Designing process-driven information systems in nursing care

Master's Thesis 2005 86 Pages

Computer Science - Commercial Information Technology



1 Introduction and Motivation
1.1 Defining Nursing Care
1.2 Fields of Nursing Care
1.3 Historical Development and Social Changes
1.4 Summary

2 Nursing Care in Process Context
2.1 The Process of Nursing
2.1.1 4-step Nursing Process Model
2.1.2 6-step Nursing Process Model
2.1.3 Nursing Rounds
2.2 Conceptual Models of Nursing
2.2.1 Determining the Need of Care
2.2.2 Structural Hierarchy of Nursing Knowledge
2.2.3 Coping with Differentiation of Nursing Concepts
2.3 Scientific Background and Research
2.3.1 Nursing Science
2.3.2 Evidence-based Nursing
2.3.3 Knowledge Management
2.4 Quality Assurance
2.4.1 Defining Quality of Care
2.4.2 Quality Process and Systematic Approaches
2.4.3 Measuring the Quality of Care
2.5 Summary

3 Architecture for a Process-driven Information System
3.1 Information Systems Modeling and Design
3.1.1 Date and Function Oriented Perspectives
3.1.2 Integrated System Design
3.1.3 Process-oriented Architectures
3.1.4 Information Systems Design for Nursing Care
3.2 Implementation of Workflow Process Systems
3.2.1 Process Automation and Workflows
3.2.2 Workflow Reference Model
3.2.3 Considering Business Rules
3.2.4 Workflow Systems in Nursing Care
3.3 Conceptual Design for Nursing Care Requirements
3.3.1 Vertical Perspective – Stages of the Nursing Process
3.3.2 Horizontal Perspective – Following the Nursing Pathways
3.3.3 Overall Process-oriented Architecture Assessment Module Planning Module Implementation Module Evaluation Module Quality Assurance Module
3.4 Summary

4 Potentials of Implementing the Architecture
4.1 Fall Prevention
4.1.1 Assessment
4.1.2 Planning
4.1.3 Implementation
4.1.4 Evaluation and Quality Assurance
4.2 Pressure Ulcers
4.2.1 Assessment
4.2.2 Planning
4.2.3 Implementation
4.2.4 Evaluation and Quality Assurance
4.3 Further Applications and Potentials

5 Summary and Outlook
List of Figures
List of Tables
List of Acronyms
List of Literature
Statement of Independence

1 Introduction and Motivation

1.1 Defining Nursing Care

Nursing care is a discipline focused on assisting in attaining, recovering to, or maintaining health and functioning. The overall importance and general impact of nursing is described in the definition of the International Council of Nurses (ICN), a federation of national nurses’ associations of more than 120 countries:

“Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. (…)”[1]

Compared to work performed by physicians, it is clearly not the finding of a diagnosis, treating it, and watching the patient’s recovery. Nursing includes the care of sick and well, individuals and groups of people, helping with everything that supports the well-being of people.

With almost everybody having experienced nursing care at some time in life, it is still difficult to describe and often poorly understood. Nursing tends to be reduced to few activities, despite its manifold nature. In 1898, one of the first definitions of nursing was published that is still recognized and applied today:

“I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet--all at the least expense of vital power to the patient.”[2]

The focus on promoting the health and basic needs for living is still found in modern definitions and nursing concepts today. Nevertheless, nursing can also be described in a context of diagnosis and treatment:

“Nursing is the diagnosis and treatment of human responses to actual or potential health problems.”[3]

This definition was published in 1980 by the American Nurses Association (ANA), emphasizing the process-like fashion of nursing along with its reaction to potential problems of the human’s health. The importance of nursing was not recognized for a long time. Although skilled nursing and evidence-based nursing have become widely supported topics, still it is difficult to put into words exactly what difference these concepts make in.

The ANA definition was refined in 2003 to a more concrete statement with six essential features of professional nursing:

- Provision of a caring relationship that facilitates health and healing,
- Attention to the range of human experiences and responses to health and illness within the physical and social environments,
- Integration of objective data with knowledge gained from an appreciation of the patient or group's subjective experience,
- Application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking,
- Advancement of professional nursing knowledge through scholarly inquiry, and
- Influence on social and public policy to promote social justice.”[4]

Definitions of nursing care are tightly linked to the conceptual model and nursing standards applied in the respective context.[5] Hence, the actual definition applied depends on the location, field, and type of care being offered, as well as the perception of the organization and its employees involved.

1.2 Fields of Nursing Care

The tasks involved with nursing depend on the care environment and the patient’s needs. Long-term care, short-term care, at home services, and other environments each define their own mix of services and activities. There is a variety of job profiles and institutional contexts of which several may overlap depending on the perceived needs of clients.[6] Major roles involved with corresponding job titles in the context of nursing care are shown in Figure 1.

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Figure 1: Groups and fields of activity involved with nursing services[7]

Research and knowledge gained in recent years have shown that several professional groups are required to provide appropriate prevention and rehabilitation for the elderly. Next to doctors and nurses, therapists and social education workers, as well as jobs in the field of home economics, are involved with nursing services. Consequently, interdisciplinary management is required to assure appropriate coordination and cooperation.

1.3 Historical Development and Social Changes

For a long time, nursing care was not a discipline on its own. It has its roots in services provided by the church as part of curing people. Later on, nurses have started to serve medicine in curing the sick and caring for patients based on the doctor’s orders. The field has a young history as a discipline on its own. This new awareness has lead to active research and development, making nursing care an independent interdisciplinary field. The future is anticipated to be skilled nursing with qualified education. Evidence-based reasoning towards increased professionalism is likely to demystify nursing and its importance in health care environments.[8]

Within recent years, countries such as Germany, the United Kingdom, and the United States of America have experienced shortage of nursing staff. Providers of care facilities reported having difficulties finding qualified personnel. Next to population growth and aging workforce, improved medical treatments and shortened stays in hospital have increased the demand for nursing. Reasons for the shortage are financial compensation and underestimated influences of changes in the health care system.[9]

Additionally, the field of nursing has to cope with a growing need for care in the first half of the 21st century. Age structures in several Western countries are projected to shift towards a higher percentage of the number of people aged 60 and older. In Germany, the so-called old-age ratio[10] is going to increase from 44 to 78 by 2050. This will result in the group of persons aged 60 and over to be more than twice as big in 2050 (28 million, 37 %) compared to the beginning of the 21st century. This is shown in Figure 2 and Figure 3 below.

The projections described for Germany are similar in the United Kingdom, for example. The UK Government reported in 2003 that the number of people aged 60 and over in the UK will increase by almost 50 per cent to more than 21 million in the year 2050.[11]

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Figure 2: Age structure in Germany 2001[12]

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Figure 3: Age structure in Germany 2050 (projection)[13]

With the change in age structure, the number of people in need of care is projected to increase as well, specifically those suffering from dementia, such as the Alzheimer’s disease.[14] Therefore, the market for senior care services will grow dramatically in Western countries throughout the next 50 years. With this forecasted demand, investors are entering a prolific market to address business opportunities. Based on aforementioned estimations, there is a growing need for care homes as there are too few places available for elderly requiring long term care today.

Sunrise Senior Living, a company operating senior care facilities in several countries, describes the impact of these changes in a company brochure: “Although living longer, it is predicted by the Alzheimer’s Society that as many of 1.4 million of the UK population will suffer from Alzheimer’s and other forms of dementia by 2050”.[15]

1.4 Summary

The field of nursing has to cope with cooperation of several professional groups. It has changed to become its own discipline striving towards professionalism. At the same time, cost increases and healthcare systems financed by inter-generation contracts will have problems coping with future spending. This is further enforced by the shortage of qualified nursing staff experienced today. Moreover, many countries face an increased demand for long-term care of elderly in the next 50 years because of projected changes in age structure.

Hence, next to professionalism, there is a high pressure to come up with possible savings, process optimizations, and systems to provide professional support in work management, process management, decision making, and quality improvement. Providers of care and authorities running one or several senior care facilities have to cope with maintaining quality levels that are centrally defined, even if the communities are regionally separated or located in different countries. The next chapter reviews the major elements and structural approaches of nursing in order to identify base requirements for the design of a suitable information system.

2 Nursing Care in Process Context

2.1 The Process of Nursing

Nursing is often seen as a process with recurring cyclic events, known as the nursing process. The original concept is based on systems theory, cybernetics, and decision theory. Several steps are followed to represent a problem-solving structure integrating the relationship between clients and nurses.[16] In contrast to explicit descriptions of concrete processes, the nursing process can be seen as a template that is applied and followed for each client individually. Although there is general agreement about the order of steps, different models with four, five, and six steps in a nursing process are commonly known.[17]

2.1.1 4-step Nursing Process Model

The main stages comprise the collection of required information and corresponding nursing interventions concerning the individual situation of a person in need of care.

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Figure 4: Patient/client/nurse interaction[18]

One driver for the development of the nursing process was the inadequacy of information about the needs of persons. Assessments provided an important base for a structured problem-solving approach. As illustrated in Figure 4 above, emphasis is laid on the interaction of patient and nurse to assist the client with self-care. At the same time, feedback is collected to improve the quality of care. The World Health Organization (WHO) published a bibliography of the nursing process with four major stages in 1982, combining prior work of several authors and earlier publications. The original nursing process was elaborated starting in the 1960s. The components assessment, planning, implementation, and evaluation are approached interactively to assess outcomes and alternatives. Its cyclic illustration underlines the notion of ongoing examination and ultimate improvement for the patient.[19]

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Figure 5: 4-step nursing process model (WHO)[20]

Each component in the process contains a number of goals and tasks that are indicated in Figure 5, showing the actual representation of the 4-step nursing process.

Out of these, an individual care plan is created, put into place, and its execution is evaluated.[21]

The assessment identifies and prioritizes basic information about the patient. Objectives are established in the second phase to react upon the identified needs, planning nursing interventions and the frequency in which they are to occur. In the implementation phase, actual activities undertaken are described and documented following the care plan of the client. In the last step, evaluations review the interventions and identify the relationship of outcomes to the stated objectives.[22]

2.1.2 6-step Nursing Process Model

With the increasing professionalism in nursing, more importance has been attributed to the tasks performed between assessments and planning. A five-step representation includes standardized problem descriptions representing pre-formulated diagnoses. Contrastingly, the six-step model doesn’t rely on predefined template texts for problems, needs, and resources but considers individual situations to create unique care plans targeted to the client’s needs. Hence, these are usually written out with goals in plain text whereas interventions may be individually defined or based on a general list of services being offered.

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Figure 6: 6-step nursing process model (based on Fiechter/Meier)[23]

These individual descriptions based on earlier assessments demand analytical and communicative skills from nurses, along with social competence. Hence, the six-step representation of the nursing process needs intensive training along with knowledge and experience to create care plans appropriately.[24] This model is favored by the German insurer’s medical advisory board (“Medizinischer Dienst der Krankenkassen”) and serves as the de-facto standard in this country today.

2.1.3 Nursing Rounds

The nursing process guides problem-solving, handling the relationship between patient and nurses, and it comprises decision making which takes place numerous times every day by nursing staff.[25] Evaluations focus on care plans and interventions individually or as a whole, measuring the effectiveness of former objectives and performed activities. Nursing rounds, on the other hand, are performed in larger intervals to measure the quality of care based on the patient’s feedback, review of patient records and documentation, as well as staff discussions.

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Figure 7: Nursing rounds in the center of the nursing process[26]

The role of nursing rounds in the nursing process is illustrated in Figure 7 above. It demonstrates the comprehensive role covering all stages of the recurring care cycle. Other models see the patient in the middle of the overall process and include nursing rounds as a belt around such illustrations. This underlines the importance of external reviews and rounds that carefully consider all steps focused on the patient.[27]

2.2 Conceptual Models of Nursing

The understanding and growing importance of skilled nursing requires conceptual models and agreed philosophies. These help describing and organizing daily work in order to ease the definition and management of the actual tasks to be planned and performed. Since nursing care has become a field of financial impact and a central issue in our society, conceptual models may differentiate between long-term care and the medical perspective of healing and recovering. One important aspect in this regard is determining the need of care and the level of support required to help patients with their basic needs.

2.2.1 Determining the Need of Care

The state of being in need of care is usually caused by illnesses, disabilities, or advanced age. Defining the level of help is often laid down in laws or healthcare regulations such as the Healthcare Structural Reform Act in Germany (“Gesundheitsstrukturgesetz“). The long-term care insurance system (“Pflegeversicherung“) not only defines different levels of care depending on the needs of individuals, but it also provides a general structure that regulates staffing and the percentage of skilled nurses in correspondence with the occupation of care providers.[28]

The methods described in German laws, for example, can only be seen as a cost regulator since the official definition differs significantly from the actual need of care (in terms of quality, intensity, and time required). In Switzerland, for example, each canton employs its own method of measuring the level of care which changes periodically without foreseeable national consensus.[29] Comprehensive reviews of several systems deployed internationally haven’t found reliable definitions of the state of being in need of care. Reason for this dilemma is the difficulty in dealing with the omnipotence of nursing and the lack of a unified terminology. Hence, there is a magnitude of variations, from generalizations up to fine-grained definitions that differ even within one area of research significantly. Both endpoints - theoretical claim and practical application - have not been aligned, nor combined.[30] This situation impacts the design of information systems for nursing care requirements.

2.2.2 Structural Hierarchy of Nursing Knowledge

Conceptual models and theories are very important for the definition and structuring of nursing. They bring in formal presentations of an individual perception, thus they facilitate communication among nurses by being a common denominator for understanding and work organization. Furthermore, such theoretic definitions provide a systematic approach to research, education, administration, and practice. In order to align the different concepts and results of nursing research, Jacqueline Fawcett defined a structural hierarchy of contemporary nursing knowledge. Based on a meta-paradigm as the broadest consensus within a discipline and influenced by different philosophies, several conceptual models provide a distinctive frame of reference, acting as an approximation or simplification of reality.[31]

Each model is comprised of a systematic structure and it provides pragmatic orientation to the service nurses provide to patients. A further distinction in the hierarchy of contemporary nursing knowledge is the level of theories that are based on conceptual models. Theories appear in various degrees of abstraction. Following these, empirical indicators provide the last element in the hierarchy, serving as concrete real world proxies for middle-range theory concepts. They provide the actual instruments and procedures that are used to observe or measure the concepts of theories.[32] Conceptual models and their successors in the hierarchy help to develop and professionalize nursing care. A subjective view and observation of nursing is replaced with a general framework to make decisions and provide services.

By applying such concepts, an explicit reference for professional nursing is given that defines the area of nursing care and puts actions into a specific context for the provider of services. The translation from the structural side to practice is illustrated in Figure 8. Philosophies and conceptual models are building the base orientation for a nursing offering, following generally enforced code of ethics (for example recommended by the ANA) and the patient’s bill of rights. One or several theories comprise the concrete application of care, influencing the way nursing is carried out and activities are performed. The actual implementation aids are provided by empirical indicators that define assessment templates, steer problem identification, and provide layouts for interventions and evaluation criteria.

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Figure 8: Hierarchy of nursing knowledge translated for nursing practice[33]

2.2.3 Coping with Differentiation of Nursing Concepts

There are alternatives to the hierarchical structuring that has been suggested by Jacqueline Fawcett. Conceptual models of nursing and associated theories can also be grouped by their perspective on clients and the way care activities are to be performed. One type of grouping separates concepts into need-based models, relationship-oriented models, and outcome-focused models.[34] Next to Fawcett’s structuring there are other forms of sorting and the benefit of researching such patterns has been questioned. There is general agreement, however, that a globally accepted base definition would ease the transfer of concepts between theory and practice.

Numerous conceptual models and theories have been described and researched thoroughly. While their viewpoint and focus differs in many ways, the overall structure of the nursing process applies to all of them. Hence, conceptual models can be seen as the content provider for the nursing process, or the context in which nursing care takes place. An information system cannot be built based on just one of these concepts if the system is to be used across multiple providers of healthcare services. Nevertheless, if it is supposed to adapt closely to a specific concept, the system has to be developed with standardized structures that are ready to be customized for different deployments.

Next to the theoretical impact of different concepts, models created for subfields have to be distinguished as well – nursing homes take view points and work organizations that are different compared to acute hospitals or outpatient nursing services, for example. Furthermore, national constraints, cultural considerations, and differences in language and understanding lead to diverse deployment of such models. A major type of classification system developed by Monika Krohwinkel with 13 activities and existential experiences of life (“Aktivitäten und existenzielle Erfahrungen des Lebens”, AEDLs), for example, is little recognized internationally but used throughout many senior care offerings in Germany and Austria.[35]

2.3 Scientific Background and Research

In the development of professional nursing care concepts, the demand for research and science is increasing. Today, the practice of nursing is based on the expertise of nurses for the most part, and only a small portion or none at all is performed by applying the results of nursing research. Several examples exist were activities have been performed with good intentions for a long time, that are today known to cause the opposite of healing and recovery, for example when treating pressure ulcers.[36]

2.3.1 Nursing Science

Nursing research in the United States of America goes back to the beginning of the 20th century with the United Kingdom following about 50 years later with first university-based education in nursing. Other countries have just started to recognize nursing science after the 1980s, including Germany. Hence, there are major international differences in the progress of conducting research in this field.[37] The first initiatives focused on clinical issues only and changed to consider all aspects of nursing as a separate area. The application of conceptual models and theories provide a general framework for orientation that needs to be extended by sound scientific findings validating the interventions performed.

In nursing care, four different types of human knowledge can be differentiated that are illustrated in Table 1. Each type is part of the overall knowledge available.

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Table 1: Sources of knowledge in nursing care[38]

Despite the different sources of knowledge, types can be distinguished to find demarcation to adjacent fields of healthcare suggesting a separation into clinical knowledge and other forms (as described in Table 1). Nursing is also considered to be an evolving science, with knowledge about it being dynamic rather than static.[39]

2.3.2 Evidence-based Nursing

The application of scientifically validated knowledge in practice is known as evidence-based nursing (EBN). The method is defined to use currently best available research evidence in the process of nursing. This externally validated experience is applied to individual situations to make decisions about interventions and diagnoses. Evidence-based nursing was first described by Florence Nightingale and is today even mentioned in legal acts and laws.

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Figure 9: Six stages of the EBN method[40]

Applying the EBN method impacts standard nursing processes and changes the way diagnoses and interventions are chosen. Figure 9 demonstrates the steps involved in including external evidence in practice. By identifying a task that is to be carried out (this is the problem definition and goal formulation in the usual nursing process), a question is raised that is to be answered by literature research or other sources. Then follows a critical review of the results and the nursing process continues as usual (with implementation and evaluation phases).[41]

2.3.3 Knowledge Management

This extended step of using researched and validated external evidences to guide the nursing process should not lead to deferring time-critical decisions until all questions have been answered. Furthermore, the seamless availability of literature and other forms of external information is required since even today the daily activities of nurses are performed with lack of time and cost pressures. If knowledge is available in some explicit form, it is a technical and organizational issue to deliver it to the required place. However, tacit knowledge is intangible and tied to individuals, therefore difficult or impossible to transfer; formalize, and communicate. It contains both - cognitive elements and subjective attitudes, namely feelings, values, experiences, intuition, and possibly religious aspects.[42]

A process-driven information system should include interfaces to foster research query and review sources of evidence-based information and knowledge that are to be applied in the context of individual care. Such a system should comprise design principles that stimulate the transfer of knowledge. Once typical nursing issues have been assessed, researched, applied, and documented, the operational system may become an internal source of evidences. Such a knowledge base could provide query capabilities and templates for nursing issues. In turn, this requires measurements of effectiveness to verify the usefulness of the knowledge base’s content. This is not to aim for automated diagnoses but as a contributor to increase the quality of care.

2.4 Quality Assurance

Quality assurance in nursing means that offered services are verified to be outcome-oriented and effective. In the field of nursing with its intricate roles, tasks, and structures, it is important, yet difficult to define and measure the quality of care. Nevertheless, it is an important factor to ensure the effectiveness of activities performed, especially for institutions operating several facilities that adhere to one standardized process description.

2.4.1 Defining Quality of Care

The first definitions of quality in nursing care were proposed by Avedis Donabedian. He defined three aspects that make up the core pillars of quality management in nursing that can be used for descriptions and measurements. The fundament of medical and care related services is comprised of structural aspects such as facilities and equipment. Based on these, the two parameters of process quality and outcome quality influence each other since the assurance of either one is impossible with the other being ignored. The relationship and counter-effect of all three quality components is illustrated in Figure 10.

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Figure 10: Dependency of quality aspects (based on Donabedian)[43]

When considering these aspects in further detail (see Table 2), it can be seen that each requires its own field of attention and the overall quality depends on each part – the surrounding structure, the actual tasks performed, and the results of interventions. Quality can be measured with objective criteria, if these have been defined.[44]

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Table 2: Attributes of quality of care[45]

In order to provide instructions on how activities in practical care are to be carried out, nursing standards are used. They guide professional practice and describe the outcomes necessary for patient well being. Nursing standards have in common that they contain the approach to deliver quality care. The content and structure of these is quite different, depending on the author and context.[46] In some cases, such best practices of nursing are structured following the three aspects of quality that have been defined by Donabedian.


[1] ICN (2005).

[2] Nightingale (1898).

[3] Cf. Halek (2003), p. 9.

[4] ANA (2005).

[5] Cf. Brandenburg/Dorschner (2003), pp. 37 f.

[6] Cf. DGGG (1996), pp. 210 f.

[7] Cf. DGGG (1996), p. 211.

[8] Cf. Juchli (1997), pp. 8 f.

[9] Cf. RCN (2003), p. 5, Honor Society of Nursing (2005), KDA (2001).

[10] Old-age ratio is calculated as the population aged 60 and older / total employment for the age group, i.e. for each 100 persons at working age there are 44 persons at retirement age.

[11] Cf. Government Actuary’s Department (2005).

[12] Federal Statistical Office Germany (2003b).

[13] Federal Statistical Office Germany (2003b).

[14] Cf. Sunrise (w/o y.), Federal Statistical Office Germany (2003a).

[15] Sunrise (w/o y.).

[16] Cf. Brucker et al. (2005), pp. 10 f.

[17] Cf. Dröber/Villwock (2004), pp. 833 f., Brucker et al. (2005), pp. 11 ff.

[18] Cf. Ashworth et al. (1987), p. 35.

[19] Cf. Ashworth et al. (1987), p. 36.

[20] Cf. Dröber/Villwock (2004), p. 833, adapted from Ashworth et al. (1987), p. 37.

[21] Cf. Barth (1999), pp. 87 ff.

[22] Cf. Ashworth et al. (1987), pp. 36 ff., Dröber/Villwock (2004), p. 833, Barth (1999), pp. 87 ff.

[23] Cf. Brucker et al. (2005), p. 13, Dröber/Villwock (2004), p. 834, Juchli (1997), pp. 66 ff.

[24] Cf. Brucker et al. (2005), pp. 12 ff.

[25] Cf. Juchli (1997), pp. 66 ff.

[26] Cf. Gültekin/Liebchen (2003), p. 33.

[27] Cf. Althammer/Noßbach (2004), pp. 39 ff.

[28] Cf. Dröber/Villwock (2004), pp. 827 f.

[29] Cf. Just (2005), pp. 14 f.

[30] Cf. Bartholomeyczik (2004), pp. 11 ff.

[31] Cf. Fawcett (1995), pp. 4 ff.

[32] Cf. Fawcett (1995), pp. 24 ff.

[33] Fawcett (1995), p. 521.

[34] Cf. Brandenburg/Dorschner (2003), pp. 100 ff.

[35] Cf. Bartholomeyczik/Halek (2004), pp. 132 ff., Barth (1999), pp. 68 ff.

[36] Cf. Behrens/Langer (2004), p. 22 ff.

[37] Cf. Mayer (1999), pp. 24 ff., Brandenburg/Dorschner (2003), pp. 44 ff.

[38] Cf. Brandenburg/Dorschner (2003), pp. 41 ff.

[39] Cf. Lanara (2002), p. 14.

[40] Cf. Behrens/Langer (2004), p. 37.

[41] Cf. Haas (2005), pp. 580 ff., Behrens/Langer (2004), pp. 36 ff.

[42] Cf. Krallmann (2003), pp. 2 ff.

[43] Cf. Rudhart-Dyczynski (2003), p. 32.

[44] Cf. Juchli (1997), p. 68.

[45] Cf. Giebing et al. (1999), pp. 18 ff., Dröber/Villwock (2004), p. 896.

[46] Cf. Juchli (1997), pp. 68 ff., Barth (1999), pp. 117 ff.


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Title: Designing process-driven information systems in nursing care