1. Information and Knowledge Needs of Nurses in the 21st Century
Chapter 9 by Lynn M. Nagle
Information and Knowledge Needs of Nurses in the 21st Century

2. Key Terms Defined Clinical information system
Clinical decision support
Evidence-based practice
Nursing informatics
Nursing knowledge
Research utilization
Clinical information system (CIS) - Array or collection of applications and functionality; amalgamation of systems, medical equipment, and technologies working together that are committed or dedicated to collecting, storing and manipulating healthcare data and information and providing secure access to inter-disciplinary clinicians navigating the continuum of cient care; designed to collect patient data in real time to enhance care by providing data at the clinician's fingertips and enabling decision making where it needs to occur, at the bedside; also known as clinical documentation systems.
Clinical decision support (CDS) -A computer based program designed to assist clinicians in making clinical decisions by filtering or integrating vast amounts of information, and providing suggestions for clinical intervention. May also be called a clinical decision support system (CDSS) .
Evidence-based practice (EBP) -Nursing practice that is informed by research generated evidence of best practices. "The conscientious, explicit and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (Ingersoll, 2000, p. 152); integration of clinical expertise and best practices based on systematic research to enhance decision-making and improve patient care; "evidence-based nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences. Three areas of research competence are: interpreting and using research, evaluating practice, and conducting research” (Simpson, 2004, p. 10).
Nursing informatics (NI) - A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge and wisdom in nursing 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.
Nursing knowledge - A body of facts accumulated over time from experience, education, and research that are used to make nursing decisions. “simultaneously the laws and relationships that exist between the elements that describe the phenomena of concern in nursing (factual knowledge) and the laws or rules that the nurse uses to combine the facts to make clinical nursing decisions” (Graves & Corcoran, 1989, p. 230).
Research utilization (RU)-The process of moving new understandings generated in research into practice.

3. Informatics Defined Nursing informatics has evolved over the years
Nurses focus their efforts on:
a) articulating
b) identifying
c) determining
While varied and evolving over the years, the most commonly applied definitions of nursing informatics describe it as the intersection of computer, information, and nursing science (Graves and Corcoran, 1989; Staggers & Thompson, 2002).
Nurses in identified informatics roles typically focus their efforts on:
a) articulating meaningful clinical nursing data and information structures that can be codified and processed
b) identifying the information processes associated with nurses’ work
c) determining ways in which information and communication technologies can be most effectively utilized to support the capture, retrieval, and use of data, information, and knowledge.

4. The Goal of Informatics
“Informatics” in a broader sense
Those de-emphasizing “nursing informatics”
Health informatics
The umbrella of “health” informatics
Although already in use for a number of decades, the term “informatics” is typically viewed by the broader nursing community as the use of computers by nurses.
There are some nurse authors beginning to de-emphasize the notion of “nursing informatics” and discussing the role of nurses and their work processes in the context of “health informatics” (Hannah, 1995).
Health informatics has been described as “knowledge of health services delivery, technology, applications, information, methodologies, and data management processes” (Kathryn Hannah cited in Thede, 2006).
The umbrella of “health” informatics suggests that the informatics work being done by nurses must fit within the context of the “whole system”.

5. The Goal of Informatics
More timely access to data
Healthcare delivery must be:
a) safer b) knowledge-based
c) cost-effective d) seamless
e) timely
Additional challenges in nursing
The focus of IT in nursing
What is the potential of IT?
More timely access to data and information, clinical and financial, has been identified as a necessity in the climate of 21st century healthcare delivery (Hannah, 1995).
Health service organizations, societies, and governments throughout the industrialized world are obsessed with assuring that healthcare delivery is:
a) safer
b) knowledge-based
c) cost-effective
d) seamless
e) timely
An additional challenge within the nursing profession is the pending human resource crisis and dire projections of imminent shortages.
Nursing’s focus on IT has been elevated as a central means by which nurses can be sufficiently supported in their work environments.
IT has the potential to reduce the waste of valuable nursing resources by reducing the time spent in the “care and feeding” of patient records. Having more time for direct client care that is supported by ready access to information and knowledge translates into the provision of safer, quality care.

6. Nurse – Knowledge Worker
Knowledge workers
Nurses spending time managing and recording clinical information
Supporting nurses
Nurses as informaticians
Nurses have overwhelming contribution power
Nurses definitely fall into the category of knowledge workers.
Studies have identified that depending upon the setting, nurses spend anywhere between 25-50% of their day managing and recording clinical information and seeking knowledge to inform their practice (Gugerty et al, 2007).
As the evidence to support nursing practice continues to be uncovered by researchers and integrated into healthcare delivery, attention must be given to the tools that will afford ready and easy access to same.
It could be suggested that as knowledge workers, nurses are also, albeit unwittingly, informaticians to a large extent.
With the advent of clinical information systems (CIS), specifically electronic documentation and clinical decision support (CDS) applications, every nurse has the capacity to be contributing to the advancement of nursing knowledge on many different levels.

7. Creating Clinical Knowledge
Graves and Corcoran (1989) define nursing knowledge
Capturing multi-faceted data
Adding new dimensions to information
Emerging capabilities in regards to data
Graves and Corcoran (1989) suggest that nursing knowledge is “simultaneously the laws and relationships that exist between the elements that describe the phenomena of concern in nursing (factual knowledge) and the laws or rules that the nurse uses to combine the facts to make clinical nursing decisions” (p. 230).
New technologies have made the capture of multi-faceted data and information possible through the use of technologies like digital imaging (e.g., photography to support wound management).
Now part of the clinical record, such images add a new dimension to the assessment, monitoring and treatment of illness and the maintenance of wellness.
These are but a few of the emerging capabilities that will allow for numerous data inputs to be transposed -- combined, analyzed, and displayed to provide information and views of clinical situations currently not possible in a world dominated by hard copy documentation.

8. Creating Clinical Knowledge
Nurses and the use of knowledge
The genesis of using knowledge
Empirics
Esthetics
Personal
Ethics
Many renowned nurse authors have described the knowledge used by nurses (Benner, 1983; Carper, 1978; Schultz & Meleis, 1988).
Carper’s (1978) landmark paper on the “fundamental patterns of knowing” was the genesis of many subsequent papers and analyses.
Empirics – access to factual knowledge derived from repositories of aggregated clinical research findings and integrated with the CIS.
Esthetics – access to multicultural practices and beliefs.
Personal – access to a personal repository of clinical experiences and reactions.
Ethics – access to standards of ethical practice, but also access to experts in the field of moral reasoning to guide interaction.

9. Creating Clinical Knowledge
Nurses will continue to generate information
As nurses build on this knowledge their practices are affected
There will come a day when all nurses become generators of new knowledge by virtue of CIS that embed “machine learning” and “case-based reasoning” methods within their core functionality.
Based upon the evidence gathered through several studies, we are now aware of the potentially deleterious effects of this practice.

10. Using Clinical Knowledge
Evidence-based practice
Research utilization
Best practice guidelines
The consensus on the adoption of data standards
A potential for a more uniform data is on the horizon
Evidence-based practice (EBP) and research utilization (RU) are concepts which have been widely addressed in the nursing literature.
Best practice guidelines hold much promise for the future, but again in their typical form of paper volumes and oft unsearchable online versions, these resources will not realize significant adoption by an already stressed and stretched nursing workforce.
The profession has been steadily moving towards consensus on the adoption of data standards and recent work suggests that we are achieving significant strides (Bickford & Hunter, 2006; Delaney, 2006).
Consider that as CIS are widely implemented, as standards for nursing documentation and reporting are adopted, and as healthcare IT solutions continue to evolve, the potential to synthesize findings from a variety of methods and world-views becomes much more probable.

11. Clinical Decision Support
Clinical decision support tools
The simplicity of clinical decision support
Clinical decision support (CDS) tools have evolved beyond the previously prevailing notion of accessible reference texts and written resource materials like policies and procedures.
Most available clinical decision support (CDS) for nursing practice, although promising, are simplistic and in early development.

12. Challenges The growth of nurse leaders
Nurse informaticians as advocates
Helping the nurse educator succeed
Mentorship programs
The field of nurse leaders in health informatics has markedly grown in the past two decades.
For several years, nurse informaticians have advocated for the need for all nursing leaders to become knowledgeable and engaged in setting the direction for informatics in the profession (Nagle, 2005; Simpson, 2000).
Identify the informatics education needs of nurse leaders.
Develop mentorship programs for the acquisition of informatics leadership skills.

13. Challenges Getting support from nurse educators Implementation of CIS
Nurses know what they need
Nurses know what is required for success
Assure enrollment of nurse leaders as sponsors for electronic health records initiatives.
Despite many valiant efforts to implement comprehensive CIS throughout North American healthcare settings, there are still many provider organizations with limited online functionality available to nurses.
Over the years, nurses have been on the receiving end of systems which either did not add value to their work or by virtue of poor design, created additional work.
The opportunity to avoid future installations of IT solutions that do nothing to benefit and support the clinical practice of nurses and healthcare teams is upon us now.

14. Challenges Nurses must be involved in the process Nurses should :
be encouraged
demand a standard
be provided with necessary material
It behooves nurses to be engaged in the acquisition, design, implementation and evaluation of CIS to assure the realization of benefits for clinical care and outcomes.
Nurses should:
Be encouraged and supported to participate in the acquisition, design, implementation, and evaluation phases of CIS.
Demand the adoption of IT solutions that support the delivery of safe, quality care.
Be provided with material and people resources to support their acquisition of informatics competencies.

15. Challenges Identify the core of informatics
Nursing informatics as a specialty
Using informatics as a core piece of curriculum
Inter-professional education and informatics
Over the years, numerous efforts have been undertaken to identify the core informatics competencies needed by nurses.
In recognizing nursing informatics as a specialty, the American Nurses Association (2001) has articulated “scope and standards of nursing informatics practice”.
Recent studies of schools of nursing indicate that few basic nursing education programs have embedded the concepts and processes associated with informatics within the core curricula (Carty & Rosenfeld, 1998; Nagle & Clarke, 2004).
The core concepts and competencies of informatics are particularly well suited to a model of inter-professional education.

16. Challenges Will all future graduates be more computer literate?
Being comfortable with a computer is not the only key to success
A presumption is often made that future graduates will be more computer literate than nurses currently in practice.
Although likely true, computer comfort does not equate to an understanding of the facilitative and transformative role that IT will have in the future.

17. A View of the Future Informatics is still new
Technology is still not completely understood
The future of nursing is dependent on informatics
The use and understanding of informatics will be used in all areas of nursing
Overall, it is fair to say that a majority of nurses have yet to embrace the notion of “informatics” and understand its meaning and relevance to their work.
The future holds a landscape yet to be understood as technology evolves with a rapidity and unfolding that is rich with promise and potential peril.
The future of healthcare will be highly dependent upon the use of CIS and CDS to achieve the systems’ global aspirations of safer, quality care for all citizens.
The core concepts and competencies associated with informatics will be embedded in the practice of every nurse, whether administrator, researcher, educator, or practitioner.

18. A View of the Future Opportunities exist for : Further enhancement
Advancing designs
Delivering care
Engaging with others
With the availability of such rich repositories, there will be opportunities to:
Further enhance the training of health professionals;
Advance the design and application of CDS;
Deliver care that is informed by the most current evidence and
Engage with individuals and families in ways yet unimagined.

19. Thought Provoking Questions
1. What are the possibilities to accelerate the generation and uptake of new nursing knowledge? 2. What should be the areas of priority for the advancement of informatics in nursing?