Chapter 8 by Julie A. Kenney and Ida Androwich Nursing Informatics Roles, Competencies and Skills

Objectives Provide an overview of nursing informatics historical development. Explore the concept of nurses as knowledge workers. Discuss the evolving roles and competencies of nursing informatics practice.

Key Terms Defined Advocate/Policy developer Certification Cognitive Activity Consultant Continuous Learner Core Sciences Advocate/policy developer-A nurse informatics specialist who is key to developing the infrastructure of health policy. Policy development on a local, national, and international level is an integral part of this role. Certification - Validates that a nurse possesses certain skills and knowledge or is competent to complete a task; competence and skill level determined by or based on an external review, assessment, examination or education. Cognitive Activity - any process or task (activity) that involves the capacity to think, reason, imagine and learn. Consultant - A person hired to provide their expert advice, opinions, and recommendations based on their area of expertise. Continuous Learner - Gleans lessons or learns from success as well as failures; constantly searches for information to add to their knowledge base. Core Sciences - Nursing, computer and information sciemces are considered core sciences for nursing informatics (NI); some believe, including the editors of this text, that cognitive science should also be included in the core sciences.

Key Terms Defined Data Data Gatherer Decision support Educator Entrepreneur Data - Raw fact; lacks meaning. Data Gatherer - Direct procurement of raw facts (data); raw fact (data) collector. Decision support - A single recommendation or series of recommendations implying next steps based on care protocols; the computer reminders and alerts to improve the diagnosis and care of a patient including screening for correct drug selection and dosing, medication interactions with other medications, preventive health reminders in areas such as vaccinations, health risk screening and detection and clinical guidelines for patient disease treatment (IOM, 2003). Educator - Sage, leader and/or guide who assists in the process or practice of learning. Entrepreneur -One who assumes the risks of beginning an enterprise or business and accepts responsibility for organizing and managing the organization.

Key Terms Defined Industrial Age Informatics Informatics Innovator Informatics Nurse Specialist Information Industrial Age - Late 18th and early 19th centuries when there were major changes in manufacturing, farming and transportation, inventions and innovations led these changes. Informatics - A specialty that integrates the specialty's science, computer science, and information science to manage and communicate data, information, knowledge and wisdom in a specialty's practice; Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology; “a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge” (Staggers & Thompson, 2002, p. 260); synthesis of nursing science, information science, computer science and cognitive science to facilitate the management of healthcare data for the improvement of patient care and advancement of the nursing profession. Informatics Innovator - Process of making enhancements or improvements; creative, novel and inventive solutions in the informatics specialty. Informatics Nurse Specialist (INS) - An RN with formal, graduate education in the field of informatics or a related field and is considered a specialist in the field of nursing informatics. Information - Data that are interpreted, organized, or structured; data that is processed using knowledge or data made functional through the application of knowledge.

Key Terms Defined Information Age Information User Informatique Interdisciplinary Knowledge Team Knowledge Information Age - At the end of the 20th century, information was easily accessible using computers, networks and Internet. Information User - The person who accesses and makes use of information made available to her/him. Informatique - French term that refers to the computer milieu. Interdisciplinary Knowledge Team - A team composed of members of various disciplines in a health care organization who each contribute their unique knowledge to the team in problem-solving or management situations. Knowledge - The awareness and understanding of a set of information and ways that information can be made useful to support a specific task or arrive at a decision; abounds with others’ thoughts and information; information that is synthesized so that relationships are identified and formalized; understanding that comes through a process of interaction or experience with world around us ; info that has judgment applied to it or meaning extracted from it; processed information that helps to clarify or explain some portion of our environment or world that we can use as a basis for action or upon which we can act; internal process of thinking or cognition; external process of testing, senses, observation, interacting.

Key Terms Defined Knowledge Builder Knowledge User Knowledge Worker Medical Informatics Nursing Informatics Competencies Knowledge Builder - Nurses will transition from knowledge users to knowledge builders when they examine clinical data and trends across groups of patients. These trends are interpreted and compared to current scientific data to determine if this data would improve the nursing knowledge domain. An example of the transition to knowledge builder would be an observation of patients’, diagnosed with chronic high blood pressure, medication compliance rates over a specified time period and then comparing these rates to evidenced based literature to determine if this information would improve the nursing knowledge-base (Snyder-Halpern, et al.). Knowledge User - Individuals or groups who benefit from valuable, viable knowledge. Knowledge Worker - Work with information and generate information and knowledge as a product. Medical Informatics - A specialty that integrates medical science, computer science, cognitive science and information science to manage and communicate data, information, knowledge and wisdom in medical practice; collected informational technologies which affect the medical decisions made regarding patient care (Hannah, Ball, & Edwards, 2006). Nursing Informatics Competencies - Abilities to perform NI tasks.

Key Terms Defined Product Developer Project Manager Researcher Technologist TIGER Initiative Product Developer - Designs, creates and builds a product, for example, a computer program, network and/or system; user that employs productivity software to create a product. Project Manager - Responsible for the success of a project by managing the planning and enactment of the project. Researcher - Conducts research or investigates phenomena. Technologist - Person skilled in the use of technology. TIGER Initiative - They were called the Technology Informatics Guiding Education Reform or TIGER Team. This group determined that “utilizing informatics” was a core competency for all healthcare workers. They also determined that many nurses lack IT skills which limit their ability to access evidenced based information that could be incorporated into their daily practice. This group is currently working on a plan to incorporate informatics courses into all levels of nursing education and then they will look at how to get the information out to practicing nurses who are not currently enrolled in an academic program (TIGER Initiative, 2007). Many of the items identified as lacking in both nursing students and practicing nurses are items that Staggers, et al. (2002) determined to be NI competencies.

What is Nursing Informatics? The origin of informatics How the Health Information and Management Systems Society defines informatics What is nursing informatics? The term informatics was derived from the French term informatique, which means to refer to the computer milieu (Saba, 2001). The Health Information and Management Systems Society (HIMSS) defines informatics as “the discipline concerned with the study of information and manipulation of information via computer-based tools” (2006, p. 44). Graves and Corcoran define NI as a “combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care” (p.227).

What is Nursing Informatics? Nursing Informatics as a science Key components of NI practice The foundation of NI practice The use of computers in the 1950’s The ANA points out that even though NI is based on science, it is an applied science and not a basic science. Graves and Corcoran (1989) and the ANA (2001) both believe that data, information, and knowledge are key components of NI practice. Data, information, knowledge, and the core sciences, when combined, represent the foundation of NI practice. Healthcare began to use computers in the 1950’s.

History How were computers used in the 1950’s? The importance of computers in the 1970’s What emerged in the 1980’s? What affected NI in 1995? Computers, in this era, were typically used in the business office (Saba & McCormick, 2006). In the 1970’s, nursing began to realize the importance of computers to the nursing profession and became involved in the design, purchase, and implementation of information systems (Saba & McCormick). In the 1980’s, medical and nursing informatics specialties emerged. 1995 saw the first certification exam for NI (Saba & McCormick).

History More sophistication post 2000 Telemedicine as a specialty Nursing Informatics rapid growth The post-2000 era saw an unprecedented explosion in the number and sophistication of both computer hardware and software. Telemedicine became possible and was recognized as a specialty in the late 1990’s (Saba & McCormick). NI has experienced rapid growth in the last 40 years which does not appear to be slowing.

The Nurse as a Knowledge Worker The use of data and nursing Data becomes knowledge How nurses use data and knowledge A definition of knowledge It has been established that nurses use data and information. This information is then converted to knowledge. The nurse then acts upon this knowledge by initiating a plan of care, updating an existing one or maintaining status quo. Knowledge can be defined as “the distillation of information that has been collected, classified, organized, integrated, abstracted, and value added” (HIMSS, 2006, p. 49).

The Nurse as a Knowledge Worker How a worker is defined What is a knowledge worker? Who is a knowledge worker? A worker is “one that works especially at manual or industrial labor or with a particular material” (Merriam-Webster, 2007). Drucker (1994) describes a knowledge worker as one who has advanced formal education and is able to apply theoretical and analytical knowledge. The knowledge worker must be a continuous learner and a specialist in a field.

Knowledge Worker Concept More knowledge workers are needed, what are the obstacles? New training is needed Knowledge workers as innovators The need for individuals with multiple disciplines Many industrial workers are finding it more and more difficult to obtain jobs as they do not have the educational base or mind set required of knowledge workers (Drucker). The technologist is no longer trained on the job as were the industrial workers which can cause significant problems for the industrial worker who does not have the education required to transition to a knowledge worker position (Drucker; Sorrels-Jones & Weaver, 1999a). Knowledge workers are innovators and the work they produce is the foundation for organizational sustainability and growth. Knowledge workers are most efficient when they are working in a multi-disciplinary team.

Knowledge Worker Concept Shifting leadership The importance of a well functioning team The danger of a lack of information Leadership will shift and change as the team tackles different parts of the project, with the topic expert taking the lead. A well-functioning team will consistently outperform an individual (Sorrells-Jones & Weaver, 1999b). A key impediment to an effective team is a lack of understanding between team members as well as a lack of respect for each other’s knowledge and experience (Sorrells-Jones & Weaver, 1999a).

Knowledge Worker Concept A change in management to support knowledge workers Earning loyalty from knowledge workers Companies that employ knowledge workers have had to change their management structure to support the knowledge workers. Loyalty is no longer purchased with a paycheck but is earned by giving the knowledge workers the ability to use their knowledge effectively and innovatively (Drucker, 1992).

Knowledge Workers and Healthcare Healthcare’s transition How to accomplish this transition Supporting employees in our age of knowledge Outcomes should be measured by quality instead of quantity Healthcare needs to begin making the transition from the Industrial Age to the Information Age. Healthcare can begin this transition by adopting a new philosophy that recognizes that employees are mature, self-reliant, independent-thinking adults who function as partners in carrying out the work of the organization. Management needs to understand and support the knowledge work and non-knowledge work that is performed daily in healthcare. Organizations must switch from measuring the number of tasks completed to measuring the outcomes obtained by knowledge workers (Sorrells-Jones & Weaver, 1999b).

Nurses as Knowledge Workers A combination in nursing What knowledge workers interpret Non-knowledge workers are needed too What do nurses rely on? Nursing entails a significant amount of knowledge and non-knowledge work. Knowledge work would include such things as interpreting trends in labs and symptoms. Non-knowledge work would include such items as calling the lab to check on lab results or making beds. Nurses rely on their extensive clinical information and specialized knowledge in order to implement and evaluate the processes and outcomes related to patient care.

Nurses as Knowledge Workers Data gatherers Collection and recording Transitions that nurses face What the data gatherer requires Nurses are data gatherers by nature. Nurses collect and record objective clinical data on a daily basis (Snyder-Halpern, et al., 2001). Nurses will transition from knowledge users to knowledge builders when they examine clinical data and trends across groups of patients. The data gatherer requires a system that will capture and store data accurately and reliably and allow the data to be readily accessed.

Nurses as Knowledge Workers What the information-user role requires The knowledge-user role The knowledge-builder role The knowledge needs of nurses The information-user role requires a system that can transform clinical data into a format that allows for easy recognition of patterns and trends. The knowledge-user role is the least supported role and many systems are currently looking at ways to support the nurses in this role. The knowledge-builder role is typically seen in conjunction with the nurse researcher role and quality management roles. The knowledge needs of nurses will continue to improve as the systems improve.

Nursing Challenges The first step is to be recognized as a knowledge worker The road needed to travel is still long In order for nurses to be treated as a knowledge workers, nurses must first be recognized as knowledge workers (Snyder-Halpern, et al., 2001). Nursing still has a long way to go before being accepted as an equal participant in the interdisciplinary knowledge team.

The Nurses Knowledge Needs What is helping the healthcare field? The amount of knowledge nurses deal with What do nurses rely on? Decision support systems Computers, technology, and the informatics fields are assisting healthcare workers in dealing with this information explosion. Nurses deal with a vast amount of information and knowledge every day which they use to care for their patients. Nurses rely on their own knowledge but there are times when this is not adequate and they must access information in order to provide safe patient care. Decision support systems (DSSs) may be incorporated into the EHR.

The Nurses Knowledge Needs One challenge in healthcare Validating the placement of the competencies Looking at identified competencies One challenge, that healthcare is currently facing, is the vast differences in computer literacy and information management skills that healthcare workers possess (McNeil, Elfrink, Beyea, Pierce, & Bickford, 2006). Staggers, Gassert, & Curran (2002) conducted a Delphi Study to validate the placement of the competencies into the correct skill level. Of the 305 original competencies identified, 281 achieved an 80% approval rating for both importance as a competency and for placement in the correct practice level.

Nursing Informatics Specialty Practice NI as a profession Nursing and information systems Nursing and the design of educational materials The revolution of computers and the way patients are cared for NI is an established and ever evolving profession which began when computers were introduced into healthcare (Belanger, 2006). Nursing has been involved in the purchase, design, and implementation of Information Systems (IS) since the 1970’s (Saba & McCormick, 2006). Nursing is involved heavily in the design of educational materials for practicing nurses, student nurses, other healthcare workers, and patients. Computers have revolutionized the way patients access information as well as revolutionized the educational process (Saba).

Nursing Informatics Specialty Practice What does NI represent? NI : A viable and essential nursing specialty Are nurses entering this field on purpose? Helping nurses incorporate this new technology NI is important to nursing and healthcare as it focuses on representing nursing data, information, and knowledge. NI has become a viable and essential nursing specialty with the introduction of computers and the electronic health record (EHR) to healthcare. Nurses who enter this field may have done so by accident because they were comfortable working with computers and their co-workers used them as a resource for computer related questions. Assisting nurses to incorporate this new technology into their daily workflow is one of many challenges that the nurse informatics specialist (NIS) may tackle.

Nursing Informatics Specialty Practice Nurses as project managers The first two graduate NI programs Programs should be researched to see if they include informatics What is the focus of NI as a nursing specialty? Continuing education is important in NI One position that nurses do quite well in is the role of the project manager which is a result of their ability to manage multiple complex situations at one time (HIMSS Nursing Informatics Awareness Task Force). The first two graduate NI programs were introduced at the University of Maryland and the University of Utah in 1989. The first doctoral program was offered in 1991 at the University of Maryland (Duke University School of Nursing, 2007). Local colleges and universities should be researched to see which may have added informatics programs. NI is a nursing specialty that does not focus on direct patient care but instead focuses on how to improve patient care and safety as well as improving the workflow and work processes of nurses and other healthcare workers. Continuing education allows the NIS to improve a process or workflow within the hospital or to change the way a system upgrade is rolled out.

Thought Provoking Questions Hospital C is looking to implement an EHR. It has been suggested that a NIS be hired. This position does not involve direct patient care and the administration is struggling with how to justify the position. How can this position be justified?

Thought Provoking Questions This chapter discusses the fact that nurses are knowledge workers. How does nursing move from measuring the tasks completed to measuring the final outcome of the patient?