Tell us about your clinical decision support study.

When I was in practice, I noticed gaps in how we were making decisions in the neonatal intensive care unit and I wanted to help clinicians by providing them better systematic and convenient information about the context of care and the factors that put a baby at risk to develop complications. CDS has been shown to improve the process and outcomes of care delivered by physicians but we need more studies that target the decisions that nurses make. For the paper published in JAMIA, we wanted to discover what the state of the science was for bedside nursing CDS. 

Tell us more about CDS for nurses.

Simply put, CDS matches patient characteristics to best recommended care and delivers reminders, alerts or advisory messages to support nursing care that aligns best with expert recommendations. The best and most effective CDS is built on data that comes directly from the electronic health record. It generates context and communicates a recommendation through an alert.  So instead of communicating ‘This patient has an early warning score of nine and it’s high-risk,’ the message would say, ‘This patient’s early warning score is nine and you should do this.’ Even better, the message would be delivered directly to the clinician or set of clinicians who can act on the information.

What are some of the decisions nurses make that this work would benefit?

Nurses make decisions all the time. They’re assessing how at-risk a patient is for a fall, to develop an adverse complication, or to develop sepsis. They’re deciding how to prevent a patient from getting a complication they shouldn’t. One critical decision nurses make is about monitoring and communicating signs of a patient getting worse. CDS is especially good at making the decision about care more systematic, expert-informed and consistent. It keeps nurses from missing the simple signs, which is important because their work environments can be very fragmented, interruptive and rapidly changing. 

What makes your study particularly unique?

Nurses put more information into the electronic health record (HER) than anybody else in the hospital and their needs are the least well met. So far, nurses get very little value for what they put in. In some situations, it has not been designed or adapted to help them do their job easier or more efficiently. With our paper, we showed how little evaluation of nursing CDS is available and how underdeveloped it is to meet nurses’ decision-making and ultimately patients’ needs. The message we came away with is that there’s a huge need for people to study this, and to develop CDS that meets CDS design best practices. 

What’s the future of this project?

We proposed some very specific recommendations about what needs to be done to help design better decision support that is aligned with people’s workflow. We recommend expansion of nursing CDS, to integrate it into workflow and to allow shared views of CDS delivered across the health-care team (e.g. nurses to be able to see what CDS was offered to the physician for their patient and how they responded to it). Dr. Dunn-Lopez and I are also both individually developing CDS that targets nurses.

How will the results of your study impact nursing education?

It brings more visibility to the decisions that nurses make and how they need technology to support them to add value to the EHR for them. I’ve taught the methods for systematic reviews to my students and conducted others since then. Systematic reviews are important to make sense of a body of research and to identify next steps. This helps both PhD and DNP nursing students. They need to be able to take in the whole breadth of what’s going on, find the gap, and decide what to do next.

How is this project helping to build better futures?

When we support nursing decisions, we help them to do their work better, which can keep a patient healthy or even save their life. This project showed that more decision support is needed in nursing, especially in the pediatric and maternal child settings, where my work fits. It highlights opportunities to improve the value of electronic health records for nursing. As nursing informatics and CDS develop, trends are pointing toward better integration of EHRs with decision support – making their structure more open. The future is bright for nursing informatics!

Jeremey Jason Marine

Third-year online Doctor of Nursing Practice (DNP) psychiatric mental health nurse practitioner student; from Southern California

Why did you decide to pursue a nursing degree?

As a child, I was a ward of the court. From early on, I witnessed the mistreatment of those suffering from mental illnesses. As I got older and worked my way out of that environment, I felt an intense drive to try to position myself to make a difference. After working for over a decade as a behavioral health technician, I realized I could do much more if I returned to school to obtain an RN.  My many years of behavioral health experience afforded me the ability to move into management positions fairly quickly and executive leadership within just four years. I realized I needed to continue my education and worked on my BSN. However, I felt that as an RN, even in executive leadership, I was still limited in my ability to influence policy affecting patient outcomes.  I decided that I could make an even greater impact if I returned to school for my DNP.

What drew you to the UA College of Nursing?

I wanted to earn my DNP at a prestigious institution. The UA College of Nursing has a reputation for excellence in both education and research. My wife is a triple alumna and a true Wildcat. We knew we wanted to stay in Tucson, so it was a great opportunity to become an official Wildcat.

What features of your program are you especially passionate about?

I enjoy the discussions with my peers and faculty and learn a great deal from them. However, my passion lies, as always, in the clinical setting. Hands-on hours in the clinic seeing patients have been the highlight of the program for me. 

Share your favorite memory from your time at the CON.

In the Spring 2017 semester, I did a focused exam with Dr. Kate Sheppard, the outcome of which would dictate whether or not I could continue in the program. I was a bundle of nerves -- sweating, shaking, heart racing.  As I moved through the "patient visit" and examination, what I had learned thus far and the guidance I had received just started to flow naturally. I scored 100% on the focused exam, and I correctly diagnosed pulmonary embolism. This was an ah-ha moment for me, that I was going to be able to succeed in this program and that I really could do this.

How do you intend to Build Better Futures?

Initially, I intend to Build Better Futures by working as a provider and helping people in underserved populations. After gathering some practice experience, I can see myself moving back into executive leadership to help create policy that is beneficial for patients and their families.  I will also continue to advocate for the integrated healthcare model, including the mind, body and spirit.

Mosima Choshi

PhD candidate, expected graduation in August 2017; from South Africa

Why did you decide to pursue a nursing degree?

I was born and raised in rural South Africa, where health care services are either unavailable or inaccessible. When I was 12 years old I saw my mother lovingly take care of my late grandmother using traditional medicines from a medicine man. Without help or guidance, she did the best she could. After graduating from high school, I went to the local hospital and knocked at the door of “The Matron,” which is what they call the Chief Nursing Officer, and told her I wanted to be a nurse because I wanted to be able to better take care of my mother if she gets sick and build a clinic at my local village for all the villagers to get health care.  

What drew you to the UA College of Nursing?

When I started at the University of Arizona College of Nursing it was for convenience. I was a full-time employee and a single mother raising my teenage son and had just moved to the United States. I was still struggling with understanding American culture, so it was a very challenging time. The College’s mission and values gave me comfort and motivation, especially its values of balance and social responsibility.

What features of your program are you especially passionate about?

My research topic was self-care behaviors of rural women post-invasive coronary interventions. Rural women and cardiovascular disease are my passion. Working with rural health expert, Dr. Sally Reel , and cardiovascular health expert, Dr. Anne Rosenfeld, was all I could ever ask for. To top it off, I had the opportunity to start my rural cardiovascular health career by working with rural populations during my dissertation. 

Share your favorite memory from your time at the CON.

Attending RISE [Residential Intensive Summer Experience, an on-campus intensive for PhD and DNP students] was my favorite time in the whole program and I was very sad when I couldn’t attend anymore. To meet with my cohort, my professors and the IT people was always very exciting. 

How do you intend to Build Better Futures?

For me, nursing is the center and the pillar of health care provision. Through research and teaching, I will make an impact on the nursing practice and nursing profession. Building a better nursing future is not only for nurses, but also for the populations receiving the nursing care. Heart disease is a number one killer worldwide, but most people do not know that. Empowering the new nursing generation to disseminate the knowledge they acquired to the populations they serve is the key to disease management, including lower mortality and morbidity rates. The one-size-fits-all approach to health care is not practical and rural populations’ perceptions of health are different from urban populations’ perceptions of health. New health innovations must be disseminated using methods that are suitable for specific populations and communities.

Eric Smith is a Bachelor of Science in Nursing (BSN) student at the University of Arizona College of Nursing and a UA Foundation scholarship recipient. He is also an eagle scout and a former firefighter.

During the 2014 University of Arizona College of Nursing Donor Appreciation Tea, Ishmail Sillah, a student in the Master's Entry into the Profession of Nursing (MEPN) program, shares how his experience growing up in war-torn Sierra Leone and having limited health care access inspired him to become a nurse.

University of Arizona College of Nursing Clinical Assistant Professor Patricia Daly, PhD, FNP-BC, ENP-BC, has been an emergency and urgent care nurse practitioner for more than 25 years. A 2013 graduate from the UA College of Nursing PhD program, she has championed integrative nursing techniques throughout her career. Currently, she investigates mindful-eating interventions to address obesity in adolescents and adults. We sat down with her recently to discuss her history with integrative health care.

How do you incorporate integrative health into pain management?

My interest actually began when I was working in emergency room nursing. Back then, adult and child patients were often kept in the same area, and working with children was a real focus of mine. Whenever I’d have to suture someone I’d explain that they’ll want to focus their attention away from the pain. For children the kindest thing you can be is fast, but you also want to engage their mind somewhere else. I began telling children participatory stories to help that distraction. It’s actually a real integrative therapy called guided imagery, a powerful psychological strategy that enhances coping skills. I can time the story to the length of the suture, so if need be it can be a very long story. But the child is always the hero. Interestingly, adults who happened to overhear these stories started asking me to tell them stories, too. They would also be the heroes if the story, but I’d always start out with, ‘You just won the lottery. Where are you going to travel?’ and go from there. It was a really effective use of integrative therapy and I still employ it today.

You’re a big advocate of alternative pain management. Can you tell us about that?

In all my years in the ER, I have never written a prescription for more than six narcotic pills because I think pain management is not done best with pharmacological agents. Considering today’s opioid epidemic, that’s really important. Almost every narcotic addict is addicted because one of us wrote the first script. They told them, ‘Take this for pain,’ when they should have said ‘You’re going to have pain and that’s not going to kill you, but that drug might kill you.’ I teach nurse practitioners that when someone is drug-seeking that person has a health care issue: its addiction. If you just write them a prescription for some medicine you’ve done nothing but perpetuate the problem. I tell students ‘Okay, try to go in that room and make it a win-win. You are not giving the narcotic pain prescription and the patient’s going to leave satisfied. That is your goal.’ That person is suffering and so it’s important to listen to the patient, and that’s what integrative health is about: the whole person.

How has integrative care changed over the years?

From my perspective, nursing has always been integrative. In the ‘70s, the definition of nursing was ‘helping people cope with illness or changes in their life cycle.’ That’s why nursing was always strong in hospice, always strong in end-of-life care. Comparatively, disease-focused models, or germ theory, for the most part doesn’t work. Health has to do with how much sleep you get, what you eat and other lifestyle choices. It’s important to realize that almost all of pharmacology imitates what your body does. Why can a Yogi lower their blood pressure at will without a beta-blocker? How can someone walk across hot coals without serious injury? The receptors that drugs tie to in your brain or other parts of your body didn’t grow there because they thought you might make a drug someday that might go there. That’s your body chemistry.  For some people it’s very controllable, and that’s where eastern medicine kind of came from. There is something more than we can measure, and I feel like nurses always know that.

How do you inform your students about the importance of integrative care?

I talk to students about balance constantly. In nursing, that’s especially true because a lot of them are overachievers. They can work all night. They have so much compassion, and they are so giving of themselves to the point where they don’t fill themselves back up. In the end, it’s about life balance. That’s true for almost every patient, too: You help them try to find some life balance, and integrative nursing is the way that’s done.