Columbia Univ. Nurses improve medical diagnosis skills with DDSS
Guest blog by Columbia University Medical Center's Rita Marie John, DNP, EdD, CPNP -- Associate Professor of Clinical Nursing, PNP/NNP Program Director
Recognizing that diagnostic errors are a problem for all practitioners, we saw the opportunity to use Isabel Diagnostic Decision Support System (DDSS) to improve the diagnostic skills of Advanced Practice Nurse (APN) students in the Pediatric Nurse Practitioner (PNP) and Family Nurse Practitioner (FNP) programs at Columbia University School of Nursing. While the use of DDSS has been studied in health care providers, the use of decision support among APN students has not been studied.
Study: Nursing Diagnosis Skill at Columbia University: The goals of our study are to evaluate the confidence and diagnostic accuracy of PNP and FNP students over the course of their program, track diagnostic accuracy over the study period, and evaluate differences in diagnostic accuracy between FNP and PNP students in reviewing pediatric cases.
Isabel IDEAS Program at Columbia: This innovative project utilizes a separate program within Isabel called Isabel IDEAS. The IDEAS program uses online cases which are developed based upon actual cases without revealing protected health information. Cases represent three level of diagnostic difficulty: easy, medium, and hard. Experienced PNPs reviewed the cases and critiquee the actual denouement and differential diagnoses generated by Isabel to create a gold standard for diagnostic decision making for each case. Prior to using the Isabel DDSS, students read the cases in IDEAS, document the history and physical exam, enter their differential diagnosis, diagnostic tests, and treatment plan and rate their level of confidence for each case. The student repeats the process of differential diagnosis, diagnostic test, and treatment plan following use of the Isabel DDSS. The denouement of the case is made available to the student after a specified period of time.
Student Diagnosis Results: Students completed a total of 20 cases over two semesters and were graded on their work so that they would take the case generation seriously. In each semester, there was only one student in the PNP program that did not complete all 20 cases. Informally, students have reported that reading the denouement helped them understand diagnostic reasoning. The harder cases posed a challenge to some of the students. In all of the cases, the right diagnosis was obtained by at least one of the students. Students had more difficulties with the two cases that were unusual and had never seen in clinical practice. Students felt that deciding on which differential to list was challenging at times. In some cases, there was no difference between the pre and post Isabel in differential, diagnostics, or plan. This will need to be explored further in a focus group.
We are still in the process of data evaluation and are excited to see what the results will show.