The potential for Nursing Informatics to enhance nursing practice, study clinical problem-solving and ultimately improve the quality of care has been a long-standing expectation (Peterson & Gerden-Jelger, 1988). However, unlike many other information intensive industries, health care has been slow in adopting information technology. The U. S. National Advisory Council notes nurses, like other health care professionals, have yet to develop a culture “to promote acceptance and use of information technologies as basic tools for information management and exchange.
” To begin to address these needs a National Steering Committee was formed with representatives from five key nursing organizations, including the Canadian Association of University Schools of Nursing, Canadian Nurses Association, Registered Nurses Association of British Columbia, Academy of Canadian Executive Nurses, and the Nursing Informatics Special Interest Group of COACH.
A Working Committee was struck to undertake a National Nursing Informatics Project which has four goals: to develop consensus on a definition of Nursing Informatics for Canada; to recommend Nursing Informatics (NI) competencies for entry level nurses and specialists, managers, educators and researchers; to identify curriculum implications and strategies for both basic and continuing nursing education; and to determine priorities for implementing national nursing informatics education strategies.
Following a review of the literature the Working Committee determined that an initial step in developing Nursing Informatics education strategies was to develop a discussion paper and elicit feedback from stakeholders in national nursing organizations, educational institutions and employing agencies. 2. 0Background Nursing leaders and educators have recognized the need for every nurse to participate in Nursing Informatics, that is, the use of information and communications technologies in the collection of data, use of information and generation of knowledge to support nursing practice.
The history of Nursing Informatics began with a few individual nurses taking responsibility as representatives of nursing, but originally with a narrower perspective on the subject. However, it is now recognized by many that advocacy for NI responsibilities must be broad and include every domain and level of nursing practice. The role of Nursing Informatics Specialists began in the early to mid 1980’s as acute care facilities began implementing Hospital Information Systems. These systems included clinical applications (e. g.
order entry and results reporting) and Information Systems (IS) Departments quickly realized they could not implement these systems without some clinical knowledge of operations. Hospitals hired nurses to provide this clinical-technical bridge in response to the need for clinical input. These nurses had a variety of titles such as “Nursing Systems Coordinator,” “Nurse Analyst” and “Nursing Coordinator-Computer Project. ” Initially the NI Specialist role centered around implementation and training nurses to use the technology.
In many institutions this role has now been expanded to include support for all clinical areas, hence a change in title to Clinical Systems Coordinator. Nursing Informatics continues to be seen by many nurses and other health care workers as a purvey of specialists, resulting in relatively few nurses being involved in decisions around how information systems will be used by nurses to support nursing practice. For this reason, a national strategy for NI education should address ways to broaden all nurses’ interest, involvement and competence in Nursing Informatics.
As well it must demonstrate the benefits of this approach to nurses, health information system specialists and administrators. Many promises have been made about the benefits of using information technology (IT), but have frequently not materialized, in part due to the lack of nurse involvement in applications. More sophisticated and powerful information systems are available which have the potential to affect the work of nurses in clinical practice, education, research and administration (including governance and policy making).
Nursing education and involvement with information and communications technologies (ICT) must change to keep pace with the increasing opportunities the technology provides. Nurses, in all domains of practice and at all levels, must be “technology literate” to be able to participate in decision making and evaluation of these systems – systems that should support them in information management, knowledge development and evaluation of new ways of practicing. 3. 0Defining Nursing Informatics A definition for Nursing Informatics (NI) is the starting point for establishing competencies related to informatics education and practice.
Consensus on a definition is required for the NI education project to progress in a coordinated and consolidated fashion. While the history of Nursing Informatics reflects one of specialization, the potential scope for nursing involvement and influence is more extensive than that. The intent of the proposed definition is to convey NI in a broader context, one that is relevant to all domains of practice: Nursing Informatics (NI) is the application of computer science and information science to nursing.
NI promotes the generation, management and processing of relevant data in order to use information and develop knowledge that supports nursing in all practice domains. 4. 0Establishing Nursing Informatics Competencies Evidence-based practice in all practice domains requires competencies in informatics. However, there have been no systematic processes for determining competencies or the education required to meet them. Three levels are proposed on a continuum of Nursing Informatics competencies: 1. Entry level RN/manager/educator/researcher – core NI competencies; 2.
Practicing (more experienced) RN/manager/educator/researcher – intermediate NI competencies; 3. Nursing Informatics Specialists – advanced NI competencies in one or more practice domains. Nurses gather data (e. g. from client assessments) which they then interpret, organize and turn into information about the status and care requirements of the client. This information, combined with information from other clients, is used to build new nursing knowledge about client assessment, status, nursing interventions and outcomes.
The Canadian Nurses Association (CNA) notes that evidence-based decision-making requires the inclusion of data about nursing practice in health information systems (CNA 1998). The CNA policy statement emphasizes the need for data to be analysed and interpreted to become usable information, and that information, to become knowledge, requires synthesis and application in practice; furthermore that competencies must be developed in all these areas through basic and continuing nursing education programs.
Therefore, each competency level includes both knowledge and skills required to: use information and communication technologies to enter, retrieve and manipulate data; interpret and organize data into information to affect nursing practice; and combine information to contribute to knowledge development in nursing. 5. 0Achieving Nursing Informatics Competencies The need to adopt a culture in nursing that promotes acceptance and use of information technology has been identified as an important parallel initiative to establishing Nursing Informatics competencies and educational strategies.
Strategies for achieving NI competencies in the workplace include understanding theory and practice behind adoption of innovations, training, access to resources (e. g. CNA’s plans for a “Virtual Library”), and opportunities for continuing education. Barriers to achieving NI competencies in the workplace include restricted access to training and training systems for nurses and nursing students, few leaders and educators with NI skills, and limited empirical support for the contributions ICT can or will realistically make to nursing and patient outcomes.
6. 0Current Opportunities for Nursing Informatics Education With the increasing potential for IT to influence all domains of nursing, it is imperative to prepare nurses to be knowledgeable participants in the process of selecting, developing, implementing and evaluating information technology and health information systems to produce data, use information and generate knowledge.
There are four potential strategies for providing NI education: undergraduate and diploma nursing programs (integrated into the curriculum or as individual courses) graduate programs (NI specialty or electives); formal continuing education for practicing nurses/NI Certificate Programs non-credit/informal continuing education. No single strategy will adequately prepare all nurses with NI competencies. The emphasis on one strategy over another, and the resulting shifting of resources, requires discussion to develop an overall national NI education strategy.
Factors in a number of areas will influence the success of NI education initiatives, including funding for faculty preparation and innovative projects; policy changes around tenure requirements which recognize development of informatics resources; requiring NI competencies for all graduating nurses; including NI content in all certificate programs in nursing management; lobbying for NI specialists in each provincial nursing association, union and Ministry of Health. Collaborative initiatives have been successful in furthering Nursing Informatics education in a variety of settings.
These include collaboration among: nursing programs to identify the competencies needed and how these might be met; healthcare agencies within a geographic area to provide basic NI education programs for practicing nurses; departments of health care professions within the educational setting to provide core IT skills and resources to all students; educational institutions and industries to develop partnerships as avenues to address infrastructure requirements; faculties campus-wide to provide informatics education through core facilities, training all students in the basic competencies and providing forums for information exchanges (while responsibility for higher level competencies remains with each professional school); vendors, health care organizations and educational facilities to provide training facilities resulting in creative solutions for limited infrastructure budgets; and vendors, consultants, other healthcare professions as well as educational institutions have also been successful in providing access to expertise, hardware and software. Barriers to advances of NI in nursing education including integrating NI into the curriculum includes a need for a nursing culture to promote acceptance and use of information technologies as basic tools for information management and exchange. Barriers occur in three areas:
human resources – lack of time, lack of knowledge, limited faculty preparation technical resources – unsuitable software, limited access to appropriate computer hardware and software and rapid rate of change within the technology industry making it difficult to keep skills and educational materials current system resources – little or no support from administration, financial burden of maintaining and upgrading computers and a lack of funding to develop and present programs, as well as declining financial support for continuing nursing education Workplace constraints also contribute to difficulties in developing NI competencies. For example, nursing workload limits access to existing NI education programs, and few practical learning opportunities exist in the workplace.
Without NI competencies, otherwise skilled and experienced nurses are not able to mentor students and there is limited student access to training facilities and trainers. 7. 0Developing a National Strategy for Addressing Nursing Informatics Education The overall goal of this project is to propose a strategy for addressing Nursing Informatics education in Canada. At this stage of the process the Working Committee aim is to: establish a national definition of Nursing Informatics; proposal core competencies for Canadian nurses; identify Nursing Informatics education opportunities currently available to Canadian nurses; and determine Nursing Informatics education priorities. All of these will be done within the framework of extensive feedback from interested stakeholders.
The question to consider is this: “What difference will it make if Nursing Informatics is not part of the nursing curriculum – today and in the future? ” The CNA Workbook Nursing & Health Information: Toward Consensus on Nursing Care Elements (January 1998) notes: “Nursing … is invisible in most clinical and administrative databases. This invisibility has many consequences such as the following: nursing practice may be described as the practice of others, especially physicians; the costs of nursing care are not differentiated from other costs in the health system; and professional accountability is difficult to demonstrate; … It is important …
for nurses to become knowledgeable about capturing nursing data because health information systems are being developed with the capacity to include nursing information. ” As well, the ability to effectively use the available information and communication technologies contributes to managing data, creating information from that data and ultimately generating knowledge about the practice of nursing. An opportunity to provide feedback on six areas raised in the discussion paper is provided in a separate document, including: 1. Definition of Nursing Informatics 2. Proposed Taxonomy of Nursing Informatics Competencies 3. Current Opportunities for Nursing Informatics Education 4. Key Support Factors in Developing Nursing Informatics Education 5.
Key Barriers in Developing Nursing Informatics Education 6. Developing a National Nursing Informatics Education Plan 1. 0Introduction The potential of Nursing Informatics to enhance nursing practice, study clinical problem-solving and ultimately improve the quality of care has been a long-standing expectation (Peterson & Gerden-Jelger, 1988). However, unlike many other information intensive industries, health care has been slow in adopting IT. Nurses, like other health care professionals, have yet to develop a culture “to promote acceptance and use of information technologies as basic tools for information management and exchange” (National Advisory Council, 1997).
Nursing leaders and educators find themselves with a longstanding need for: -experts to contribute to shaping the use of computers in nursing; -appropriate software and hardware to assist nurses in collecting and utilizing nursing/health information; and -nursing and educational leadership in nursing informatics. To begin to address these needs a National Steering Committee was formed with representatives from five key nursing organizations, including the Academy of Canadian Executive Nurses, Canadian Nurses Association, Canadian Association of University Schools of Nursing, Registered Nurses Association of British Columbia and the Nursing Informatics Special Interest Group of COACH.
A Working Committee was struck to undertake a National Nursing Informatics Project, which has four goals: to develop consensus on a definition of Nursing Informatics for Canada; to recommend Nursing Informatics competencies for entry level nurses, NI specialists, managers, educators and researchers; to identify curriculum implications and strategies for both basic and continuing nursing education; and to determine priorities for implementing national nursing informatics education strategies. In their literature review the Working Committee found limited information about NI competencies and education in Canada. Given their experience, the Committee members felt the U. S. and U. K. literature reflected a situation similar to one in Canadian schools.
For example, a survey of a stratified sample of National League for Nursing accredited diploma, associate, baccalaureate and master programs was conducted to determine the status of computer and information technology in nursing education (Carty & Rosenfeld, 1998). Fifty-five percent of the 347 selected schools responded and all programs were proportionately represented. They noted several key findings: Schools have almost universal access to computers and educational software. However, a majority of schools lacked a coordinated plan for technology implementation and were under-financed for technology and related personnel. In addition, less than one third of the schools addressed nursing informatics (the information of nursing) in the curriculum and only 19 schools indicated that nursing informatics was offered as a separate course. (p. 259)
The Working Committee determined little additional information could be gained at this time by surveying Canadian Nursing schools and faculties to determine current courses and competencies. Alternatively, they agreed a discussion paper outlining the issues would be a valuable first step in defining a national nursing informatics education agenda. The purpose of the discussion paper is to: outline the scope of Nursing Informatics today and in the future as background to the identification of issues; propose a definition for Nursing Informatics; identify informatics competencies for four domains of Nursing; outline basic and continuing education implications of these competencies; solicit feedback from nursing managers, educators and policy makers on the definition, competencies and suggested education strategies.
The long-term intent of the Working Committee is to make recommendations to appropriate National Nursing organizations with respect to developing a National Nursing Informatics Education Strategy. This will include educating nursing students, faculty and practising nurses to meet relevant and necessary competencies. These are essential to fulfill the requirements of data generation, information use and knowledge building today and in the future. The discussion paper is intended as an initial step in this process. A Glossary of Terms is provided to assist the reader in understanding terminology and the context in which terms are used in this document (Appendix A). 2.
0Background 2. 1Introduction Recently nursing leaders and educators have recognized the need for every nurse to participate in nursing informatics, that is, the use of information and communications technologies in the collection of data, use of information and generation of knowledge to support nursing practice. The history of nursing informatics, however began with individual nurses who took on these responsibilities as representatives of nursing. It is important to recognize this history within the context of current advocacy for NI responsibilities in every domain and level of nursing practice. 2. 2History and Role of Nursing Informatics Specialists
In the early to mid 1980’s, Canadian hospitals began implementing Hospital Information Systems (HIS). These systems included clinical applications such as order entry and results reporting that nurses were expected to use. Information Systems (IS) Departments quickly realized that they could not implement these systems without some clinical knowledge of operations. Hospitals hired nurses to provide this clinical-technical bridge in response to the need for clinical input. These nurses had a variety of titles such as “Nursing Systems Coordinator,” “Nurse Analyst” and “Nursing Coordinator-Computer Project. ” Similarly, in the UK, “Computer Project Nurses” were hired as a result of a flurry of computer implementations as Barnett (1995, p.
1317) describes: “A centrally funded resource management program was implemented in 1989. This provided money for hardware and systems in all moderate-sized acute hospitals in the National Health Service. It created a short burst of growth in the number of nurses employed to implement nursing information systems. Many of these “Project Nurses” came into the post with little informatics knowledge or experience. They relied on the commercial companies providing the software and on their IT colleagues within the hospitals for technical advice”. In Canada as well NI positions were not initiated by nursing, but were in response to health system requirements.
Nursing Systems Coordinators (NSC) were either hired in the nursing department, and worked in a joint relationship with IS, or hired directly by the IS department. (Both these reporting relationships had benefits and drawbacks. The location of these positions in the organization continues to reflect a debate around whether NI should be a nursing specialty within the CNA or an informatics specialty within health informatics. ) The role of early Nursing Systems Coordinators (NSC) was not generally one of reflection on the role of computers in nursing, but focused more on implementation and training nurses to use the system. Once massive implementation efforts were completed and the HIS operational, NSC were less in demand.
As well, in response to budget cuts, ongoing training for new employees was often assumed by the Education Department and the NSC position phased out. However, in more recent years clinical expertise is again sought and the position is being reintroduced, but with a broader mandate. The Clinical Systems Coordinator, who is responsible for all clinical systems, may or may not be a nurse. A newer concept of Health Care Informatics Specialist as “a health care professional with direct responsibility for automated information systems within a health care context” represents a recent acceptance of the general need for specialists in this area (Desborough, 1998). A variety of health care professionals may take on these roles, from nurses to physicians, lab technologists and pharmacists.
Desborough notes that Health Care Informatics Specialists may assume a number responsibilities including identifying health care information requirements, assisting with the development and testing of hardware and software, preparing IS documents such as proposals or training manuals, implementing and evaluating IS, training staff and supporting IS operations. Nationally and internationally, NI specialists have sought support from colleagues. Whether NI Specialists belong to a sub-specialty in nursing or health care informatics has not been resolved. For example, in Canada the Nursing Informatics Special Interest Group (NISIG) has been the first and strongest special interest group of COACH. There are also provincial chapters such as the Ontario Nursing Informatics Group, but they maintain a close affiliation with the Canadian Nurses Association. The British Computer Society has five Health Informatics Specialist Groups, with Nursing being one of them.
The US also has a strong group of NI specialists. Annual conferences, meetings and publications have provided opportunities to network, for ongoing education and to share knowledge and expertise. Barnett (1995, p. 1318) concluded that in the UK “it would appear after 20 years of effort, only a small proportion of the nursing and midwifery professions have become active in applying nursing informatics to their field of practice. ” Generally, Nursing Informatics continues to be seen as a purvey of specialists. This means relatively few nurses are involved in decisions around how information systems will be used by nursing to support nursing practice.
For this reason, a National Strategy for NI Education should address ways to broaden all nurses’ interest and involvement in Nursing Informatics as well as demonstrating the benefits of this approach. 2. 3Moving from Technology to Information Technology Promises Not Met… There have been many promises around the benefits of using information technology (IT), but these often do not materialize. For example, a sample of recent promises includes: “Informatics will change the way clinicians understand the information that is available to them” (Turley, 1996). Health care professionals “can make better clinical decisions through effective management of patient care information” (Nagelkirk, et al. 1998). “Nurses and others collect reams of data they can’t access.
Technology can transform that data into information nurses can use to help their patients” (Sibbald, 1998). In a recent case study of the impact of Patient Care Information Systems, nurses noted that using the hospital system did not further the work of nursing (Hebert, 1998b). They felt automating the clerical functions was really a benefit to other departments. Automated information systems have been in place for 10-15 years in some hospitals and many of the benefits predicted for nursing have not materialized. One of the prime selling features for HIS is that nurses and other health care professionals will have more time to spend with patients.
However, nurses in the study reported the opposite often occurs, as documentation requirements are increased and new programs become possible with the introduction of the computer system (Hebert, 1998a). Nurses are also often unaware of any empirical evidence supporting that benefits do occur. In fact, it is not the technology that will bring about these expected changes, but knowledgeable users and developers of the technology that will make the difference. The emphasis must shift from using the technology to facilitating information management and knowledge generation. Activities such as developing critical pathways, performance indicators and outcome evaluation require information.
However, in spite of a strong history of nurses who specialize in Nursing Informatics, there has not been widespread adoption of information technology into the culture of nursing. This is a key impetus for identifying necessary competencies and developing educational strategies to achieve them. More sophisticated and powerful information systems are available… McDonald (1998, p. 9-10) describes the information infrastructure as the nervous system for health care. His eight elements have the potential to affect the work of nurses in clinical practice, education, research and administration (including governance and policy making): 1. Administrative information systems, providing complex operating information on which to base decisions. 2.
Clinical information systems, including the computerized patient record and clinical support systems which provide health professionals with easy access to individual case information as well as a rapidly expanding pool of global clinical knowledge. 3. Telehealth, including teleconsultation, telementoring, etc. uses telecommunications to bridge the distance between consumers and health professionals, or between those professionals and specialists who are not physically present. 4. Population health databases provide executives and policymakers the information they need to increase the health of the population. Researchers can also benefit from access to this kind of information. 5. System coordination provides “nuts-and-bolts” information tools such as geographic information systems (GIS) used to map out health needs in a population, e. g. immunization.
Service delivery that is currently available can be overlaid on the key needs and mismatches between needs and service identified. 6. Educational information systems provide both clinical and non-clinical training for health professionals and consumers. For example, the use of simulation software may improve retention and help people understand complex procedures. 7. Health informatics provides consumers with easy access to personalized information and interactive self-management. Not only do some people have access to information about their health 24 hours a day, seven days a week, they also have decision support. 8. Community networks link consumers with similar problems, or to resources or healthy lifestyle interests.
True healthy communities communications networks, using the tool sets we are developing, will allow users to both measure and influence the social ecology of health at the community level. Nursing education and involvement with ICT must change to keep pace… Nurses in all practice domains and at all levels must be technology literate to be able to participate in decision making and evaluation of systems. As well, this knowledge prepares them to take advantage of opportunities to use information and communications technologies (ICT) to support nursing or envision new ways of doing work. McDonald (1998) describes health system integration in the early 21st century that will offer new opportunities for “Virtual Health Management” through increasing use of the Internet.
There are already many examples of this, such as empowering consumer’s to take active roles in health decision making through on-line and telephone support (e. g. telephone triage pilot study in Victoria, B. C. ). Nursing Informatics Education Projects in the US and Europe… Projects in other countries have already been initiated to address the concerns of nursing leaders and educators around the ability of nursing to shape its own destiny with respect to information systems and the use of ICT. The US National Advisory Council on Nurse Education and Practice (NACNEP) “recognized a need to more adequately prepare the registered nurse workforce to manage information using technology.
” They commissioned a panel of 19 NI experts to consider the current status, future directions and major barriers to reaching full use of cutting edge information technologies, telecommunications, distance learning, data sets and information systems. A nominal group technique was used to identify and prioritize informatics needs. From this process they developed A National Informatics Agenda for Nursing Education and Practice in December 1997. The Nightingale Project in Europe has a different purpose in mind and limits its scope to providing curriculum development for Nursing Informatics. They began the project by reaching a consensus on NI competencies and developing partnerships with users, educators and software developers. Currently they are implementing the curriculum at various pilot sites across Europe and evaluating their success. Need for Nursing Informatics Education in Canada
Canadian Nursing Leaders and Educators have reached similar conclusions on the need for NI education. This national project is part of the process of considering how nurses, now and in the future, can best be prepared to actively participate in the decisions related to using and evaluating information and ICT in their practice, as well as developing new applications which benefit nursing and seeing opportunities for new ways of doing work. While in the past the focus may have been more on using the technology, in all of these areas the preparation of nurses must focus more on producing and using information that supports knowledge generation in nursing. 3. 0Defining Nursing Informatics.
Why Is It Important to Define Nursing Informatics? Understanding the scope of Nursing Informatics (NI) today and in the future provides a background for the identification of issues. The U. S. National Advisory Council on Nurse Education and Practice suggests that the definition of Nursing Informatics is a dynamic one that is “changing to reflect the maturity of the specialty. ” This is true in part because the technology is developing in sophistication and computing power, introducing new opportunities for application. For example, new internet based education tools hold much promise for nurses to support the health care consumer (Desborough, 1999).
However, it remains imperative that the focus for NI be on information and its value to nursing, not the technology. A definition is the starting point for establishing competencies related to informatics education and practice. Consensus on this definition supports the NI education project in moving forward in a coordinated and consolidated fashion. While the history of Nursing Informatics reflects one of specialization, the potential scope for nursing involvement and influence is more extensive than that. The intent of the current definition is to convey NI in a broader context, one that is relevant to all domains of practice. A definition is the starting point for establishing competencies related to informatics education and practice. Co