1
Nurses and Informatics
We have entered the information age. Home computers, laptops, handheld computers, and iPODs are pervasive. Banks and stock markets move and track billions of dollars around the world every day through information systems. Factories and stores buy, build, sell, and account for the products in our lives through information systems. In schools, computers are being used as teaching tools and as instructional resources for students in such varied disciplines as astronomy, Chinese, and chemistry. The airline industry uses information systems to book seats, calculate loads, order meals, determine flight plans, determine fuel requirements, and even fly the planes and control air traffic.
The information age has not left the health industry untouched. Mov- ing beyond standard data processing for administrative functions common to all organizations such as human resources, payroll, and financial infor- mation systems now play an important role in patient care by interpret- ing electrocardiograms, scheduling, entering orders, reporting results, and preventing drug interactions (by cross-referencing drug compatibility and warning appropriate staff). We are beginning to see the advent of life- time electronic health records in many countries. In addition, informa- tion systems are now being more widely used in support of population health and public health activities related to health protection (e.g., im- munization), health promotion (e.g., well baby clinics), disease prevention (e.g., smoking cessation or needle exchange programs), and health mon- itoring or surveillance (e.g., restaurant inspection or air quality monitor- ing).
Nurses have always had a major communication role at the interface between the patient/client and the health system. This role is now labeled information management, and nurses are increasingly using information sys- tems to assist them to fulfill this role in clinical practice, administration, research, and education. Before attempting to talk about the role of nurs- ing in informatics, let us first establish definitions of nursing and “nursing informatics.”
3
What Is Nursing?
Nursing is emerging as a professional practice discipline. Based on the work of theorists, nursing practitioners see its goals as the promotion of adapta- tion in health and illness and the facilitation of achievement of the highest possible individual state of health (Rogers, 1970; Roy, 1976). These early theoretical models have provided the impetus for the development of cur- rent approaches to the classification of phenomena of concern to nursing care (see Chapter 12 for a detailed discussion of nursing classification and nomenclature systems).
The practitioner of nursing has many roles and responsibilities. Among these roles are those of an interface between the client and the healthcare system and that of client advocate in the healthcare system. Nursing functions can be considered under three major categories.
rManagerial, which includes establishing nursing care plans, keeping charts, transcribing orders and requisitions, and scheduling patient appointments for diagnostic procedures or therapy
rDelegated tasks, which include physical treatments and administration of medications under the direction of a physician
rAutonomous nursing functions, which include interpersonal communica- tion skills, application of the psychological principles of client care, and providing physical care to patients.
It is the third category of nursing activities that is the core of nursing practice. In this category of autonomous activity nurses use their knowledge, skills, judgment, and experience to exercise independent decision making re- lated to the phenomena for which nurses provide care and the nursing inter- ventions that effect those phenomena and influence patient care outcomes.
What Is “Medical/Healthcare Informatics?”
Before we explore the nature of hospital and nursing information systems, we need to review the definitions of health, medical, and nursing informatics.
Francois Gremy of France is widely credited with coining the term infor- matique medical, which was translated into English as medical informatics.
Early on, the term medical informatics was used to describe “those collected informational technologies which concern themselves with the patient care, medical decision making process” (Greenburg, 1975). Another early defini- tion, in the first issue of the Journal of Medical Informatics, proposed that medical informatics was “the complex processing of data by a computer to produce new kinds of information” (Anderson, 1976). As our understanding of this discipline developed, Greenes and Shortliffe (1990) redefined medical informatics as “the field that concerns itself with the cognitive, information processing and communication tasks of medical practice, education, and
research, including the information science and the technology to support these tasks. An intrinsically interdisciplinary field . . . [with] an applied fo- cus, . . . [addressing] a number of fundamental research problems as well as planning and policy issues.” More recently, Shortliffe et al. (2001) defined medical informatics as “the scientific field that deals with biomedical infor- mation, data, and knowledge—their storage, retrieval and optimal use for problem-solving and decision-making.”
One question consistently arose: “Does the word medical refer only to physicians, or does it refer to all healthcare professions?” In the first edition of this book, the premise was that medical referred to all healthcare profes- sions and that a parallel definition of medical informatics might be “those collected informational technologies that concern themselves with the pa- tient care decision-making process performed by healthcare practitioners.”
Thus, because nurses are healthcare practitioners who are involved in the patient care and the decision-making process that uses information cap- tured by and extracted from the information technologies, there clearly was a place for nursing in medical informatics. Increasingly, as research was con- ducted and medical informatics evolved, nurses realized there was a discrete body of knowledge related to nursing and the use of informatics. During the early 1990s, other health professions began to explore the use of informatics in their disciplines. Mandil (1989) coined the phrase “health informatics,”
which he defined as the use of information technology (including both hard- ware and software) in combination with information management concepts and methods to support the delivery of healthcare. Thus, health informatics has become the umbrella term encompassing medical, nursing, dental, and pharmacy informatics among others. Health informatics focuses attention on the recipient of care rather than on the discipline of the caregiver.
Nursing’s Early Role in Medical Informatics
The nurse’s early role in medical informatics was that of a consumer. The literature clearly shows the contributions of medical informatics to the prac- tice of nursing and patient care. Early developments in medical informatics and their advantages to nursing have been thoroughly documented (Hannah, 1976; see also Chapter 3, this volume). These initial developments were fragmentary and generally restricted to automating existing functions or activities such as automated charting of nurses’ notes, automated nursing care plans, automated patient monitoring, automated personnel time as- signment, and the gathering of epidemiological and administrative statis- tics. Subsequently, an integrated approach to medical informatics resulted in the development and marketing of sophisticated hospital information systems that included nursing applications or modules. As models of health services delivery have shifted toward integrated care delivery across the entire spectrum of health services, integrated information systems have de- veloped. These enterprise systems provided an integrated clinical record
within a complex integrated healthcare organization. Such systems support evidence-based nursing practice, facilitate nurses’ participation in the health- care team, and document nurses’ contribution to patient care outcomes. They have failed, however, to meet the challenge of providing a nationwide com- prehensive, lifelong, electronic health record that integrates the information generated by all of a person’s contacts with the healthcare system.
Development of Nursing Informatics
Nursing informatics, as originally defined (Hannah, 1985, p. 181) referred to the use of information technologies in relation to those functions within the purview of nursing that are carried out by nurses when performing their duties. Therefore, any use of information technologies by nurses in relation to the care of patients, the administration of healthcare facilities, or the educational preparation of individuals to practice the discipline is considered nursing informatics. For example, nursing informatics would include, but not be limited to the following.
rUse of artificial intelligence or decision-making systems to support the use of the nursing process
rUse of a computer-based scheduling package to allocate staff in a hospital or healthcare organization
rUse of computers for patient education
rUse of computer-assisted learning in nursing education rNursing use of a hospital information system
rResearch related to what information nurses use when making patient care decisions and how those decisions are made
As the field of nursing informatics has evolved, the definition of nursing informatics has been elaborated and refined. Graves and Corcoran (1989) suggested that nursing informatics is “a combination of computer science, information science, and nursing science designed to assist in the manage- ment and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care.” An Expert Panel of the American Nurses Association (2001) promoted nursing informatics as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge 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 and information technology.
In an extensive review and analysis of the evolution of definitions of nurs- ing informatics, Staggers and Thompson (2002, p. 259) concluded that after three decades as a specialty there was still a proliferation of definitions for
nursing informatics. Staggers and Thompson (2002) modified the ANA def- inition and proposed a revised definition of nursing informatics as
a specialty that integrates nursing science, computer science, and information science to manage and communicate 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 pro- cesses and information technology.
Furthermore, Staggers and Thompson (2002, p. 259–260) built on the ANA work to propose that the goal of nursing informatics is
to improve the health of populations, communities, families and individuals by op- timizing information management and communication. This includes the use of in- formation and technology in the direct provision of care, in establishing effective administrative systems, in managing and delivering educational experiences, in sup- porting lifelong learning, and in supporting nursing research.
Impact of Informatics on Nursing
As we mentioned earlier, nursing informatics has moved beyond merely the use of computers and is increasingly referring to the impact of information and information management on the discipline of nursing. Staggers and Thompson (2002) affirmed our long-held position that nurses are “infor- mation integrators at the patient level.” Nurses form the largest group of healthcare professionals in any setting to have a health information system.
Therefore, when providing patient care, nurses make use of information management more often than any other group of healthcare professionals.
(The advantages to the practice of nursing that come from information systems and information management are described in detail in Chapters 7 and 8.)
The nursing profession is recognizing the potential of informatics to im- prove nursing practice and the quality of patient care. New roles are evolv- ing for nurses. The American Nurses Association (2001) recognized nursing informatics as a nursing specialty in 2001. Hospitals and other healthcare organizations are now hiring informatics nurse specialists and informatics nurse consultants to help in the design and implementation of information systems. Nurse educators are using information systems to manage the edu- cational environment. Computer-based information systems are used to in- struct, evaluate, and identify problem areas of specific students; gather data on how each student learns; process data for research purposes; and carry out continued education. Nurse researchers, who have been using comput- erized software for data manipulation for years, are turning their attention to the problems of identifying variables for data sets essential to the diag- nosing of nursing problems, choosing nursing actions, and evaluating patient care. As Figures 1.1 and 1.2 illustrate, there is no doubt that we have reached the information age in nursing. We must now prepare for the full impact of informatics on nursing.
FIGURE1.1. Nursing informatics at the bedside. (Photograph courtesy of Aironet Wireless Communications, Inc.)
FIGURE 1.2. Nursing informatics at the nursing station. (Photograph courtesy of Clinicare Corporation.)
Future Implications
Technology has historically relieved people of backbreaking drudgery and dreary monotony, providing them with more free time to pursue personal relations and creative activities. Nurses, too, when relieved of routine and time-consuming clerical or managerial paper handling chores, can devote more time to the unique problems and needs of individual patients or clients.
Increasingly, across the world, the managerial and clerical paper-handling tasks of nursing are being performed by information systems. In addition, robotics (e.g., lifting and turning patients, delivering medications or meals, and recording temperature, pulse, and other physiological measurements) might assist with the physical care category of nursing tasks. Similarly, deci- sion support systems may actively assist with nursing judgments.
Relieved of routine and less complex chores, the professional nurse hav- ing enhanced information management skills and working in an environ- ment enhanced by information systems will be expected to carry out higher level, more complex activities that cannot be programmed. Nurses are be- ing held responsible and accountable for the systematic planning of holis- tic and humanistic nursing care for patients and their families. Nurses are also increasingly responsible for the continual review and examination of nursing practice (using innovative, continuous quality improvement ap- proaches), as well as applying basic research to finding creative solutions for patient care problems and the development of new models for the de- livery of nursing care. Increasingly, nurses will provide more primary care through community-based programs providing health promotion and early recognition and prevention of illness. Nurses’ role as patient educator is being extended by means of multimedia programs and the Internet. At the same time nurses must assume greater responsibility for assisting the public to become discriminating users of information as they select, sort, interpret, evaluate, and use the vast volumes of facts available across the Internet.
Nurses still must assess, plan, carry out, and evaluate patient care, but ad- vances in the use of information management, information processes, and technology will continue to create a more scientific, complex approach to the nursing care process. They will have to be better equipped by their edu- cation and preparation to have a more inquiring and investigative approach to patient care. Evidence-based nursing practice is becoming the standard.
As information systems assume more routine clerical functions, nurses will have more time for direct patient care. Accordingly, nursing must be part of future developments in nursing informatics with strong input regarding such decisions as the following.
1. Which patient care-related nursing functions could be accomplished by nursing informatics?
2. What information do nurses require to make patient care decisions?
3. What information do caregivers from other health professions require from nursing?
4. To what extent can nursing informatics support improvements in the qual- ity of nursing care received by patients?
5. How can the financial and emotional costs of care to patients be reduced using nursing informatics?
6. What is the impact of nursing on client outcomes?
7. What do nursing interventions contribute to patient outcomes?
The implication is that nursing must continually reassess its status and reward systems. Presently, a nurse gains status and financial reward by moving away from the bedside into supervisory and managerial roles. If more of these coordinating functions are taken over by the computer, nurs- ing must reappraise its value system and reward quality of care at the bedside with prestige and money. Some movement in this direction is al- ready beginning: for example, the movement toward employment of clin- ical nurse specialists prepared at the master’s degree level to work at the bedside. However, currently this movement seems to be too little and too slow.
Summary
The role of the nurse will intensify and diversify with the widespread in- tegration of computer technology and information science into healthcare agencies and institutions. Redefinition, refinement, and modification of the practice of nursing will intensify the nurse’s role in the delivery of patient care. At the same time, nurses will have greater diversity by virtue of em- ployment opportunities in the nursing informatics field.
Nursing’s contributions can and will influence the evolution of healthcare informatics. Nursing will also be influenced by informatics, resulting in a better understanding of our knowledge and a closer link of that knowledge to nursing practice (Turley, 1997). As a profession, nursing must anticipate the expansion and development of nursing informatics. Leadership and di- rection must be provided to ensure that nursing informatics expands and improves the quality of healthcare received by patients within the collabo- rative interdisciplinary venue of health informatics.
References
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