These different approaches have different names for their phases.
McGonigle and Mastrian, (2022) discuss the Systems Development life cycle or SDLC. They cite various approaches to the SDLC, including The waterfall model, where the output from one stage flows into the next, RAD or rapid application development that uses a quickly developed prototype that can be tested by users, Object Oriented Systems Development or OOSD, which assigns commodities that exist in reality to objects within computer software. Per Gogou et al, (2002), the benefit of this is that the system can focus on the relationship of these objects to each other rather than be designed from a procedural standpoint. There is also DSDM or the Dynamic System Development Model, which per McGonigle and Mastrian, (2022) is useful when a new system must be developed quickly and may have to be adjusted to meet unforeseen needs as it is developed. There is also a method discussed called Agile, which emphasizes the way the work (that the system will be supporting) is done and the way the people doing the work perform together.
These different approaches have different names for their phases. However, per Dr. Kevin Johnson in Walden (2018) the four general phases of SDLC are Planning, Design, Implementation, and Evaluation/ Maintenance. This video also stresses the importance of nurse involvement in each phase for the success of the new system.
In the planning stage, Dr. Johnson (Walden, 2018) describes two critical steps. First, he states that the individuals involved in systems development must remember that the whole thing is a cycle, and steps may need to be revisited. Second, he states that we must define what we need the system to do. It is essential that there is nurse representation, especially in this stage, because nurses will be the ones using the system, and they need to have input on how the system should operate. McGonigle and Mastrian, (2022) discuss for example, working with stakeholders (in this case, the nurses) to ask what a system “should have, must have, could have and would have,” identifying the “must have” facets of a system as the ones necessary for its success.
Per McGonigle and Mastrian, (2022) use of healthcare technology can save lives, but when it is implemented without regard to actual workflow, it can create more danger than safety. This is why a nurse needs to be involved in the design stage of the systems development life cycle. These writers state that workflow analysis is a key part of the design (or re-design) process and that workflow analysis is a key skill that a nurse informaticist should possess to be part of the team that looks at workflow during the design stage of the SDLC. . I can think of a time in my last agency when the project team spent months “redesigning” the system with little or no influence from the direct care staff, and the result was basically to move all our widgets around and give the calendar a new look. There were no processes added that could have enhanced our workflow, such as the ability to create a working client list for each nurse or to do batch processes like adding vitals for all clients on a list. If the nurse staff had any input into this planning stage, it could have given the project management team better direction and resulted in changes that were more meaningful to patient care. The new design, without input from staff, actually got in the way of care by offering no meaningful changes to actually help the workflow. It also required a few days of learning where the design team relocated the same old tools to just affect a different “look”.
In Walden University (2018) Kevin Johnson speaks about the most significant challenge to implementation being acceptance of change among the end users of the system. To ensure buy-in, he speaks about the necessity of collecting input from staff, with the recognition that not all views on what is the best direction can be satisfied. So during implementation, there needs to be the recognition that not all system users will be happy with the new system (because even if they had input, their input might not have been utilized). Cho et al, (2021) discuss resistance to change during implementation and state that resistance may not be apparent because nurses may understand the implications to their career by overtly resisting the change. But there may be hidden resistance, which can be even more damaging to the process. These writers state that an important nurse role in the implementation change is to have nurses that are super users (that they refer to as “nurse champions”) who are well trained in the use of the EHR, and can demonstrate and also promote from within the benefit of the EHR to other staff. McGonigle and Mastrian, (2022) also discuss training as an important step of implementation. In this area, nurses need to participate to be trained. But another critical role for the nurse and nurse informaticist is to be able to train their cohorts. And in the case of a major change like the adoption of a new system, it is not just about educating people on use but leading them to embrace change. Tyler (2019) describes an important role of a nurse informaticist as being able to lead their cohorts through change. The nurse informaticist needs to be involved to get people to “unfreeze” and accept change, move through the process of change, and then embrace the new way of working. I was not here for the new implementation of EPIC at my present place of employment. However, the physician I work under told me of several Physicians, who were at the end of their careers, and quit due to the complexities of the new system. These were providers who may have delayed their retirement by a few years but got so frustrated learning to use EPIC that they left early. It is clearly important that there are cohorts who can help new users learn the system , not just for the success of the system, but also for employee engagement.
In the Maintenance and evaluation stage of the SDLC the new system needs to be evaluated to see if it is working and have the necessary changes applied (This goes back to Dr. Kevin Johnson’s statement in Walden (2018) that the process is cyclic and constantly needs to be revisited and evaluated to ensure it is meeting the needs of the healthcare facility and its patients. Untalan et al, (2022), besides recommending the use of super users for direct staff training as part of implementation also support the importance of evaluation and maintenance of the system through some sort of metric like lean sigma six to see if the system is meeting its goals. In their case, they created an audit tool. They combined it with nursing huddles to discuss barriers and pathways to meet specified nursing issues until their system had 100% resolution of identified issues. This demonstrates the importance of nursing involvement in this phase. If the nurses are not able to meet their care goals with the use of the system, and if the system cannot be modified to let nurses meet their patient care goals then it is not going to be much help to the facility’s nurses or patients. In my old agency, we were at least asked for feedback after the changes. I did not see any immediate changes to the system after feedback was collected. But there was at least an avenue for quality improvement that was staff experience related.
Along the SDLC the involvement of nurses (the people who will be mostly utilizing the system for patient care ) will always be of the strongest importance. Input into what a system will be used for, how it can be designed to do the job, whether it is accepted, embraced, and learnable, and how it works for its users revolves around the nursing staff. It is especially up to the nurse informaticist to bridge the gap between the nursing staff and the IT professionals who will be coding and building the system.
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