Upon completion of this chapter, the reader will be able to:
Some of the key concepts and terms you will hear in the discipline of nursing informatics (NI) are included here. The professional organizations listed provide the guidelines and standards for NI practice.
What are some of your experiences with informatics at work and in your associate degree program? Have you been involved in an EHR implementation during which you used technology to document patient information? Consider some of the general experiences you have in your current practice environment. Do you use informatics to document in your job role? What is your definition of NI? What you already know from your practice and what you have learned from an associate degree program will provide the answers to these questions, especially if you have been involved with an EHR implementation through which you began to develop informatics skills and an understanding of what informatics is. These considerations may also stimulate curiosity regarding how informatics skills can be developed if you have not had the opportunities to do so yet.
Nursing Informatics, as a new, evolving discipline, is an established specialty within nursing. Its definition is the fundamental element shaping the specialty. The definition guides role description for nurses interested in informatics and recommends components of practice, education, training, and research, and supports the legitimacy of the practice and the general competencies of a nurse who specializes in informatics. The definition is the introductory element shaping documents of national scope for the NI specialty. In addition, the definition is used by funding agencies to outline projects and fund NI efforts, such as the Division of Nursing in the Department of Health and Human Services (DHHS) and the National Institute for Nursing Research (NINR). The profession of nursing was among the first health disciplines to embrace informatics through its recognition of NI as a specialty practice area (Bickford, 2015). In little over two decades, NI has evolved into an expanding body of knowledge, confirming and supporting its relevance and applicability to all domains of nursing (e.g., education, research, practice, information management and technology, administration). The evolution of NI is apparent in the establishment of many higher educational NI programs. Its growth is seen through the development of professional organizations dedicated to NI, as standards and scope of practice are set, and certification is made possible (Anderson & Sensmeier, 2014; Bickford, 2015; HIMSS Nursing Informatics Awareness Task Force, 2007). The Technology Informatics Guiding Education Reform (TIGER; n.d.) project in the United States (Fung, 2016; Schlak & Troseth, 2013; Staggers, Gassert, & Curran, 2001, 2002) has facilitated and promoted NI in practice and in academia to improve and support better overall quality of care for patients. The TIGER initiative began in 2006 as the result of nursing leaders coming together to harness the benefits of EHRs for the nursing profession (Hebda & Czar, 2013). The goals of the TIGER summit were to improve patient care through use of informatics and technology by the healthcare team. The work of the TIGER initiative has produced measurable results in competency implementation and validation (ANA, 2015a). Currently, 21 countries have come together through this initiative TIGER to create international informatics competencies that incorporate evidence-based research and technology that will improve patient care globally. Today, the TIGER initiative is responsible for developing what is known as the Health Information Technology Competencies (HITCOMP) tool, which is used to assess informatics competences on a universal scale. There are a number of different definitions of informatics; the three listed here are the ones most frequently used. The ANA (2015a) defined NI as “the specialty that integrates nursing science with multiple information and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice (pp. 1–2)”. Examples of how these might be used are discussed in the following text. NI supports nurses, consumers, patients, the interprofessional healthcare team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology (IT). The AMIA defines consumer health informatics as “the field devoted to informatics from multiple consumer or patient views. These include patient-focused informatics, health literacy and consumer education” (p. 1). The focus of this type of informatics is different; it emphasizes “information structures and processes that empower consumers to manage their own health—for example health information literacy, consumer-friendly language, personal health records, and Internet-based strategies and resources” (AMIA, 2018, p. 1). Health informatics, defined by the U.S. National Library of Medicine, is “the interdisciplinary study of the design, development, adoption, and application of IT-based innovations in healthcare services delivery, management, and planning (p. 1).” The ANA includes the advancement of outcomes for population heath in their informatics framework (ANA, 2015b, p. 2). When nurses have a degree of informatics proficiency, they are better equipped to manage patients' complex medical data and provide high-quality patient care as well as support consumers, the interprofessional healthcare team, and other stakeholders in their decision-making in all roles and settings to achieve desired outcomes. Nurse informaticists work to advance healthcare as developers of communication and information technologies, researchers, chief nursing officers (CNOs), chief information officers (CIOs), software engineers, implementation consultants, and policy developers. This support is accomplished through the use of information structures, information processes, and IT. Other definitions vary, but, in general, NI is an integration of computer and nursing science to convey “data information, knowledge, and wisdom in nursing practice” (ANA, 2015b, p. 2). Because the use of technology is extensive, every aspect of nursing practice falls within the category of an informatics nurse (IN), regardless of whether she or he has board certification or not (ANA, 2015b).
Many professional organizations realized early on that the integration of computers and other high-tech processes into the practice of healthcare would change how that care is provided today. These organizations provided the first recommendations intended to meet the needs of the high-tech nursing workforce of the future, when they realized they needed to provide improved quality and safety of patient care today, especially through the use of computer technology. Examples of the competencies they identified include computer skills and literacy, informatics knowledge and ability used to organize and collect data to improve practice by all nurses for the sake of patient safety and outcomes of care. Historically, the IOM (2003) identified five core competencies needed by all healthcare care providers. Two of the five specifically define informatics requirements:
In 2008, both the American Association of Colleges of Nursing (AACN) and the National League of Nursing (NLN) emphasized that knowledge and skills in information management and patient care technology (informatics) are critical components in nursing education and accreditation. At this time, many also identified that informatics competencies and skills were seriously lacking in nursing education and practice. The IOM prepared a groundbreaking report, The Future of Nursing: Leading Change, Advancing Health (2010), which looked 10 years to the future of nursing practice and suggested that the nursing workforce of 2020 will primarily be technology based, requiring high-tech informatics skills. This report was driven by the legislation of the Affordable Care Act (ACA, 2010) and its objective to overhaul the healthcare system. The NLN (2015) issued a recent call for further action to prepare students for a technological (informatics) future in healthcare, highlighting a clear need for nursing education “to teach with and about technology (informatics) to better inform healthcare interventions that improve healthcare outcomes and prepare the nursing workforce” (p. 4). You will see the terms informatics nurse (IN) used interchangeably with the term nurse informatisists (NI), depending on their organization's definitions. Both are used in ANA's (2015b) Nursing Informatics: Scope and Standards of Practice Both terms, informatics nurse and nurse informaticist, refer to the nurse who has basic informatics skills, knowledge, and competencies as compared to the informatics nurse specialist (INS), who has at minimum a master's degree and advanced expertise. Jill has been working in a healthcare facility that is still using a paper-based system in which she documents patient information into a paper medical record every day. She has just found out that her facility will start implementing an electronic health system (EHR) system in the next 6 months. She has been told that she will need to start working to develop informatics skills so that she will become more competent when documenting patient information. She is reluctant to do this because the way she has been documenting patient information over the past 10 years is satisfactory and she feels she does not need to learn to use the new electronic medical record (EMR) system. Questions Jill begins to consider:
What would you need to do in order to better understand the value and benefits of the new EHR? You begin to evaluate and discuss the skills you will need to use the new EHR system and ask questions such as:
The IOM (2010) report reviewed how nurses' roles, responsibilities, and educational needs must change to meet the needs of an aging, increasingly diverse population and indicated that the should respond to the more complex, technology-rich healthcare system with the increased use of informatics. One of the key recommendations to come out of the report is the recommendation that by 2020, 80% of practicing nurses should have more education in NI and should achieve an advanced degree, defined as a bachelor of science in nursing (BSN). Based on The Future of Nursing: Leading Change, Advancing Health (IOM, 2010) and focused on transforming the nursing profession, the IOM report was used as a framework to recommend skills and education needed by all nurses in the new high-tech healthcare environment. Today, patient healthcare needs and care have become more complex, yet often nurses' knowledge, skills, and competencies have not kept up with the changes required to provide safe, high-quality, high-tech healthcare. Certain basic competencies suggested include the need for nurses to use technology to:
To achieve an understanding of the informatics skills, knowledge, and competencies required in today's high-tech healthcare environments, the IOM (2010) urged that nurses achieve higher levels of education and educators use newer methods and technology. Further, the report noted that other areas where informatics competencies are needed include workforce planning and policy making based on data collection, both of which require use of technology and computer skills, an essential component of nursing education. The World Health Organization (WHO) also has a number of informatics initiatives in place to help meet its e-Health mandate, which includes the eHealth Technical Advisory Group formed solely to support WHO's work in e-Health (WHO, 2015); the WHO is another organization that recognizes the need for nurses to possess informatics competencies and skills. The NLN (2015) also identified the need to prepare students for technological/digital healthcare through the nursing education “to teach . . . about technology (informatics) to better inform healthcare interventions that improve healthcare outcomes and prepare the nursing workforce” (p. 4). As mentioned, professional organizations recognized the need for and recommended specific competencies all nurses must have in today's high-tech healthcare environment. Other such competencies are discussed later in this chapter. The Quality and Safety Education for Nurses (QSEN) Institute initiative that specifically defines knowledge, skills, and attitudes (KSAs) related to NI is discussed in Box 1.3.
With the rapid evolution of NI, many organizations are beginning to recognize the impact and value NI professionals can have on the quality of patient care, including improved safety. Nurse informaticists impact workflow, facilitate communication between IT and nursing, as well as support more acceptance of clinical systems used in healthcare on a daily basis (Health, Information and Management Systems Society [HIMSS], 2014). A number of organizations have provided guidelines and standards of practice for the discipline of NI. Of these, there are the ANA's (2015b) Nursing Informatics: Scope and Standards of Practice, AACN, Commission on Collegiate Nursing Education (CCNE), the QSEN initiative supported by the Robert Wood Johnson Foundation (RWJF), and the TIGER initiative, to name a few. Regardless of the organizational framework used or regulatory body, all organizations and regulatory agencies are in consensus that there is a need for all nurses to understand these basic guiding principles and have NI knowledge, skills, and competencies in order to practice better, high-quality, safer patient care. The contributions of the different organizations are discussed in the following text. The ANA has developed its own standards and scope of practice for NI. Nursing Informatics: The Scope and Standards of Practice (ANA, 2015b) describe the common performance, level of care, and quality of practice for which nurses are accountable. There are two main levels of standards for NI—the NI standards of practice and the professional performance standards. The Standards of Practice for Nursing Informatics are guidelines for practice that have both general and specific recommendations for the specialty; general recommendations follow the nursing process of assessment, planning, outcome planning, diagnosis, implementation, and evaluation. Standards of Professional Performance for Nursing Informatics speak to the nursing role with regard to ethics, research, education, and resource utilization. An overview of the ANA's (2015b) Nursing Informatics: Scope and Standards of Practice is presented in Box 1.1, which includes the six Standards of Practice and 10 Standards of Professional Performance for Nursing Informatics as defined by the ANA (2015). BOX 1.1 ANA's NURSING INFORMATICS: SCOPE AND STANDARDS OF PRACTICE
In 2006, the AACN convened a taskforce which identified competencies including those for informatics, which should be achieved by professional nurses to achieve high-quality and safe patient care (Box 1.2). An overview of the major competencies were identified in the following areas:
The AACN Essentials needed by nurses that specifically apply to nursing informatics competencies, skills, and knowledge include Essential IV listed in Box 1.2.
The AACN (2008) further defined specific skills needed by the baccalaureate graduate, which are different from the Essentials needed in master of science in nursing and doctor of nursing practice graduate programs:
Each of the Essentials listed above will be discussed in the chapter relevant to chapter content. The CCNE, which falls under the umbrella of the AACN, ensures nursing programs meet a certain set of quality standards. The scope of CCNE includes the accreditation of BSN and NI degree programs. Its purpose is to accredit BSN programs that are in compliance with standards of practice as defined and required by other organizations and to monitor programs' continuous quality-improvement (CQI) efforts. The CCNE recognizes that education plays a key role in nurses being able to build the fundamental knowledge, skills, and competencies necessary to become leaders as well as public advocates for their patients and profession (CCNE, 2017). The overall goal of the QSEN initiative is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to provide high quality safe healthcare (Cronenwett et al., 2007). Gaps were identified in NI knowledge, education, and skills required for nurses to competently use EHRs to provide patient care (Cronenwett et al., 2007; Disch, Barnsteiner, & McGuinn, 2013). This initiative is discussed in subsequent chapters as it applies to their specific content. Based on the IOM recommendations, the QSEN initiative developed NI competencies that closely examine the nursing KSAs needed in BSN programs. Of the six key areas involved in KSA competencies, the most relevant here include quailty improvement, patient safety, and informatics (Bryant, Whitehead, & Kleier, 2016; Guillermo, & Orta, 2016). The KSA definitions for NI as well as sets of KSAs for the informatics competencies that were created for use in nursing prelicensure programs and BSN education programs are listed in Box 1.3. These are suggested as guides for NI curricular development, and allow transition to practice or to other education programs. You will see QSEN KSAs in other chapters as they are integrated into various topics. BOX 1.3 QUALITY AND SAFETY EDUCATION FOR NURSES
SOURCE: Adapted from Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131. doi:10.1016/j.outlook.2007.02.006 You have been asked to explain why information and technology (nursing informatics) skills are essential for the practice of safe patient care. How would you respond?
As discussed previously, NI is the specialty that integrates nursing science with multiple information and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. For many, NI and healthcare informatics are about technology. Queries raised by recent researchers pose the questions—as technology becomes more ubiquitous, is there a need to focus on computer literacy, knowledge, and skills (Skiba, 2017)? Should the focus be on digital literacy? This is particularly true if EHRs are required of all care facilities. Many of these questions will be explored in future chapters of this textbook. Risling (2017) suggested that the pace of technological evolution in healthcare is advancing as discussed previously. Key technological trends that are likely to influence nursing practice and education over the next decade have been discussed by many professional organizations. The complexity of curricular revision will create challenges due to rapid practice change. Nurse educators are encouraged to consider the role of EHRs, wearable technologies, big data and data analytics, and increased patient engagement as key areas for curriculum development. Student nurses, and those already in practice, should be offered ongoing educational opportunities to enhance a wide spectrum of professional informatics skills. A key consideration is that the nurses of 2025 will most certainly inhabit a very different practice environment than the one that exists today and technology will be key in this transformation (Risling, 2017). The ANA's 16 NI standards, which provide a framework for evaluating practice outcomes and goals, are those to which all informatics nurses are held accountable in practice. The set of specific NI competencies accompanying each standard serves as essential evidence of compliance with that standard (ANA, 2015b). The six Standards of Practice for Nursing Informatics are defined in Box 1.4 and include activities demonstrating competency requirements for RNs in their practice area. The ANA textbook, Nursing Informatics: Scope and Standards of Practice, includes details of the many competencies that meet these standards (ANA, 2015b, pp. 68–94). Box 1.5 explores the 10 professional performance competency standards for the nurse informaticist (Box 1.5). The standards identified and the competency examples provided in Boxes 1.4 and 1.5 are the expected, basic NI levels required for BSN nurses. ANA's Nursing Informatics: Scope and Standards of Practice (2015b) also lists competencies expected at the advanced NI level, the INS, for those with an MSN degree. Additional competencies expected of the INS are listed within the same basic standards used for the NI. BOX 1.4 STANDARDS OF PRACTICE FOR NURSING INFORMATICS
BOX 1.5 STANDARDS OF PROFESSIONAL PERFORMANCE FOR NURSING INFORMATICS
The definition, history, and evolution of NI were discussed as were many of the driving forces used to evaluate then provide recommendations to meet the needs of the 2020 and 2030 workforce today. The reason nurses need to develop informatics skills, based on a number of reports, including the very influential IOM (2010) report, was described. To meet this growing need for new skill, the IOM (2010) urged nurses to achieve higher levels of education; the need for education in NI as well as lists of competencies offered by many national nursing organizations were described. The profession of nursing was among the first health disciplines to embrace informatics through the recognition of NI as a specialty practice area. A number of organizations have provided guidelines for the practice and discipline of NI. Of these, there are the ANA Standards and Scope of Practice for Nursing Informatics, AACN, and CCNE, the QSEN initiative supported by RWJF, and the TIGER initiative. Each of these organizations developed standards and competencies required to function at the basic NI level and are provided in detail and include examples of application to practice as the NI.
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When nursing professionals use data, information knowledge and wisdom as a foundational framework to provide care they are working in which nursing role?
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