

Device Description
Minicomputers The minicomputer, with some of the processing power of the mainframe, allowed for multiple
users, but was smaller and less expensive. Microcomputers were in common use in healthcare
settings in the 1980s and 1990s and could be found in radiology and pathology departments
Personal computers PCs are microcomputers, which are also referred to as desktop computers. PCs have an entire
(PCs) processing unit on one microprocessing chip. PCs may function independently or in a network
situation such as when the PC may be connected to servers and other PCs

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Laptop computers/ The laptop/notebook is a version of a PC that is transportable and small enough to sit on the

l
notebooks user’s lap. Laptops are now smaller and more intelligent, and are commonly referred to as

ra
‘notebook’ computers. The laptop/notebook may be plugged into a docking station on a desk,
which then allows for utilisation of a larger screen, keyboard and storage space, as well as

st
connection to the internet. In many healthcare settings, these devices are mounted on trolleys
to provide increased convenience and greater mobility in WiFi networks

Au
Wireless tablets In a clinical environment, the wireless tablet is often seen as a ‘ruggedised’ device, roughly the
size of a large laptop and usually weighing about 1 kg. These devices (such as the motion by
Xplore C5M, illustrated in Figure 5.4) are designed to withstand the rigours of use at the bed-
side. They can be cleaned using agents such as isopropyl alcohol and can withstand the bumps

er
and drops that occur frequently in clinical settings. Tablets are now considered as having even
greater utility than WOWs for point-of-care data entry in healthcare with their larger screens, the

vi
facilities for handwriting, individual ID scanning and digital photography functions
se
iPads, iPhones and These devices are essentially a convergent technology that provide computing, email,
smartphones networking, voice recognition and internet connectivity. A number of healthcare applications
(such as ECGs and picture archiving and communication systems) can download visual images
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to smartphones. This provides clinicians with the ability to review data about individuals
anywhere at any time
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m
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Figure 5.4 Motion by Xplore C5M

(Reprinted with permission from Xplore Technologies Corporation of
America. Photographer: Scott Van Osdol. © 2010)

as C, C⫹⫹, Basic, Visual Basic, Java and SQL. Each of

Figure 5.3 Workstation on wheels
(© InterMetro Industries Corporation)
these languages is used to compile various programs or ap-
plications, which then perform the various functions on a
computer. Software can be divided into operating system
software or application software.
Operating systems are ‘software in the background’.
They consist of a number of programs that control the

Historically, a duty to honour confidentiality has been inher-
ent in particular relationships such as between the healthcare
provider and an individual (Department of Human Services
2018). Given the importance our Western culture places on
privacy, it is not difficult to understand the significance of
privacy in the relationship between healthcare provider and
an individual. For example, the NMBA Code of Conduct for
Nurses (2018) states that nurses have a duty to maintain in
confidence personal information obtained in a professional
capacity.
An effective security plan must be a balance between secu-
rity of data and access to that data. Decisions regarding the level
of security, disaster minimisation and/or recovery, user privi-
leges, use of encryption, multiple passwords, system back-ups
and audit trails need to be made as part of the security planning
process (Marselas 2016). An attitude of ‘It won’t happen here’
could leave the organisation vulnerable to significant risk.
With increasing growth in technology, there are people
constantly attempting to find ways in which to obtain un-
authorised access to information systems, or to corrupt data
and information systems. We see this through regular alerts
to new viruses and reports of hacking of various computer
systems. As more and more health data is computerised, on-
going developments in security are also needed.
To look at data security, a good place to start is with de-
se
fining people who should have access. This can be achieved
in a number of ways. You probably have an ID badge that
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you wear within your workplace. This tells people that you
are authorised to be there. Similarly, keys, badges or plastic
cards are one way of limiting who has access to particular
©
areas such as rooms where computers are located (see Clinical
Interest Box 5.6). We know, however, that many ward-based
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CLINICAL INTEREST BOX 5.6
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Passwords
Passwords are common tools for regulating access
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to information systems. These are generally safe if
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not passed on to others. There are some standard
recommendations for selecting and using passwords.
m
These include:
΄ They have at least six characters
΄ They combine upper and lower case letters,
Sa
numbers and other symbols
΄ They do not contain proper names, people’s
initials or words taken from the dictionary
΄ Avoid using reversed words or syllables
΄ No dates, telephone numbers, vehicle
registration numbers or numbers such as
Medicare number
΄ They should never be stored in the computer,
and must be kept private
΄ They need to be changed regularly and not
reused for a significant length of time.
(Hebda et al 2018)
Nursing informatics and technology in healthcare | CHAPTER 5 117
computer terminals are located at the nurses’ station in a
relatively public area. Wearing a badge alone will generally
not limit who can access these machines.
CRITICAL THINKING EXERCISE 5.2
Your best friend texts you while you are at work on a
surgical ward and tells you that her mother has just
been involved in a car accident and has been admitted
to the emergency department of your hospital. She
ia
asks if you can search the hospital system to see what
is happening with her mother. What would you do in
l
this situation?
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st
A security risk in computing terms is any situation in
which there is loss or damage to computer hardware, soft-
Au
ware, data or information (Vermaat et al 2014). Social
networking is a particular threat in terms of the theft of
personal information (identity theft). Email is a very com-
mon method by which computers are put at risk. Many cy-
er
bercriminals use malware to package and deliver computer
viruses. These computer programs are intended to negative-
vi
ly alter the function of the device onto which it is loaded.
Clinical Interest Box 5.7 describes other similar forms of
malicious programs.
There are a number of strategies in place to ensure these
risks either do not occur or are limited in their effect. One
of the more exciting developments in information security
involves the use of biometrics. This science works on mea-
suring specific body characteristics and in doing so can ver-
ify whether a person seeking access to an area is in fact that
person. Some of the ways in which this is done include fin-
gerprint recognition, retinal scanning, voice recognition or
facial recognition (Hebda et al 2018; Vermaat et al 2014).
Other means for promoting security of information
systems include the use of firewalls, antiviral software and
audit trails:
t
Firewalls employ a combination of software and hard-
ware to create a barrier between systems, or different
system parts. They increase system protection by block-
ing unauthorised use such as through hacking. It is also
possible to obtain firewalls for individual PCs to protect
against unauthorised access through the internet.
t
Antiviral software is commonly available software that
searches your computer for viruses and, where pos-
sible, eliminates them or provides alternatives for the
user. New viruses are always appearing that existing
software will not be sensitive to. Consequently, antivi-
ral software needs regular updating. Some companies
provide downloaded upgrades from their websites after
you initially purchase and install the software package.
t
Audit trails allow for the tracking of data flows within
a system, allowing for inappropriate use to be identi-
fied and addressed. Audits can keep records on who is
accessing what data and when, for how long, and what
was done to the data. Audit trails are very common in
 CHAPTER
Quality and safety
8 in healthcare

ia
Taryn Kellerman

l
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KEY TERMS LEARNING OUTCOMES

Au
accreditation At the completion of this chapter and with further reading, students should be
adverse event able to:

er
audit • Understand quality and safety in the context of the health system, the
benchmark nursing profession and person-centred care

clinical indicators
error management
governance
human error
human factors engineering
vi
• Understand the role of nurses in ensuring that individuals receive safe
quality nursing care
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• Contribute to quality and safety activities in the practice setting
• Understand the link between workplace health and safety and safe quality
service delivery
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nursing-sensitive indicators • Maintain health and wellbeing through the prevention and management of
patient safety personal stress
personal stress
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preventable patient harm

quality
quality improvements
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second victim
standards
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m
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194 UNIT 2 | The contemporary healthcare environment

CHAPTER FOCUS
Australia’s health system is a multifaceted web of public and private providers, settings, participants and supporting
mechanisms.
Across the globe, healthcare is seen as a complex environment. In Australia, the health system has been described
as a multifaceted network of private and public providers, participants, settings and supporting structures (Australian
Institute of Health and Welfare [AIHW] 2016) with further complexities of varying funding models, government and
non-government service providers and diverse user demands. It is often asserted that Australians enjoy reasonably
good health. In 2017, life expectancy at birth for males was 80.5 years, and 84.6 years for females. Life expectancy
has increased over the past 10 years for both males and females (Australian Bureau of Statistics 2018; AIHW 2019a).
Against other developed countries, this outcome could be seen as an indicator of a high-quality, safe healthcare

ia
system. Of course, a long life expectancy is also dependent on other social and political factors, with the system
healthcare being a major contributor.

l
Achieving optimal quality and safety outcomes for healthcare in Australia remains a challenge, particularly in

ra
the context of the ageing population, increasing prevalence of chronic diseases and high costs of new medical
technologies. Additionally, in Australia’s complex healthcare system, where services are delivered by both government

st
and non-government agencies at local, state and national levels, with extraordinary efforts made to promote choices
with respect to treatment options, there is potential for duplication of services on the one hand and gaps in service

Au
provision on the other. To be confident that the system is working efficiently and effectively, our system needs
governance, coordination and regulation (AIHW 2016).

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LIVED EXPERIENCE

vi
I have worked in many hospitals around South Africa and Australia where the health system struggles to cope with
se
delivering an optimal level of quality and safety around patient care. This is more often than not likely due to the immense
pressure that the national systems face regarding lack of resources, inefficient use of resources, poor delivery systems
or high-acuity patients. As a nurse, you always strive to work to your best abilities, even in a suboptimal environment.
El

As I reflect on these situations, it becomes clear that the missing element in each of my environments was the neglect
of a strong focus towards the quality of safety in patients. Patient safety is a dimension of quality assurance, and
although standards had to be met, this was largely focused on a system to meet compliance rather than a genuine
©

attempt at improving the safety and quality of care. Although I had wonderful colleagues who all had a sincere interest
in providing the best possible nursing care, and were competent in their nursing skills and abilities, there was no
driving force regarding the motivation to making changes and improving patient care. For the last 2 years, I have been
fs

lucky enough to work for an organisation that really values all their employee inputs and suggestions into cultivating
a work culture of optimum quality and safety, leading to an increase in patient care. I feel that every day I go to work, I
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am part of a culture that is changing patient outcomes for the better, and making a real difference.
Georgina, Aged Care Nursing Specialist
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QUALITY AND SAFETY IN THE

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who receive our services believe that they will receive safe,
CONTEXT OF HEALTHCARE quality care from health professionals. Nurses are a highly
m

visible contributor to outcomes of the individual under

The community expects the healthcare system to deliver the our care, and as such, they consistently strive to meet this
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right services to the right people, at the right time, using the
right workforce with the right resources. Efforts to ensure
our healthcare system meets the needs of all Australians are
supported by a range of governance mechanisms, each with
a differing purpose, function and application.
The Australian Safety and Quality Framework for
Health Care (Australian Commission on Safety and Qual-
ity in Health Care [ACSQHC] 2019) demands that all
healthcare services are always consumer focused, provided
with evidence-based information and driven by safe and
high-quality healthcare. Our community expects to trust
our health service providers to deliver quality care. Those
expectation, delivering safe, quality care resulting in a
positive experience. To meet this goal an understanding of
quality and safety in healthcare must be present.
QUALITY IN HEALTHCARE
Quality in healthcare is multidimensional, and as such is
difficult to define in simple terms. It is often subjective,
leading people to interpret their experiences differently.
Some might believe that quality is about how much the
health services improve the health outcome for particular
individuals. Does their health improve because of the care?

Additionally, quality can be determined in the context
of the service that was provided using the best evidence
available to the health practitioners and whether the care
meets the expectations of the individual and community
(Edvardsson et al 2017).
Quality can be a reflection of the ‘extent to which a
healthcare service or product produces a desired outcome’
(Runciman et al 2017). This is a simplistic perspective, most
notably from the individual or their healthcare professional.
However, at a system level, a quality healthcare service needs
to be safe, person-centred, timely, effective, efficient and
equitable to be considered a quality service (World Health
Organization [WHO] 2019b).
In Australia, the Australian Health Performance
Framework (AHPF) provides the tools needed to report on
healthcare performance. This includes the assessment and
evaluation of sustainability, value and the identification
of priorities for improvement. Together with the AHPF
Conceptual Framework, this identifies the domains that
are significant to the assessment of the health system as a
whole, and assists in understanding factors that affect the
health system. The key domains include determinants of
health and wellbeing, equity, health status, health system,
and the health system context (AIHW 2017).
se
Quality frameworks
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Health service professionals in nursing have increasingly
started focusing on quality care and what it means. Health-
care organisation leaders have been engaged in bringing ro-
©
bust systems of quality assurance and control. One of the
early conceptual models proposed to examine and evaluate
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healthcare is the Donabedian model. Avedis Donabedian,
in 1966, argued that quality of care could be measured
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through the collection of information from three categories
or dimensions of care: structure, process and outcome. The
model assumes a unidirectional approach to measurement,
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commencing at structure, then process and onto outcome.
It is also proposed that this model could be applied in a
variety of healthcare contexts (Voyce et al 2015).
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Structure refers to all the elements in the contexts in
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which care is delivered. Types of elements include the phys-
ical environment, equipment and human resources. They
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also include training, information and financial systems.
These elements are the foundation for the processes and
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outcomes, and if they are inefficient and/or ineffective, they
will affect the quality in the other categories of process and
outcome.
Process is every action that makes up health service pro-
vision. The process category includes specific activities such
as diagnosis, treatment, rehabilitation, health promotion
and early intervention. This category includes examining
the process of how care is delivered (in a technical sense).
The effectiveness of interpersonal interactions is observed
and measured to determine quality of care. The information
is collected from records, direct observation or interviews
with staff and people receiving services.
Quality and safety in healthcare | CHAPTER 8 195
Outcome is the effects of healthcare. This can be at
the individual or community level. Measures of health
status changes, behaviour changes, level of satisfaction
(individuals and family) and reported quality of life con-
tribute to the interpretations drawn about the outcomes.
Achieving positive outcomes for individuals in our care is
considered the most important goal for healthcare pro-
fessionals and can sometimes be interpreted as the most
important indicator of quality. Unfortunately, establish-
ing a proven cause and effect relationship between process
and outcome in the context of quality is complex and
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challenging, resulting in only a few true connections be-
l
ing made between process and outcome in the healthcare
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environment.
Modern-day quality frameworks are based on the three
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dimensions of care, with the understanding that each of the
three dimensions influences the others and that individuals
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and environmental factors play a critical role in measuring
quality in healthcare (Kajonius & Kazemi 2016).
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Aspects of quality
There are many players engaged in the healthcare environ-
vi
ment. They include the health service users, the individuals
in our care, their families, their community; the caregiv-
ers, the healthcare practitioners, non-clinical support staff;
and the healthcare system, the leaders and managers of the
hospitals and clinics, and the funders of the services such
as government agencies. Each of these groups has a differ-
ent motivation in understanding the level of quality of the
healthcare service.
Measurable quality
Measurable quality is simply compliance with standards
relevant to that setting. This is commonly seen or experi-
enced by nurses when the healthcare services in which they
work are surveyed by an external agency for the purpose
of ‘accreditation’. Essentially, an external group reviews
the structures and processes of that service, evaluating the
levels of conformance or compliance with an agreed set of
standards suitable to that setting. An accredited health-
care service provider meets the requirements for funding,
assures the community that the services offered meet in-
dustry standards and assures the leaders and managers of
the service that its organisation is delivering quality care
(ACSQHC 2019).
Appreciative quality
Peer review bodies primarily undertake this type of re-
view. As part of the journey towards clinical excellence
and quality improvements in clinical care, their peers will
review health practitioners’ clinical decisions and interac-
tions. These activities will vary across services. In some set-
tings, clinical information may be uploaded into national
data collections. This will allow comparisons to be made
and benchmarking activities to be undertaken (Victorian
Quality Council 2017).

CLINICAL INTEREST BOX 8.1 An
example of a National Safety and
Quality Health Service Standard
‘Clinical leaders and senior managers of a health
service organisation implement systems to prevent
and manage healthcare-associated infections and
communicate these to the workforce to achieve
appropriate outcomes. Clinicians and other members
of the workforce use the healthcare-associated
infection prevention and control systems.’
When unpacked, this Standard can be measured from
a structure, process and outcome perspective. For
example:
Undertaking quality improvement activities to reduce
healthcare-associated infections through changes to
practice.
Actions are:
• Quality improvement activities are implemented
to reduce and prevent healthcare-associated
infections (process)
• Compliance with changes in practice are
monitored (structure if using technology, process)
The effectiveness of changes to practice are
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evaluated (outcome) (ACSQHC 2017).
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area. They came into effect from 1st July 2019 (Australian
Government Ageing and Aged Care 2019). Additionally,
©
some health or aged care services may elect to measure their
care against additional standards appropriate to their set-
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ting, such as the Australian Council on Health Standards
(ACHS) Evaluation and Quality Improvement Program
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(EQuIP). They assist all organisations that provide healthcare
to strive for excellence in addition to the NSQHS Standards.
(ACHS 2018). It is also common for some organisations to
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use the International Standards Organisation (ISO) in addi-
tion to the compulsory NSQHS Standards.
One of the most useful ways of measuring compliance
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to standards is to conduct an audit, which can be an in-
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ternal activity or can be conducted by an external agency.
Nurses will commonly assist in internal audits seeking level
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of compliance with the standards identified by the service
as being relevant, as well as any relevant service-based pro-
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cedures. An example of this activity is medication chart
audits conducted at ward level. The audit tool used has
been designed to capture any non-compliance between the
documents and the standards and procedures. Undertaking
an activity like an audit will often lead to the design and
implementation of changes to systems and processes at lo-
cal (or service) level. These changes are considered quality
improvements (ACSQHC 2017).
Quality improvements can originate from a range of
sources, including results of audits, examination of reported
incidents and hazards, and through adopting ideas from
the best available evidence. All nurses are encouraged to
Quality and safety in healthcare | CHAPTER 8 197
share their ideas for more effective and efficient evidence-
informed practice.
Benchmarking In healthcare, a benchmark is the point of
output or outcome that is considered best practice in that
area of service delivery. The benchmarking process incor-
porates finding that point of best practice, clearly defining
it and disseminating this benchmark to others in the par-
ticular healthcare setting. Benchmarking is an important
tool that facilitators can use to encourage an organisation to
actively engage in working towards an improved environ-
ia
ment. It helps members to understand where their perfor-
l
mance is in comparison to others (Huber 2018). As a nurse
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you may be exposed to two types of benchmarking: internal
and external.
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Internal benchmarking is a process whereby the bench-
mark is developed over time, focusing on internal processes.
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This may occur in two different ways. Firstly, it can be
within one setting. The primary actions would be monitor-
ing and measuring performance over time in response to
a quality improvement activity such as a practice change.
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Results may be captured and graphed using a balanced
scorecard approach. Secondly, internal benchmarking may
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also occur across similar products or outputs within the
same organisation with multiple sites. The key to this type
of benchmark is that the services involved in the bench-
marking process must be of similar size, offering similar
services and using similar workforces (Business Dictionary
2019; Watkins 2018).
External benchmarking is where agencies who would
normally be competitors share performance information
with others. In the healthcare sector, this information is
often mandatory reporting as part of funding agreements.
This is where particular benchmarks result from the scru-
tiny, interpretation and analysis of the reported data around
a clinical issue (e.g. hospital-acquired pressure injuries) and
determine the national benchmark for that issue. As the re-
porting process is ongoing, these benchmarks will change
over time (Watkins 2018).
Clinical indicators Clinical indicators are generally spe-
cific outcomes of care that may provide an understanding
of the safety and quality of care provided by a service. The
Australian Medical Association (AMA), in 2016, published a
position statement on clinical indicators whereby it measures:
the extent to which set targets are achieved. They are ex-
pressed as numbers, rates or averages that can provide a
basis for clinicians, organisations and planners aiming to
achieve improvement in care and the process in which pa-
tient care is provided. They can be measures of structure,
process and outcome, either as generic measures relevant
for all diseases or disease-specific measures that describe
the quality of patient care related to a specific diagnosis.
(AMA 2016)
The AMA further proposes that clinical indicators are de-
veloped from evidence and in collaboration with clinicians.

SAFETY IN HEALTHCARE
Safety in healthcare has attracted a great deal of attention in
recent decades. The first step is to understand what is meant
by the phrase ‘safety in healthcare’, or ‘patient safety’.
Patient safety means to avoid or reduce harm, either
actual or potential, in delivery of healthcare. Although this
definition suggests that harm can be reduced or avoided,
it is important to understand that not all harm is prevent-
able. Estimates show that in high-income countries, around
10% of all hospital patients are harmed while receiving care
within the hospital setting; of this number, 50% are consid-
ered preventable (WHO 2019a).
In some countries, funding may be associated with
the provision of safe healthcare. This connection may be
by way of penalty or incentive. In the United States in
2014, Medicare funding was reduced at those hospitals
that had unacceptably high rates of preventable hospital-
acquired conditions such as pressure injuries, central-line-
associated bloodstream infections and catheter-associated
infections (Latner 2015). In Australia, the notion of pe-
nalising services that have high rates of preventable harm
has not taken root. However, the funding model that
is increasingly being used to fund public services across
the country, activity-based funding (ABF), is reported
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to reward those services that provide a safe healthcare
experience for service users. There are mechanisms built
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into the system to encourage improvements in safety and
quality. The ABF model funds an episode of care based on
the cost that same episode of care would require in similar
©
conditions elsewhere in Australia. There is little evidence
to date that demonstrates how this funding model influ-
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ences rates of preventable harm to individuals (IHPA
2019).
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In Australia, there are eight NSQHS Standards, which
all provide a consistent account about the level of care
every consumer can expect from health services nationally
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(see Clinical Interest Box 8.2). They are focused on areas:
• That commonly cause harm
• Where there is a gap between current and best
e
practice
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• Where improvement strategies that are evidence-based
and achievable exist (ACSQHC 2019).
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Preventable patient harm
Sa
Recently, the recognition that a proportion of patient harm
is not preventable has gained a lot of interest. Previously,
most of the attention had been focused on the quality of
the healthcare provided, assuming that quality processes
led to safe patient care. We now know that this is not true.
Having quality systems and processes in place will certainly
help but other factors must also be considered. Key sources
of preventable patient harm include the actions of health-
care professionals, healthcare systems and patient charac-
teristics, all of which need to facilitate towards safe care
(Panagioti et al 2019). The most common factor, which
Quality and safety in healthcare | CHAPTER 8 199
CLINICAL INTEREST BOX 8.2
National Safety and Quality Health
Service Standards
1. Clinical Governance Standard describes the
framework and systems needed in place within
healthcare organisations to maintain and improve
the safety, quality and reliability of healthcare
provided.
2. Partnering with Consumers Standard recognises
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the importance of involving patients in their
own care and providing clear communication to
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patients. This standard aims to create healthcare
organisations that have mutually beneficial
outcomes.
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3. Preventing and Controlling Healthcare
Associated Infection Standard aims to improve
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infection prevention and control measures
to help prevent infections and the spread of
antimicrobial resistance.
4. Medication Safety Standard describes the
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systems and strategies to ensure clinicians safely
prescribe, dispense and administer appropriate
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medicines to informed patients.
5. Comprehensive Care Standard aims to ensure
patients receive comprehensive healthcare that
meets each individual’s need and considers the
impact that their health issues have on their life
and wellbeing. It also aims to ensure that any
risks of harm for patients during their healthcare
are prevented and managed through targeted
strategies.
6. Communicating for Safety Standard describes
the systems and strategies for effective clinical
communication whenever accountability and
responsibility for a patient’s care is transferred.
7. Blood Management Standard describes the
systems and strategies for the safe, effective and
appropriate management of blood and blood
products so that any patients receiving blood are
safe.
8. Recognising and Responding to Acute
Deterioration Standard describes the systems and
processes to be implemented by health service
organisations to respond effectively to patients
with acute deterioration. This standard aims to
ensure that acute deterioration is recognised
promptly and appropriate action is taken.
(ACSQHC 2019)
has many variables affecting it, is that health professionals
are people.
Health professionals are human and, being human, can
and will make mistakes. Despite having been trained well
and having developed high-level skills and knowledge in
practice, a perfect practitioner does not exist. In all work
places, mistakes are made. Some result in damage, some do
not. Some damage is considered to be of greater importance
200 UNIT 2 | The contemporary healthcare environment
than others. Think of the person who cuts your hair—your
local hairdresser or barber. Making a mistake such as cut-
ting your hair too short will not commonly end up in a
courtroom or in the media. Now consider a surgeon who
removes the wrong ovary and, realising the error, removes
the correct one in the same operation, leaving the patient
without any ovaries. It is highly likely that both litigation
and media scrutiny may become a reality.
It is important to note that the extent of harm can only be
confirmed by the person who has been harmed.
Thinking about the error made by the hairdresser above,
imagine the two possible scenarios below:
1. The supermodel whose work relies on her appearance
may feel extremely damaged by the error. It could cost
her some modelling contracts or a photographer may
have taken a photo of her with a poor hairstyle.
2. The retired banker, who takes pride in his appearance
and values a good haircut, may feel annoyed. However,
he will most likely vow never to return to that
hairdresser or even take the philosophical approach
that ‘there are only 3 weeks between a good and bad
haircut’.
Now think about the woman who had the wrong ovary
removed. Imagine the two possible scenarios below:
1. She is 60 years old, menopausal, and did not place
high value on the need to keep the healthy ovary
remaining in place. She may not perceive high-level
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harm. She may even be pleased as she does not require
further surgery to remove the diseased ovary and
considers this outcome acceptable.
©
2. She is 30 years old, recently married and eager to start
her family. This will be devastating to this woman and
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her husband.
It is important for all nurses to understand this key point:
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the individual’s and family’s perception of the harm in
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Assessed as low falls
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risk on admission
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m
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Change in mental
state triggers a new
falls risk review
Figure 8.1 Using the Swiss cheese model to describe an adverse event
(Adapted from Reason 2000)
the context of a preventable error. In healthcare, the most
important element is the determination of the severity of
that harm.
Healthcare workers are expected to always focus on
the person and their experience of the care provided. Being
able to see the harm from their perspective is very impor-
tant and is a key element of person-centred care. In this
model of care, the healthcare worker tailors their activity
to the individual. However, in earlier discussion the no-
tion of standardisation is promoted as a key patient safety
strategy. Can these two concepts co-exist? Through strong
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communication, where listening to and hearing the person
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is as important as the person listening to the healthcare
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worker, it is possible.
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Error management
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To reduce patient harm or injury from errors, nurses must
understand how errors result in the injury; this is known
as error management. Reason (1990) suggested a simple
way of understanding this process; he called it the Swiss
er
cheese model. He asserted that errors occur at every stage of
a process. By the time a patient is provided direct care, there
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have been many activities where one or more errors have
occurred, hence the reference to Swiss cheese. The holes
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represent the errors (Lazarovici et al 2017).
To get to an outcome there are a number of activities
that need to occur. Consider each of these activities as a
layer of Swiss cheese. A slice of Swiss cheese has holes, some
small, some large. Imagine the hole to be an error, either
small or large, in that activity. Now lay each slice of cheese
on top of one another. If there is a hole seen through all the
layers, it is suggested that there will be an error at the patient
level. Depending on the error, the patient may be harmed.
Figure 8.1 illustrates how harm can occur when a series of
Becomes confused and
disoriented postoperatively
Falls risk
review not
completed
Falls from bed,
fractures hip
202 UNIT 2 | The contemporary healthcare environment

Standardisation of practices and processes is a key HFE

strategy. Having the same system in place across all variations TABLE 8.2 | Graded assertiveness and
of the practice or product will improve reliability and infor- examples using the advocacy approach
mation flow, therefore reducing training needs. For example,
consider your experiences in driving a car. Many cars have Level 1 Get attention Excuse me, doctor …
the indicator on the right of the steering wheel. If you find Level 2 Raise your There is no end-tidal CO2
yourself in a vehicle with the indicator on the left side, as it is concern trace …
in many European vehicles, you will find yourself making an
error with respect to using the indicator. In a healthcare set- Level 3 State the I am concerned that the in-
ting, an electronic information system ensures that all staff problem as tubation was unsuccessful …
know how to access information in any clinical area of that you see it

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setting, regardless of their usual work area (AHRQ 2019a). Level 4 Suggest a Are we able to remove

l
Usability testing is used to ensure that new processes solution the ETT and go back to

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and practices are efficient and effective in the workplace. If bagging the patient?
blocks or barriers occur and create an inefficient or ineffective

st
outcome, inevitably the nurse will find a work-around to suit Level 5 Obtain and Does that sound like a safe
agreement thing to do?
their needs. Unfortunately, these work-arounds are developed

on the fly and can be unsafe. All changes to systems should be
tested to ensure the outcome is suitable to the staff that use
them (AHRQ 2019a).
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(Victorian Department of Health 2019)
Communication and teamwork are other important

Patient safety in the workplace
Many nurses work in settings that will have an established
routine that could change in an instant due to an unexpected
event, such as two or three new admissions arriving at once
or a patient’s clinical condition rapidly deteriorating. The
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er
mechanisms that play a significant role in patient safety.
The AHRQ discovered over many years from collecting
vi
data that poor communication was the number one cause
of preventable medical errors. From this the TeamSTEPPS
se
program was developed (AHRQ 2016; Huber 2018). This
is an evidence-based and comprehensive program estab-

nurse needs to be vigilant for the unexpected, but not to the lished to enhance communication and teamwork, which
detriment of the expected or routine tasks. Reason (2000) have been found to be useful in healthcare settings and
advances the notion that it is the routine tasks that are most therefore improve patient safety. TeamSTEPPS stands
©

subject to human error. for Team Strategies and Tools to Enhance Performance
Situation awareness (SA) refers to being aware of things and Patient Safety. Other tools utilised that are known to
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happening around you and being able to identify, analyse enhance communication and teamwork include, but are
and interpret relevant information. You have lost situational not limited to:
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awareness when you not only do not know how to fix a • A situational briefing guide known as SBAR (Situation,
problem, but you are not even aware you have a problem. It Background, Assessment, Recommendation) or ISBAR
is important to understand that only those around you can (Introduction, Situation, Background, Assessment,
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see you have lost SA—you cannot see it for yourself. If you Recommendation)
accept this last point, when a colleague raises an issue with • Team huddles
you about an unsafe practice or decision it could be because • Briefing
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you have lost situational awareness (AHRQ 2019d). • Multidisciplinary rounds

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It can be difficult for a nurse to point out an unsafe • Clinical handover using a variety of information-
practice to someone who is in a higher position than them. sharing techniques such as SBAR, ISBAR and
m

In most clinical situations, when a doctor is present they SHARED (Situation, History, Assessment, Risk,
will have a higher authority than the nurse. In situations Expectation, Documentation).
Sa

where those with a higher authority have lost their situ-
ational awareness, those at a lower level must have the abil-
ity speak up and get the point across. Sometimes the com-
munication needs to be assertive, using a method called
graded assertiveness. This is a communication technique
that allows anyone to challenge an action or behaviour that
they may think is unsafe and/or inappropriate (Victorian
Department of Health 2019). Table 8.2 describes graded
assertiveness using an example of how the communication
technique may be used, using the advocacy approach. This
type of communication will allow the relationship between
the parties to remain professional into the future.
There has been a lot of discussion over the past decade
regarding patient safety culture. This term refers to the
healthcare workers’ shared values and beliefs about and
towards safe practice (Huber 2018).
If a nurse was asked to define safety culture, the response
would commonly be ‘The way we do things’. The culture of
a work setting is impacted on by a variety of elements. This
will include how the healthcare workers function as a team
(including the way they communicate with people inside
and outside of the team). The perception of job satisfaction
and stress recognition also will impact on safety culture.
Achieving a culture of safety requires an understanding from
 Quality and safety in healthcare | CHAPTER 8 203

both management and leadership of an organisation of the
values, beliefs, attitudes and norms that are important in
the healthcare setting. These include what behaviours and
attitudes they find appropriate and expected from employ-
ees for patient safety to occur (Lawati et al 2018). This is
achieved by:
• Being vigilant regarding opportunities to learn from
errors using robust reporting systems and patient safety
rounds
• Dedicating resources to patient safety activities
• Involving patients and their families in safety
• Always look to the system to find the solutions to
adverse events (AHRQ 2019b).
WORK HEALTH AND SAFETY
ISSUES
There is always potential for injuries in our workplace. The
practice of nursing in itself demands a degree of physical,
emotional and psychological effort. It is important for each of
us to understand that standards and procedures will keep all of

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initiatives. us safe while ensuring the care is efficient and effective. A good

l
Most healthcare services now have a rigorous incident-man- example of this is the trauma experienced by the people con-

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agement system. These systems are commonly electronic, nected to an error that has resulted in serious harm, particu-
creating a user-friendly approach to understanding issues at larly those who work closely with the person who was harmed,

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a system level rather than at an individual level. Staff are often the nurse or the doctor. This type of harm is known as
encouraged to report safety concerns and both actual and the second victim (AHRQ 2019c; Clarkson et al 2019).

potential safety events. Reporting the incident is only the
beginning of the process. What happens next is what will
influence the embedding of a strong safety culture. Analysis
is the most important factor in understanding and learning
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When a patient is harmed, whether it was preventable
or not, the direct healthcare provider will also ‘feel’ the pain
and stress. That person will often feel guilty, even though
they are often not, and never were, in a position to have pre-

from an incident (also called an adverse event) which will
further strengthen the patient safety culture of the organisa-
tion. The key steps in the analysis of the incident include:
• Have all the information—access all possible sources
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of information. Avoid jumping to conclusions
• Understand the cause of the event. Track down all
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er
vented the event. This person is also a victim of the adverse
event, but often not recognised as being traumatised as a
vi
result of the event and subsequently not supported through
the issue. Some will feel unworthy of the support, taking
on full responsibility for the harm. Unresolved, these feel-
ings will create harm and that person may suffer burnout,

parts of the process leading up to the event. Most stress and anxiety disorders. They are a second victim to the
events have errors occurring in many points along the error causing harm. See Case Study 8.1 for an example of a
timeline second victim scenario (AHRQ 2019c).
©
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CASE STUDY 8.1A Incident management

James studied to become an Enrolled Nurse. He then further developed his knowledge and skills by working in the
pr

clinical setting over a number of years and attending professional development and training activities. He cares for his
patients and works really hard. He is considered by his colleagues and other members of the healthcare team to be
a ‘good’ nurse.
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James is on a shift where a drug error has occurred. He participated in the administration of a restricted drug
(morphine) where excess to what was ordered by the medical officer was administered. He was named as a party to
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this error. James is devastated. He questions his ability as a nurse.

What are your thoughts? Is James now incompetent because of this one mistake?
m

Before you can decide, you may ask, ‘Was the patient harmed?’. Patient safety focuses on preventable patient
harm, after all.
Sa

In this circumstance, the patient had been in severe pain and had not been sleeping well. The effect of the
medication on the patient was that he was more heavily sedated than was necessary, and he slept deeply for 12 hours.
1. At this point, do you think the patient suffered harm?
Back to James. His confidence is shattered. Before you make your judgment about his level of competence, you
will also need to know a little more about James and the shift.
• James was on his eighth shift in a row and was working an afternoon shift after seven night duty shifts. This was
an overtime shift and he had only an 8-hour break between the shifts. He was to have 4 days off at the end of
the seven night duty shifts.
• The ward is a very busy medical ward with three new admissions in the previous 2 hours.
• The patient was under a surgical team and was being cared for in this medical ward as there were no beds
available in the correct ward.
• The incident occurred when two staff (of the rostered five) were at a compulsory training session.
2. Is James incompetent? Explain your answer.
204 UNIT 2 | The contemporary healthcare environment

CASE STUDY 8.1B

Let us follow the patient from the above Case Study. The next morning the patient is in need of going to the toilet.
He rings the buzzer for assistance, but before the nurse arrives, he feels he is unable to hold on and gets out of bed.
On his third step towards the bathroom he falls. He suffers a fractured hip.
With only the information above, you may be tempted to attribute the injury to be a result of the excess drug.
However, after analysis of the event, the following information has been identified:
• The patient had been assessed as a high falls risk. Strategies included wearing hip protectors but he was not
wearing them at this time as he had been ordered to ‘Rest in bed’.
• The patient has a history of transient periods of confusion.
• The shift had just commenced and the nursing allocation had not been completed as there was a delay of some

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agency nurses arriving on the ward.
1. Is the drug error the cause of this preventable patient harm—fractured hip? What is your rationale for this answer?

l
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2. What are some possible system issues relating to the drug error in the first part of the scenario?
3. What are some possible system issues relating to the fall in the second part of the scenario?

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PERSONAL STRESSORS IN the needs of others before themselves. It is difficult to
THE WORK ENVIRONMENT effectively care for others and be productive at work
if you do not take the time to care for yourself too.
It is very important for nurses to be aware that due to the Self-care is unique to each individual, but generally

nature of their work they are at a higher risk for anxiety
and stress disorders and burnout. Being able to create an
environment where you are able to recognise sources and
triggers of personal stress, and identifying, developing and
•
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adjusting strategies to minimise stress and balance work/
life priorities, will enable you to have a greater resilience
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includes having enough sleep, nutrition intake, a
strong support network and some form of exercise.
vi
Setting boundaries—boundaries may change over
time, depending on the person’s lifestyle, but it is
important to make sure that clear boundaries are
always set around individual needs. The key factor is

and performance at work, leading to improved patient out- ensuring that the boundaries set do not induce more
comes. Communication, conflict and stress feed off each stress than not having them at all.
other and contribute to destructive work environments. • Relaxation—stress can often produce both emotional
©

Nurses can either manage this conflict and stress through and physical responses in the body, so it is important
disrespectful communication, further destroying the envi- to find ways that relax both the body and mind. By
fs

ronment, or through respectful and caring communication, being able to calm the mind, physiological responses
contributing towards a positive culture. Stress is reduced to stressors are also reversed, allowing the individual to
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when nurses feel as though they are being listened to and think more clearly.
have a supportive work environment. Some strategies to • Journalling—for some people, keeping a journal or
help further reduce stress include, but are not limited to: diary benefits them immensely in helping them iden-
pr

• Self-care—one of the most important strategies to tify the specific triggers that are causing them stress.
mitigate stress includes self-care. Often nurses put (Huber 2018)
e
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Summary
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The nursing profession has a long history of seeking out and re-accreditation with a particular accreditation
ways to give our best to our patients through monitoring agency, depending on the practice service type, relying
Sa

and evaluating our care. Florence Nightingale was
known to be an early pioneer of the practical application
of quality improvement (Allegranzi et al 2019). Nurses are
committed to service based on evidence-based practice,
clinical guidelines, professional standards and scope
of practice. Nurses practise to the best of their ability.
Quality and safety are not optional extras; they should be
what nurses simply do.
Nurses also, on a daily basis, participate at some level
in a range of measurement activities such as audits,
benchmarking, safety scorecards and nursing-sensitive
indicators. Their practice setting then seeks accreditation
upon nurses to collect and collate data as evidence of
meeting accreditation standards.
Quality and safety are imperative in any healthcare
organisation and it is important that we know the
difference between the two. In simple terms, healthcare
quality is about getting the right service to the right
patient at the right time and at the right cost. Patient
safety is about protecting the patient from preventable
harm. The nurse is a key player in both quality and safety.
Nurses must understand quality and safety and be
able to define them, identify them and measure them.
The patients depend on it.

Review Questions
1. What is your understanding of quality in healthcare?
2. What does accreditation mean for a healthcare facility?
3. Explain:
> Benchmarking
> Clinical indicators.
4. How is patient safety different from quality?
5. Why is the perspective of the person who was harmed important when measuring severity of harm?
6. What is the difference between active and latent errors?
7. What is meant by ‘contributing factors’?
8. Why is standardisation considered a powerful patient safety initiative?
9. Why is it important to create a positive culture in the workplace environment?
Answer guide for the Review Questions, Critical Thinking Exercises, Decision-making Frame-
work Exercises and Critical Thinking Questions in Case Studies is hosted on Evolve: http://evolve.
elsevier.com/AU/Koutoukidis/Tabbner/
References
Agency for Healthcare Research and Quality (AHRQ), 2016.
Team STEPPS: strategies and tools to enhance performance
and patient safety. Rockville, MD. Available at: http://
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www.ahrq.gov/professionals/education/curriculum-tools/
teamstepps/index.html.
Agency for Healthcare Research and Quality (AHRQ), 2019a.
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Human factors engineering. Available at: https://search.ahrq.
gov/search?q=human%20factor%20engineering&search_
icon.x=0&search_icon.y=0&start=0&siteDomain=www.
©
ahrq.gov (accessed 11.10.19).
Agency for Healthcare Research and Quality (AHRQ), 2019b.
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Reporting patient safety events. Available at: https://psnet.
ahrq.gov/primer/reporting-patient-safety-events (accessed
oo
31.10.19).
Agency for Healthcare Research and Quality (AHRQ), 2019c.
Second victims: support for clinicians involved in errors
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and adverse events. Available at: https://psnet.ahrq.gov/
primer/second-victims-support-clinicians-involved-errors-
and-adverse-events (accessed 31.10.17).
e
Agency for Healthcare Research and Quality (AHRQ),
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2019d. Team STEPPS fundamentals course: module 5.
Situation monitoring. Available at: https://www.ahrq.gov/
m
teamstepps/instructor/fundamentals/module5/igsitmonitor.
html (accessed 31.10.19).
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Allegranzi, B., Donaldson, L.J., Kilpatrick, C.et al., 2019. Infection
prevention: laying an essential foundation for quality universal
health coverage. The Lancet Global Health 7 (6), 698–700.
Australian Bureau of Statistics, 2018. Life tables, states,
territories and Australia, 2015–2017 – 3302.0.55.001.
Available at: https://ww.abs.gov.au/
Australian Commission on Safety and Quality in Health Care
(ACSQHC), 2017. National Safety and Quality Health Service
Standards. Available at: https://www.safetyandquality.gov.au/
sites/default/files/migrated/National-Safety-and-Quality-Health-
Service-Standards-second-edition.pdf (accessed 31.10.19).
Australian Commission on Safety and Quality in Health
Care (ACSQHC), 2019. Australian Safety and Quality
Quality and safety in healthcare | CHAPTER 8 205
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Framework for Health Care 2017. Available at: https://www.
safetyandquality.gov.au/sites/default/files/2019-04/National-
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Safety-and-Quality-Health-Service-Standards-second-edition.
pdf (accessed 04.10.19).
Australian Council on Healthcare Standards (ACHS), 2018.
Programs and services – EquIP6. Available at: https://www.
achs.org.au/programs-services/equip6/ (accessed 04.10.19).
Australian Council on Healthcare Standards (ACHS), 2019. What
is accreditation? Available at: https://www.achs.org.au/about-
us/what-we-do/what-is-accreditation/ (accessed 31.10.19).
Australian Digital Health Agency, 2019. Clinical governance
framework. Available at: https://www.myhealthrecord.
gov.au/sites/default/files/clinical_governance_framework_
v2.5.pdf (accessed 04.10.19).
Australian Government. Aged Care Quality and Safety
Commission, 2019. About accreditation. Available at:
https://www.agedcarequality.gov.au/consumers/about-
accreditation (accessed 31.10.19).
Australian Government Ageing and Aged Care. Department
of Health, 2019. Aged care quality standards. Available at:
https://agedcare.health.gov.au/quality/aged-care-quality-
standards (accessed 04.10.19).
Australian Government. Department of Health, 2019. The
Australian health system. Available at: https://www.health.gov.
au/about-us/the-australian-health-system (accessed 31.10.19).
Australian Institute of Health and Welfare (AIHW), 2016.
Australia’s health 2016. Australia’s health series no. 15. Cat.
no. AUS 199. AIHW, Canberra. Available at: https://
www.aihw.gov.au/getmedia/f2ae1191-bbf2-47b6-a9d4-
1b2ca65553a1 (accessed 29.10.19).
Australian Institute of Health and Welfare (AIHW), 2017.
The Australian health performance framework. Available at:
https://www.aihw.gov.au/reports-data/indicators/australia-
s-health-indicators (accessed 30.09.19).
Australian Institute of Health and Welfare (AIHW), 2019a.
Life expectancy and death. Available at: https://www.aihw.
gov.au/reports/life-expectancy-death/deaths-in-australia/
contents/life-expectancy (accessed 29.09.19).
 WORKBOOK

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Essential Enrolled
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Nursing Skills
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FOR PERSON-CENTRED CARE 2E

Gabrielle Koutoukidis & Kate Stainton

Activate your eBook at evolve.elsevier.com

 Essential Enrolled
Nursing Skills

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FOR PERSON-CENTRED CARE 2E

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©
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Gabrielle Koutoukidis
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MPH, BN(Mid), DipAppSci(Nur), AdvDipN(Ed), DipBus,

Voc Grad Cert Business (Transformational Management), MACN,
International Specialised Skills Institute Fellow, Candidate EdD (Research),
e

Dean, Faculty Health Science, Youth & Community Studies, Holmesglen,

Melbourne, Victoria, Australia
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Kate Stainton
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MA HlthSci(Nurs), GDipNurs(Ed), BN(Mid), DipAppSci(Nurs), Cert IV TAE,

Industry Relationship Lead, Health, Wellbeing and Community Services SkillsPoint, TAFE NSW,
New South Wales, Australia
 v

CONTENTS

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Contributors vii Maintenance of health: hygiene
Acknowledgments ix
and comfort care 114

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Introduction x

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The five-point Bondy Rating Scale xii Clinical skill 23.1 Assisting with a shower or bath 116
Standard steps for all clinical skills/procedures/interventions xiii Clinical skill 23.2 Performing a bed bath 121

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Clinical skill 23.3 Performing an eye toilet 126
Nursing informatics and technology Clinical skill 23.4 Assisting with oral hygiene,

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in healthcare 1 cleaning teeth and dentures 130
Clinical skill 5.1 Nursing informatics competency 4 Clinical skill 23.5 Performing special mouth care 134
Clinical skill 23.6 Making an unoccupied bed 138
Health information: nursing Clinical skill 23.7 Making a theatre bed 143

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documentation and clinical handover 13 Clinical skill 23.8 Making the occupied bed 147
Clinical skill 6.1 Documentation 16
Clinical skill 6.2 Clinical handover 21
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Medication administration and monitoring 151
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Clinical skill 24.1 Administering oral medications 153
Understanding and promoting health 27 Clinical skill 24.2 Administering medications via
Clinical skill 7.1 Health teaching 29 enteral routes (nasogastric tube, percutaneous
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endoscopic gastrostomy tube, percutaneous

Health assessment frameworks: initial endoscopic gastrojejunostomy tube) 158
and ongoing 33 Clinical skill 24.3 Inserting a rectal suppository or
©

Clinical skill 19.1 Pressure injury risk assessment 35 disposable enema 163
Clinical skill 19.2 Mental health assessment 40 Clinical skill 24.4 Administering subcutaneous and
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Clinical skill 19.3 Falls risk assessment 45 intramuscular injections 167

Clinical skill 19.4 Venous thromboembolism Clinical skill 24.5 Establishing intravenous (IV)
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assessment 50 therapy (assisting) 172

Clinical skill 19.5 Nutritional assessment/weight, Clinical skill 24.6 Intravenous management 176
height and BMI 55 Clinical skill 24.7 Administration of intravenous
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Clinical skill 19.6 Mobility assessment 59 (IV) medications: infusion and bolus 180
Clinical skill 24.8 Removal of intravenous cannula 187
Vital sign assessment 63 Clinical skill 24.9 Administration of intravenous
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Clinical skill 20.1 Assessing body temperature 65 (IV) blood products 191
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Clinical skill 20.2 Assessing pulse (radial) 72 Clinical skill 24.10 Administration of subcutaneous
Clinical skill 20.3 Assessment of respirations 76 (subcut) medications: infusion 195
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Clinical skill 20.4 Measuring oxygen saturation Clinical skill 24.11 Administration of a topical
(pulse oximetry, SpO2) 80 medication 200
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Clinical skill 20.5 Measuring blood pressure 84 Clinical skill 24.12 Applying transdermal
medications 204
Admission, transfer and discharge Clinical skill 24.13 Instilling eye drops or ointment 208
processes 92 Clinical skill 24.14 Instilling ear drops 212
Clinical skill 21.1 Admission and discharge process 94 Clinical skill 24.15 Administration of a vaginal
medication 216
Infection prevention and control 102 Clinical skill 24.16 Administration of a medication
Clinical skill 22.1 Handwashing/hand hygiene 103 via nebuliser 220
Clinical skill 22.2 Donning and doffing PPE Clinical skill 24.17 Use of a hand-held inhaler and
(gloves, gown, mask, eyewear) 107 spacer 224
Clinical skill 22.3 Open gloving (donning and Clinical skill 24.18 Administering nasal sprays
removing sterile gloves) 111 and drops 228
 vi Contents

Nursing care of an individual: Clinical skill 31.3 Assisting with toileting: bedpan,
cardiovascular and respiratory 233 urinal, commode 346
Clinical skill 31.4 Applying a sheath/condom
Clinical skill 25.1 Preparing and monitoring
drainage device 351
an individual undergoing a blood transfusion 235
Clinical skill 31.5 Emptying a urine drainage bag 355
Clinical skill 25.2 Performing an ECG 240
Clinical skill 31.6 Urinary catheterisation (female) 358
Clinical skill 25.3 Incentive spirometry 244
Clinical skill 31.7 Removal of indwelling urinary
Clinical skill 25.4 Collection of sputum 247
catheter 364
Clinical skill 25.5 Collecting a nasopharyngeal
(nasal) or nasalpharynx (throat) swab 250 Nursing care: bowel elimination and
Clinical skill 25.6 Oronasopharyngeal suction 254 continence 369

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Clinical skill 25.7 Tracheostomy suctioning and
tracheal stoma care 258 Clinical skill 32.1 Changing an ostomy appliance 371

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Clinical skill 25.8 Care of chest tube/drainage Clinical skill 32.2 Stool assessment/collection 374

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and dressing change 263 Nursing assessment and management
Clinical skill 25.9 Oxygen therapy—nasal, mask 268

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of sensory health 377
Nursing care of an individual: fluid Clinical skill 34.1 Application of eye pad 378

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and electrolyte homeostasis 274 Clinical skill 34.2 Eye irrigation 382
Clinical skill 26.1 Fluid balance charting 276 Nursing assessment and management
of neurological health 386

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Promotion of health and wellbeing:
movement and exercise 280 Clinical skill 35.1 Performing a neurological
assessment 387
Clinical skill 28.1 Assisting with transfer
Clinical skill 28.2 Positioning individuals in bed
281
286
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Clinical skill 35.2 Neurovascular assessment 394
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Clinical skill 28.3 Application of anti-embolic Nursing assessment and management
stockings 290 of endocrine health 399
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Maintaining and promoting skin Clinical skill 36.1 Measuring blood glucose 400
integrity and wound care 294
Nursing in the acute care environment 404
©

Clinical skill 29.1 Wound swab 296

Clinical skill 29.2 Dressing a wound 300 Clinical skill 42.1 Venipuncture 405
Clinical skill 29.3 Assessment and management Clinical skill 42.2 Central venous access device
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of skin tears 304 management: dressing, removal and medication

Clinical skill 29.4 Packing a wound 308 administration 409
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Clinical skill 29.5 Removal of sutures and staples 312 Nursing in the perioperative care
Clinical skill 29.6 Shortening a drain tube 316 environment 414
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Promotion of health and wellbeing: Clinical skill 43.1 Pre- and postoperative exercises 416
nutrition 321
Nursing in the emergency care
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Clinical skill 30.1 Assisting with eating and drinking 322 environment 423
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Clinical skill 30.2 Inserting a nasogastric tube 326

Clinical skill 30.3 Enteral feed 331 Clinical skill 44.1 Cardiopulmonary
resuscitation/basic life support (BLS) 425
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Nursing care: urinary elimination and

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continence 337 Standards for Practice: Enrolled Nurse 430

Clinical skill 31.1 Routine urinalysis 338 Index 439
Clinical skill 31.2 Mid-stream urine collection 342

Lindsay Bava RN, BHlthSc(Nur), Cert IV TAE, Cert
IV TESOL, MEd, GDipIndEd, DipVET
Manager, Bourke Street Campus, Holmesglen Institute,
Melbourne, Victoria, Australia
Ann Bolton RN, BN, MCN, GDipAdNurs, GDipMid,
GDipVET, GDipCritCare, Cert IV TAE
Educator, Partners in Training, Shepparton; GOTAFE,
Seymour, Victoria; Batchelor Institute of Indigenous
Tertiary Education, Batchelor, Northern Territory,
Australia
Marie Casamento RN, BN, GradCert Clinical
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Education Certificate in Wound Management, Cert IV in
Training & Assessment
Nurse Educator, Holmesglen Institute, Victoria, Australia
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Colin Cassells MGeront, PG DipAdvNsg (Community
Health), Cert Cont Prom, BSc, RN, MCNA
©
Continence Nurse Specialist (private practice), Melbourne,
Victoria, Australia
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Meagan Gaskett RN, BN, BHSc, Cert IV TAE Grad
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Dip VET (Adult Ed), MSN
TAFE Trainer & Assessor Nursing
Clinical Nurse Educator/Clinical Support Nurse, Northern
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Health, Melbourne, Victoria, Australia
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Toni Kennison RN, Bachelor Nursing Practice,
Emergency Nursing Cert IV TAE
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Lecturer in Nursing TAFE, Gilles Plains, South Australia,
Australia
m
Rehana Khan Master Clinical Education, RN, BSN,
Sa
DipCounselling, Cert IV TAE
NSW Health Workforce Development Consultant,
Centre for Education & Workforce Development
(SLHD), Sydney, New South Wales, Australia
Gabrielle Koutoukidis MPH, BN(Mid),
DipAppSci(Nur), AdvDipN(Ed), DipBus, Voc Grad Cert
Business (Transformational Management), MACN
International Specialised Skills Institute Fellow,
Candidate EdD (Research)
vii
Contributors
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Dean, Faculty Health Science, Youth & Community
l
Studies, Holmesglen, Melbourne, Victoria, Australia
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Anne MacLeod ME (Adult), GC (Flexible Learning
st
& Simulation for Health Professionals), GCEd (Adult),
GDip (Adult), BN, DipAppSci(Nur), DipVocEd,
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CertNero, CertAcCare
Teacher, Health Wellbeing and Community Services,
TAFE NSW North Region
er
Nurse Educator, Quality, Risk Manager, Toronto Private
Hospital, Toronto, New South Wales, Australia
vi
Sally Moyle BN, MClinNursTeach, Cert IV TAE
Clinical Nurse Educator, Epworth Health Care,
Melbourne, Victoria, Australia
Kylie Porritt RN, GradDipNursSc(Cardiac), MNSc, PhD
Senior Research Fellow, Joanna Briggs Institute, University
of Adelaide, South Australia, Australia
Kalpana Raghunathan RN, PhD student,
MNursEd, MHRM, MDevStudies, GradDip DevStudies,
BNurs, BA Sociology, Dip ComDev, Dip BusMgt,
CertIV TAE
Education Development Consultant, Carramar
Educational Design, Victoria, Australia
Heather Redmond RN, BN, MN, BNHon, GradDip
CritCare, GradCert HDU Nursing, DipVET
Program Manager, TAFE Gippsland, Victoria, Australia
Desiree Rodier RN (Emergency), BNurs
Teacher, Nursing Health, Wellbeing and Community Services
Skills Team, TAFE NSW, New South Wales, Australia
Bianca Rohlje RN, MEd, BNurs, DipVET
Lecturer in Nursing and Health Sciences, Latrobe
University and Latrobe College, Victoria, Australia
Patricia Sinasac, RN, STN, MASc (Research), GradDip
AdvNrsg Educ, GradCert Stomal Therapy, BN
Clinical Nurse Consultant, Wound Management &
Stomal Therapy, Community and Oral Health, MNHHS,
Chermside, Queensland, Australia
 viii Contributors

Kate Stainton MA HlthSci(Nurs), GDipNurs(Ed),
BN(Mid), DipAppSci(Nurs), Cert IV TAE
Industry Relationship Lead, Health, Wellbeing and
Community Services SkillsPoint, TAFE NSW, New South
Wales, Australia
Glenda Verrinder, PhD, MHSci, GradDip Public &
Community Hlth, GradCert Higher Education, GradCert
Community Nsg, RN, Midwife
Honorary Associate, La Trobe Rural Health School,
La Trobe University, Australia

Karren Taber, BNurs, RN (Anaesthetics and Recovery), Heather Wakefield PostGradDip Advanced Clinical
GradCert Anaesthetic and Recovery Room Nursing, Nursing (Crit Care), GradDip Clinical Nursing Education
GradCert Perioperative Nursing, Cert IV TAE Dip VET, Cert IV TAE, RN, BN
Registered Nurse, Operating Theatres, John Hunter Senior Teacher, Diploma of Nursing, Department of

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Hospital Health, Science and Community, Swinburne University,
Casual Teacher, Nursing, TAFE NSW, Hunter Institute, Melbourne, Victoria, Australia

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Newcastle, New South Wales, Australia

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Denise B Tomaras BA(Psych), RN, PostGrad(Nsg Crit

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Care), DipEd, DipSci, DipFP
Education Manager—Department of Nursing,

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Holmesglen Institute, Melbourne, Victoria, Australia

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NURSING
INFORMATICS AND

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TECHNOLOGY IN

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HEALTHCARE

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Kalpana Raghunathan
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Overview
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NURSING INFORMATICS
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Health informatics is the interdisciplinary science of how to use data, information

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and knowledge to improve human health and delivery of healthcare, focusing on

the use of health information technologies, and involves computers, analytical and
social sciences (AMIA 2011; Nelson & Staggers 2018). Nursing informatics is a
pr

specialty within health informatics that integrates nursing science with multiple
information management and analytical systems to identify, define, manage and
communicate data, information, knowledge and wisdom in nursing practice
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and support decision making (ANA 2015). Essentially, it involves the use of
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computers, and information and communication technologies (ICT) to support

nursing practice (Sun & Falan 2013). Given the rapid digital advancements and
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pervasive use of ICT in healthcare, an essential minimum standard of informatics

knowledge and skills is necessary for all nurses to support nursing care activities
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and to operate effectively as clinicians in the digitally enabled work environment.

Being equipped with core informatics competencies will assist nurses in the
delivery of safer, better integrated and evidence-based care, resulting in positive
health outcomes for the community (ANMF 2015; Hebda et al 2018; McGonigle
et al 2014). A basic level of knowledge of informatics concepts and principles,
and digital capability is vital for nursing students to be prepared for clinical
placement settings and transitioning to professional practice (Raghunathan &
Tomkins 2019).
Informatics competency is essential for all health professionals to be able to
engage and interact with the different point-of-care technologies and informa-
tion systems used to support clinical workflows, decision-making tools, health
data management, and safety and quality improvements. Informatics skills and
 2 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

technology ability are critical to navigate the workplace information technologies and participate in decision making to
support safe and informed person-centred care (Nelson & Staggers 2018).
Information management in the healthcare environment
Health information technologies (health IT) are a necessary and critical part of the evolving healthcare landscape with the
advancement of ‘digital health’—the use of sophisticated information and communication technology (ICT) for health
(Rowlands 2019). Computerised health information systems such as electronic medical records (EMRs) and electronic
health records (EHRs) are being implemented to improve access to health data, reduce healthcare costs, result in better
integrated and safer care and improve overall care outcomes (Seckman 2018). EMRs are digital systems created and utilised
within a single healthcare organisation such as a clinic, medical centre or hospital; EHRs are digital systems that can be
managed, added to and accessed across multiple healthcare organisations (ADHA 2019). These health IT systems are the

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core of information management in the health setting. They incorporate many levels of health data that inform integrated

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clinical databases, workflows and clinical information and decision support systems used by clinicians. They are informatics

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tools designed to collect, store and make available important health data to facilitate individual care planning and clinical
decision making by clinicians (Hebda et al 2018; Nibblelink et al 2018).

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Healthcare organisations rely on EMRs and EHRs for data gathering, communication and decision making by clini-
cians, which involve interdisciplinary engagement, with nurses having an integral role in the collection, recording and

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managing of health data (Jenkins et al 2018). Nurses need to be proficient in not only point-of-care technology skills,
but also in utilising the different workplace health IT to support clinical decision making and deliver high-quality and
safe healthcare at the same time (Ali et al 2018; Cummings et al 2016; Herbert & Connors 2016; Sun & Falan 2013).
In the clinical environment, a range of ICT software systems are in use, and their functionality and applications vary

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between providers and the different care contexts. As frontline users of health IT, it is expected that nurses have some basic
ICT skills, as well as informatics capabilities, to manage and use the technology and data applications at the point of care

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and in a variety of practice environments to deliver safe and competent person-centred care (Gonen et al 2016; Rahman
2015). Competent use of ICT and related hardware and software underpins nursing informatics competencies. This includes
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actual psychomotor skills to use computer tools and devices confidently and specific informatics knowledge and skills, which
require working with health data, processing information and contributing to knowledge development for nursing practice
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(Nursing Informatics Learning Centre 2010–2012; Schleyer et al 2011). Proficiency in the use of computing devices and
workplace health IT systems used to manage clinical data and quality care is vital to support safe and informed clinical
practice for health professionals.
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Applying nursing informatics in practice

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The application of nursing informatics knowledge and skill in everyday nursing practice processes involves active engagement
with information technologies and computerised health information management systems in the practice environment.
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Informatics and ICT skills are necessary for direct and indirect care processes. The way nurses use informatics skills in daily
routine nursing care practice is through:
• The effective use of ICT to access, record, retrieve and manage health data
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• Interpretation and organisation of health information for decision support and nursing care (Hebert 2008)
• Synthesising the health data to generate new knowledge for nursing practice.
Nurses play a significant role in health information processes, being at the frontline in the delivery of care, and informatics
e

skills are essential for nurses in the ubiquitous information-technology-enhanced healthcare environment. With increasing
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adoption of digital information systems, such as EMRs and EHRs, by healthcare organisations, it is important that nurses
are equipped with adequate informatics capabilities to engage with the hardware and software of health IT and critically
m

manage the health data to support person-centred safe and quality care for the individual (Hebda et al 2018; Pordeli
2018). As clinicians, knowledge of clinical data systems and informatics competencies will assist nurses to not only support
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healthcare delivery, but also improve the healthcare outcomes for individuals through informed and evidence-based clinical
decisions at the point of care.
Nursing informatics standards and digital health capabilities
In Australia, the National Informatics Standards for Nurses and Midwives (ANMF 2015), developed with funding from the
Australian government, provide a framework and a set of essential and minimum informatics competencies that nurses
should possess to operate in the technology-dependent healthcare contexts. The standards serve as a detailed resource and a
valuable tool for practising nurses, educators and nursing students to build informatics capability to support practice (Reeves
2016).
Three domains of practice for nursing informatics education and competence for nurses at all levels are identified in
these standards; they include computer literacy, information literacy and information management. There are technical,
cognitive and application-based competencies necessary to support routine daily nursing practice activities and processes
 Nursing Informatics and Technology in Healthcare 3

in the digital work environment described within these informatics standards. Adherence to professional practice require-
ments, legal and ethical parameters and compliance with local policies and procedures are essential criteria within each
domain of the standards.
Aligned with the nursing informatics standards is the Australian National Nursing and Midwifery Digital Health Capa-
bilities Framework, which provides guidance for individuals and organisations towards developing digital health knowledge
and skills, in an increasingly ICT embedded work environment (AIDH 2020). Five key domains broadly set within the
context of roles, workplace settings and the professional standards informing practice are identified, they are; digital profes-
sionalism, leadership and advocacy, data and information quality, information-enabled care, and technology. Three progres-
sive achievement levels, from novice to expert, are also described for each capability area, they are; formative, intermediate
and proficient, which relate to the role and practice setting of the professional (AIDH 2020). The informatics standards and
digital health capability framework should be used by nurses to evaluate own individual capability, which can then be used

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to inform continuing professional development needs.

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Nursing informatics competencies
In the practice setting, the required level of work-related informatics proficiency among health professionals will vary

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depending the clinician’s specific work area and role, which can be viewed along a continuum from basic to advanced
competencies as informatics specialists (Nelson & Staggers 2018). The skill (Clinical Skill 5.1) presented in this chapter

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describes the core informatics competencies necessary to support beginning-level nurses in everyday routine nursing activities
in the delivery of healthcare, no matter where they work.
The level of performance identified within the skill (Clinical Skill 5.1) is a basic level of proficiency. It outlines essential
professional practice requirements and fundamental computer technology and information management skills needed to

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use informatics tools utilised in the healthcare setting. The aim is to facilitate a key set of transferable knowledge and skills
for students to be comfortable and confident to manage encounters with the health IT used in different clinical environ-

vi
ments during placements, as well as preparation for entering the health workforce. On entry to practice, it will be necessary
to develop more specific and advanced understanding of health informatics concepts and processes depending on context,
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the nurse’s role and different ICT applications in the work setting. As with all nursing competencies, a commitment to
lifelong learning and ongoing continuing education is necessary to keep up to date with evolving health IT advancements
El

to support practice.
The skill has been developed based on the three domains of practice identified by National Informatics Standards for Nurses
and Midwives (ANMF 2015). It is aligned to the National Nursing and Midwifery Digital Health Capabilities Framework
©

(AIDH 2020), as well as Code of Conduct for Nurses (NMBA 2018), and Enrolled Nurse Standards for Practice (NMBA 2016).
It is also informed by Australian and international perspectives on nursing informatics competency within the nursing educa-
fs

tion curriculum.
The following four areas of competence can assist to facilitate a basic level of knowledge and skills to guide quality,
oo

safety and informed practice. The nursing informatics competencies to support beginning-level practice include:
• Digital literacy: the application of basic knowledge and skills in ICT to support work practice
• Professional practice: working in accordance with the legal and regulatory requirements, professional standards and
pr

ethical principles for all uses of ICT used in work practice

• Information literacy: application of fundamental knowledge and skills to identify, locate, access, evaluate and apply
information to support work practice
e

• Information management: application of fundamental knowledge and skills in collection, use, management, storage
pl

of data and information, and ICT to support safe and informed practice.
m
Sa
4 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 5.1 Nursing informatics competency

Review and carry out the standard steps for all clinical skills/interventions; these steps must be performed
consistently with each individual to ensure safe nursing care is provided

NMBA Decision-making Framework considerations Equipment:

(refer to NMBA Decision-making framework for nursing Computer
and midwifery 2020): Tablets and handheld devices
1. Am I educated? ICT external devices, multimedia tools
2. Am I authorised? Telecommunication tools
3. Am I competent? Smartphones

ia
If you answer ‘no’ to any of these, do not perform that Internet web access
activity. Seek guidance and support from your teacher/a Healthcare records

l
nurse team leader/clinical facilitator/educator Learning software/applications

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Information databases/educational platforms
Educational learning technologies

st
Digital literacy

Au
Skill activity Rationale
Application of basic knowledge and skills in information and communication technology (ICT) to support work practice

er
Understand basic ICT terminology Knowledge of common ICT terminology such as web browser,
website, cloud based, internet, intranet, interoperability,
operating systems, home page, hypertext link, bookmark, URL

vi
(Uniform Resource Locator) address, encryption, backing up
se
Basic use of ICT to support work, includes: Demonstrates psychomotor skills as well as knowledge to
• Computer system use the software and device applications optimally
• Computer and device security
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Able to use hardware (e.g. mouse, screen, workstation) and

• Electronic devices
the software (primary operating systems, programs and
• Intranet, internet, the world wide web and WiFi
applications) relevant to work; knows basic troubleshooting
• Electronic communication tools
for checking power, rebooting and printing
©

• Electronic file management

• Word processing Understands and respects legal and organisation policy
• Spreadsheets guidelines to protect data privacy and confidentially, login
fs

• Databases and logging out, suspending sessions and password

• Presentation protection
oo

Protects against computer viruses and malware

Reports unauthorised use or breach to appropriate
pr

personnel
Knows how to use external/peripheral devices such as
e

USBs, tablets and handheld devices, smartphones apps

and point-of-care (POC) digital devices, wearables
pl

Able to use internal organisational (intranet, private networks,

m

shared file servers); and external web-based (world wide

web, cloud computing, internet browsers) systems
Sa

Able to use remote communication tools such as emails,

facsimile, skype, online discussion forums, chat or other
messaging applications and telehealth apps and tools
Able to navigate the computer operating systems to
access installed applications such as Microsoft Windows
to organise and manage information files and data
Able to use basic desktop software Microsoft Word and
Excel to create, access, categorise and store reports and
documents. Able to save, cut, copy, paste and delete
information
Able to locate online search engines and electronic
collections of data to research and search information
Continued
 Nursing Informatics and Technology in Healthcare 5

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Consider the workspace design, the environment and
workstation safety
Able to use basic desktop software Microsoft PowerPoint
and other web-based multimedia tools, e.g. videos,
podcasts, You Tube, slideshow, etc
Understands workplace health and safety requirements,
to protect self and others in relation to equipment, body
mechanics and safe work practices, and minimise risk
of injury or harm. Includes bedside, workstation and
portable technology

ia
Professional practice

l
ra
Skill activity Rationale

Work in accordance with the legal and regulatory requirements, professional standards and ethical principles for

st
all uses of ICT in work practice

Uphold the legal, regulatory and ethical standards related
to the use of digital health information
Au
Understands and respects legislation and policies.
E.g. data security, storage, disposal, protection of health
information, privacy, confidentiality, individual’s rights,
impact on individual and community, harmful content,
safety, social media, professional boundaries, passwords,

er
information sharing, unauthorised or illegal use and
breaches in data security

vi
Standards for safe and appropriate use of ICT in health.
se
E.g. the Australian Council on Healthcare Standards
(ACHS) (EQuIP) Information Management Standard
includes: criteria for Health Records Management;
El

Corporate Records Management; Collection, Use

and Storage of Information; and Information and
Communication Technology
©

Follow requirements for intellectual property, copyright Understands and respects legislation and policies
and fair use of copyrighted material pertaining to patents, design, trademarks, authorship,
fs

publications, ownership of material, etc

Aware of Australian Copyright Act, statutes, fair dealings,
oo

provisions and exceptions

Consider cultural, ethical and socioeconomic issues Understands and respects legislation and policies. E.g.
pr

related to accessing and using the information protection of privacy and confidentiality, impact on
individual and community, human rights, cultural safety,
access and equity issues
e

Proactive use of ICT to improve health outcomes, support Actively promotes and engages in the use of educational,
pl

professional practice and lifelong learning informatics and other ICT tools to build on digital
capability to support work, professional development
m

and ongoing learning

Sa

Information literacy
Skill activity Rationale
Application of fundamental knowledge and skills to identify, locate, access, evaluate and apply information to
support work practice
Use the internet to search, locate and download relevant Able to use basic online searching options through a
information search engine to locate organisations, services, websites
etc (e.g. Google, Ask.com, Bing)
Continued
6 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Plan and use online search strategies for scholarly
literature
Use multiple sources of data to retrieve information to
support work
Knows how to conduct literature search and locate
evidence-based resources and websites to support
informed and safe practice
Knows how to use available proprietary search databases
such as CINAHL, EBSCO, JBI, etc.
Able to use various and additional services such as
library resources, professional associations, government
websites, research institutes, peak bodies, community

ia
resources, relevant experts and practitioners to obtain or
retrieve information needed to support clinical judgment

l
and evidence-based decision making

ra
Use ICT and informatics tools to obtain information Able to use electronic records, POC databases, clinical

st
applications and communication tools to assist workflow,
evidence-based decision making and care planning, and

Au
for health teaching
E.g. digital systems for care plans, admission and
discharge, clinical information systems (CIS), handovers,
medication management and proprietary clinical decision

er
solutions such as Clinical Key and UpToDate
Evaluate various sources of information Ensures information is evidence-based, best practice,

vi
current and supports safe and informed high-quality practice.
Analyses and understands the available information, by
se
critically evaluating reliability, currency, validity, accuracy,
authority, timeliness and point of view or bias in information
for determining its suitability and appropriate use
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E.g. guidelines, policies, procedures and protocols,

scholarly and best practice literature
©

Recognises specific cultural, physical or other context of

information. Understands the background and specific
nature or type of information, including its range and
fs

limitations, when interpreting and applying it to practice

E.g. population health, demography, cultural safety,
oo

gender, specific health needs, etc

Manage information collected or generated Organises and documents data and information using
ICT tools
pr

Appropriate use of POC digital tools and CIS (e.g. vital

signs, measurements, observations, progress notes,
e

care plans, medication management), electronic record

systems (e.g. EMRs, EHRs and personal health records
pl

(PHRs)) and other ICT tools used in healthcare

m

Information management
Sa

Skill activity Rationale

Application of fundamental knowledge and skills in collection, use, management and storage of data, information
and ICT to support safe and informed practice
Recognise digital data storage methods and formats
Knowledge of EHRs, EMRs, PHRs (e.g. My Health
Records), including levels and types of POC applications
E.g. practice management systems, patient administration
systems, bed management systems, hospital
management systems, aged care and long-term care
systems, clinical portals and patient acuity systems,
digital monitoring systems, prescribing and medication
administration systems, order entry systems, health and
safety reporting, quality and audit systems, and clinical
data repositories and POC decision tools
Continued
 Nursing Informatics and Technology in Healthcare 7

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Distinguish between data and information and how it can
be used to support work
Understands that data is raw, unorganised and
unprocessed individual information (facts) which may
not be useful by itself. When this data is organised,
processed and given context to make it meaningful it
becomes information
E.g. by itself, a person’s vital signs, measurements,
pathology or diagnostic test results are raw data. When
this data is organised and presented to obtain a picture
of the person’s health it is information about the individual

ia
Use of digital records and information systems Knows how to use digital health records, clinical
appropriately databases and other informatics tools for accessing and

l
ra
investigating information to support safe and informed
practice as per organisation policy (e.g. use of EMR,
EHRs, PHRs, CIS, and other data systems)

st
Integrate and use digital communication Communicates remotely with other healthcare

Au
professionals, services, colleagues and healthcare
recipients/their families/carers in delivery and
management of timely care

er
Knows how to use networks, intranets, and internet
for emails, messaging, referrals, reports, handovers,
transfers, telehealth, etc
Recognise embedded decision support systems and
vi
Responds to safety alerts, reporting and workflow triggers
se
clinical workflows to guide work and parameters
Reviews POC clinical data to guide timely decisions,
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interventions and workflow

Knowledge of system-generated administrative, clinical
and safety workflows and reporting prompts and
©

requirements
E.g. electronic applications used for admissions and
discharge, bed management, patient care activities,
fs

medication safety alerts, best practice alerts,

credentialing, etc
oo

Use data and statistical reports for quality improvement Understands value and link between quality nursing care
and health outcomes, which has the ability to influence
pr

policy, budgets, practice, allocation of resources,

research and education
E.g. episode of care outcomes and activities can be
e

evaluated for improvements

pl

Recognise common informatics classifications, coding Aware of technical and IT specific coding systems,
systems and languages classifications, terminology and language used to
m

describe, standardise and collate the computer data or

common set of data to make it meaningful
Sa

E.g. application of data standards, minimum data sets,

clinical dictionaries and clinical language system such
as Systemised Nomenclature of Medicine (SNOMED)
International Classification of Diseases (ICD-10) and the
North American Nursing Diagnosis Association (NANDA)
Maintain accurate and up-to-date records and Accurate, comprehensive, timely and up-to-date
documentation information enhances quality of data and increases
reliability and validity of information to guide timely
decisions and improve safety and health outcomes
Continued
8 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 5.1 Nursing informatics competency—cont’d

Interdisciplinary and stakeholder engagement relating to Demonstrates interprofessional- interdisciplinary and
digital records individual/family/carer collaboration for effective and
efficient holistic and person-centred model of care
Uses digital applications and information methods for
health teaching
Note: There are several different digital health and ICT systems in the clinical environment. How each facility and
healthcare agency uses these information management and clinical support systems varies. With rapid technology
developments and ICT constantly evolving, new POC and information management solutions to improve health

ia
services and delivery of care continue to emerge. In reality, it is not practical to learn the use of each and every
individual ICT tool in the work environment. Therefore, the emphasis for developing nursing informatics competencies

l
among nursing students is an understanding of the core principles and essential skills that can be built upon with

ra
ongoing exposure to health IT and professional experiences.
Due to liability for data entry errors, confidentiality and data security concerns, some facilities may restrict or only allow

st
limited access to the digital data systems during clinical placement for students. At some clinical facilities, students may
be required to complete an orientation module before being allowed access to the system. In the clinical environment,

Au
all staff are required to complete user training modules before being allowed to use the health IT systems.
It is recommended that students optimise opportunities to master ICT and informatics skills through educational and
communication technologies used in the course and the institution.

er
(AIDH 2020; ANMF 2015; Honey et al 2018; Nagle et al 2014; Nursing Informatics Learning Centre 2010–2012; Rahman 2015; Sun & Falan 2013)

vi
se
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©
fs
oo
pr
e
pl
m
Sa
 Nursing Informatics and Technology in Healthcare 9

OBSERVATION CHECKLIST: NURSING INFORMATICS Independent (I)

COMPETENCY
STUDENT NAME: _____________________________________________________ Supervised (S)

CLINICAL SKILL 5.1: Nursing informatics competency Assisted (A)

DOMAIN(S): Professional and collaborative practice; provision of care; and reflective Marginal (M)
and analytical practice Dependent (D)
EN STANDARDS FOR PRACTICE INDICATOR:
1.1, 1.2, 1.3, 1.8, 1.9, 2.2, 2.7, 2.9, 3.1, 3.2, 3.6, 3.7, 3.9, 4.1, 4.2, 4.4, 5.2, 5.3, 6.3, 6.4, 7.1, 7.3,
7.2, 7.3, 7.4, 7.5, 8.2, 8.3, 8.5, 8.6, 9.2, 9.3, 9.4, 10.2, 10.3

ia
DEMONSTRATION OF: The ability to apply essential information and communication
technology, and informatics knowledge and skills to guide quality, safety and informed

l
ra
practice
If the observation checklist is being used as an assessment tool, the student will need

st
to obtain a scale of independence for each of the performance criteria/evidence.

Au
er
COMPETENCY
PERFORMANCE CRITERIA/EVIDENCE I S A M D
ELEMENTS
•
vi
Identifies indications and rationale for performing the activity
se
• Checks facility/organisation policy
Preparation for the • Locates and gathers equipment/resources
activity • Discusses activity with instructor/supervisor/team leader if
El

required
• Obtains necessary instructions and computer/ICT access
Information and communication technology (ICT):
©

• Uses ICT hardware and peripheral devices appropriately

• Uses ICT safely (data security, protection, password, login
and log out, suspending sessions, work health and safety)
fs

• Demonstrates basic troubleshooting skills (power, rebooting

and printing)
oo

• Uses computer operating systems

• Uses the intranet, internet and WiFi to support work
• Uses digital/telecommunication tools and networks, and
pr

Performs activity emails effectively

• Navigates Microsoft Windows environment effectively
informed by • Uses word processing applications
e

evidence • Uses spreadsheet applications

• Uses presentation tools and multimedia presentations
pl

Information literacy:
• Searches and locates information online
m

• Plans and conducts database literature searches

• Accesses evidence-based sources of information related to
Sa

nursing practice and care

• Able to access multiple sources for information
• Synthesises data from various sources
• Organises and manages information collected
Continued
 Nursing Informatics and Technology in Healthcare 11

Educator/Facilitator Feedback:

Educator/Facilitator Score: Competent Needs further development

ia
How would you rate your overall performance while undertaking this skill activity in the four areas? (use a 
& initial)

l
ra
1. Digital Literacy
Unsatisfactory Satisfactory Good Excellent

st
2. Professional Practice

Au
Unsatisfactory Satisfactory Good Excellent
3. Information Literacy
Unsatisfactory Satisfactory Good Excellent

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4. Information Management
Unsatisfactory Satisfactory
vi Good Excellent
Student Reflection: (discuss how you would approach your practice differently or more effectively)
se
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©
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EDUCATOR/FACILITATOR NAME/SIGNATURE:

STUDENT NAME/SIGNATURE: DATE:

pr
e
pl

References
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Ali, R.A., Benjamin, K. Munir, S., et al., 2018. A review of informatics competencies tools for nurses and nurse managers. Canadian Journal of
Nursing Informatics 13 (1). Online. Available at: http://cjni.net/journal/?p=5370.
Sa

American Medical Informatics Association (AMIA), 2011. What is informatics? Fact Sheet. Online. Available at: https://www.amia.org/fact-sheets/
what-informatics.
American Nurses Association (ANA), 2015. Nursing informatics: scope and standards of practice. Silver Spring: Nursebooks.org
Australian Digital Health Agency (ADHA), 2019. Types of digital health records. Online. Available at: https://www.digitalhealth.gov.au/
get-started-with-digital-health/digital-health-evidence-review/types-of-digital-health-records.
Australasian Institute of Digital Health (AIDH), 2020. Draft National Nursing and Midwifery Digital Health Capabilities Framework. Online.
Available at: https://digitalhealth.org.au/wp-content/uploads/2020/02/DRAFT-National-Digital-Health-Capability-Framework-for-Nurses-
and-Midwives-v4.7_For-Consultation.pdf.
Australian Nursing and Midwifery Federation (ANMF), 2015. National Informatics Standards for Nurses and Midwives. Australian Government
Department of Health and Ageing. Online. Available at: http://anmf.org.au/documents/National_Informatics_Standards_For_Nurses_And_
Midwives.pdf.
Cummings, E.A., Shin, E.H., Mather, C.A., et al., 2016. Embedding nursing informatics education into an Australian undergraduate nursing
degree. Studies in Health Technology and Informatics 225, 329–333. Online. Available at: http://ebooks.iospress.nl/bookseries/studies-in-
health-technology-and-informatics.
HEALTH
ASSESSMENT

ial
FRAMEWORKS:

ra
st
INITIAL AND

Au
ONGOING
er
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Gabrielle Koutoukidis and
El

Kate Stainton
©
fs
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Overview
pr

A general health assessment is the acquisition and interpretation of data that will
allow a nurse to plan effective care to assist the improvement of an individual’s
overall health status. It is largely dependent on the ability of a nurse to communicate
e

effectively with an individual (McCormack & McCance 2017). It consists of a

pl

systematic and holistic collection of both subjective data (history obtained from the
individual) and objective data (evidence collected through observation). A general
m

health assessment consists of assessing an individual’s physical and mental health

and socioeconomic and financial statuses. The data collected will assist the nurse to
Sa

focus on the effects health and illnesses have on quality of life (Jensen 2019).
A general health assessment generally consists of the following elements:
• Information collection, including an individual’s history
• Arranging appropriate allied health staff for examinations that may be
required
• Referring or undertaking ordered investigations as required
• Constructing an overall assessment of an individual
• Assessing, evaluating and recommending appropriate interventions
• Educating and providing advice and information to an individual
• Retaining a record of a health assessment of the individual in a written
report
• Recommending an individual’s family or carer for assistance and/or services.
 34 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

Sometimes a more focused assessment may be necessary. Focused assessments are used to observe and monitor systems-
related complications. A focused assessment is a more detailed assessment of a particular problem (Brown et al 2020;
Lewis & Foley 2020).
Health assessments are a fundamental process in which nurses collect data, both intrinsically and extrinsically, to
develop an individualised plan of care. Data collection generally is derived from the individual themselves by direct
observation and verbal communication, but students should be aware of the other forms of imperative data collection that
are necessary for a holistic overview. The collection of data provides a sound baseline for clinical judgments, in consultation
with the wider interdisciplinary team, to be made and evaluated.
Nurses are generally with the individuals the majority of the time; therefore, the ability to assess and respond quickly to
health needs or concerns is imperative to ensure an individual’s condition does not worsen. Student Enrolled Nurses must
have the sound knowledge of how to assess and collect data, and how to make sound clinical judgments in consultation with

ia
the wider allied health team.

l
This chapter will explore, describe and allow for the practice and consolidation of the skills required for screening for

ra
general health assessments to determine an individual’s needs and requirements.

st
Au
er
vi
se
El
©
fs
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pr
e
pl
m
Sa
 Health Assessment Frameworks: Initial and Ongoing 35

CLINICAL SKILL 19.1 Pressure injury risk assessment

Review and carry out the standard steps for all clinical skills/interventions; these steps must be performed
consistently with each individual to ensure safe nursing care is provided

NMBA Decision-making Framework considerations Equipment:

(refer to NMBA Decision-making framework for nursing Assessment tool used in the clinical facility/organisation
and midwifery 2020):
The individual’s nursing care plan and history
1. Am I educated?
2. Am I authorised?
3. Am I competent?

ia
If you answer ‘no’ to any of these, do not perform that
activity. Seek guidance and support from your teacher/a

l
nurse team leader/clinical facilitator/educator

ra
Skill activity Rationale

st
Identify indications and rationale for performing the activity. Reduces unnecessary assessments performed on an
individual
This may include identifying:

Au
• Past history of pressure injuries
• Intrinsic and extrinsic factors that may contribute to
pressure injuries
• Understanding reasons why the pressure injury risk

er
assessment needs to be performed or has been
ordered
Identify the individual using three individual identifiers.
vi
Reduces the incidence of performing an assessment on
the incorrect individual
se
This may include but is not limited to:
• Identification—allocated healthcare number on
hospital bracelet/band
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• Verbal confirmation from the individual of given

and family name
• Date of birth
©

• Gender
• Address
• Medical record number
fs

Explain and communicate the activity clearly to the Reduces anxiety/apprehension and gains an individual’s
oo

individual. This may include but is not limited to explaining trust and cooperation
to the individual:
• Why the assessment has been ordered
pr

• Why the assessment will be undertaken and the

frequency
• What is involved in undertaking the assessment
• What will be done with the data collected
e

Ensure therapeutic interaction Assists with alleviation of fear prior to the assessment
pl

Identify lifespan, cultural and language barriers Identifies any considerations required by the nurse when
m

undertaking the assessment, influenced by an individual’s

past experience, ability to understand and comprehend
instructions, and age-related considerations
Sa

Gain the individual’s consent
Perform hand hygiene
Ensure provision of comfort measures prior to the
assessment including the removal of restrictive clothing
and providing pain relief if required
Ensures that the individual understands why the assessment
needs to be performed, therefore promoting cooperation
Prevents cross-infection
Promotes an individual’s cooperation, removes risk factors
with clothing and ensures accurate data is collected
Continued
36 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 19.1 Pressure injury risk assessment—cont’d

Assess and document the individual’s sensory perception
in the progress notes and facility/organisational chart:
• By assessing the individual’s ability to detect pain
• In unconscious individuals, the ability to react to
pain
Assess and document the individual’s degree of exposure
Assesses the individual’s ability to verbalise pressure-
related discomfort that will indicate skin damage
Prompts the EN to apply interventions and strategies on
how often to replace and clean linen, incontinence aids
Assesses the unconscious individual’s ability to react
to pressure-related discomfort, which will indicate skin
damage
Assesses the individual’s risk of skin damage and

ia
to moisture in the progress notes and organisation chart degeneration if exposed to excessive moisture
by direct observation or assessment of turgor, dampness,

l
Prompts the EN to apply interventions and strategies on
excessive moisture loss affecting skin

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how often to replace and clean linen, incontinence aids
Assess continence

st
Assess and document the individual’s activity and mobility Assesses the individual’s risk of skin damage and
status in the progress notes and organisational chart: degeneration from the degree of physical mobility

Au
• By assessing the ability of the individual to move
Prompts the EN to apply interventions and strategies
or the ability to be moved
on how often to assist the individual in changing body
• In unconscious individuals, the ability to be moved
position to relieve pressure on the skin
• Observing for any reddened skin that blanches

white under light pressure
Assess and document the individual’s nutritional status in
the progress notes and organisational chart
Nutritional data collection will include:
• Loss of appetite of an individual
El
er
Prompts the EN to engage the use and expertise of an
occupational therapist and physiotherapist
vi
Assess the individual’s risk of skin damage and
degeneration caused by malnutrition or poor nutritional
se
status
Prompts the EN to apply interventions and strategies on

• Unusual weight loss or gain in an individual
• Fluid intake of an individual
©
how often to assist the individual with meals
Prompts the EN to engage the use and expertise of a
dietitian

Assess and document vascular/perfusion status of lower May help to lower risk and incidence of pressure injuries.
limbs, heels and feet
Prompts the EN to apply interventions and strategies on
fs

If at risk of heel pressure injury, elevate the heels, preventing pressure injuries
ensuring weight of the leg is distributed along the calf
oo

without placing pressure on the Achilles tendon and

popliteal vein
pr

Assess support surface and whether it is meeting the
needs of the individual in terms of pressure redistribution
e
May help to lower risk and incidence of pressure injuries.
Prompts the EN to apply interventions and strategies on
preventing pressure injuries

Assess and document the individual’s risk of friction Assesses the individual’s risk of skin damage and
pl

and shear when moving in the progress notes and degeneration from friction or shearing of the skin when
organisational chart by: moving
m

• Assessing and identifying any mechanical force

Prompts the EN to apply interventions and strategies
that could occur when two surfaces rub together,
on how often to assist the individual in changing body
Sa

creating resistance between the skin and a surface

• Identifying typical areas where this will occur (e.g.
heels and elbows), resulting from repositioning
• Assessing and identifying any mechanical force
created from parallel loads (e.g. movement on
a bed sheet), which can create an occlusion or
displacement of tissue
position to relieve pressure on the skin
Prompts the EN to engage the use and expertise of an
occupational therapist and physiotherapist
Shear forces are a significant risk for pressure injury
formation as blood flow is disrupted
 Health Assessment Frameworks: Initial and Ongoing 37

CLINICAL SKILL 19.1 Pressure injury risk assessment—cont’d

Undertake a head-to-toe assessment of the skin to These are warning signs of impending skin damage
identify any existing or new skin tears, especially over
Ensures pressure areas are identified and treated early
bony prominences such as sacrum, elbows, shoulder
blades. This includes identifying:
• Intact skin or skin loss
• Blanchable or non-blanchable skin
• Areas that may be painful, warmer, cooler or
oedematous
If skin breaks have been identified:

ia
• Skin break is measured and documented in depth
and width on the pressure area risk tool

l
• Colour and/or ooze is documented on the pressure

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area risk tool
• Location is identified on the pressure area risk tool

st
• Treatment plan is documented on the pressure-risk
tool in consultation with the Registered Nurse

Au
Determine the frequency of the pressure-risk monitoring Ensures a range of data is collected over different
by identifying and evaluating the individual’s risk status, situations and times.
such as high, medium or low, according to the pressure
injury chart

Ensure provision of comfort measures after the
assessment including repositioning of the individual
Link theory to practice
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er
Promotes the individual’s comfort and privacy
vi
An understanding of why the nurse is undertaking the
se
assessment ensures a thorough collection of data and an
understanding of the data collected

Demonstrate current best practice in the care provided Ensures quality care is provided to the individual
by understanding the current trends in pressure injury
management
©

Adhere to the policy and procedures of the facility/ Policies and procedures are written documents that
organisation by locating and reading prior to assessment include guidelines and practices developed to address
to ensure the delegation is valid legal, ethical and regulatory requirements
fs

Both policies and procedures convey to employees and

oo

to other stakeholders the organisation’s interests and the

vision, mission and methods it intends to use to achieve
those goals
pr

Work in collaboration with other allied healthcare staff by Referral to other health professions ensures holistic care
working with the Registered Nurse and identifying referral with appropriate interventions
to allied health staff if required
e

Demonstrate a structured clinical handover process, either Ensures current and correct information is relayed to other
pl

verbal or written, using the identified organisation policy health professionals for continuity and safety of care
Document assessment findings using the correct Ensures a systematic record for reference by other allied
m

documentation tools as per the policy of the organisation healthcare professionals

Sa

Record the assessment findings with the date, time and
signature on the pressure injury chart
Report abnormal assessment findings to the Registered
Nurse
(Adapted from ACSQHC 2017; EPUAP et al 2019; Jensen 2019)
Provides a baseline observation for assessment
improvement or deterioration
Ensures appropriate strategies and interventions are put
in place to encourage positive outcomes
 38 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

OBSERVATION CHECKLIST: PRESSURE INJURY RISK Independent (I)

ASSESSMENT
STUDENT NAME: _____________________________________________________ Supervised (S)

CLINICAL SKILL 19.1: Pressure injury risk assessment Assisted (A)

DOMAIN(S): Professional and collaborative practice; provision of care; reflective and Marginal (M)
analytical practice Dependent (D)
EN STANDARDS FOR PRACTICE INDICATOR: 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 2.1, 2.2, 2.3, 2.4,
2.5, 2.6, 2.7, 2.8, 2.10, 3.1, 3.2, 3.3, 3.4, 4.1, 4.2, 4.3, 4.4, 5.1, 5.2, 5.3, 5.6, 6.2, 6.3, 6.4, 6.6,
7.1, 7.2, 7.3, 7.4, 7.5, 8.1, 8.2, 8.3, 8.4, 8.5, 9.2, 10.1, 10.6

ia
DEMONSTRATION OF: The ability to effectively and safely assess an individual’s
pressure risk status

l
ra
If the observation checklist is being used as an assessment tool, the student will need
to obtain a scale of independence for each of the performance criteria/evidence.

st
Au
COMPETENCY
PERFORMANCE CRITERIA/EVIDENCE I S A M D
ELEMENTS

er
Identifies indications and rationale for performing the activity
Identifies the individual using three individual identifiers

vi
Ensures therapeutic interaction
Preparation for the Gains the individual’s consent
se
activity Checks facility/organisation policy
Validates the order in the individual’s record
Locates and gathers equipment
El

Assists the individual into an appropriate position

Assesses the individual’s sensory perception
Assesses the individual’s exposure to moisture
©

Performs activity
Assesses the individual’s activity and mobility status
informed by Assesses the individual’s nutritional status
evidence Assesses the individual’s risk of friction and shear when moving
fs

Undertakes a head-to-toe assessment of the skin

oo

Applies critical Is able to link theory to practice

thinking and Demonstrates current best practice in the care provided
reflective practice Assesses own performance
pr

Practises within Reviews against facility/organisation policy

safety and Performs hand hygiene
e

Ensures provision of comfort measures after the assessment

quality assurance including repositioning of the individual
pl

guidelines Determines the frequency of the falls risk monitoring

m

Explains and communicates the activity clearly to the individual

Communicates outcome and ongoing care to individual and
significant others
Sa

Communicates abnormal findings to appropriate personnel

Documentation and Reports and documents all relevant information and any
communication complications correctly in the healthcare record
Reports any complications and/or inability to perform the procedure
to the RN and/or medical officer
Asks the individual to report any complications during and post
procedure
 Health Assessment Frameworks: Initial and Ongoing 39

Educator/Facilitator Feedback:

Educator/Facilitator Score: Competent Needs further development

How would you rate your overall performance while undertaking this clinical activity? (use a  & initial)

ia
Unsatisfactory Satisfactory Good Excellent

l
ra
Student Reflection: (discuss how you would approach your practice differently or more effectively)

st
Au
EDUCATOR/FACILITATOR NAME/SIGNATURE:

er
STUDENT NAME/SIGNATURE: DATE:

vi
se
El
©
fs
oo
pr
e
pl
m
Sa
40 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 19.2 Mental health assessment

Review and carry out the standard steps for all clinical skills/interventions; these steps must be performed
consistently with each individual to ensure safe nursing care is provided

NMBA Decision-making Framework considerations Equipment:

(refer to NMBA Decision-making framework for nursing Assessment tool used in the clinical facility/organisation
and midwifery 2020):
The individual’s nursing care plan and history
1. Am I educated?
2. Am I authorised?
3. Am I competent?

ia
If you answer ‘no’ to any of these, do not perform that
activity. Seek guidance and support from your teacher/a

l
nurse team leader/clinical facilitator/educator

ra
Skill activity Rationale

st
Identify indications and rationale for performing the activity Reduces unnecessary assessments performed on an individual
Identify the individual’s need for assistance and Ensures the nurse has factored into the assessment

Au
comorbidities by accessing the individual’s nursing care already-known risk factors prior to the assessment being
plan prior to undertaking the assessment undertaken
Identify the individual using three individual identifiers. Reduces the incidence of performing an assessment on

er
This may include but is not limited to: the incorrect individual
• Identification—allocated healthcare number on
hospital bracelet/band
• Verbal confirmation from the individual of given
and family name vi
se
• Date of birth
• Gender
• Address
El

• Medical record number

Explain and communicate the activity clearly to the Reduces anxiety/apprehension and gains an individual’s
©

individual. This may include but is not limited to explaining trust and cooperation
to the individual:
• Why the assessment has been ordered
fs

• Why the assessment will be undertaken and frequency

• What is involved in undertaking the assessment
oo

• What will be done with the data collected

Ensure therapeutic interaction Assists with alleviation of fear prior to the assessment
pr

Identify lifespan, cultural and language barriers Identifies any considerations required by the nurse when
undertaking the assessment, influenced by an individual’s
past experience, ability to understand and comprehend
e

instructions and age-related considerations

pl

Gain the individual’s consent Ensures that the individual understands why the
assessment needs to be performed therefore promoting
cooperation
m

Assess presenting problems Provides a baseline data set and possible links to an
Sa

individual’s mental health

Assess history of presenting problems (onset, duration,
course, severity)
Assess current functioning (across domains e.g.
employment/education, family, social)
Assess previous assessments and interventions
Assess psychiatric history (personal and family history)
Assess current medications
Assess medical history
Assess family history of mental health
Assess developmental history
 Health Assessment Frameworks: Initial and Ongoing 41

CLINICAL SKILL 19.2 Mental health assessment—cont’d

Assess substance use
Assess forensic and legal history
Assess risk screen (e.g. suicide, self-harm, aggression,
vulnerability, absconding risk, risks to dependent children)
Assess mental status Gathers data on the individual’s current status and
highlights indications of the individual’s mental health
status

ia
Appearance: Provides a baseline data set and possible links to an
• Usual and unusual appearance (e.g. statue) individual’s mental health

l
• Grooming or any evidence of neglect

ra
• Apparent age vs real age
• Facial features
• Identifying features such as skin marks, moles

st
Behaviour: Provides a baseline data set and possible links to an

Au
• Any physical signs of anxiety individual’s mental health
• Restlessness, relaxed
• Hand or facial gestures
• Eye contact

er
Speech: Provides a baseline data set and possible links to an
• Rate—slow, fast, normal individual’s mental health
• Logic
• Ability to complete sentences
vi
se
• Absence
Mood and affect: Provides a baseline data set and possible links to an
El

• Responses to questions individual’s mental health

• Emotional status—crying, laughing inappropriately
• Anger
• Anxiety
©

• Irritability
Form of thought, content of thought: Provides a baseline data set and possible links to an
fs

• Hallucinations—visual or auditory individual’s mental health

• Hearing of voices
oo

• Concerns
• Evidence of paranoia
Provides a baseline data set and possible links to an
pr

Insight and cognition:

• Orientation to time, place, person individual’s mental health
• Understanding of health issues
• Understanding of medication therapy and treatment
e

Memory: Provides a baseline data set and possible links to an

pl

• Long-term memory individual’s mental health

• Short-term memory
m

Demonstrate current best practice in the care provided Ensures quality care is provided to the individual
Sa

Adhere to the policy and procedures of the facility/
organisation to ensure the delegation is valid
Ensure the individual’s rights are respected
Ensure informed consent
Policies and procedures are written documents that
include guidelines and practices developed to address
legal, ethical and regulatory requirements
Both policies and procedures convey to employees and
to other stakeholders the organisation’s interests and the
vision, mission and methods it intends to use to achieve
those goals
Demonstrates quality individual care
Demonstrates informed consent
Continued
42 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 19.2 Mental health assessment—cont’d

Work in collaboration with other allied healthcare staff
Demonstrate a structured clinical handover process,
either verbal or written
Document assessment findings using the correct
documentation tools
Record the assessment findings with the date, time and
signature
Referral to other health professions ensures holistic care
with appropriate interventions
Ensures current and correct information is relayed to other
health professionals for continuity and safety of care
Ensures a systematic record for reference by other allied
healthcare professionals
Provides a baseline observation for assessment
improvement or deterioration

ia
Report abnormal assessment findings to the Registered Ensures appropriate strategies and intervention are put in
Nurse place to encourage positive outcomes

l
ra
(Adapted from ACSQHC 2017; Carniaux-Moran 2013; Jensen 2019)

st
Au
er
vi
se
El
©
fs
oo
pr
e
pl
m
Sa
 Health Assessment Frameworks: Initial and Ongoing 43

OBSERVATION CHECKLIST: MENTAL HEALTH Independent (I)

ASSESSMENT
STUDENT NAME: _____________________________________________________ Supervised (S)

CLINICAL SKILL 19.2: Mental health assessment Assisted (A)

DOMAIN(S): Professional and collaborative practice; provision of care; reflective and Marginal (M)
analytical practice Dependent (D)
EN STANDARDS FOR PRACTICE INDICATOR: 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 2.1, 2.2, 2.3, 2.4,
2.5, 2.6, 2.7, 2.8, 2.9, 2.10, 3.1, 3.2, 3.3, 3.4, 4.1, 4.2, 4.3, 4.4, 5.1, 5.2, 5.3, 5.6, 6.1, 6.2, 6.3,
6.4, 6.6, 7.1, 7.2, 7.3, 7.4, 7.5, 8.1, 8.2, 8.3, 8.4, 8.5, 9.2, 10.1, 10.6

ia
DEMONSTRATION OF: The ability to effectively and safely assess an individual’s mental
health status

l
ra
If the observation checklist is being used as an assessment tool, the student will need
to obtain a scale of independence for each of the performance criteria/evidence.

st
Au
er
COMPETENCY
PERFORMANCE CRITERIA/EVIDENCE I S A M D
ELEMENTS

vi
Identifies indications and rationale for performing the activity
Identifies the individual using three individual identifiers
se
Preparation for the Ensures therapeutic interaction
Gains the individual’s consent
activity Checks facility/organisation policy
El

Validates the order in the individual’s record

Locates and gathers equipment
Assesses presenting problems
©

Assesses history of presenting problems (onset, duration, course,

severity)
Assesses current functioning (across domains; e.g. employment/
fs

education, family, social)

Assesses previous assessments and interventions
oo

Assesses psychiatric history (personal and family history)

Assesses current medications
Assesses medical history
pr

Assesses family history of mental health

Assesses developmental history
Assesses substance use
e

Assesses forensic and legal history

pl

Performs activity Assesses risk screen (e.g. suicide, self-harm, aggression,

vulnerability, absconding risk, risks to dependent children)
informed by Assessing mental status:
m

evidence • Appearance (identifying features such as skin marks, moles)

• Behaviour
Sa

• Speech
• Mood and affect
• Irritability
• Form of thought, content of thought
• Evidence of paranoia
• Insight and cognition
Assesses understanding of medication therapy and treatment
Assesses memory
Identifies lifespan, cultural and language barriers
Provides privacy
Ensures therapeutic interaction
Works in collaboration with other allied healthcare staff
Continued
44 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

COMPETENCY
PERFORMANCE CRITERIA/EVIDENCE I S A M D
ELEMENTS
Applies critical Is able to link theory to practice
thinking and Demonstrates current best practice in the care provided
reflective practice Assesses own performance

Practises within
Reviews against facility/organisation policy
safety and quality Performs hand hygiene
assurance guidelines
Explains and communicates the activity clearly to the individual

ia
Communicates outcome and ongoing care to individual and
significant others

l
Communicates abnormal findings to appropriate personnel

ra
Documentation and
communication Reports and documents all relevant information and any
complications correctly in the healthcare record

st
Reports any complications and/or inability to perform the procedure
to the RN and/or medical officer

Au
er
Educator/Facilitator Feedback:

vi
se
El

Educator/Facilitator Score: Competent Needs further development

©

How would you rate your overall performance while undertaking this clinical activity? (use a  & initial)
fs

Unsatisfactory Satisfactory Good Excellent

oo

Student Reflection: (discuss how you would approach your practice differently or more effectively)
pr
e
pl

EDUCATOR/FACILITATOR NAME/SIGNATURE:
m

STUDENT NAME/SIGNATURE: DATE:

Sa
50 ESSENTIAL ENROLLED NURSING SKILLS FOR PERSON-CENTRED CARE

CLINICAL SKILL 19.4 Venous thromboembolism assessment

Review and carry out the standard steps for all clinical skills/interventions; these steps must be performed
consistently with each individual to ensure safe nursing care is provided

NMBA Decision-making Framework considerations Equipment:

(refer to NMBA Decision-making framework for nursing Assessment tool used in the clinical facility/organisation
and midwifery 2020):
The individual’s nursing care plan and history
1. Am I educated?
2. Am I authorised?
3. Am I competent?

ia
If you answer ‘no’ to any of these, do not perform that
activity. Seek guidance and support from your teacher/a

l
nurse team leader/clinical facilitator/educator

ra
Skill activity Rationale

st
Identify indications and rationale for performing the Reduces unnecessary assessments performed on an
activity. This may include identifying the individual’s: individual

Au
• Past history of thromboembolisms
Can allow for early intervention
• Intrinsic and extrinsic factors that may contribute to
emboli
• Understanding reasons why the venous

er
thromboembolism assessment needs to be
performed or has been ordered
Identify the individual using three individual identifiers.
This may include but is not limited to:
vi
Reduces the incidence of performing an assessment on
the incorrect individual
se
• Identification—allocated healthcare number on
hospital bracelet/band
• Verbal confirmation from the individual of given
El

and family name

• Date of birth
• Gender
©

• Address
• Medical record number
Explain and communicate the activity clearly to the Reduces anxiety/apprehension and gains an individual’s
fs

individual. This may include but is not limited to explaining trust and cooperation
to the individual:
oo

• Why the assessment has been ordered

• Why the assessment will be undertaken and
frequency
pr

• What is involved in undertaking the assessment

• What will be done with the data collected
e

Ensure therapeutic interaction Assists with the alleviation of fear prior to the assessment.
pl

Identify lifespan, cultural and language barriers Identifies any considerations required by the nurse when
undertaking the assessment, influenced by an individual’s
m

past experience, ability to understand and comprehend

instructions, and age-related considerations
Sa

Gain the individual’s consent Ensures that the individual understands why the
assessment needs to be performed, therefore promoting
cooperation
Determine individual’s reason for hospitalisation: The indication of VTE risk can be established by
• Assess the likelihood of, for example, a surgical site identifying if an individual is a medical or surgical patient
bleed, an intracranial bleed or a gastrointestinal bleed,
and the consequences of bleeding should it occur
• Assess individual patient-related factors that may
increase risk of bleeding:
> Procedures with potentially critical
consequences of bleeding (such as a lumbar
puncture, epidural or spinal anaesthesia)
> Abnormal renal function or liver disease
 Health Assessment Frameworks: Initial and Ongoing 51

CLINICAL SKILL 19.4 Venous thromboembolism assessment—cont’d

> Uncontrolled hypertension
> Active peptic ulcer or ulcerative gastrointestinal
disease
> Thrombocytopenia (platelet count less than
50000 mcg/L)
> Acute haemorrhagic stroke
• Bleeding history:
> Family history of bleeding or personal history
of bleeding disorders

ia
> Recent bleeding (within the week) or active
bleeding
• Medication history:

l
ra
> Use of other medicines known to either
increase bleeding risk or to increase the risk
of clotting, or that alter the metabolism of

st
medicines used to prevent VTE
> Other medicine that may interact with

Au
medicines used to prevent VTE
• Assess mobility:
> Identify concerns in an individual’s gait such as
swaying or holding onto furniture to assist with

er
walking
> Identify an individual’s decrease in mobility
> Identify an individual’s concerns with limb
weakness or reduced sensation
vi
se
Assess baseline risk (intrinsic factors) from the individual, The indication of VTE risk can be established by
family or by direct observation: identifying an individual’s age, pregnancy status, previous
El

• Past and present medical history history of VTE, obesity, varicose veins, active malignancy
• Past or present medication history
• Past or present nutritional impairments
©

Medical history includes:

• Past history of the individual
• Relevant history of the individual
fs

• Symptoms of shortness of breath

oo

Assess additional risk of VTE (extrinsic) by direct The indication of additional VTE risk can allow for early
observation or talking with the individual or family: intervention
• Dehydration status
pr

• Surgical risk by type (pelvic, orthopaedic, joint

surgery)
• Medical risk by type (stroke, heart failure,
myocardial infarction)
e

Administer and document in the individual’s medication The administration of prescribed pharmacological
pl

chart pharmacological treatments as ordered by reviewing treatments will decrease the VTE risk
the individual’s medication chart
m

Assess contraindications to pharmacological treatments Understanding the contraindications of administering

by reviewing the individual’s medication chart. This may the pharmacological treatment and drug interactions will
Sa

include but is not limited to:
• Known hypersensitivity to agents used in
pharmacological prophylaxis
• Active bleeding or risk of bleeding
Apply and document in the individual’s progress notes
mechanical VTE inventions as ordered:
• Anti-embolic stockings at correct size by measuring
length and width of extremity and applying the
appropriate size as indicated on the packaging
decrease the risk of bleeding or reaction. This must be
reported to the Registered Nurse before the treatment is
withheld
The application of mechanical compression stockings will
decrease the VTE risk. Bunching of the stockings from
incorrect fitting could result in leg ulceration, pressure
injuries, slipping and falling on mobilisation
Continued