Dowding D et al. 2009 "Nurses' use of computerised clinical decision support systems: a case site analysis."

Dowding D, Mitchell N, Randell R, et al. Nurses' use of computerised clinical decision support systems: a case site analysis. J Clin Nurs 2009;18(8):1159-1167.
"Aims and objectives. To explore how nurses use computerised clinical decision support systems in clinical practice and the factors that influence use.
Background. There is limited evidence for the benefits of computerised clinical decision support systems in nursing, with the majority of existing research focusing on nurses' use of decision support for telephone triage. Research has suggested that several factors including nurses' experience, features of the technology system and organisational factors may influence how decision support is used in practice. Design. A multiple case site study. Methods. Four case sites were purposively selected to provide variation in staff experience, technology used and decisions supported by the technology. Data were collected in each case site using non-participant observation of nurse/patient consultations (n = 115) and interviews with nurses (n = 55). Data were analysed using thematic content analysis.
Results. Computerised decision support systems were used in a variety of ways by nurses, including recording information, monitoring patients' progress and confirming decisions that had already been made. Nurses' experience with the decision and the technology affected how they used a decision support system and whether or not they over-rode recommendations made by the system. The ability of nurses to adapt the technology also affected its use. Conclusions. How nurses use computerised decision support appears to be the result of an interaction between a nurses' experience and their ability to adapt the technology to 'fit' with local clinical practice. Relevance to clinical practice. One of the stated aims of introducing computerised decision support systems to assist nursing practice is to reduce variation and/or the number of errors associated with clinical practice. The study found unanticipated uses in such systems such as the routine over-riding of recommendations which could lead to an increase rather than a decrease in variation or errors."
To "explore how nurses use computerized clinical decision support systems in clinical practice and the factors that influence use."
Tools Used
Type Clinic
Primary care and specialty care
Small, medium and large
Other Information
Four clinics were involved in this case study. They were all located in England, were within the National Health Service (NHS) trusts, and included: (1) an anti-coagulation team working in a primary care clinic, (2) a spinal assessment clinic, (3) a walk-in clinic, and (4) a hospital-based respiratory clinic.
Type of Health IT
Decision support system
Type of Health IT Functions
In the anticoagulation clinic, "Nurses used a ... meter to measure the patient's [International Normalized Ratio] INR and this information was then input into the [clinical decision support system] CDSS which calculated the patient's anticoagulant dosage (the 'dose recommendation') and the date of their next clinic visit (the 'date recommendation'). The nurse was able to over-ride the CDSS to adjust both the dose and/or date recommendation if they believed it was appropriate. Use of the system was compulsory." In the spinal assessment clinic, patients were asked to complete several questions on the computer. The data were automatically fed into the CDSS. "Based on the patient's answers, the software calculated a range of quality of life scores (including pain and depression scores) for that patient that were printed out for the initial assessment consultation, but not for review consultations. The scores were intended to inform the nurses' decision-making... Use of the system was optional." In the walk-in center "The CDSS was commercially developed and was originally designed as a telephone triage system, assisting nurses to provide a telephone based information and advice service to patients. The system was based on algorithms that were logically structured, ordered symptom-based questions, which lead to an endpoint (disposition), which advised the appropriate level of care required. If a nurse disagreed with the suggested endpoint there was a facility to over-ride the disposition. Use of the system had been compulsory on its introduction to the walk-in centre but at the time of the study use of the system was becoming optional." At the respiratory center in the community hospital, "the CDSS was used to monitor patients with chronic obstructive pulmonary disease (COPD) who were living at home, with the aim of preventing their readmission to hospital. Each patient had a hand held data collection unit which consisted of a screen and some large buttons, which was connected to their home telephone line. Patients used the unit twice daily to provide information about their own health and well-being, such as their weight, level of breathlessness, characteristics of sputum and medication used. Patients provided this information by using buttons on the unit to answer a series of questions displayed on the screen. Collected data was sent to a secure database via the patient's telephone line in the early hours of the following morning. The database could be accessed, via an internet web browser, by nurses in the respiratory centre and trends in patient responses were monitored over time. The system displayed warning alerts when patient responses exceeded a certain level, thresholds that were previously determined by the nurses in the respiratory centre. Thus nurses could monitor patients' conditions over time and decide how best to intervene when a patient's condition appeared to be deteriorating. At the time of this study, nine patients under the care of the respiratory centre were using the CDSS."
Context or other IT in place
The context varied across clinics.
Workflow-Related Findings
"In all of the case sites, CDSS were used as a way of recording information about patients.... In case site 3 (walk-in centre) the software was predominantly used during consultations to check, amend or add to patients' details. Nurses made several comments on the usefulness of the CDSS as a source of documentation. They considered that recording and storing patients' notes electronically meant that the notes were consistently well presented, did not get lost and were easily stored."
"In case site 2 (spinal assessment) and case site 4 (remote monitoring) the CDSS were designed to assist nurses monitor a patient's condition. Despite rarely looking at the system during consultations nurses from case site 2 reported that one of its main benefits was how it allowed them to track patient changes over time. They were therefore able to assess whether a patient had improved, worsened or stayed the same."
"In case site 4 (routine monitoring), the CDSS monitored patients' responses to a series of questions about their health. It automatically alerted the nurse when a patient's answers indicated worsening symptoms. Nurses also looked at trends in the data for each patient, which allowed them to identify potential problems that had not triggered an alert. When the CDSS indicated a patient with deteriorating symptoms and the nurse felt that there was cause for concern the patient would be telephoned at home. Depending on the outcome of this phone call, the patient might be advised to visit a clinic or their own [general practitioner] GP, be visited at home by a respiratory centre nurse or continue with home management."
"In case sites 1 (anticoagulation) and 3 (walk-in centre), nurses appeared to use the CDSS to 'confirm' a decision that they had already made. In case site 1 this occurred frequently, with the nurse telling the patient what their dose of medication would be, before the software had provided its recommendation (although the dose usually matched what the software recommended)."
"In case site 3 (walk-in centre)...the only instance where we observed a nurse using the software during a consultation was as a way of confirming the diagnosis. During the interviews two nurses commented on occasionally using the CDSS algorithms as a back-up when a patient had queried the nurse's diagnosis and proposed treatment decision."
"In case site 1 (anticoagulation), in only six of the 26 routine consultations we observed that the nurse recorded as accepting both the dose recommendation and the date recommendation made by the CDSS. In part, this was because the software would only allow a maximum gap between appointments of six weeks, whereas the anticoagulation team routinely saw stable patients only every eight weeks. Nurses described several main reasons for over-riding. Key among these was a reluctance to change a patient's dose if they were normally stable, particularly if they could identify possible reasons why the patient's INR had risen or fallen, for example, they had drunk alcohol or had missed a dose. However, if they were to over-ride this, they would also get the patient to return to the clinic earlier to check whether their INR had returned to normal."
In the anticoagulation clinic, "One nurse was not familiar with all the patients, however using the CDSS meant she still found she was able to get a good overall impression about the patient's condition based on the data displayed. She was aware that she may not be able to interpret trends as easily as a nurse who knew the patient better."
"In case site 3 (walk-in centre) familiarity with the patient condition was also a factor in whether or not the CDSS was used, with some nurses reporting occasionally using the CDSS algorithms to aid decision-making in particular situations where there was uncertainty about the best course of action."
"Although some nurses felt that the CDSS algorithms could be useful as a guide or information source for the decision making process, others felt that after repeated use of certain algorithms the process became automatic and meaningless with little attention being paid to the CDSS. Some nurses who were familiar with the algorithms discussed how they 'tailored' them to suit their needs: 'I end up almost engineering the answers, because you think "oh I can't put that because it's going to say..."'"
"Some nurses reported that their use of the algorithms had changed over time, they felt that the algorithms had been more useful when first starting in the job when they may not have felt so confident to make decisions by themselves. Similarly, it was felt that that the algorithms would be most useful for nurses new to the job, who may not have had so much experience in decision-making."
"In case site 3 (walk-in centre) issues were raised with the way in which the computer software worked....Nurses reported being unhappy with aspects of both the structure and content of the algorithms. They commented on the lack of suitable algorithms for the variety of conditions with which they were presented....Nurses also spoke about the inflexible way in which the algorithms were structured, for example: having to work through an algorithm from start to finish, beginning with very basic questions; not being able to easily exit an algorithm; not being able to input all the information gleaned by examination of the patient. They also commented that they felt the content of the algorithms was not always appropriate, in particular dispositions were seen as being too risk averse."
"In case site 4 (remote monitoring) nurses described difficulties in interpreting patient data when displayed on the CDSS. The scales used in the graphical displays of data depended on maximum and minimum scores entered for each patient. Consequently a small difference in a particular measure could appear to be a large difference on the display. A second problem concerned the direction of the scales: an increasing score indicated deteriorating health. Nurses found such reversed scoring counter-intuitive and commented on how they needed to remember how to read the scale."
Study Design
Only postintervention (no control group)
Study Participants
The study participants included nurses using decision support systems in the case study clinics.