Informatics is an established area of specialty practice in nursing. As with all specialty areas, each practicing nurse should have an essential awareness and understanding of its components. The purpose of this activity is to provide the learner with an opportunity to review historical perspectives of nursing informatics, discuss how nursing informatics impacts current bedside nursing practice, and consider the future of nursing informatics.
Nurses may think of informatics as an area that is not “for them”, in the same way some would say, “I could never be a (insert least favorite specialty here) nurse!" This module challenges the reader, the every-day-nurse at the bedside, to push past the thought that nursing informatics is just about computers and not “for them”. A challenge to think about how informatics is a tool in the toolbox for every nurse in the developed world, every day, with every patient encounter.
If bedside nurses were asked to define nursing informatics, a variety of responses would likely follow. Nurses who have been educated within the last 15 years have a general idea of the concept. Nurses who trained 20 to 30 years ago and are still practicing may remember the days of paper charting when within normal limits (WNL) was a taught as a best practice for nursing documentation in the chart by exception era. During this era, one physician reports learning the definition of the abbreviation WNL as, we never looked instead of within normal limits. Many nurses, regardless of the period of their education, may define informatics as primarily related to documentation and computers (Cummin, Gundlapalli, Marray, Park, & Lehmann, 2016).
The Quality and Safety Education in Nursing (QSEN) Institute defines nursing informatics as the “use of information and technology to communicate, manage knowledge, mitigate error, and support decision making” (QSEN, 2019, para 1). The QSEN definition explains why nursing informatics is more than documentation and provides the best rationale for why nursing informatics is more than just another nursing specialty. Communication, managing knowledge, and clinical decision support are worlds apart from the quick nursing note of WNL. Communicating, managing knowledge, and making clinical decisions are bedrocks of each nurse’s scope of practice. These are not areas to be dismissed as a specialty that the nurse may or may not be interested in pursuing (Cummin et al., 2016).
Nursing informatics evolved against the backdrop of the Fourth Industrial Revolution’s impact on healthcare (McMaster, 2018). Before the advent of computer charting, documentation amongst nurses and other healthcare providers was inconsistent between organizations, and often among organizations as well. The exponential growth of technology in the early 2000s provided opportunities for innovative thinkers to find solutions to complex problems in healthcare communication. Health information is the broad field birthed through this period. Nursing, the professionals who work closest to the patient every day, were early adopters of technology when the benefit to the patient was evident (Cummin et al., 2016).
The Centers for Disease Control and Prevention (CDC, 2019) provides an excellent overview of the timeline leading up to the current state of health information in the US. A concerted effort to update government infrastructure led to the American Reinvestment and Recovery Act (ARRA) in 2009, which included language addressing health information management in the Health Information Technology for Economic and Clinical Health (HITECH) Act. The Centers for Medicaid and Medicare, and The Office of the National Coordinator for Health IT (ONC) worked to implement changes to support meaningful use of electronic data in healthcare (CDC, 2019).
Snowdon (2017) authored the Healthcare Information and Management Systems Society’s (HIMSS) white paper calling for transparency in clinically integrated systems on an international level. Snowdon’s work punctuated the mortality statistics related to medical error and cited the Institutes of Medicine (IOM), Canadian, and European Union’s responses to these challenges. Peltonen, Sensmeier, Saranto, Newbold, and Ramírez (2018) provide a historical overview and lessons learned from nursing informatics globally, highlighting similarities and differences, and called for more international collaboration and consistency.
In 2010, the Healthcare Information and Management Systems Society published the Technology Informatics Guiding Education Reform (TIGER) initiative, informatics competencies for the nurse generalist. Ten years later, the three TIGER initiative competencies of primary/basic computer skills, information literacy, and information management are included in pre-licensure education. The third TIGER competency, information management, is the area with the most exponential growth (HIMSS, 2010).
Decades of hard work, legislation, non-profit organizations, professional organizations, and individuals in practice are responsible for the positive effects that are seen at the bedside today. The revolution has not been painless, and it has not been without casualties. Ivory (2019), describes the process as a tug-of-war with technology pulling against patient care.
General Nursing Education
Today, formal training in informatics is part of the required undergraduate curriculum in the United States. The content is typically integrated throughout the curriculum, instead of an individual course at the undergraduate level. The National Council of State Boards of Nursing licensure examination (NCLEX) includes items related to nursing informatics. Peltonen et al. (2018) describe competency requirements at the undergraduate, masters, and doctoral levels for nurses. At the graduate level, individual courses in nursing informatics are standard. Continuing education in practice is not standardized at this time. Borycki, Cummings, Kushniruk, and Saranto (2017) describe the need for health information competencies to improve patient safety and reduce the risk of technology-related errors. Nurses in practice have continuing education opportunities to stay current in nursing informatics trends (Kleib, Simpson, & Rhodes, 2016). Despite the systematic approach to integrating nursing informatics into nursing education, gaps in practice and knowledge are still evident.
Nursing Specialty Development
Nurses may obtain further formal and professional education to obtain specialty status. A nurse may complete a Master of Science in Nursing program with an emphasis in nursing informatics at an accredited university. Additionally, nurses may also complete a Doctorate in Nursing Practice in Informatics. Graduate school is not the only path to a specialized career in nursing informatics. Practicing registered nurses with the experience to meet the eligibility criteria may take a nationally recognized credentialing examination through a professional organization that offers such certifications, such as the American Nurses Credentialing Center (Cummin et al., 2016).
Nurses who specialize in informatics are in high demand in healthcare institutions around the world. Nurse informatics are forward thinkers. Brennan and Bakken (2015) explain the puzzle of big data in nursing. The colloquial saying, "more is better", may not always be true when it comes to healthcare data. While knowing more about a patient's history and the condition assists in developing the patient's plan of care, having reams and reams of data to sift through may slow down the process and delay the genuine care the patient needs. The word panopticon has been used to describe the electronic health data, all-seeing structure recording volumes, and volumes of data (Dillard, 2019).
Society needs individuals who are trained, first and foremost, as a nurse, to embrace the challenges of big data and find ways to manage the knowledge that is available to reduce errors and improve communication as the needs relate to nursing care of the patient. Hussey and Kennedy (2016) connect the specialty of nursing informatics with holistic patient care. An ongoing argument against technology in healthcare is the decrease in person-to-person interaction and the seemingly endless increase in person-to-technology communication. A visitor to a patient in a hospital room may notice a nurse walk into the room, look at the monitors, check the infusion pumps, and silence an alarm all before the nurse speaks to the patient or the visitor. A specialty degree in nursing informatics is not required to deliver holistic, person-centered care. Still, a nurse with a specialty in informatics may be able to collaborate with the design team and the bedside staff to create a way for the nurse the see the patient before the nurse considers the technology (Cummin et al., 2016).
Impact on Patient Safety
Keeping patients safe is an explicit goal of all patient care encounters. With the changes over the last two decades from a paper to an electronic world of healthcare, the debate on patient safety continues. Sewell (2019) emphasizes how big data can be used to prevent deaths. While there are several positive aspects of informatics in healthcare, with every benefit, there is an inherent risk. Borycki et al. (2017) provide a literature review to develop an understanding of the concept of technology-induced errors.
Sewell (2019) provides an overview of several quality measures related to informatics tools available for bedside nursing practice as well as some of the potential risks. Clinical decision support provides nurses and providers with direct support at the point of care. Administering medications with the assistance of an electronic medication administration record (eMAR) decreases the risk of order entry error. The use of technology improves positive patient identification to protect the patient. The risks are often related to the reality of workarounds (Brenan & Bakken, 2015).
Workarounds are unfortunate examples of what happens when technology makes the actual nursing care difficult or nearly impossible to complete within the time demands of concern for the patient. Thus, clinically competent and experienced nurses with advanced training in informatics are needed to design systems and processes that are genuinely workable for nurses at the bedside. Technology is only as safe as the person who uses it. A systems approach to problem-solving is required to eliminate the practice of workarounds. Bedside nurses should know when and how to communicate technical issues and to understand that problems should be addressed with patient safety in mind. This gap between technology advances and expected uses and the actual functionality issues at the bedside create the space for workarounds. The need for workarounds and the feeling that technology is impeding on safe patient care are additional battlegrounds in the tug-of-war (Ivory, 2019).
Research and Innovations
Borycki et al. (2017) describe the nursing informatics researchers and innovators as nurses who utilize informatics and health information theories and work to create new research. These nurses work to interpret and find new, meaningful ways to use big data. Kieft et al. (2017) discuss the need for improvements in nursing terminology to improve the interoperability of data. Language for medical diagnosis and order sets have developed over the last two decades as the diagnoses and orders are now tied directly to billing. Nursing diagnoses and clinical documentation are now directly related to reimbursement. As more nurses become experts in informatics, nursing documentation will continue to move toward a clear standard for terminology.
Ronquillo, Topaz, Pruinelli, Peltonen, and Nibber (2017) list collaboration and integration as a significant theme to consider for nursing informatics. As nurses continue to refine the language of nursing, the ability to integrate the unique perspectives of nurses into the management of information in healthcare will improve. Kim (2019) suggests that some of the best solutions may lie in a shared educational experience. Combining nursing students with engineering students to change perspectives and induce creative solutions. Murphy, Honey, Newbold, Weber, and Wu (2018) propose shared informatics competencies across healthcare disciplines. Nursing informatics innovators see the trends in technology and health and collaborate with other disciplines, even outside healthcare, to find creative solutions to challenges. Nurses have to leverage technology for the best patient care possible.
In summary, nursing informatics is one of the fastest-growing specialty areas in the profession. Unlike many of the specialty areas of nursing, informatics is used habitually by every nurse in practice with every patient encounter in the developed world where technology is present. Nurses, regardless of the level of education, use this technology to improve communication and patient safety. Nurses can obtain advanced degrees in informatics as well as earn specialty credentials. The history of nursing informatics is grounded in what some have called the Fourth Industrial Revolution. Sweeping changes following the American Reinvestment and Recovery Act in 2009 in the United States propelled the development of informatics in healthcare as well as competencies required.
Future research and trends focus on the meaningful use of the volumes of big data available for patient health as well as finding ways to mitigate the risk of technology-induced errors (Westra et al., 2017; QSEN, 2019; Brennan & Bakken, 2015). The primary focus of all nursing care is the patient. In the future, nursing informatics innovators will continue to refine processes, connect-the-dots, improve communication, and empower patients by harnessing the momentum of technology in practical and innovative ways.
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