A software development life cycle or SDLC is a project management model that involves several stages to bring a project from an idea or concept and turning it into a functional platform (McGonigle & Mastrian, 2017). There are several models for SDLC including a waterfall or linear model, a V-shaped or parallel model, and a spiral model that performs risk management in a circular pattern (Swati, 2021). Despite different models being available to complete a project, each model has similar stages that must be completed for a successful project to be built and launched. The stages involved in this process include planning, design, implementation, and maintenance (Swati, 2021).

When looking at healthcare projects undertaken by companies, it is important to include nurses in each step of the life cycle of project development. Approximately 18 months ago, our facility switched EHR documentation systems. During training, nurses were taught that this new system would simplify documentation and allow for more hands-on patient time, however, in reality, this was not the case. The new EHR system was designed to allow records and documentation to follow a patient for their entire stay starting with the ER triage documentation through their stay in the ICU, medical floor, or surgery. This is a great concept, except, for financial reasons and HIPAA concerns,  not all nurses were given access to all areas of charting. Additionally, if you don’t have access to that area of the chart you can not see the details for that part of the hospital stay. As an ICU nurse, I am not able to see any details from the ER or OR charting such as assessments completed or vitals completed under those flowsheets. In this case, the consequence of not involving a nurse in the design of this product leads to a lack of valuable patient information available for the next level of care.

When considering the life cycle of the design of health systems, it is important to include nurses at each step. Nurses are the primary users of health information systems and as such have a key viewpoint of how systems should work and flow (Zadvinskis et al., 2018). During planning, nurses can be an important voice in identifying what is important and what tools need to be available. It is equally important that nurses be included in the design of tools as they are the ones that use them the most and spend the most time with patients. During implementation, it is important that nurses be involved to ensure a smooth deployment and transition. Lastly, nurses are best able to identify what challenges are being seen and what improvements may be necessary during the maintenance phase of this life cycle. Ideally, input should come from bedside nurses, nurse educators, nurse informatics specialists, and nurse practitioners (or providers) in order to fully identify potential risks and impacts of program design and workflow (Freeman, 2016).

 

Freeman, R. (2016, May 12). How nurses and “non-it” factors can improve the health it experience. Health IT Buzz. https://www.healthit.gov/buzz-blog/health-it/nurses-non-factors-can-improve-health-experience.

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Swati. (2021). What is sdlc (software development life cycle) phases & process. Software Testing Help. https://www.softwaretestinghelp.com/software-development-life-cycle-sdlc/.

Zadvinskis, I. M., Garvey Smith, J., & Yen, P.-Y. (2018). Nurses’ experience with health Information TECHNOLOGY: Longitudinal qualitative study. JMIR Medical Informatics, 6(2). https://doi.org/10.2196/medinform.8734

 

 

sample 2

The Systems Development Life Cycle (SDLC) is pertinent in managing and improving health care today. There are multiple methods such as: The Waterfall Model, Rapid Prototyping or Rapid Application Development, Object-Oriented Systems Development and Dynamic System Development Method. It is important to involve nurses in each stage of the SDLC. There can be multiple consequences that result from not including nurses. First, nurses are working frontline with patients and must use the electronic documentation system day in and day out. They will be the first ones to tell someone when something is not working correctly or there is a glitch that needs to be fixed. Also, important information or critical results can be overlooked or not noted correctly if there is an issue, and the nurses are not heard regarding their concerns. The nursing team can offer suggestions that will help the flow of the system be more beneficial and easier to work with and bring issues to the table that need addressed that could be causing a delay in care or a possible problem in the future (McGonigle & Mastrian, 2018).

While developing each stage of the SDCL, there can be potential issues that result, and nurses being included in this process can help address them before they do become a problem. First, developing a system that comes from understanding the problems or needs an organization must include the nurses’ input. Even though medical directors, senior leadership and technical support staff may have worked the floor before, times have changed and it is important to bring in the nurses currently working on the floor, listen and understand where change needs to take place, recognize the change in patient population and address the acuity level of patients coming in requiring a longer hospital stay. A potential issue that could result in not addressing these issues can result in a nurse shortage, burn out of staff, and increase health care costs. This could result in safety issues for the patients and more medication errors due to patient overload and nursing fatigue. Developing and implementing a plan is a process in itself. There needs to be one issue put on the table at a time, management and staff nurses need to have an understanding as a whole regarding potential issues, develop an action plan, role it out and discuss positive and negatives of what is working or not working in this stage to show improvement in this process and develop success. Once the working phase is done with and new plans have been developed, evaluation, maintenance, review, and destruction take place. This stage is important when it comes to involving nurses because having an organization that listens, care and shows it allows room for these nurses to feel confident in sharing their feed back and offering suggestions and knowing they are supported in a process of change as well. Involving nurses in this process facilitates a smooth transition. It is important nurses learn and understand new technology as well as technology engineers understand how their software will need to be used to benefit nurses in their care for patients (Weckman & Janzen, 2009).

I have been included in the switching of electronic documentation systems at my current place of employment about two years ago. I can say that the process is a lot and luckily, I work for an organization that listens to its nurses and cares about feedback. There were many glitches that needed fixed. We had a team of people that were trained in EPIC (new system) that worked one each unit, every shift for probably about a month. They were hired to help us navigate the system and make tickets that were submitted for review for areas that needed improvement or even things that were missing that we needed to care for patients or document on them. The facility had nurses on each unit sign up as “super users” to get extra training on the system in case there were times/situations we needed more assistance. We advanced from Meditech to EPIC. There are way more flowsheets in EPIC, which makes documentation sometimes difficult. There are rows and columns that can be added under each system to document on, but it is a learning curve for each one. It is one of those things where you won’t know unless you have done it. We also took a lot of verbal/telephone orders from physicians prior to changing systems and the organization did not want us doing that with the new one. It did cause a bit of frustration with the physicians because they were so used to doing it, we received attitude from a few when we asked them to put the orders in. They were supposed to be written up each time, but here we are two years later and taking verbal/telephone orders as we did before. I can say it has gotten better, but it still happens. There are also more nursing protocol orders which helps with having to call the physician over every little thing. Even though the process involves a lot of training, feedback and change, patient care and outcomes has improved. The electronic health record is easily accessible and treatment for the patient is prompter and more efficient (Menachemi & Collum, 2011).

References

McGonigle, D. & Mastrian, K.G. (2018). Nursing Informatics and the foundation of knowledge

(4^th ed.). Chapter 9, “Systems Development Life Cycle: Nursing Informatics and

Organizational Decision Making” (pp. 175-187).

Menachemi, N. & Collum, T. (2011, May 11). Benefits and drawbacks of electronic health

record systems. US National Library of Medicine. https://www.ncbi.nlm.nih.gov/

pmc/articles/PMC3270933/

Weckman, H.  & Janzen, S. (2009, May 31). “The Critical Nature of Early Nursing Involvement

for Introducing New Technologies.” The Online Journal of Issues in Nursing, Vol 14,

No.2, Manuscript 2. DOI:10.3912/OJIN.Vol14No02Man02

 

 

sample 3

The Systems Development Life Cycle (SDLC) can be defined as “a conceptual model used in project management that describes the stages involved in an information system development project, from an initial feasibility study through maintenance of the completed application” (Gillis, 2019).  This week we looked at the critical role that nurses have in this complex process.  As nurses, we are often focused on the well-being of our patients and do not realize the vital role we play in the SDLC cycle when a new EHR is implemented.

Not including nurses in the implementation of a new EHR can prove to be disastrous.  I can speak from firsthand experience as I worked at a hospital that implemented a new and untested EHR that did not receive input from any staff members.  In exchange for agreeing to be the first hospital to implement this new EHR, it was given to the hospital for free.  The hospital rolled out the new EHR, and it was an absolute disaster that they were forced to continue to work with for two years.  Documentation items were missing in multiple places requiring free text charting; charting was redundant in other portions. It was next to impossible to compare daily patient labs, to name a few issues.  Most of these issues would have been pointed out immediately if staff members provided input into the new EHR.

In the planning phase, approval for the project is obtained.  The feasibility of implementing a new EHR needs to be considered, including a plan and schedule. With this being the first part of the implementation, the organization must start the project correctly. One of the most complex parts of the implementation of a new EHR is encouraging staff buy-in.  Aguirre et al. (2019) state that one of the ways to ensure better staff buy-in is to include staff in each step of implementation and to select staff members who are enthusiastic about implementing a new EHR.

Analysis and design are the next steps in the SDLC, and this is when the needs of both the organization and the specific users are reviewed.  At these stages of the SDLC, an assessment is made on what the organization needs, and a design is created.  Nursing input is required for this portion of the SDLC to help the developers understand what nursing needs in terms of system communication.  An EHR is complicated and involves more than just patient documentation.  Nursing needs multiple systems to communicate effectively with each other.  For the EHR to properly work, the system needs to communicate with the lab for bloodwork and other samples, the pharmacy for medications, and other devices such as bedside scanners, blood glucose monitors, and others, to name a few.  A nurse is one of many staff members who need to provide input to ensure a smooth implementation.

Implementation is the next crucial step in the SDLC.  The Office of the National Coordinator for Health Information Technology (2021) recommends that five essential steps are taken to assist with a smooth implementation.  These are identification of fears or misunderstandings by staff, involve all staff members in the process, reinforce the value of each member of the organization, addressing any negative behaviors, and listen to the staff and the feedback they give.  Implementation can be rewarding if each step of the SDLC is correctly performed, but it will still require work.  Nurses can provide support in this stage by being trainers for staff members and providing feedback and input on the new system.  Zadvinskis et al. (2018) found that when nurses provided feedback during the implementation period, adjustments to the EHR were made that eventually allowed more straightforward navigation and quick documentation.

The final stage of the SDLC is post-implementation support. Post-implementation support is vital because it allows the organization to ensure that the new EHR continues to meet the organization’s needs, and it also allows for the enhancement when necessary.  Zadvinskis et al. (2018) state that with post-implementation support and adjustments, nurses who had a negative view of the EHR nine months after implementation eventually reported a more balanced view of the system at 18 months.

Nurses play an essential part in many aspects of an organization.  Nurses provide a large portion of the care the patients receive. Their attitude towards the organization can impact their perception of how much the organization values their input.  By involving nurses and other staff members in each step of the SDLC, the organization is taking a crucial step in ensuring a smooth implementation.

References

Aguirre, R. R., Suarez, O., Fuentes, M., & Sanchez-Gonzalez, M. A. (2019). Electronic Health Record Implementation: A Review of Resources and Tools. Cureus. Published. https://doi.org/10.7759/cureus.5649

Gillis, A. S. (2019, June 21). systems development life cycle (SDLC). SearchSoftwareQuality. https://searchsoftwarequality.techtarget.com/definition/systems-development-life-cycle

The Office of the National Coordinator for Health Information Technology (ONC). (2021). How do I overcome resistance within my organization during electronic health record implementation? | HealthIT.gov. HealthyIT.Gov. https://www.healthit.gov/faq/how-do-i-overcome-resistance-within-my-organization-during-electronic-health-record

Zadvinskis, I. M., Garvey Smith, J., & Yen, P. Y. (2018). Nurses’ Experience With Health Information Technology: Longitudinal Qualitative Study. JMIR Medical Informatics, 6(2), e38. https://doi.org/10.2196/medinform.8734

 

 

 

sample 4

Nurses providing direct patient care should be included from the beginning when new health information technology (HIT) or major changes to current HIT are pursued. While nurse informaticists or nurses working in management are often involved, it is less common for end-users (nurses providing direct care) to be utilized during these projects. According to Wayne (2016), 98% of nurses surveyed said they had never been included in decisions related to electronic health record implementation. When health care organizations do not correctly identify the impact of HIT in current work flows communication among staff worsens, productivity falls, and job satisfaction decreases (Wayne, 2016). Nurses using the HIT while providing patient care can better predict work flow problems and can provide practical suggestions on way to prevent the problems or work around them (Jelec et al., 2016).

According to McGonigle and Mastrian (2018), there are six basic steps in the systems development life cycle (SDLC). Nurses should have a role in each step to improve HIT implementation. Nursing insight can prevent bottlenecks in work flow, reduce costs, and increase buy-in for implementation (Jelec et al., 2016).

1. Understand problem or need
   1. Nurses can provide additional insight into the extent of a problem and how it directly affects workflows and patient care.
2. Determine how to address need
   1. Nurses can offer solutions that would help fix the problem, providing practical and creative ways to solve it.
3. Develop plan
   1. Nurses should be included in any major purchasing decisions for new HIT. As end-users they can easily identify concerns with usability and application during patient care.
4. Implement plan
   1. Nurses should be involved in implementation to help colleagues navigate new HIT and serve as role models for application.
5. Evaluate plan
   1. Nurses can identify positive and negative outcomes of HIT implementation and share this feedback to help find solutions.
6. Maintenance
   1. As end-users, nurses can alert management when issues arise with HIT or recommend possible improvements for future use.

In my nursing career I have never had any input or part in the selection, planning, or implementation of HIT. In a previous role as an RN unit manager, it was very frustrating to be expected to support and train staff related to changes in EHR usage and application when all of the decisions were made at the corporate level. Detailed and accurate nursing documentation is a challenge in skilled nursing facilities because it is required for reimbursement, but nurses are often caring for 15-30 patients at any given time. Corporate management often implemented new pre-set documentation guides without considering the feasibility using them in the middle of medication pass or patient care. For the nurses to access the guides, they had to exit the MAR and enter a separate part of the EHR. This interrupted medication pass and the nurses frequently reported issues toggling back and forth between the sections of the EHR. Management did not acknowledge the barriers and did not understand why the guides were not being utilized.

References

Jelec, K., Sukalic, S., & Friganovic, A. (2016). Nursing and implementation of modern technology. Signa Vitae, 12(1), 23-27. https://doi.org/10.22514/SV121.102016.3

Mcgonigle, D. & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Jones & Bartlett Learning.

Wayne, T. (2016, January 21). Nurses vs EHRs: Why nurses need to be included in EHR planning. Capterra. https://blog.capterra.com/nurses-vs-ehrs-why-nurses-need-to-be-included-in-ehr-planning/

 

 

sample 5

When implementing new health information technology systems in a workplace, it is critical to delve into each aspect of the systems development life cycle (SDLC) to have a successful product and launch. Having a well-rounded and educated team to assist in the development is crucial (McGonigle & Mastrian, 2017). According to the American Nurses Association, clinical nurses should be involved in every aspect of the SDLC of healthcare technology used for patient care (Daly, 2015). If nurses are not involved in all stages of the SDLC, the entire system could be compromised and not work for the needs of the intended employees.

The stages of SDLC are understanding the problems or needs of the workplace, gathering an idea of how to address those problems or needs, creating a plan, implementing, evaluating, and maintaining, reviewing, and destruction (McGonigle & Mastrian, 2017). Without nurses’ input on the needs that this technology can provide, it is difficult to understand what issues need solving. Nurses can explain their workplace needs and ideas on ways to solve these needs that would work best for them in their day-to-day workflow. Nursing staff would be using the health information technology system and therefore should be involved in the implementation process. Once the technology system has been used, nursing staff can evaluate how it functions for their original need and workflow. Without nurses’ input on how the technology is working for them, there is no way of knowing if the technology is effective. Finally, the continued support and input from nursing staff for maintenance, reviewing, and destruction will help evolve the system into the most beneficial and effective system that it could be for the staff using it.

There are constant updates to our electronic medical record (EMR) system at work. Some of these updates do not involve staff nurses, but recently, there has been one where staff nurses were involved in voting to improve workflow. Management came around throughout the week to get each staff nurse’s input on certain ‘pop-up’ reminders they found helpful and least helpful. Their goal was to decrease some of these reminders by getting rid of unhelpful or unimportant ones on our main screens for our unit. There was even an option at the bottom to add one if we did not see it on the list given. I thought this was a great idea and has improved my workflow by decreasing unnecessary clicking and charting. If our staff was not included in this decision, then helpful reminders could have been taken away and negatively impacted our workflow.

By including input from those who use the technology regularly, a worksite can help create a better and more functional system for its employees. A 2011 study found that nurses must have good usability and usefulness for the system in order for nurses to accept the new technology (Carayon et al.). Therefore, healthcare organizations need to continue to optimize the design even after implementation (Carayon et al.).

References

Carayon, P., Cartmill, R., Blosky, M. A., Brown, R., Hackenberg, M., Hoonakker, P., Hundt, A. S., Norfolk, E., Wetterneck, T. B., & Walker, J. M. (2011). ICU nurses’ acceptance of electronic health records. Journal of the American Medical Informatics Association, 18(6), 812–819. https://doi.org/10.1136/amiajnl-2010-000018

Daly, P. (2015). Clinical nurses lead the charge with EHR. Nursing, 45(10), 25–26. https://doi.org/10.1097/01.nurse.0000471426.47075.d2

McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4^th ed.). Burlington, MA: Jones & Bartlett Learning