Which health care team member is familiar with all the needs of an individual client?

ANS Adv Nurs Sci. Author manuscript; available in PMC 2014 Oct 1.

Published in final edited form as:

PMCID: PMC4000752

NIHMSID: NIHMS541669

Tiffany Kelley, Ph.D., MBA, RN,

Imagine a time when you, as a nurse, are providing care to a patient on your unit. Someone from the health care team comes to ask you a question about another patient, and you find yourself saying, “Yes, I know that patient.” Or, maybe the person is asking about a patient whom you have never cared for and you say, “No, I don’t know that patient. I have never cared for that patient.” The expression “I know that patient” is commonly heard in practice settings. Yet, what does knowing the patient really mean? Additionally how do nurses obtain the information needed to know their patients? This paper explores the meaning of “knowing the patient” and presents results from a study of how nurses obtain the information they need to support their knowledge of the patient for the delivery of care.

Knowing in Nursing

Several key scholars introduced the profession to the critical nature of “knowing the patient”. Carper1 conducted the seminal work, exploring the sources that nurses use to develop knowledge and beliefs about their practice and patient care. She described four patterns of knowing: aesthetic, moral, empirical and personal. Aesthetic knowing referred to the art of nursing; moral as knowing right and wrong for the patient; empirical knowing as objective and factual knowledge that could be generalized to others; and personal knowing as knowing oneself. These patterns of knowing are not mutually exclusive and nurses use attributes of all four patterns to successfully care for patients.1 Following Carper, advances in how nurses come to know the patient became rooted in theory and research on caring. Watson’s Transpersonal Caring theory 2 has evolved since it originated in 1979, but the persistence of the key proposition that nurses gain insight into a patient’s response to illness through a relationship exemplified by respect, compassion, and support, points out the critical link between a deep connection with the patient and the nurse’s knowing. As one of five caring processes Swanson3, in her middle range theory of caring, further delineated knowing to include dimensions of avoiding assumptions, centering on the one cared for, thorough assessment, cue seeking, and engagement of self.

Tanner and colleagues4 shed light on the recurring discourse of nurses on knowing the patient with their study of intensive care nurses and described it as central to skilled clinical judgment and involved knowledge of the patients’ day-to-day routines, clinical patterns and responses to care. Benner and Tanner5 examined the clinical judgment of nurses in intensive care settings that linked “knowing the patient” to skills in pattern recognition. Research suggests communication with the patient is required to support knowing the patient.6 Several studies followed this line of investigation of knowing and were able to link clinical judgment and decision making to communication, interactions, and the nurse-patient relationship.4, 6–10 Other scholars proposed that knowing the patient is an essential precursor to the delivery of high quality patient care.11,12 In addition, as sources of information, nurses integrate knowledge gained from prior clinical experiences to each new patient,8–10 and through interactions with the patient and family, nurses collect personalized characteristics that go beyond diagnosis or condition. 8,9

To summarize, the work of these scholars have provided a firm foundation to the concept of knowing as emerging from a deep relationship between the nurse and patient, in which the nurse engages in a continuous assessment and striving to understand and interpret the patient’s needs across dimensions. Most nurses have a collective understanding of knowing the patient that defies articulation. The concept has been linked in the literature with safe and efficient care. 4, 7–10 While nurses use prior clinical experiences and interactions with the patient as important sources of knowledge, these sources are constrained for nurses with less experience, and in care situations in which the patient’s ability to interact may be limited by developmental age (e.g., an infant) or medical state (e.g., intubated). Families may not always be present at the patient’s bedside to serve as an informant. It is apparent then, that nurses rely on other information sources that have not previously been identified in the literature. Thus, in building upon the strong conceptual foundation of the meaning of knowing, we sought to deepen our understanding of how nurses define knowing the patient, and exemplify the essential sources of information nurses use to know the patient.

Information Sources

While prior studies have alluded to the influence of “other information sources” to know the patient,7,13 little evidence exists to describe specific types of information sources and the information needed from these sources. In hospital settings, nurses have several key information sources that they use to support knowing the patient.14–19 In addition to verbal interactions with the patient and family, nurses also obtain information through verbal interactions with other members of the health care team. Components of the patient’s medical record (e.g., nursing documentation flow sheets, nursing notes, orders, provider notes and consultant notes) are also sources of patient information and nurses use nursing documentation as the primary mechanism to collect and communicate patient information.20 In response to federal regulations of the 2009 American Recovery and Reinvestment Act 21, health care settings in the United States are in the process of integrating a fully electronic patient record over the next several years, thus currently the patient’s medical record may be in a paper-based format, an electronic format, or a combination of the two (e.g., hybrid). There is a critical need to understand and contrast how nurses use paper and electronic-based nursing documentation sources how these information sources support knowing the patient. 22

In addition to the use of nursing documentation and the broader patient record, nurses have a ritual of using a paper-based report sheet that is not part of the medical record during handoffs.23 Nurses often use these unique, personal notes to store information that is communicated by the patient’s care nurse from the prior shift. 24 Thus, in addition to the medical record and verbal interactions with patients, families, and health care providers, the paper-based report sheet appears to be used as a key information source to support knowing the patient. However, little is known about how nurses use these report sheets nor the specific types of information that is stored on them.

In order to exemplify the meaning of knowing the patient, as well as the type of information sources nurses use to know the patient, we chose to study a highly vulnerable patient population and care setting that was likely to challenge the nurses’ ability to know the patient. Pediatric patients require vigilant nursing attention due to their rapidly changing physiology 25–30 and these patients are at a greater risk for medical error compared to other age groups. 28,29 Because of their developing cognitive and structural systems, pediatric patients may be limited in their ability to serve as a verbal source of information. Pediatric patients in intensive care settings often require mechanical ventilation and sedation, 21 thus further limiting their ability to communicate with the nurse and serve as a source of verbal information. Thus the study of information sources used to know the patient in this clinical setting serves to illuminate this phenomenon. Therefore, the purposes of this study were to describe the meaning of “knowing the patient” from the perspective of nurses caring for pediatric patients in an intensive care unit (ICU), and describe the information sources nurses use to support knowing the patient.

Methods

Setting and Sample

Two pediatric intensive care units (PICUs) within a children’s hospital in a southeastern academic medical center in the United States were purposively sampled to serve as the study setting. These units provide care for pediatric patients ranging in age from birth through young adulthood. One unit provides care primarily to pediatric patients with complex cardiac conditions that require medical or surgical interventions. The second PICU provides care to a range of non-cardiac medical and surgical pediatric conditions. At the time the study was conducted, both PICUs maintained a hybrid patient medical record system with electronic nursing documentation, order entry and results, and paper-based clinical notes and medication administration records.

Data Collection Procedures

After obtaining IRB approval, the nursing leadership from both PICUs provided a roster of nurses’ names, their corresponding years of nursing experience, and their email addresses. The principal investigator (first author) attended a staff meeting on each of the two PICUs to provide information on the purpose, potential risks, and benefits of participating in the study. During the meeting, the investigator told the nurses they may receive an email inviting them to participate in the study.

A total of 123 nurses were employed on either of the two PICUs during the study timeframe (July through September 2009). While prior studies primarily recruited nurses with extensive clinical practice experience, 8–10 we wanted to include nurses with a range of experience to broaden the understanding. Therefore, exclusions were limited to nurses who had less than 6 months of experience, nurses who were not employed by either PICU (e.g., travel, float, or agency nurses), and nurses who no longer provided direct patient care. These criteria were set to ensure that the participants had completed the orientation period and were familiar with the patient population on the unit. We used a convenience sampling technique to recruit study participants.

Using the nursing roster, and a convenience sampling technique, study invitations were staggered by only sending out two to three emails every few days. Within the text of the email, the PI requested that the nurse respond to the email if he/she was interested in participating in the study. If no response was received after three days, the next nurse was contacted from the staff nurse roster. The staggered email invitations controlled the number of nurses engaged in data collection at a time and allowed the investigators to begin to analyze the data while data collection was ongoing and judge when data saturation occurred. Data saturation, or the point at which no new information was seen in the interview data, was reached following the 12th participant. At the time that we reached saturation, a total of 52 nurses were contacted and 15 nurses volunteered to participate for a response rate of 29%. Three nurses responded to the invitation to participate after we had reached data saturation.

The PI met with each participant individually to obtain informed consent. Recruitment and data collection occurred over 9 weeks. Each participant completed a demographic sheet asking for the age, gender, ethnicity, and education level of the nurse. Each nurse then participated in an audio-recorded semi-structured interview either face-to-face (N=8) or over the telephone (N=4). The interviews that could not be arranged face-to-face were conducted over the telephone at a time convenient for the participant. The investigators did not detect any differences in data from the interviews that were conducted face-to-face and the interviews conducted over the telephone.

The interviews ranged in duration from 20 to 60 minutes. The interview began by asking the nurse to “tell me what knowing the patient means to you.” After the nurse responded, the investigator probed further to get a more detailed description. Next, each nurse was asked to describe how he/she went about getting to know the patient. Probes about the influence of each information source on knowing the patient was further explored by using phrases such as “tell me more about that” or “what do you mean by that”. Once the investigator had completed the interview questions, each nurse was offered the opportunity to offer additional data he/she felt relevant that may not have been prompted from the questions.

Data Analysis

The audio-recorded interviews were transcribed verbatim and double-checked for accuracy. The transcripts were analyzed using content analysis.31,32 Each interview was first read in its entirety to gain an overall sense of the nurse’s perspective. Next, the transcripts were analyzed line-by-line and coded using an inductive procedure. Provisional codes were applied to sections of meaningful text and once the codebook became almost fully developed the labels were derived using a consensus procedure with two of the investigators (TK and DB). Next, codes were clustered into categories and the core themes developed.32

Throughout the design of the study and analysis procedure we implemented a range of techniques to support transferability, dependability, confirmability, and credibility in order to ensure trustworthiness of the study findings.32 We present a rich description of the results to allow the reader to examine the transferability of the findings to other care settings and patient populations. Consistent data collection procedures and methods of analyzing the interview transcripts enhanced the dependability of the data. We maintained an audit trail of the stages of the analysis and decisions made that led to the final themes. The third author analyzed every other interview transcript to confirm that the findings were consistent between the two authors. We met weekly for several months to discuss the study progress and ensure that we did not impose any of our own individual biases on the data. Once the findings were agreed upon, we presented the results to nurses on both PICUs during staff meetings as another strategy to validate the credibility of the findings.32 The nurses provided additional details supportive of the study findings however, the findings did not change based on their comments.

Results

We sought to answer two primary aims in this study. First, we aimed to describe the meaning of knowing the patient from the perspective of nurses providing care to a vulnerable patient population. We nurses caring for pediatric patients in an intensive care setting in order to illuminate the phenomenon of knowing the patient in a challenging clinical setting. Second, we aimed to understand how nurses used available information sources to support knowing the patient.

The final study sample consisted of nine female and three male nurses. One nurse self-identified as Asian. All other nurses self-identified as Caucasians. The average age was 32 years (range= 23–52). In an effort to understand the concept of knowing the patient from nurses of all experience levels, the final sample consisted of nurses with 1 to 30 years (median =5 years) of experience. Four nurses had an associate’s degree, seven had a bachelor’s degree and one had a master’s degree.

Analysis of the interviews revealed the meaning of knowing the patient consisted of two broad domains of information needs. Nurses emphasized the need for knowing clinical information and knowing personal information about the patient. By knowing both the clinical and personal information about the patient, nurses were able to provide individualized care to the patient. In response to exemplifying the information sources that were essential for nurses to obtain the clinical and personal information needed to know the patient, nurses described needing to obtain information through verbal interactions, nursing documentation within the patient’s medical record, and the nurses’ paper-based report sheet. The types of information sources may appear obvious however, the less obvious findings existed in how the information sources were or were not used to obtain the clinical and personal information needed to know the patient.

Knowing the Patient

Need for Knowing Clinical Information

In response to the first question, “tell me what knowing the patient means to you”, most of the nurses began by listing clinical information about each patient that he or she needs to know the patient. Clinical information included characteristics such as the age, weight, allergies, current diagnosis, and the past medical history of the patient. The nurses also expressed needing to know the patient’s physiological and psychosocial assessment, prior clinical events, and the patient’s treatment plan going forward. One nurse described the physiological information needs as, “getting to know the patient neurologically, respiratory, cardiovascular, and all of the systems individually”. Another nurse provided an account of the importance of a psychosocial assessment, “some of them (patients) are more anxious and naive. They come into the unit with a very scared attitude. So getting to know where their state, is very important to me.”

Both the physical and psychosocial assessments contributed to knowing the patient’s current clinical condition. Yet, nurses also wanted to know trends and normative patterns in the patient’s clinical condition over time. From theses nurses were able to identify when patients required a change in their treatment plan. As one nurse pointed out, “perhaps there is too much fluid on them (patients), or you’ve dehydrated them too much with diuretics. That is important to look at the trends.” Together the patient’s clinical information allowed nurses to know how clinical changes over time foreshadowed the patient’s current and future care needs. While all nurses in the study described the need for clinical information, they also emphasized that the clinical information was not the only domain needed to know the patient.

Knowing Personal Information

To know the patient, nurses also reported that personal information about their patients was important. The personal information allowed nurses to know each patient beyond his or her clinical diagnoses. This information included knowing the patient’s typical behaviors, schedules and preferences at home and while staying in the hospital. For example, nurses wanted to know “what was he like at home? What kinds of things does he like? Is he potty trained or walking appropriately?” By knowing what the patient was like at home and what he or she was able to do, the nurses were able to gauge how to address the patient’s care needs. Another nurse further explained the need for this information in relation to a patient’s preferences, “they (patients) have all got their intricacies. This one likes to be bundled. This one won’t tolerate it.” In the example described, while the nurses would often bundle all patients in a certain age group, one infant was not able to maintain his oxygen saturations when tightly bundled. Thus, the nurses would adjust their care delivery according to how the patient responded and this highlighted the individualized personal care needs. Additionally, the patients may have specific home schedules that could be incorporated into the care while in the hospital. By incorporating the home schedules, nurses felt that the patients would be better able to adjust to the hospital stay.

The nurses described the challenges in assessing personal information and how it was not always possible to gather this type of information. Some patients, such as newborns, don’t have established behaviors or schedules and thus the personal information may be more limited. However, for the patients who had spent time at home with their family, the nurses wanted to know how they could personalize the nursing care to address the patient’s preferences, routines at home and baseline behavioral responses to care.

Knowing Clinical and Personal Information for Individualized Care

Together the clinical information and the personal information provided nurses with the information they needed to individualize care for the patients. Each nurse strived to make each patient feel as though he or she was being cared for based on the individual needs. Having both the clinical and personal information allowed nurses to establish that individualized plan of care. As one nurse described, “on the clinical level is all of the tangible things you do. What are the vital signs? What is the fluid balance? The personal level is getting to know the patient a little bit better and that is getting a better feel for how this patient reacts and knowing their typical behaviors.” This is just one example that depicts both domains of information that are needed to know the patient. Together, the information, “helps us understand the patient’s situation as a whole”. By knowing the patient as a whole person, the nurses could aim to understand and anticipate the “little things that each patient does on every single shift”. If prepared for the individual needs and responses, the nurse could effectively assess, plan, intervene, and evaluate the patient in a way that synchronizes with the routine that the patient has experienced while hospitalized and make the patient feel as though his or her nurse really “knows” him or her.

Types of Information Sources Needed to Support “Knowing the Patient”

After the nurses described the meaning of knowing the patient from their perspective, each nurse was then asked, “How would you obtain the information you need to know the patient?” The authors expected that nurses would describe the need to interact with the patient and family as was previously identified in prior studies. The nurses described the use of available verbal interactions, the nursing documentation within the patient’s medical record, and the nurses’ paper-based report sheets. The verbal interactions occurred between the patient (when developmentally/clinically feasible), family members, other nurses and the larger health care team. Additionally, the nursing documentation within the patient’s medical record served as a continuing source of information needed to know the patient. However, the paper-based report sheets were consistently described as the most valuable information source used by the nurses to support knowing the patient over the other available sources.

Verbal Interactions

Nurses in this study immediately recognized that conversing with the patient was the ideal verbal interaction for obtaining information needed to know the patient. However, due to the patient population and severity of illness for the majority of the patients cared for on the two PICU study units, the nurses recognize that interacting with the patient was an infrequent possibility. One nurse stated, “Most of the time they are intubated and if they are of the age they could actually talk to us they are too sick and in a different environment. So, they are more scared and shy. They are not going to tell us a lot of information.” While this placed the nurses at a disadvantage to getting to know the patient, the nurses simply turned to the next source: the patient’s family.

The parents were often the next source after the patient to describe the patient’s individual needs. One nurse described the importance of knowing the patient’s baseline, “if the parents tell me that the child hasn’t really started talking yet but he will say a few words that is good for me to know. From that, I know what the goal is, of what I want the child to do later on.” Beyond the long-term responses to care, the parents were often a valuable source of informing the nurse of short-term interventions that would make the patient’s experience more pleasant while in the PICU. Nurses would ask the parents, “do they have a comfort object, a blanket they need with them? How do they respond to procedures?” By having this information, nurses could disseminate to the larger health care team and ensure that all appropriate specialists were involved in the patient’s treatment plan.

Beyond the patient and the patient’s family, the nurse also verbally interacted with the extended health care team. To name just a few roles, the nurses described verbal interactions with other nurses, social workers and therapists (e.g., respiratory, physical, occupational) and providers about the PICU patients. Each individual role group provided different insights that supported the nurse in his or her ability to provide individualized care to the patient. For example, nurses interacted with other nurses at the very beginning of the workday during handoffs. A nursing handoff, sometimes referred to as a shift report, is the process of handing off the care responsibility of a patient from one nurse to another. In our study, nurses highly valued the verbal nursing handoff, as often the information shared during these verbal interactions was not written in the electronic medical record. For example, one nurse described a certain situation, “a patient that might be an impossible stick (IV stick), is nowhere in the chart but it is really valuable to know. That is something you will only get in report.” From the providers, nurses gained insight into changes in the patient’s medical plan of care for the day. The social workers were available to inform the nurses about any family dynamic issues that may affect the nurse’s ability toward discharge planning. Each health care team member provided a supportive role for the nurse gain the clinical and personal information that allowed the nurse to better establish his or her knowledge of the patient.

Nursing Documentation within the Patient’s Medical Record

Nurses primarily relied on electronic nursing documentation for clinical information about the patient. Nurses used the nursing documentation as a supportive information tool to inform the patient’s physiological assessment, ongoing vital signs, intake and output totals and any associated hemodynamic or hydration related trends and norms. The discrete data values were informative as a single instance of the patient’s response to treatment. However, of even greater value was the ability to scan the information when the patient’s physiological response was not within the normative patterns that the patient was previously experiencing. The trends and norms about the patient allow the nurse to differentiate between what is normal for the patient and when to notify the physician for further intervention. One nurse provides an example by stating, “I had a patient that had got hypotensive and I had to look back at the blood pressures to see what they were tolerating and see how low they had gotten. This (blood pressure) was way lower than any of the charting had shown. I knew to immediately call the resident and push volume because this was a change away from the threshold.” Through the flow sheet, the nurse could visually scan for highs and lows, make a cognitive assessment about the patient’s condition, and decide how best to intervene for the patient’s condition.

Yet, despite the value of the electronic nursing documentation for knowing the patient’s clinical information, the electronic nursing documentation was viewed as the least valuable source to collect the personal information needed to know the patient. Nurses often felt as though the structure of the electronic documentation did not fully allow the nurse to elaborate on the emotional state and intricacies of the patient. As described by one nurse, “maybe our documentation doesn’t give us enough reign. Maybe it is too tight so we are not able to elaborate.” While nurses could enter a narrative comment, the comments and structured fields did not provide the nurse with the full picture of the patient’s personal needs. We are able to enter notes into different parts of our charting but a lot of times, you are not really able to elaborate on a situation without just telling someone.” The struggle to describe the personal information needed for care within the confines of structured fields led nurses to further rely on their own verbal interactions with each another. Additionally, nurses had their paper-based report sheet as another supportive information source.

Nurses’ Paper-based Report Sheet

The nurses in this study described the use of a unique, individualized paper-based report sheet as essential to knowing the patient as it temporarily stored much of the clinical and personal information needed to know the patient. As described by a nurse participant, “it (paper-based report sheet) puts all of the salient details that a nurse needs to know into one nice packet. Another nurse described the value she saw in the paper-based report sheet by stating, “it’s (paper-based report sheet) frankly the Bible.”

In both PICU settings each nurse typed their report sheet information into a word document template before the end of the nurse’s workday. The typed report sheet was prepared for the next nurse to use during his or her workday. Each nurse was expected to update and edit clinical and personal information that the oncoming nurse would need to know about the patient. The transcribed information from the paper-based report sheet was printed and given to the oncoming nurse who was about to start his or her workday. The oncoming nurse would also temporarily store by handwriting additional information as needed to support his or her information needs to know the patient.

The paper-based report sheet served as a quick reference for the nurse about his or her patient. As described by one nurse, “this [report sheet] is something that lasts that shift and the nurse will have it kept in a pocket, in the room at the patient’s bedside, or tucked inside the front side of our red chart [bedside chart].” By having the information about the patient on one sheet of paper, the nurse could quickly look back at the sheet and find the clinical or personal information the nurse needed at that moment in time. The nurses consistently described the critical importance and high value of the report sheet when caring for a new patient, “so a lot of times when I have a patient that I’ve never had before, I’ll look back on that sheet real quick and get a quick gist of their history.” In addition to knowing the patient’s history the report sheet served as a quick reminder of the patients scheduled care needs. One nurse stated, “you look back at that [report sheet] because it definitely tells you what you are doing.” Thus in addition to providing the clinical and personal information about the patient, the paper-based report sheet was an accessible and trusted source of information to support nurses in the provision of their individualized care.

The value of paper-based report sheet was heightened because nurses found it to be more accessible than the patient’s medical record. In addition to accessibility, the nurses stated that important information found on the report sheet was unlikely to be found in the nursing documentation or perhaps difficult to locate in comparison to the report sheet. For example, one nurse described a patient’s feeding regimen: “There is nowhere in our computer charting like if your feeds are going to advance 5 cc q 3 or whatever it is, to a goal of 25, that is not charted anywhere in our computer charting.” Yet, despite the expressed value and unique information provided by the paper-based report sheet, it is not included as part of the patient’s medical record. In fact, the report sheet is shredded at the end of each nurse’s workday. The next nurse receives a new printed report sheet for his or her workday. This process takes place twice per day, per patient in the PICUs.

Discussion

In this study, we described the meaning of knowing the patient from the perspective of nurses caring for a vulnerable patient population. Knowing the patient in this study was defined as knowing clinical and personal information about the patient. Both domains of information were essential for the nurse to be able to care for the patient, as a unique person with individual care needs instead of a diagnosis. Clinical information included characteristics about the patient, the physiological and psychosocial status, as well as trends and identified norms for that patient’s clinical condition. Personal information included unique characteristics of the patient’s behaviors and responses to treatments, schedules at home and preferences for care during the hospitalization. Prior studies have described the importance of knowing the patient’s patterns and responses to care.4, 6–8,10,11 This study supports that finding and expands the definition of knowing the patient by describing two broad domains of information that can be built upon in future studies to identify the discrete categories of information within the two domains of information needed to know the patient. From such research, efforts can be made to improve nurses ability to articulate and measure knowing the patient in practice.

Findings from this study also advance the concept of “knowing the patient” by exploring nurses’ use of available information sources to obtain the information needed to know the patient. In prior studies, the nurse’s verbal interaction with the patient and the family was identified as integral to knowing the patient.4, 6,7,10 Nurses in this study also support the need to have verbal interactions with the patient, the patient’s parents, and extended families. This finding is consistent with recent findings by Bundgaard et al. in 2011. Yet, the nurses recognized the potential for limited verbal interactions with the patient in a PICU setting due to the patient’s illness severity, age or developmental status. Therefore, when possible, nurses need to rely on information collected verbally from the patient’s parents and extended family in an effort to know the patient. In the instances where the parents and extended family either are not available to the nurse, or they have not established the patterns of a newborn infant, the nurse is often left with a relative information deficit.

Electronic Nursing Documentation in the Patient’s Medical Record

The electronic nursing documentation was the primary source of the patient’s medical record that nurses used to obtain any information to know the patient. The authors expected that nurses in the study would report using the electronic nursing documentation (e.g., flow sheets, narrative notes, assessments) as a primary information source needed to know the patient. However, the results demonstrated that nurses used the electronic nursing documentation primarily for clinical information. The nurses described limited use of the electronic nursing documentation for the personal information. Part of the limited use of the electronic nursing documentation may be due to accessibility of the information within the nursing documentation and the time required to retrieve the information from the electronic nursing documentation. For example, Bundgaard et al. discussed the importance of medical record documents for knowing the patient but found the nurses had limited time to refer back to the documents for information about the patient. A future study incorporating direct observations to visualize nurses’ behavioral use of information sources would allow exploration of Bundgaard et al.’s finding.

Of larger importance is the finding that nurses perceived limited benefits of the electronic nursing documentation to collect all of the clinical and personal information needed to know the patient. A patient’s medical record should be comprehensive and support the full information needs and work processes of nurses and the larger health care team. Nurses expressed the difficulty in findings a “spot” or place to put the personal information needs that would capture the information in a way that could be easily found by other nurses. The structure of the electronic nursing documentation encouraged the use of pick lists and drop down menus with few open free-text options. The free-text was available as a comment in the patient’s record but the comments were hidden behind each field and required the nurse to “hover” with a mouse to visualize the information. It may be difficult to provide the details needed, such as the feeding schedule described in the results section, when reducing this information to a few words within a drop-down menu or pick list. Thus additional research efforts are needed to understand the specific clinical and personal information required to know the patient and how to incorporate these requirements into the current patient record system.

Nurses’ Paper-Based Report Sheets

The nurses’ paper-based report sheets in this study were the most comprehensive tangible information source nurses used to collect the information needed to know the patient. Yet, the report sheets were created by each individual nurse and were not part of the patient’s medical record. The creation of and use of the paper-based report sheet as an information source can be viewed as a systemic work-around created by the nurses in order to ensure they have the information they need in a usable and efficient modality. However, due to the highly individualized nature of the paper-based report sheet for each nurse, and not being part of the medical record, there is the potential for loss of information needed to know the patient across caregivers. Such a limitation could contribute to gaps in the continuity of care as nurses hand over care responsibility to one another.

We believe that the use of a paper-based report sheet is not isolated to the nurses in this study and that most bedside care nurses will be able to connect with the studied nurses’ description and use of a report sheet. To date, the meaning and use of the paper-based report sheets for knowing the patient are not well understood in the literature.23 The legal, ethical, care (safety and quality), and system related implications of the use of a paper-based report sheet, that is not considered part of the permanent patient record, as a source of information to know the patient, needs to be more fully explored and studied. 28,29

Future Directions in Practice Settings

The findings from how the information sources were and were not used have significant implications for redesigning supportive tools for nurses to provide care. It is important for nursing leaders, educators and staff nurses to view the information sources found within the patient’s medical record as a mechanism by which nurses can collect and communicate information in an effort to know their patients. Often the use of the medical record is relegated to and viewed as a means by which to document care to remain in compliance with requirements set forth by the unit, hospital or regulatory agencies. While electronic nursing documentation supports nurses in knowing the clinical information, much of the personal information needed to care for the patient is not available or easily accessible in the patient’s electronic nursing documentation record. Instead, nurses communicate much of the patient’s personal information during nursing handoff through verbal communication and the temporary storage of the information on the paper-based report sheets. Inherent in this current practice, is the potential risk for error or omission of the nurses’ necessary clinical and personal information due to variability between individual nurses and the reliance on an information source that is not considered part of the patient’s medical record. The potential loss of information may impact the delivery of safe, high quality care. The limited empirical evidence on the use of nurses’ report sheets17 suggests that the nurses’ use of report sheets is not completely understood and may represent a hidden aspect of nursing practice. However, perhaps we can leverage the established practice to design clinical information tools that provide the information needed for care in a way that supports the uses and inherent values of the paper-based report sheet while promoting safe and individualized care.

Implications for Future Research

To our knowledge, this study was the first study to explore the meaning of knowing the patient from the perspective of nurses providing care to patients in pediatric intensive care settings. Further, we used a convenience sample that resulted in nurses with a 30-year range of nursing experience. It was beyond the design and scope of this study to compare and contrast the findings between nurses with different levels of experience. Future research seeking to understand such differences would need to include a larger sample using a stratified purposive sampling technique to recruit based on years of nursing experience. Finally, nurses in this study used nursing documentation in an electronic format whereas other nursing units may still be using paper-based forms.

A study utilizing behavioral observations of nurses delivering patient care is needed in order to understand how information needed to know the patient is discretely collected and communicated using the available sources. By directly observing nurses, researchers could identify the categories of the clinical and personal information nurses need to know the patient and develop an observational measure. By knowing the discrete information needs and the associated information sources, we can begin to understand the specific uses of verbal, paper-based and electronic information sources for specific categories of information needed to know the patient. Additional research is needed to understand why and how the patient’s medical record, especially the nursing documentation, does not allow the nurse to collect the patient information needed to care for the patient. This knowledge is necessary especially in the current climate of healthcare information technology where hospitals across the U.S. are being incentivized to adopt and use electronic health records in efforts to improve the quality of care delivered to patients.28 Finally, findings from this study suggest that further research is needed to understand the preferred methods of exchanging the information through available information sources. The paper-based report sheets introduced a method of temporarily storing information needed to know the patient however presents great risks. Thus continued efforts through observational research would reveal ways where EHRs could be designed to more effectively collect the information needed for care to the patient.

Conclusion

“Knowing the patient” is an essential element to the practice of nursing. Every nurse should have the ability to obtain the clinical and personal information needed to know the patient. Additionally, the information should be consistent across all nurses and only vary based on the individual patient’s care needs. In this study, we were able to expand on the concept of knowing the patient. We revealed that while available verbal interactions and the patient’s medical record provided nurses with some clinical and personal information, the use of these sources were not sufficient on their own. Instead, the nurses’ paper-based report sheet provided the most comprehensive information source for the nurses to obtain the clinical and personal information needed to know the patient. Future studies are needed to explore the specific information temporarily stored on the paper-based report sheets and the work processes supported by the report sheets. From these studies, we can begin to understand the current limitations of existing patient record systems and design supportive tools that can accommodate nurses’ information needs. Such supportive tools may also allow for improved standardization of information across caregivers and reduction in the need for tangible information sources that are not considered part of the patient’s medical record.

Acknowledgments

This research was supported in part by Duke University’s Center for Translational Science Award (CTSA) NIH Grant 1 TL1 RR024126. We would like to thank and acknowledge the nurses that participated in this study for their contributions.

Contributor Information

Tiffany Kelley, Duke University School of Nursing, Box 3322, 307 Trent Drive, Room 3080, Durham, NC, 27710, Phone: (857)-919-0600, Fax: (919)-684-8899.

Sharron Docherty, Duke University School of Nursing, Pediatric Nurse Practitioner, Children’s Health Center, Duke University Hospital, Box 3322, 307 Trent Drive, Durham, NC, 27710.

Debra Brandon, Duke University School of Nursing, Department of Pediatrics, Box 3322, 307 Trent Drive, Durham, NC, 27710.

References

1. Carper B. Fundamental patterns of knowing in nursing. Adv in Nurs Sci. 1978;1:13–23. [PubMed] [Google Scholar]

2. Watson J. Nursing: The philosophy and science of caring 1979. Liittle Brown; Boston, MA: 1985. Reprinted. Colorado Associated. [Google Scholar]

3. Swanson KM. Empirical development of a middle range theory of caring. Nurs Res. 1991;40(3):161–166. [PubMed] [Google Scholar]

4. Tanner CA, Benner P, Chesla C, Gordon DR. The phenomenology of knowing the patient. J Nurs Scholarsh. 1993;25(4):273–280. [PubMed] [Google Scholar]

5. Benner P, Tanner C. Clinical judgment: How expert nurses use intuition. Am J Nurs. 1987;87(1):23–31. [PubMed] [Google Scholar]

6. Bundgaard K, Nielsen KB, Delmar C, Sorensen EE. What to know and how to get to know? A fieldwork study outlining the understanding of knowing the patient in facilities for short-term stay. J Adv Nurs. 2011;68(10):2280–2288. [PubMed] [Google Scholar]

7. Jenny J, Logan J. Knowing the patient: One aspect of clinical knowledge. J Nurs Scholarsh. 1992;24(4):254–258. [PubMed] [Google Scholar]

8. Radwin LE. Knowing the patient: A process model for individual interventions. Nurs Res. 1995;44(6):364–370. [PubMed] [Google Scholar]

9. Radwin LE. Empirically generated attributes of experience in nursing. J Adv Nurs 1998. 1998;27:590–595. [PubMed] [Google Scholar]

10. Takemura Y, Kanda K. How Japanese nurses provide care: a practice base on continuously knowing the patient. J Adv Nurs. 2003;42(3):252–259. [PubMed] [Google Scholar]

11. Luker KA, Austin L, Caress A, Hallett CE. The importance of 'knowing the patient': Community nurses' constructions of quality in providing palliative care. J Adv Nurs. 2000;31(4):775–782. [PubMed] [Google Scholar]

12. Whittemore R. Consequences of not “knowing the patient” Clin Nurse Spec. 2000;14(2):75–81. [PubMed] [Google Scholar]

13. Speed S, Luker KA. Changes in patterns of knowing the patient: The case of British district nurses. Int J Nurs Std. 2004;41:921–931. [PubMed] [Google Scholar]

14. Blythe J, Royle J. Brief communications: Assessing nurses’ information needs. Bull Med Libr Assoc. 1993;81(4):433–435. [PMC free article] [PubMed] [Google Scholar]

15. Corcoran-Perry S, Graves J. Supplemental-information-seeking behavior of cardiovascular nurses. Res in Nurs Health. 1990;13(2):119–127. [PubMed] [Google Scholar]

16. Ekman I, Segesten K. Deputed power of medical control: The hidden message in the ritual of oral shift reports. J Adv Nurs. 1995;22:1006–1011. [PubMed] [Google Scholar]

17. Lange L. Information seeking by nurses during beginning-of-shift activities. Proceedings from the Annual Symposium Computers Applied Medical Care. 1992:317–321. [PMC free article] [PubMed] [Google Scholar]

18. McKnight M. The information seeking of on-duty critical care nurses. J Med Libr Assoc. 2006;94(2):145–151. [PMC free article] [PubMed] [Google Scholar]

19. Zhou X, Ackerman M, Zheng K. I just don’t know why it’s gone: maintaining informal information use in inpatient care. Proceedings from CHI. 2009 [Google Scholar]

20. Ammenwerth E, Mansmann U, Uler C, Eichstadter R. Fcators affecting and affected by user acceptance of computer-based nursing documentation: Results of a two-year study. JAMIA. 2003;10(1):69–84. [PMC free article] [PubMed] [Google Scholar]

22. Kelley TF, Brandon D, Docherty S. Electronic nursing documentation as a strategy to improve the quality of patient care. J Nurs Scholarsh. 2011;43(2):154–162. [PubMed] [Google Scholar]

23. Staggers N, Jennings BM. The content and context of change of shift report on medical and surgical units. J Nurs Adm. 2009;39(9):393–398. [PubMed] [Google Scholar]

24. Kelley TF. Dissertation. Durham: NC: Duke University; 2012. Information use with paper and electronic nursing documentation by nurses caring for pediatric patients. [Google Scholar]

25. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114–2120. [PubMed] [Google Scholar]

26. Lannon CM, Coven BJ, Lane France F, Hickson GB, Miles PV, Swanson JT, et al. Principles of patient safety in pediatrics. Pediatrics 2001. 2001;107(6):1473–1475. [PubMed] [Google Scholar]

27. Miller MR, Elixhauser A, Zhan C. Patient safety events during pediatric hospitalizations. Pediatrics. 2003;111(6 Pt 1):1358–1366. [PubMed] [Google Scholar]

28. Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ, Adams JL, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15):1515–1523. [PubMed] [Google Scholar]

29. Miles PV, Miller M, Payne DM, Perelman R, Saffer M, Zimmerman E. Alliance for pediatric quality: creating a community of practice to improve health care for America's children. Pediatrics. 2009;123(Suppl 2):S64–66. [PubMed] [Google Scholar]

30. Lin C, Hsieh K. Pediatric critical care–A new frontier. Pediatric Neonatalogy. 2009;50(5):184–189. [PubMed] [Google Scholar]

31. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288. [PubMed] [Google Scholar]

32. Miles MB, Huberman AM, Saldana J. Qualitative data analysis: An expanded Sourcebook. 2. Thousand Oaks: Sage; 2013. [Google Scholar]