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Abstract
There is no doubt that the care delivery environment has witnessed considerable changes in the last five decades. Amidst these changes, nurses are faced with the challenge of providing safe and competent care. As a result, contemporary nurses needed to be continually informed of any new technologies, medications and developments. In addition, with the increasing number of patients, it is becoming more crucial for nursing personnel to be up-to-date. In response to these changes in the care delivery settings, nursing information systems play a pivotal role in improving the quality of care. In addition, the nursing profession is information-extensive. Like other sectors, the nursing discipline is gradually relying on the use of computers for diverse aspects of their routine tasks such as documentation and developing information database among others. For nurses to have the capability to respond to changes in the care delivery environment, a new specially surfaced referred to Nursing Informatics, which combines information science, computer science and nursing science in managing and communicating knowledge, information and data in the practice of nursing. From the definitions of nursing informatics, the core elements that make up the framework for nursing informatics include nursing science, information science and computer science. Four main roles of nursing personnel in informatics have been identified, which include user liaison, product management, installation of clinical systems, and analysis of systems. Other roles for nursing personnel in informatics include clinical information liaison, nursing informatics educator, data repository specialists, network administrators, nursing informatics consultants and chief information officers. Nursing informatics can be applied in four main areas, which include clinical practice, nursing education, nursing education and nursing research.
Nursing Informatics
Introduction
According to the Canadian Nurses Association (2006), information plays a pivotal role in ensuring best nursing practice and decision-making. A significant proportion of the work performed by nurses entails information such as the development of care plans, analysis of a budget and staffing reports, communication of patient data, and assessment of patients’ healthcare needs. The Canadian Nurses Association considers nurses working environment to be an information intensive working environment. In the last five decades, progress in information technology has resulted in crucial opportunities requiring nursing personnel to be aware of up-to-date information, especially during the decision-making process. For instance, the speed of processing data by computers is constantly increasing, therefore, sophisticated application software are being developed to help in transforming raw data into meaningful information, and that powerful and secure means of communication enable the safe dissemination of information between health professionals and healthcare organizations.
The implementation of information systems in the healthcare environment such as electronic medical records (EHR) can be attributed to advancements in information technology. EHR have been established to enhance the decision-making capabilities of nursing personnel in terms of care delivery through improving the process through which nurses can access a patient information, facilitating data entry, and providing health personnel with electronic access to crucial scientific knowledge (American Nurses Association, 2008). In addition, advancements in information technology have resulted in new roles for nursing personnel, and have highlighted the requirement for all nursing personnel to be more informed regarding health information concepts as well as the technology designed to aid in the management and processing of information. Today, nurses acknowledge the significance of informatics when performing their duties. The word “informatics” comes from the French word informatique, which is discipline of nursing specialization. Nursing informaticians is a term used to refer to nurses who are experts in informatics. There is no doubt that there is an increasing need for all nursing personnel to incorporate informatics competences in their nursing practices (Ball, Hannah, Newbold, & Douglas, 2007).
The prospects of nursing informatics to improve healthcare quality, help in studying clinical problem-solving and improve nursing practice have been noted by several authors. Nevertheless, contrary to other sectors that are information intensive, the healthcare sector has been relatively slow in information technology adoption. Nursing personnel and other healthcare personnel are yet to embrace a culture characterized the acceptance and use of information technology in order to exchange and manage information. As a result, nursing educators and leaders are continually noting the need for suitable hardware and software to help nurses gather and use health information, and experts to help in shaping computer usage in nursing environments (Daniel & Oyetunde, 2013). To this end, current research paper outlines the background and history of nursing informatics, applications of nursing informatics, and nursing informatics competencies.
Background
In the recent past, nursing educators and leaders have highlighted and acknowledge the need for all nursing personnel to be competent in nursing informatics, which involves using information and communications technologies to gather data, generate knowledge aimed at supporting nursing practice (Technology Informatics Guiding Educational Reform, 2007). However, it is imperative to acknowledge that the history of nursing informatics commenced with individual nurses who embarked on the responsibilities of gathering data and generating knowledge when performing their nursing duties. According to Ponchitra (2013), computer technologies were first adopted in medicine during the early 1950s. The 1960s saw the emergence of specialized university departments providing informatics training programs in countries such as Netherlands, Belgium, Germany and France. Ponchitra (2013) also pointed out that medical informatics research units emerged in Poland and the United States during the 1970s. Since then, the goal of the health sector stakeholders in the United States and the European Union has been to develop high-quality health informatics research. It is also imperative to note that the historical development of nursing informatics differs from country to country. For instance, in Canada, healthcare organizations started adopting Hospital Information Systems such as Results Reporting and Order Entry Systems during the mid 1980s (Ponchitra, 2013).
For Daniel and Oyetunde (2013), the history of nursing informatics can be traced using the evolving definitions of nursing information since its inception. According to Daniel and Oyetunde (2013), the American Nurses Association provided a definition of nursing informatics as a form of specialty that seeks to integrate information science, computer science and nursing science to help in identification, collection, processing and management of information and data in order to enhance nursing research, education and administration, and expand nursing knowledge. From this definition, it is apparent the focus on the identification, processing and collection of information. In 2001, the definition provided by the American Nurses Association was updated to make nursing informatics place more emphasis on support for healthcare providers, nursing personnel and patients in decision-making. The definition of nursing informatics was recently expanded to focus on the management and communication of data in order to improve wisdom, knowledge and information in the nursing practice. Basing on the early definitions of nursing informatics, it can be argued that Florence Nightingale pioneered nursing informatics owing to the fact that she collected and analyzed data in order to seek support and make recommendations for appropriate medical and nursing protocols. Nevertheless, basing on recent definitions of nursing informatics, it can be argued that nursing informatics started during the 1960s when computer technologies were first implemented in medicine. During the early 1960s, nurses made use of computer readable punch cards to help them in checking off their patients’ observations. Data stored in these punch cards were later retrieved using computers at the San Jose Hospital that acted as an electronic repository of patients’ information in the United States. Daniel and Oyetunde (2013) also reported that during 1966, machine-readable punch cards were also being used by nurses working at the Institute of Living in Harford during 1966. Despite the fact that information technology was already in use by nursing personnel, the phrase nursing informatics was introduced in the United States during 1980, after which the American Nursing Association affirmed nursing informatics as a form of specialty. Following the mid 1990s, the concept of nursing informatics has witnessed significant expansion. During the early 1990s, nurses in the United States began receiving certifications in nursing informatics, which was occurring at the same time desktop computing and the Internet were witnessing significant advancements (Daniel & Oyetunde, 2013).
In Canada, the 1980s saw an increase in the concerns raised regarding the efficiency and effectiveness of the country’s healthcare system, which resulted in an increased recognition for the need to implement health information systems in order to improve healthcare delivery. The highlighted need for improved information to effectively manage healthcare led to the establishment of the Canadian Institute for Health Information (CIHI), which had the mandate of providing crucial data and evaluating Canadian healthcare system and Canadians’ health. The evolution of the nursing informatics in Canada can be attributed to the early efforts to implement hospital information systems in healthcare organizations across Canada. With improvements in the hospital information systems, there was an upsurge of specialized nursing information systems in the country. According to Daniel and Oyetunde (2013), the early hospital information systems used in Canada were imported mainly from the United States. Towards the end of the 1980s, most hospitals in Canada had implemented at least one basic information system requiring nursing personnel to enter fundamental data like patient admission profiles and care requirements such as treatment, medication and diet among others.
The member countries of the International Council of Nurses have also formed the International Classification for Nursing Practice (ICNP), which is a universal nursing language system that comprises of the terminology to be used in nursing practice to promote the development of local terms and cross-mapping of existing and local terminologies. Following the approval of nursing informatics as a specialty, several publications, meetings and annual conferences have offered opportunities for networking among nursing informatics and the sharing of expertise and knowledge (Hannah, Ball, & Edwards, 2006).
The historical perspective of nursing informatics can also be looked at in terms of the emergence of the role of nursing informatics specialists, especially after the adoption of information systems in hospital settings and immediate realization that such systems were not feasible in the absence of clinical knowledge regarding operations. As a result, hospitals embarked on recruiting nurses to offer the clinical-technical link to address the clinical input component of the hospital information systems. For instance, in the United Kingdom, Computer Project Nurses were recruited due to the increase in computer applications in nursing settings. In Canada, nursing did not initiate nursing informatics positions, instead, nursing informatics positions were created to respond to the hospital information system requirements. Hannah, Ball, and Edwards (2006) consider nursing informatics as still growing and yet to reach maturity.
Basics of Nursing Informatics
Dramatic changes have been observed in healthcare delivery settings; as a result, nursing has also not been spared of these dramatic changes. It is expected that healthcare providers should be able to offer competent and safe care in an environment that is increasingly becoming digital and technical. Staggers and Bagley Thompson (2002) asserted that contemporary nurses needed to be continually informed of any new technologies, medications and developments. In addition, with the increasing number of patients, it is becoming more crucial for nursing personnel to be up-to-date. A prevalent theme in the contemporary care environment is the adoption of information technologies and systems with the aim of improving both safety and quality of care. Nurses constitute the largest proportion of healthcare professionals and work in almost all settings involving the provision of patient care, which include emergency care, public health, hospice care, palliative care, long-term care, and out-patient and in-patient settings among others. Besides offering direct nursing services, nursing personnel are also involved in coordination of the care of each patient. Regardless of their duty, whether conducting a research on evidence based approaches, documentation of an assessment or reviewing the health history of a patient, there is no doubt that nurses consume and disseminate information (Schwirian, 2013).
Contemporary nursing primarily entails using the nursing process, which comprises of assessing, diagnosing, planning, implementing and evaluating. According to Ball, Hannah, Newbold, and Douglas (2007), all of these steps in the nursing process require physical interaction with patient and management of patient’s needs. As a result, when working, nurses are either documenting information or looking for information when managing a patient’s needs. As a result, Ball et al. (2007) pointed out that information management is almost existent in every activity performed by nurses. Like other sectors, the nursing discipline is gradually relying on the use of computers for diverse aspects of their routine tasks such as documentation and developing information database among others. For nurses to have the capability to respond to changes in the care delivery environment, a new specially surfaced referred to Nursing Informatics, which combines information science, computer science and nursing science in managing and communicating knowledge, information and data in the practice of nursing. The emphasis of nursing informatics is on the manner in which nurses organize data and knowledge to help in nursing research, practice and management; as a result, nursing informatics is a crucial quality tool for modern day nursing practice (Staggers & Bagley Thompson, 2002).
The concept of nursing informatics surfaced during the last two decades in order to help nursing personnel to optimally utilize information technology to enhance healthcare delivery. As mentioned before, nursing informatics is considered a type of specialty that combined information science, computer science and nursing science in order to help in data management and communication, knowledge and information in the practice of nursing. As a result, nursing informatics plays a significant role in facilitating integration of knowledge, information and data to assist nurse, patients and providers in their decision making process, which is facilitated using information technology, information processes and information structures. Daniel and Oyetunde (2013) viewed this definition of nursing informatics as a review of numerous definitions of nursing informatics owing to the fact that there is no single definition. From this definition, two things are apparent. First, nursing informatics integrates several disciplines (multidisciplinary). Second, nursing informatics is not the same as informatics in general in the sense that it is only applicable in nursing and nursing practice due to the incorporation of the nursing science component. In addition, nursing informatics does not only involve the use of computers, instead, the focus is on the computer processes that involve knowledge, information and data and how to ensure that the processes can result in the best nursing practice. Basing on the definition provided by the American Nurses Association, the transformation of data to information and knowledge is shown in the figure 1 below. In addition, the American Nurses Association (2008) also listed the five main component standards associated with the role of nursing informatics, which include identification of problem, identification of alternative solutions, development of alternative solutions, implementation of the solution, and the evaluation of the solution.


Source: American Nurses Association (2008)
Apart from the definition by the American Nurses Association, other organizations such as the Canadian Nurses Association have also defined nursing informatics as the practice and science that combined nursing, its respective knowledge and information as well as their management with information technologies to help improve the health of communities, families and people globally (Canadian Nurses Association, 2006). The basic principle of nursing informatics draws on the notions of knowledge, information and data. Data is defined as raw and discrete observations that are structured or organized. Information is defined as data that has undergone interpretation and is structured and organized in a manner that there is a meaning attached to the data. The primary purpose of nursing informatics is to support and improve care delivery by collecting, managing and communicating information regarding a patient. As Anderson and Willson (2008) explain, nursing informatics has the potential of increasing the visibility of nursing contributions in health records and help nursing personnel through offering tools that can support the decision-making process. In the current nursing practice, it is apparent that nurses receive complex information, which they are supposed to synthesize before making decisions related to patient care. Large volumes of information does not simply guarantee improvements in care delivery unless the information is thoughtfully evaluated, structured and presented in methods that are helpful to nurses as well as their practice.
Elements of Nursing Informatics
From the definitions of nursing informatics, the core elements that make up the framework for nursing informatics include nursing science, information science and computer science. Nursing science is defined as the ethical utilization of the knowledge gained using practice, research and education to offer nursing interventions and services with the main aim of maintaining, enhancing or restoring patients’ health, and generating and dissemination nursing knowledge that can be helpful in advancing the nursing profession (American Nurses Association, 2008). It has been proposed that nursing sciences provides the foundation for other sciences in the nursing informatics model. As a result, nursing informatics would be purposeless in the absence of nursing science. In addition, it is apparent that the nursing profession involves the use of vast information. Nursing practice science draws upon the use of information, application of knowledge to solve a problem, and conducting oneself with wisdom. Nurses normally gather information in small pieces, after which they convert the information into meaningful knowledge that can be used in advancing the profession.
According to Daniel and Oyetunde (2013), information science involves studying information including how information is utilized by individuals working within an organization. Information science also entails exploring the use and application of knowledge and information within organizations as well as the interactions between information systems, organizations and people. Daniel and Oyetunde (2013) consider information science as multidisciplinary science that combines the attributes of social sciences, library science, computer science, communication science and cognitive science. Daniel and Oyetunde (2013) also point out that information science focuses mainly on the data input, data processing, information output and feedback.
Computer science refers to an area of engineering that is involved with the study of the theoretical elements of computation and information as well as how they can be applied and implemented in computer systems. According to Daniel and Oyetunde (2013), computer science provides crucial tools that enable nurse acquire and manipulate data, and then synthesize them to form meaningful knowledge for nursing practice. Computer science entails using computer hardware, which comprises of the processing components such as the central processing units, hard disks and chips, output and input devices, and memory. A model for nursing informatics is shown in the figure 2 below.

 

Source: Technology Informatics Guiding Educational Reform (2007)
Nurses’ Roles in Informatics
Four main roles of nursing personnel in informatics have been identified by Daniel and Oyetunde (2013), which include user liaison, product management, installation of clinical systems, and analysis of systems. With regard to user liaison, Daniel and Oyetunde (2013) asserted that the role of a nurse is to install computer information systems as well as interfacing with users and vendor including the top management of a healthcare organization. Regarding product management, the role of nursing personnel in informatics entails continually updating the hospital information system and making sure that one is updated on the recent and emerging developments. Nurses also help in the development of handheld terminals, scheduling systems, nurse staffing systems and decision support systems (DSS). With respect to the installation of clinical systems, the role of a nurse is to work in partnership with a vendor. A nurse can also help in providing training to users of the information system implemented by the healthcare institution, and acts as a link between a vendor and an organization. Regarding their role as system analysis, nurses are placed under the information systems (IS) department to analyze and maintain the system. Daniel and Oyetunde (2013) also outlined additional roles for nursing personnel in informatics, which included clinical information liaison, nursing informatics educator, data repository specialists, network administrators, nursing informatics consultants and chief information officers.
Application of Nursing Informatics
Nursing informatics can be applied in four main areas, which include clinical practice, nursing education, nursing education and nursing research. With respect to clinical practice, nursing informatics can be incorporated in the practice of nursing to help in tasks such as care planning, monitoring of devices, documentation of patients, work lists, easy and quick access to patient information and automatic billing among others (Canadian Nurses Association, 2006). It is imperative to note that this list is not exhaustive and simply outlines the methods through nursing informatics, which can be implemented to assist in nursing practice. With respect to nursing administration, nursing informatics can assist in tasks such as automated scheduling of staff members, using e-mails to enhance communication between various departments within a healthcare institution, facilitating cost and trend analysis for budgeting purposes, and helping in the analysis of results and quality assurance. On nursing education, nursing information systems can be used to facilitate teaching and presentations, provision of web-based nursing training, tele-nursing through interactive video technology, providing computer-assisted instruction, and computerized record documentation. Another potential application of nursing informatics is nursing research. With regard to this, it is imperative to point out that the Cumulative Index to Nursing and Allied Literature commenced during 1940 using a set of index card, after which an online database was launched during 1984. Consequently, it implies that nursing literature search prior to the introduction of online database involved looking for the index card and then trying to locate the hard copy of the article in the library stacks in order to locate relevant publications. However, with nursing information systems, nurse researchers no longer need to go over library stacks since the online database offers access to full-text journals (Canadian Nurses Association, 2006). Daniel and Oyetunde (2013) considered this change as phenomenal. This is because the implementation of standardized languages by the ICNP associated with nursing terms has played a significant role in facilitating the searching process and reducing the time required to locate relevant publications. In addition, Daniel and Oyetunde (2013) pointed out that being able to analyze trends and find aggregated data can enable nurse researchers to look at relatively large populations using diverse databases like MEDLINE, PubMed, and Community Health Information Networks among others. Daniel and Oyetunde (2013) summarized the use of nursing informatics in nursing research to include using knowledge bases through the Internet, retrieving evidence-based practice and computerized search for literature. All these applications play a significant role in easing the process of conducting research.
Competencies in Nursing Informatics
In contemporary nursing, competency in nursing informatics is gradually becoming a mandatory requirement for all registered nurses globally. At present, schools, continuing education and official organizations offering programs aimed at preparing nurses to engage in informatics-related practice are sprouting worldwide. However, there is an increasing demand for practicing nurse administrators, nurse researchers and nurse educators to make sure that the pertinent competencies are fulfilled. According to Ponchitra (2013), nurses with a nursing informatics certification have skills in information systems analysis, design and implementation; they can act as liaisons between informational technology specialists and nursing personnel; and must be certain that the nursing information systems collect accurate clinical information. Three nursing informatics competencies have been outlined by Daniel and Oyetunde (2013), which include information management, information literacy and basic computer literacy. According to Grobe (1989), quoted in Daniel and Oyetunde (2013), three competency levels exist including the user level/ beginner entry, modifier/intermediate level, and innovator/advanced level. Daniel and Oyetunde (2013) further point out that each of these competency levels require skills and knowledge needed to be able to use information and communication technologies in data entry, retrieval and manipulation; combining information in a manner that advance nursing knowledge; and have the capability of interpreting and organizing data and information in a way that it impacts the practice of nursing. In order to have these expertises, the competencies required include technical competencies, utility competencies and leadership competencies. Technical competencies refer to the ability to use technological equipments incorporated in the nursing environment in a knowledgeable and comfortable manner. The American Nurses Association (2008) highlighted the importance of nurses being comfortable and confident when using computers to administer care. Utility competencies entail the capability to use computers and equipment in nursing administration, research, education and practice. Dome of the particular utility competencies in nursing informatics are critical thinking and application of evidence-based practice in a manner that is knowledgeable and comfortable. Leadership competencies are concerned with management and ethics issues associated with the use of computers in nursing administration, research, education and practice. Examples of leadership competencies in nursing informatics include quality assurance when using selected applications, ensuring the confidentiality and privacy of patient information, and accountability among others.
Implications and Conclusion
Nursing informatics has the objective of effectively managing the exploding medical information through management and communication of information aimed at promoting knowledge in the practice of nursing as well as improving care delivery. The underlying purpose of nursing informatics is to make optimal use of technology to ensure availability and accessibility of vital information at the point of care, which in turn increases the effectiveness, efficiency and safety of healthcare. In order for nursing informatics to meet the future needs of the healthcare sector, nursing students, practicing registered nurses, nurse researchers and nurse leaders have to exhibit commitment to professional development and continuing education. Healthcare institutions are tasked with the responsibility of supporting the changing role of nursing information systems. This can be achieved in the future through advancing nursing informatics education programs using partnerships with learning institutions; encouraging the management of healthcare institutions to make sure that practicing registered nurses develop nursing informatics competencies; creating a culture that is supportive of nursing informatics using programs that draw on recognition and rewards, performance assessment and planning, professionals and career development; and conducting research to develop new frameworks and models for the competencies, responsibilities and roles of nursing personnel in nursing information systems.

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