One-stop online shop for nursing procedures

1 November 2011

MICHAEL BLAND and JOHN CLAYTON outline a project to provide up-to-date nursing procedures online to all nurses in the Midland region.

Safe nursing practice is reliant on nurses’ ability to access evidenced-based procedures that guide their practice. Traditionally, most district health boards have used their own nursing experts to develop procedures that are signed off by their respective directors of nursing. However, it’s a problem when 20 DHBs undertake the same lengthy exercise and then attempt to meet hospital accreditation standards in an annual cycle.

Michael Bland, clinical nurse director for Waikato DHB, recognised the futility of board staff trying to keep the DHB’s extensive procedure database up to date. The DHB’s quality and risk department estimates it takes 80 hours from starting with a blank sheet of paper to having a procedure signed off, and up to 20 health professionals may have input in between.

Bland sought a solution and successfully approached the Ministry of Health for project funding. John Clayton of Wintec’s Emerging Technology Centre was engaged to provide the IT skills for the project seeking to deliver universal nursing procedures to the whole of the Midland region’s 8500 nurses. (The Midland region covers the Bay of Plenty, Lakes, Taira¯whiti, Taranaki and Waikato boards.)

The project’s objective is to review online procedure manuals, select the ‘best fit’ and then develop an electronic platform that nurses, regardless of where they are, can access.

The final piece of the project puzzle is to evaluate the reward for putting the procedures online. Lynda Pryor, knowledge services manager for Waikato DHB, says in her experience ease of access, good quality resources and a strong search engine are critical in getting nurses to use online resources.

A project team was set up of two clinical nurse directors, lead librarian staff and information technology staff. Team leader Bland reported directly to a reference committee made up of the region’s five directors of nursing. Bland says a key to the project was getting ‘buy in’ from the directors of nursing at the five DHBs and once their imagination was stimulated the rest was easy.

Sue Hayward, Waikato DHB’s director of nursing and midwifery, says the project is a “great opportunity to provide nurses with clear evidence-based procedures to support their practice”.

Selection of best evidence resources and eEnvironment

The project team’s first eight months were spent selecting a preferred nursing procedure manual; developing and testing the e-platform; and developing an instrument to evaluate the project. The gap analysis indicated that the US-based Lippincott Nursing Procedures and Skills manual, which covers more than 80 per cent of Waikato’s procedure portfolio, was the most appropriate manual to pilot.

The pilot

An initial pilot group was set up of 135 registered nurses working across the five DHBs, and covering all the major nursing scopes, and sectors from primary to tertiary, including non-DHB nurses,

nurse tutors and nurses in management and recruitment. The pilot nurses were asked to critically review a minimum of three of the manual’s procedures, including at least one “non-specialist” procedure. In addition, a group of senior nurses and key stakeholders were invited to complete at least one critique and the evaluation.

The evaluation

The project team developed two evaluation instruments to gauge the pilot nurses’ perceptions of both ease-of-access to the electronic resources and their evaluation and critique of the procedures they reviewed.

At the conclusion of the pilot, 155 RNs and midwives had completed both instruments and evaluated more than 430 procedures. But some procedures were evaluated by more than one nurse, so in total 302 of the 920 procedures in the Lippincott Nursing Procedures and Skills manual were evaluated during the pilot.


Analysis of the ease-of-access evaluations indicated a significant majority of respondents:

were confident and competent using their computers and with searching, retrieving, storing and manipulating information from the internet;

found the webspace created was visually appealing;

were able to clearly read all materials;

felt the procedures reviewed were presented in a logical manner, were current and appropriate to their current level of skill;

could access the appropriate software applications to complete activities assigned;

had robust and reliable connections.

Analysis of the procedure evaluations indicated:

procedures need to be tidied slightly, particularly around the language style;

there was an overwhelmingly positive response to accessing online procedures and the ‘fitness for purpose’ of the procedures;

the procedures had a good ‘technical fit’ with New Zealand nursing practice.

It was notable that the greatest

support for online procedures was from nurses who were either independent of

the main provider hospital or in rural settings with limited access to these resources.

Pilot summary

Key points learnt from the pilot phase were:

an electronic online procedure manual is recognised as having great value to nurses and accurately matches their practice needs and expectations around content,

the e-environment created was easy to navigate for nurses and provided seamless access to the procedure manual;

the procedures themselves were generally received well with very little criticism of the technical aspects of the procedure detail.

However, many nurses found:

the cultural safety elements were not given sufficient attention;

in many critiques, nurses displayed some frustration around the ‘Americanisation’ of the language used in the procedure.

Future directions

The next phase of the pilot is to provide staged access to the online procedure manual and resources to all 8500 registered nurses in the Midland region.

Initial access will be granted to provider-arm hospitals, followed by primary healthcare organisations and finally aged care and iwi providers.

At the same time, an expert editorial review panel will systematically assign every procedure to an expert nurse to review and critique each procedure in fine detail.

On completion of the full review, the panel will send its final report and recommendations to the directors of nursing group. Once the directors are satisfied that all procedures work in the New Zealand context, the procedures will go live across the Midland region. It is anticipated that this will be in around May 2012.

A business case will also be developed to ensure the long-term sustainability of this product in the original five host DHBs.

Authors:Michael Bland, RGON, BSc (Hons), PGDipHEd, MPhil – Waikato DHB clinical nurse director and John Clayton, PhD, of Wintec’s Emerging Technologies Centre. Thanks also to Lynda Pryor, Angela Broring, Jeremy FitzPatrick and Sue Hayward for their contributions.