INTEGRATIVE REVIEW ARTICLE DECISION-MAKING SYSTEM FOR ...

Miranda LN, Farias IP, Almeida TG et al. Sistema de tomada de decisão para enfermagem...

English/Portuguese

J Nurs UFPE on line., Recife, 11(Suppl. 10):4263-72, Oct., 2017 4263

ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10712-95194-3-SM.1110sup201732

DECISION-MAKING SYSTEM FOR NURSING: INTEGRATIVE REVIEW SISTEMA DE TOMADA DE DECISÃO PARA ENFERMAGEM: REVISÃO INTEGRATIVA

SISTEMA DE TOMA DE DECISIÓN PARA ENFERMERÍA: REVISIÓN INTEGRATIVA Lays Nogueira Miranda1, Isadora Pereira Farias2, Thayse Gomes Almeida3, Ruth França Cizino da Trindade4,

Daniel Antunes Freitas5, Eveline Lucena Vasconcelos6

ABSTRACT

Objective: to analyze specifications of similar systems in order to find out what requirements must contain software for Nursing care. Method: integrative review, through search of articles in full, in the databases MEDLINE, LILACS, Science Direct and SCIELO virtual library. The research was conducted in September / 2016, with a temporal cut from January / 2005 to August / 2016, using controlled descriptors contemplated in DeCS. Results: Brazil is the country that most published on the subject. Conclusion: integrative review is efficient in searching for specifications for a clinical decision support system. Descriptors: Decision Support Systems, Management; Nursing; Criticalcare; Review.

RESUMO

Objetivo: analisar as especificações de sistemas similares no intuito de descobrir que requisitos deve conter um software para a assistência de Enfermagem. Método: revisão integrativa, por meio de busca de artigos na íntegra, nas bases de dados MEDLINE, LILACS, Science Direct e biblioteca virtual SCIELO. A pesquisa foi realizada em setembro/2016, com recorte temporal de janeiro/2005 a agosto/2016, utilizando descritores controlados contemplados no DeCS. Resultados: o Brasil é o país que mais publicou sobre o tema. Conclusão: a revisão integrativa é eficiente na busca de especificações para um sistema de apoio a decisões clínicas. Descritores: Sistemas de Apoio a Decisões Administrativas; Enfermagem; Cuidados Críticos; Revisão.

RESUMEN

Objetivo: analizar las especificaciones de sistemas similares con el fin de descubrir que requisitos deben contener un software para la asistencia de Enfermería. Método: revisión integrativa, por medio de búsqueda de artículos en su totalidad, en las bases de datos MEDLINE, LILACS, Science Direct y biblioteca virtual SCIELO. La encuesta fue realizada en septiembre / 2016, con recorte temporal de enero / 2005 a agosto / 2016, utilizando descriptores controlados contemplados en el DeCS. Resultados: Brasil es el país que más publicó sobre el tema. Conclusión: la revisión integrativa es eficiente en la búsqueda de especificaciones para uno sistema de apoyo a decisiones clínicas. Descriptores: Sistemas de Apoyo a Decisiones Administrativas; Enfermería; Cuidados Críticos; Revisión. 1Nurse, Master, Federal University of Alagoas / UFAL. Maceió (AL), Brazil. E-mail: [email protected]; 2Nurse, Master's student, Post-Graduate Program in Nursing, Federal University of Alagoas / UFAL. Maceió (AL), Brazil. E-mail: [email protected]; 3Nurse, Master, Federal University of Alagoas / UFAL. Maceió (AL), Brazil. E-mail: [email protected]; 4,6Nurse, PhD, Professor, Federal University of Alagoas / UFAL. Maceió (AL), Brazil. E-mail: [email protected]; [email protected]; 5Odontologist, PhD, Professor, University of Montes Claros / UNIMONTES. Montes Claros (MG), Brazil. E-mail: [email protected]

INTEGRATIVE REVIEW ARTICLE

mailto:[email protected]






English/Portuguese



The information volume and increasing

complexity of the health treatment protocols

is detected, so that the manual records

become insufficient to cover all aspects of

care. Clinical Decision Support Systems (CDSS)

appear in this scenario as a promoter to

improve the quality of care provided, since

they have great potential to help nurses deal

with the volume of information related to

clinical practice.1 -2

Studies indicate that, despite the benefits

described in the use of CDSS, there is still an

underutilization of these by users, usually,

due to failures in the software design stage.3-

In a study carried out in the United States, it

was identified that the main flaws in the

design of the software were due to the lack of

involvement of the users (13%), incomplete

requirements (12%), requirements change

(11%), unrealistic expectations (6%) and

unclear objectives (5%).4

In the area of Nursing, the underutilization

of CDSS has been related to the fact that

these systems are based on data from the

medical practice.4 This finding affirms the

importance of involving nurses in the process

of defining the requirements of specific

systems for their professional practice, that

knowledge in the field of Nursing care, in its

genesis, is available to these professionals

through the use of CDSS.

The requirements of a system are the

descriptions of what the system should do, the

services it offers and the restrictions on its

operation. These reflect the needs of users for

a system that serves a particular purpose. The

process of discovering, analyzing,

documenting, and verifying these services and

constraints is called requirements

engineering.5

In spite of the existence of methodologies

to support the software design stage, such as

the Requirements Engineering Process

proposed by Sommerville, 5 it is observed in

the literature, that the systems developed, to

support nurses in the development of Nursing

care, are often, elaborated empirically and do

not follow a methodology for the software

design process.6-10 It should be emphasized

that this may result in ineffective software,

which does not satisfy the needs of its users.11

According to the literature5, Requirements

Engineering encompasses four high level

activities: 1. Feasibility Study (which has the

purpose of identifying the problem and

assessing the usefulness of the system for the

market); 2. Elicitation and Analysis of

Requirements (survey of the services that the

system must offer); 3. Specification (process

of writing user and system requirements in a

requirements document); 4. Validation

(examination of the specification to ensure

that all software requirements have been

unambiguously stated; inconsistencies,

omissions, and errors have been detected and

corrected).

In this sense, the researchers started with

the following guiding question to carry out

this review: What requirements must be

contained in Nursing care software, with

direct and active involvement of nurses, based

on a methodology that bases the design

process on the same one as a Decision Support

System Clinics in Cardiology Intensive Care

Unit (CICU)?

● To analyze the specifications of similar

systems in order to discover the requirements

that Nursing software should contain.

For the development of this review, the six

stages were covered12: 1) Establishment of a

hypothesis or question of research; 2)

Sampling or search in the literature; 3)

Categorization of studies; 4) Evaluation of

studies included in the review; 5)

Interpretation of results; 6) Synthesis of

knowledge or presentation of the review.

The search for productions was carried out

in the Latin American and Caribbean

Literature in Health Sciences (LILACS), Medcal

Literatury Analisys and Retrieval System

Online (MEDLINE), Science Direct and the

Scientific Electronic Library Online virtual

library (Scielo ), from search strategies

composed of the descriptors, included in the

Descriptors in Health Sciences -DeCs,

controlled: Nursing Informatics,

NursingProcess, Nursing, Decision Support

Systems, Clinical and Software.

Included, in this search, were articles

describing Nursing care support software,

available electronically in full, and published

from January 2005 to August 2016. Among the

exclusion criteria are articles describing

software used in teaching and research in

Nursing.

The search, was conducted, in September

2016, for online access to the databases,

following the pre-established inclusion and

exclusion criteria and generating a final

sample of 23 articles. To analyze the data, a

synoptic table containing the following

variables was constructed in the Microsoft

Office Excel 2010 for Windows program:

METHOD

OBJECTIVE

INTRODUCTION


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article title, authors, year of publication,

scope and software functionalities.

The flowcharts of the article selection

process were constructed (Figure 1), starting

with the search strategies used, the databases

consulted, the total number of articles

resulting from the search strategy, and the

number of articles selected, after the

application of the inclusion and exclusion

criteria.

Figure 1.-Selection of articles by search strategy in databases. Maceió (AL), Brazil, 2017.

For the critical evaluation of the studies,

the selected articles were read in full and

then the data collection instrument was

completed. Data were exported and analyzed

in the Statistical Package for Social Science

(SPSS) program. The results of the selected

studies were synthesized and, after analysis,

listed in the form of requirements for the

development of new software.

Next, UML language use case diagrams

were developed with the help of Argo UML,


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0.30 software, in order to support the

elicitation of the requirements. The use case

may be taken as "a simple scenario describing

what a user expects from a system."5

Were evaluated 23 scientific articles, all

with level I of evidence, scientists that met

the inclusion and exclusion criteria, previously

established. The data in Figure 2 show the

synthesis of the characteristics of the included

studies and their respective software.

Title Authors Year Software scopre

Software functions

Computerized Nursing process: methodology for the association of clinical evaluation, diagnoses, interventions and results.

Sasso GTMD, Barra DCC, Paese F, Almeida SRW, Rios GC, Marinho MM, Debétio MG.

2013 Supporting the development of the Nursing process.

1) Cadastro de avaliação clínica; 2) Seleção de Diagnósticos; 3) Seleção de Intervenções; 4) Seleção de Resultados.

Informatics in Nursing: development of free software with assistance and management application.

Santos SB. 2010 Supporting the development of the Nursing process.

1) Cadastro de Histórico; 2) Cadastro de Exame Clínico; 3) Elaboração de Plano de Cuidados; 4) Cálculo de censo estatístico; 5) Acompanhamento de indicadores hospitalares; 6) Classificação de pacientes; 7) Dimensionamento de pessoal; 8) Controle de frequência; 9) Elaboração de escala de serviço.

Integrate information systems for elective chemotherapy medication administration.

Levy MA, Giuse DA, Eck C, Holder G, Lippard G, Cartwright J, Rudge NK.

2011 Enable the safe administration of medicines.

1) Controle de administração de medicamentos; 2) Emissão de alerta (paciente errado, droga errada, dose errada, via errada e/ou horário errado).

Nursing process decision support system for urology ward.

Hao ATH, Wu LP, Kumar A, Jian WS, Huang LF, Kao CC, Hsu CY.


1) Cadastro de avaliação; 2) cadastro de diagnósticos de enfermagem; 3) Elaboração de planejamento da assistência; 4) Cadastro de dados de execução.

Development and validation of computerized assessment from Nursing support diagnosis.

Zega M, D’Agostino F, Bowles KH, Marinis MGD, Rocco G, Vellone E, Alvaro R.


1) Cadastro de Avaliação; 2) Cadastro de exame físico; 3) Seleção de diagnósticos.

Nursing care planning - proposed software-prototype.

Sperandio DJ, Évora YDM.


1) Cadastro de paciente; 2) Cadastro de entrevista; 3) Cadastro de coleta de dados; 4) definição de problemas; 5) Cadastro de prescrição de enfermagem; 6) Cadastro de sinais vitais; 7) Cadastro de balanço hídrico.

Development of Electronic System of Nursing Clinical Documentation structured in diagnoses, results and interventions.

Peres HHC, Cruz DALM, Lima AFC, Gaidzinski RR, Ortiz DCF, Trindade MM,Tsukamoto R, Conceição NB.


1) Cadastrar avaliação; 2) Selecionar diagnósticos; 3) Selecionar resultados; 4) Selecionar intervenções; 5) Geração de resumo das avaliações; 6) Geração de relatórios.

Specialist system to support the decision in topical therapy of venous ulcers.

Sellmer D, Carvalho CMG, Carvalho DR, Malucelli A.

2013 Supporting nurses' decision-making in topical wound

1) Registration of anamnesis; 2) Evaluation and registry of venous ulcers 3) Indication of treatment; 4) Report generation.

RESULTS


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therapy. Prototype of documentation system in Nursing in the puerperium.

Veríssimo RCSS, Marin HF.


1) Register bed; 2) Search bed; 3) Register user; 4) look for user; 5) Register Patient; 6) Search for Patient; 7) View patient data; 8) Register hospitalization; 9) Finish hospitalization; 10) Register anamnesis; 11) Register physical examination; 12) Register Evolution; 13) Register diagnoses and interventions; 14) View Nursing processes; 15) Print evolution.

Essential arithmetic data archetypes for the care of endometriosis patients.

Spigolon DN, Moro CMC.


1) Register Nursing history; 2) Register Nursing diagnoses; 3) Register Nursing interventions; 4) Register Nursing prescription; 5) Register results and evaluations.

Mobile technology at the bedside - computerized Nursing process in intensive care from CIPE 1.0.

Barra DCC, Sasso GTMD.


Not reported.

Conception, development and application of the "Prince" clinical Nursing records system.

Pinto N. 2011 Supporting the development of the Nursing process.

1) Registration of Nursing consultation; 2) General data file; 3) Evolution register; 4) Register of vital signs; 5) Register of Nursing diagnoses; 6) Register of Nursing interventions; 7) Medical appointment scheduling; 8) Generation of statistical reports.

System of assistance to Nursing diagnoses for victims of trauma in advanced prehospital care using the NANDA and NIC taxonomies.

Caritá CEC, Nini RA, Melo AS.


1) Register of diagnoses; 2) Registration of interventions.

Computerized application with the NursingActivities Score: instrument for the management of Nursing care in the ICU.

Castro MCN, Dell’Acqua MCQ, Corrente JE, Zornoff DCM, Arantes LF.

2009 Evaluate the daily workload of the Nursing. team

1) Patient Registration; 2) Data Collection; 3) Issuance of reports.

NAS System -NursingActivities Score in mobile technology.

Catalan VM, Silveira DT, Neutzling AL, Martinato LHM, Borges GCM.

2011 Evaluate the daily workload of the Nursing team.

1) Patient Registration; 2) Data Collection; 3) Issuance of reports.

Evaluation of the functional performance and technical quality of an electronic documentation system of the Nursing process.

Oliveira NB, Peres HHC.


1) Register evaluation; 2) Select diagnostics; 3) Select results; 4) Select interventions; 5) Generation of summary of evaluations; 6) Generating reports.

Software for mapping the risks of pressure ulcer, fall and phlebitis.

Assis MG, Assis MA, Amate FC.

2012 Map and Classify patients regarding care risks.

1) Register Patient; 2) Revalidate Risks; 3) Patient output; 4) Filter risk factors; 5) Generate risk map.

Construction of a software prototype to support the Systematization of

Oliveira CG, Barros KAAL, Oliveira AG.


1) Patient Registration; 2) History record; 3) Register of Physical Examination; 4) Diagnostic registry; 5)


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Nursing Assistance, using software engineering and usability.

Prescription record; 6) Evolution register; 7) Result register; 8) User Registration; 9) Generation of statistics.

Alert systems in a computerized Nursing process for ICUs.

Barra DCC, Sasso GTMD, Baccin CRA.


1) History Record; 2. Diagnostic Registry; 3) Registration of Interventions; 4) Results Register; 5) Issuance of alerts related to indicators of quality of care.

Ultrasonography-based model for clinical decision support of ulcer wound management.

Kin HY, Park HA.

2012 Supporting nurses' decision-making in topical wound therapy.

1) Registration of anamnesis; 2) Evaluation and registration of pressure ulcers; 3) Issuance of recommendations.

Detection and prevention of medication errors using real-time bedside nurse charting.

Nelson NC, Evans S, Samore MH, Gardner RM.

2005 Provide safe administration of medicines.

1) Control of medication administration; 2) Alert issue (wrong patient, wrong drug, wrong dose, wrong route and / or wrong time).

Evolutionary study on a computer tool for nurse management in the period 2005-2010.

Valverde MJ, Borrego AR, Alcaraz OL, Barbero JT, Perea JP, Molina PM.


Not reported.

On designing a usable interactive system to support transplant Nursing.

Narasimhadevara A, Radhakrishnan T, Leung B, Jayakumar R.


Not reported.

Figure 2. Synthesis of the studies and their respective software. Maceió, AL, Brazil, 2017.

The integrative review allowed the

identification of 23 articles, which presented

the description of software to support Nursing

care. The study countries, which composed

the sample (n = 23), were: Brazil, 15 (66%);

United States, two (9%); China, Italy,

Portugal, South Korea, Spain and Canada, with

one (4%) study each.

The characterization of the sample,

according to the year of publication of the

studies, is presented in Table 1.

Table 1. Demonstration of descriptive data with frequency and percentage values referring to the year of publication of the article (n = 23). Maceió, AL, Brazil, 2017.

Year of publication n %

2005 2 9 2008 1 4 2009 2 9 2010 4 17 2011 3 13 2012 5 22 2013 3 13 2014 2 9 2015 1 4 2016 X X

As to the design of the studies, the

majority (65%), n = 15, was characterized as a

methodological study of technological

production, while 26% (n = 6) were descriptive

studies, 4% (n = 1), and 4% (n = 1), almost

experimental studies of the before and after

type.

Twelve scientific journals were identified,

in which the studies are published, divided

equally between national and international

journals. The journals were, respectively:

Journal of the American Medical Informatics

Association and Latin American Journal of

Nursing, comQualis A1; Acta Paulista Nursing,

International Journal of Medical Informatics,

International Journal of Nursing knowledge,

Journal of Biomedical Informatics, Journal of

Nursing School, of USP and, Text and Context

Nursing, with Qualis A2; Gaúcha Nursing

Journal with Qualis B1; Clinical Nursing and


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Journal of Health Informatics, with Qualis B3;

and Journal of Oncology Practice does not

present Qualis. It is added that if the journal

presents Qualis distinct by areas, will be

presented the highest Qualis attributed to it.

As for the sites for which the technologies

were developed, the General Hospital Units

were the most prevalent (26%), n = 6,

followed by Intensive Care Units (n = 5), 22%,

and Ambulatory Units (n = 3), 13%. The other

39% (n = 9) consisted of Pre-Hospital

Emergency Care, Transplant Center, Oncology

and Urology Centers, Surgical and Medical

Clinics, Day-Hospital and Maternity.

The software was developed, mainly, in

order to support the development of the

Nursing process, (n = 16), 70%. Among the

other purposes of the softwares found in the

literature, there are: support nurses' decision

making in wound therapy, (n = 2), 9%;

evaluate the daily workload of the Nursing

team, two (9%); provide greater safety in drug

administration, (n = 2), 9%, and to map and

classify patients regarding care risks, (n = 1),

4%.

As to software (n = 16), developed to

support the increment of the Nursing process,

81% (n = 13) had their functionalities

described in the studies and, from these, it

was possible to identify which stages of the

process were supported by the use of the

software described. From this, it was

identified that no software supported all

stages of the Nursing process and that only

one software (7.7%) supported four of the five

stages of the process: data collection, Nursing

diagnosis, Nursing and evaluation.

It was also identified that 53.8% (n = 7) of

the Nursing process support software, with

features described in the articles (n = 13),

supported the development of three stages of

the Nursing process: data collection, Nursing

diagnosis and Nursing planning; 23.1% (n = 3)

supported the data collection stage and

Nursing diagnoses completely, while the

planning stage was incompletely supported

because it did not allow the establishment of

Nursing results. And the remaining 15.4% (n =

2) supported the development of two steps in

the Nursing process. Of the latter, one

supported the steps of data collection and

Nursing diagnoses, while the other supported

the steps of Nursing diagnoses and planning.

Tables 2 and 3 present, respectively, the

Nursing terminologies and the theoretical

foundations used for the development of

software to support the Nursing process.

Table 2. Demonstration of the descriptive data with frequency and percentage values referring to the Nursing terminologies used in the software to support the Nursing process (n = 16). Maceió, AL, Brazil, 2017.

Nursing terminolgy n %

CIPE 5 31 NANDA 7 44

NANDA and CIPE 1 6 Not reported 3 19

It should be noted that 69.2% (n = 9) of the

software to support the Nursing process with

described functionalities presented

managerial functionalities, in addition to

those directly related to the Nursing process

steps. Examples of these functionalities are:

calculation of the occupational census of the

unit; follow-up of care indicators (incidence of

patient fall, incidence of unplanned

extubation of the endotracheal cannula,

incidence of pressure ulcer and others);

Nursing team dimensioning; frequency

control; reporting on the incidence of Nursing

diagnoses, among others.7-9, 13

Regarding the software developed to

support nurses' decision making in wound

therapy, it was identified that they issued

treatment indications from the information

record about wound characteristics such as

extent, depth, presence and characteristics of

the wound. exudate, type of tissue present in

the wound bed and others.14

The software that evaluated the daily

workload of the Nursing team did it through

Table 3. Demonstration of descriptive data with frequency and percentage values referring to the theoretical foundations used in software to support the Nursing process (n = 16). Maceió, AL, Brazil, 2017.

Theoretical foundation n %

Not Reported 13 81 Basic Human Needs of Wanda Horta 2 12 Marjorie Gordon's Functional Health Standards 1 6


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the computerized application of the Nursing

Activities Score (NAS). While those with a

view to making drug administration more

secure were made possible through the

control of medication administration in the

dispensation, preparation and administration

stages and the issuing of warnings such as,

wrong patient, wrong drug, wrong dose,

wrong route, and / or wrong time.15-6

The software developed with the purpose

of mapping and classifying the patients

regarding the care risks carried out the risk

classification of pressure ulcer, fall and

phlebitis, by completing a computerized form

containing the factors associated with such

risks.14

After analyzing the Nursing assistance

software described in the literature, it was

identified that the software to be used in the

UTIC must support all stages of the Nursing

process, possessing, in addition to the

functionalities related to the stages of the

Nursing process, general functionalities which

will support the team in the development of

their assistance to inpatient clients.

In discussing this study, it is possible to

point out, the relevance of this study in

presenting innovative facts that will enable

the definition of the scope of the Nursing

assistance software and its initial

functionalities, focused on the development

of the Nursing Process (NP).

From this literature review, it was

identified the importance of developing a

decision support system for Nursing care, with

the objective of supporting the development

of the NP, to be used by the Nursing team

working in CICU.

Based on this literature review, it was

verified that there is a gap related to the

creation of support systems for the decision-

making in CICU, with the objective of

supporting the development of the entire NP,

to be used by the team working in that unit .

In this sense, it was possible to identify

that no job, among the ones found in the

search, contained software that supported

decision making in all stages of the NP. Thus,

emerging the need to create softwares that

help Nursing to make quick decisions and ideal

for each type of treatment performed in CICU,

because this is a unit in which the speed and

precision of the actions taken can be decisive

when saving a life.

It was verified that the year 2012 was the

year that more articles were published (five)

that presented software to support decision-

making for Nursing. Thus, it is well known that

there is still much to be studied and

disseminated so that Nursing can be a

recognized science for using technology when

making decisions that qualify caring.

This review found five softwares that

included the CIPE language. The literature

indicates that the development of software to

support the Nursing process, using the CIPE as

reference, terminology contributes to the

organization and development of the nurses'

clinical reasoning in the care process, through

the establishment of a concrete association

between clinical evaluations , the diagnoses,

the results and the Nursing interventions.

Likewise, it is affirmed that there is

improvement in communication among health

professionals, enabling a safer and more

efficient care to the client and reducing the

associated errors.17-9

It should be emphasized that the data

suggested by the system must be evaluated by

the nurses in the sector that are using the

software to accept or refuse them. This,

combined with the functionality of

constructing the diagnoses, results and

interventions, based on the seven axes of the

CIPE, guarantees the clinical reasoning and

judgment process of the professional; so that

the software will be an aid to the professional

and not a replacement of it.

Among the magazines that published on the

use of software and Nursing care, it was

verified that most have Qualis ranging from A1

to B3 and only one did not have it. However,

it is evident that even the articles, most of

them, having been published in journals

classified as A, these manuscripts did not

treat the Nursing EP in its entirety.

It is evidenced that most of the softwares

proposed in the literature are not supported

by any theoretical basis of the care proces.

So, it is believed that they do not function as

an instrument to support safe decision making

for nurses.

The analysis of the scientific production on

the identification of the specifications of

similar systems, in order to discover the

requirements that must contain a software for

Nursing care, object of this study, evidenced

the importance of the creation of clinical

decision support systems for the assistance of

Nursing, which contemplates all the stages of

the Nursing process and also, that are

supported by some theoretical foundation of

the care process.

CONCLUSION

DISCUSSION


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The integrative review has proved to be an

indispensable tool in the search for the

requirements that will be the basis for the

creation of software with the characteristics

necessary to provide an individualized and

quality assistance without giving up the work

of the nurse.

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English/Portuguese



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Submission: 2017/03/23 Accepted: 2017/09/22 Publishing: 2017/10/15

Corresponding Address

Isadora Pereira Farias Rua Izenilda Félix de Oliveira, 22 Bairro Tabuleiro dos Martins CEP: 57072-900 – Maceió (AL), Brazil

http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/3064/pdf_3797



http://dx.doi.org/10.1590/S0080-62342013000100031

http://dx.doi.org/10.1590/S0080-62342013000100031

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