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Nursing Informatics Education:
Past, Present, and Future
With contributions by Susan K. Newbold, Jo Ann Klein, and Judith V. Douglas
Today’s healthcare environment continually places increasing demands on nurses to communicate, share data, and synthesize information through the use of information systems, with or without the assistance of computers (Chapman et al., 1994; Ngin and Simms, 1996). In addition to having knowl- edge of information systems, nurses who are computer literate have the opportunity to use the power and efficiency of computer systems to play an important role in enhancing patient care delivery, offering safe care, and shaping nursing practice. In July 2004, Dr. Charles Safran, President of the American Medical Informatics Association, announced at the National Health Information Infrastructure Conference in Washington, DC that 6000 informatics nurses would be needed to support patient care delivery in the United States.
Computer-literate nurses are defined as licensed nurses who demonstrate competence in understanding and using computer hardware, software, ter- minology, and operating systems (Saba and McCormick, 2001). In today’s information age, nurses are expected to keep pace with rapidly advancing technology. Appropriate utilization of computers and information systems can help nurses make well informed decisions regarding management and patient care issues. It is therefore critical that education in the use of com- puterized healthcare knowledge systems be included as an important com- ponent of basic, as well as advanced, nursing curricula.
Nurse educators are expected to teach how to develop, retrieve, and imple- ment electronically stored data to optimize information-dependent clinical decisions. Also, the nurse educator is expected to provide guidelines con- cerning newly emerging nursing knowledge and ways that this knowledge can be accessed. This need requires the nurse educator to keep abreast of the advancing technology on a theoretical as well as practical basis.
The intent of this chapter is to explore the development of graduate- level nursing informatics education from its inception to the present, with an emphasis on the importance of computer and information literacy as an integral part of the educational program. After discussing the evolution
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of nursing informatics education and incorporating an existing nursing informatics model, goals and objectives for future nursing informatics edu- cation are suggested.
A review of the literature provides a historical overview of nursing infor- matics education, including a discussion of the recognition of nursing infor- matics as a formal specialty by the American Nurses Association (ANA) with certification through the American Nurses Credentialing Center. Through this recognition, the specialty of nursing informatics has assumed standards of practice that should be integrated into the graduate-level nursing infor- matics educational curriculum. Studies that have been conducted to de- termine the educational needs of nursing informatics students were also examined.
Review of the Literature
Historical Overview of Nursing Informatics Education
During the 1980s, nurses who were involved in informatics were primarily self-educated because of the small number of formal graduate programs available to prepare nurses to work in this specialty. During that time, the number of faculty involved in these graduate programs was small enough that they could independently network in an effort to exchange course con- tent. Education focused on teaching the use of computers as a tool for word processing, spreadsheet analysis, graphics production, and statistical appli- cations (Arnold, 1996). These early programs addressed only the nature of information systems and their selections for nursing practice (Graves et al., 1995; McGonigle, 1991).
In 1988, Dr. Barbara Heller was instrumental in establishing the first grad- uate program in nursing informatics at the University of Maryland School of Nursing in Baltimore. The focus of this formalized program included an understanding of nursing informatics science and systems theory in a clinical and management context, with particular emphasis on its impact on nursing practice (Romano and Heller, 1990).
The Maryland program was developed in close collaboration with the university’s information services division, headed by Dr. Marion J. Ball, who worked with the School of Nursing to launch their technology-assisted learning centers, develop an outside advisory board for the program, and initiate innovations in the curriculum. Together with Dr. Kathryn Hannah, she contributed the major initial texts for the program (Ball and Hannah, 1984, Ball et al., 1988, 1995; Hannah et al., 1999).
A second graduate school program followed in 1990 when the University of Utah initiated a nursing informatics program that focused on the transfor- mation of nursing data into information to support clinical decision making.
Students learned about nursing informatics theory, design and analysis of clinical nursing systems, clinical nursing database design, decision support, and administration of clinical nursing information systems (Arnold, 1996).
This program followed on the heels of a discontinued grant-funded summer postdoctoral seminar for nursing informatics that began at Utah during the summer of 1988 and ended before the opening of that university’s graduate program in nursing informatics.
Since the inception of Utah’s graduate-level nursing informatics program, a lack of federal funding has limited the development of other, similar programs. Funding resources are critical for providing adequate computer hardware, software, support services, faculty, and individual implementation strategies for these programs.
In September 1998, the New York University School of Nursing, under the direction of Dr. Barbara Carty, began a program with a nursing infor- matics graduate track. This program includes theory and clinical applications with multiple preceptorship experiences encompassing all aspects of nursing informatics.
The University of Colorado Health Sciences Center School of Nursing offers a Master of Science program in nursing designed to prepare nurses for advanced practice roles. In addition, they offer a post-master’s certificate with specialization in healthcare informatics, and a post-bachelor’s health- care informatics certificate program.
Despite a lack of funding for new programs, the need for nursing in- formatics courses has been recognized by other nursing schools. These ed- ucational institutions have integrated nursing informatics courses in their undergraduate and graduate curricula in the form of required courses, elec- tives, conferences and continuing education workshops. Furthermore, the traditional classroom has expanded beyond its walls to include distance ed- ucation, telemedicine, and continuing education offerings. Excelsior College is the first program to offer a nursing masters program focused on nursing informatics that is totally online. The program, which began in 1999, offers a Master of Science degree in nursing administration with an emphasis on clinical informatics that is accredited by the National League for Nursing.
A 17-credit post-bachelor’s certificate can also be obtained in clinical infor- matics.
In 2003 The University of Arizona College of Nursing began to offer a doctorate in nursing with one option for study being healthcare informatics.
Students can study online except for an intensive 2-week presession each year.
Continuing Education in Nursing Informatics
The University of Maryland School of Nursing hosts an annual Summer Institute in Nursing Informatics. In addition to invited speakers, attendees
can make presentations and posters. Exhibitors and networking events are included in this 3-day event. Preconference and postconference workshops are offered, including the Weekend Immersion in Nursing Informatics. Other organizations that offer yearly continuing education for nursing and health- care informatics include the American Medical Informatics Association (www.amia.org) and the Healthcare Information and Management Systems Society (www.himss.org). The Canadian Nursing Informatics Association (www.cnia.ca) also offers nursing informatics education and links to other educational offerings.
Recognition as a Nursing Specialty
In 1992, nursing informatics was formally recognized as a nursing specialty by the American Nurses Association. This recognition of nursing informatics as its own specialty was followed by the development of nursing informatics standards of practice, which were published by the American Nurses Asso- ciation in 1995 and revised in 2001. These standards require that informat- ics nurses acquire and maintain current knowledge in nursing informatics practice (American Nurses Association, 2001). To achieve this, the infor- matics nurse is required to seek additional knowledge and skills appropriate to the practice setting by participating in educational programs and activ- ities, conferences, workshops, interdisciplinary professional meetings, and self-directed learning. Thus, nursing informatics educators are needed to provide appropriate learning opportunities. The standards also suggest that each informatics nurse keep a record of his or her own learning activities and seek certification and recertification when eligible.
Nursing informatics certification became available in 1995 through the American Nurses Credentialing Center (ANCC). Major topics on the cer- tification examination include (1) system analysis and design; (2) system implementation and support; (3) system testing and evaluation; (4) human factors; (5) computer technology; (6) information/database management;
(7) professional practice/trends and issues; and (8) theories (ANCC, 2004).
To be eligible to take the nursing informatics certification examination, applicants are required to have a baccalaureate or higher degree in nursing or related areas, maintain licensure, and have 2 years of active experience as a registered nurse. In addition, each candidate must have a minimum of 2000 hours of experience in the field of nursing informatics during the 5 years before taking the examination. In lieu of this experience, 12 semester hours of academic credit in informatics in a nursing graduate program and a minimum of 1000 hours in informatics nursing may be substituted (ANCC, 2004). Since 1997, the certification examination has been available by computer at 55 testing facilities throughout the United States. It was the first computerized ANCC certification examination, and to date more than 1000 nurses have been certified.
Nursing Informatics Graduate-Level Education Today
Many educational and practice institutions have initiated programs to pre- pare nurse clinicians simply as users of automated systems, and others are preparing healthcare information systems specialists. Despite the increased use of computer systems in nursing informatics, the management component of informatics presented by Graves and Corcoran (1989) remains essential.
The nursing informatics student is still taught to have the “functional abil- ity to collect, aggregate, organize, move, and represent information in an economical, efficient way that is useful to users of the system” (Graves and Corcoran, 1989).
Today, nurses can take advantage of the virtual classroom where the ed- ucational process occurs outside the formal classroom setting. In this envi- ronment, use of telecommunication technologies through computer-based intranets, extranets, and the Internet make innovative multimedia teaching possible. This teaching methodology is ideal for students who require flexible class schedules secondary to work and family obligations. The virtual class- room, as an interactive process, enables nursing students and their teachers to utilize telecommunication software applications such as interactive video instruction, electronic mail, bulletin boards or newsgroups, and chat con- ferencing as a learning milieu. To supplement virtual classroom activities, students are guided to utilize the Internet, where databases of nursing and healthcare information and other applicable learning resources can be ac- cessed from school and home computers. It is therefore the responsibility of nurse educators to train students to access, retrieve, and implement this growing base of virtual learning tools and to provide feedback to students regarding their success in implementing these tools. O’Neil et al. (2004) have offered a practical step-by-step process to take nurse educators through the necessary steps to transform a traditional course into an on-line or partially online course.
Studies Examining Nursing Informatics Educational Needs
As early as 1990, when no formal nursing informatics program existed at their school, the Computing Advisory Council (CAC) at The University of Texas Health Science Center School of Nursing at San Antonio made rec- ommendations for integration of nursing informatics into graduate research coursework (Noll and Murphy, 1993). At that time, it was recommended that students achieve the following areas of competence upon completion of the graduate program, regardless of their major: (1) analyze and select relevant information sources; (2) access existing Internet resources for nursing and related disciplines; (3) extract, manage, and organize data; (4) analyze the nurse’s role in data security and integrity; (5) analyze the impact of nursing
information systems; (6) evaluate and use appropriate software for advanced practice; and (7) demonstrate information transfer between computer sys- tems (Noll and Murphy, 1993).
These programs, which incorporate nursing informatics coursework in their graduate level curricula, confirm that achieving computer competence is not easy for all the participants. Magnus et al. (1994) participated in a grad- uate course titled “Nursing Informatics” at the Hunter–Bellevue School of Nursing that emphasized the integration and use of computer and infor- mation technology as it related to the management and processing of data, information, and knowledge to support nursing practice and the delivery of care. At that time, there was noted resistance to using computers because of fear of the unknown. Magnus and her classmates suggested that partici- pating in the course helped diffuse the “mystery” surrounding the material (Magnus et al., 1994). Noll and Murphy (1993) reported that integration of nursing informatics material with hands-on application facilitated learning.
In addition, students noted that information about software packages, par- ticularly bibliographic databases, was extremely helpful and would be useful in the development of their graduating theses.
A study conducted by Saranto and Leino-Kilpi (1997) identified and de- scribed computer skills required in nursing and what should be taught about information technology in nursing education. A three-round Delphi survey was conducted with a panel of experts representing nursing practice, nursing education, nursing students, and consumers. The experts agreed that nurses must know how to use the computer for word-processing purposes as well as for accessing and using hospital information systems and electronic mail (e-mail). Nurses must also be aware of system security and show a positive attitude toward computers. Conclusively, the study determined that hospi- tal information systems and nursing informatics should be integrated into laboratory and hospital training (Saranto and Leino-Kilpi, 1997).
In 1996, Dr. Jean Arnold, then associated with the College of Nursing, Rutgers, the State University of New Jersey, conducted a survey among 497 respondents in a northeastern metropolitan area to determine the in- formatics needs of professional nurses. The subjects primarily represented informatics specialists, nurse educators, and nurse managers, many with mas- ters or doctoral degrees. Respondents were asked to indicate their current knowledge and desired knowledge of nursing informatics in 23 content areas that are included in the ANCC nursing informatics certification examination.
The survey revealed that 73% of the respondents were interested in re- turning to school to earn certification in nursing informatics, and 59% were interested in a graduate degree (Arnold, 1996). Decision support, integra- tion of nursing informatics, advanced nursing informatics, decision analysis, and graphics presentations were the content areas most highly ranked by informatics nurses. In addition, informatics trends and issues information were the foremost educational needs identified by informatics nurses in the survey. The results reported by informatics nurses in both areas differed
from the responses by nurse educators and nurse managers, suggesting that position titles and responsibilities have an impact on a subject’s interest in advanced education in addition to the subject’s use of computer applications (Arnold, 1996).
As a result of her survey, Arnold recommended that informatics nursing curricula content include “graphic presentation of data, decision support, electronic communications, integration of nursing informatics within ba- sic and other specialty programs, critique of computer-assisted clinical data analysis, and expert knowledge acquisition” (Arnold, 1996). She also recom- mended including review courses for the informatics certification examina- tion and emphasized the need for more graduate and continuing education programs to meet the increased demand for informatics knowledge.
Staggers et al. (2002) also conducted a Delphi study to determine the areas of competence needed for nurses in the field of information technology. Their research revealed 305 such competencies proposed for nurses at four levels of practice: the beginning nurse, the experienced nurse, the informatics nurse, and the nurse innovator.
Future of Nursing Informatics Education
Clearly, there is a need to standardize graduate nursing informatics curricula based on the standards of nursing informatics practice defined by the ANA, nursing informatics certification requirements defined by the ANCC, and utilization of a nursing informatics model such as that developed by Saba and McCormick (2001) incorporating the suggested adaptations.
For the nurse educator to teach and reinforce this newly acquired nurs- ing informatics knowledge effectively, computer systems should be readily available at all sites where nursing education occurs or clinical decisions are made, and in any place where nursing is practiced. Students must be allowed to experience situations where computer applications related to nursing in- formatics can be used, which includes utilization of the virtual classroom.
One of the primary barriers to utilization of the virtual classroom in nurs- ing informatics education has been the speed with which telecommunica- tion and computer technology has been developing, resulting in frequently changing software and hardware requirements and a financial investment that many schools are not able to sustain. It is hoped that as the cost of computer hardware and accompanying software systems continues to de- cline, computerized educational modalities and clinical information banks will become more readily accessible.
The development of nursing informatics curricula for graduate-level nurs- ing students demands that the minimum standards be based on an un- derstanding of the ANA’s nursing informatics standards of practice. Op- timally, the curricula is based on the understanding and application of the ANA’s nursing informatics standards of practice in addition to the
requirements for achieving certification in nursing informatics through the ANCC.
To achieve these goals, there must be practical application of the pre- sented information systems theory. This should include not only additional educational experiences but also substantial hands-on experience through preceptorship arrangements. First-hand experience ensures that all mas- ter’s level nursing informatics graduates have a high level of competence in both theory and practice. Because this is such a crucial goal, course- work should continue to focus on computer applications and related issues in nursing practice, nursing administration, nursing education, and nursing research.
Defining an Educational Model for Graduate-Level Nursing Informatics
Not only is there a need for more nursing informatics programs, a need also exists for an educational framework to promote standardization and structure in the nursing informatics curricula. Because the specialty is so new, there has been limited research regarding the development of models specifically designed for nursing informatics education. Utilization of educa- tional models would provide the needed framework not only for theoretical education but also for practical applications.
Riley and Saba’s nursing informatics education model (NIEM) is an ed- ucational application aimed at undergraduate students that can be adapted for graduate students. The model can fulfill the need for a theoretical and practical framework in addition to meeting the desired requirements of in- formatics nurses cited in Arnold’s survey (Saba and McCormick, 2001).
The NIEM emerged and evolved with the development of computer technology in the healthcare industry. As illustrated in Figure 20.1 NIEM identifies three dimensions of content that comprise nursing informatics computer science, information science, and nursing science. NIEM further identifies the educational outcomes that must be addressed in the three domains of learning: cognitive, affective, and psychomotor. Once the ob- jectives are achieved in each domain of learning, students can integrate nursing informatics into their nursing roles. This integration of knowledge and competence in nursing education requires that a program include con- tent, hands-on application, and attitude. The model supports the integration of computer and information technology into nursing education to enhance critical thinking skills and provide an active learning experience. Confidence, psychomotor skill level, and knowledge attainment are enhanced in the pro- cess. An advantage of using this model is the ability for the student nurse to make decisions in simulated case studies without risk to the patient (Saba and McCormick, 2001).
FPO
FIGURE20.1. Riley and Saba’s nursing informatics education model (NIEM). (From Saba V, McCormick K. Essentials of Computers for Nurses. New York: McGraw-Hill, 2001, p. 558, with permission.)
As summarized here, NIEM’s objectives occur in four steps. Because ba- sic computer skills are germane to fundamental nursing education, the first step gives students the knowledge and technical skills to function effectively (Lawless, 1993; Saba and McCormick, 2001). Computer application con- tent at this level includes concepts of computer hardware and software as well as computer system components. Students are required to use a word processing program for assignments and to format documents in American Psychological Association (APA) format. System content includes the use of computerized databases and search engines for reference material (Saba and McCormick, 2001). Although it is hoped that all students entering a graduate-level program are proficient in basic computer skills and appli- cations, this step provides the needed content and practical experience for those students entering graduate-level programs with little or no computer knowledge.
Saba and McCormick (2001) recommended that the nursing informatics student have knowledge of word processing, database, presentation, and spreadsheet software programs in addition to bibliographic retrieval using CD-ROM software as well as Internet searches. This hands-on computer experience is augmented by the assignment of e-mail addresses and required subscription to a class e-mail discussion group, which can be utilized for discussion and assignments. Nursing literature supports the use of e-mail as an informal exchange of communication to help new computer users cope with the stress of using new technology and to enhance critical thinking skills (Magnus et al., 1994; Todd, 1998).
The second step of Riley and Saba’s model involves application of com- puter technology to document and access health information for the pur- poses of patient assessment. On an undergraduate level, Riley and Saba introduce the Saba Home Healthcare Classification of Nursing Diagno- sis and Intervention in the classroom to develop patient care plans and in the hospital patient information system for recording care (Saba and McCormick, 2001).
At the graduate level, step 2 can be adapted to include organizational the- ory and associated computer applications, such as utilization of Microsoft Project software for project management simulation. In addition, students can apply computer applications to healthcare financial management course- work to determine staffing needs, cost–benefit ratios, and budgets. It is during step 2 that this author suggests the electronic health record (EHR) be in- troduced, particularly in regard to classification systems and taxonomies, managed care, and the social, legal, and ethical issues associated with the EHR.
The third step of the Riley and Saba model introduces undergraduate students to advanced concepts utilizing existing information systems in clin- ical agencies to plan and implement patient care (Saba and McCormick, 2001). On a graduate level, this step can be adapted to include telecommu- nications in healthcare with an emphasis on understanding the policy devel- opment that led to the current trend toward telemedicine and telenursing applications in addition to its utilization. Also, knowledge about system re- quirements and design and development applications should be imparted through actual student experience working in venues such as outpatient agencies, vendors, hospital information system departments, and consulting firms.
Riley and Saba’s fourth and final step requires students to integrate com- puter technology into nursing care. It includes evaluation, quality improve- ment, multidisciplinary collaboration, and utilization of available resources with the technology. In addition, students are required to examine the so- cial, legal, and ethical issues they encounter through the use of computer technology (Saba and McCormick, 2001).
This final step has been integrated into earlier steps of the graduate-level adapted model. Therefore it is suggested that the fourth step be revised to include implementation of a full systems analysis. To achieve this, the stu- dent must work on a systems development life cycle in a preceptor-based practicum real-life experience during the course of a 1-year internship. This plan would allow the student to benefit from long-term hands-on experience under the guidance of an experienced practitioner. In turn, this experience, coupled with earlier short-term practical experience, would enable students to claim credible nursing informatics experience when searching for employ- ment after graduation.
Clearly, Riley and Saba’s model is adaptable and can be applied to all levels of nursing informatics education. Because the practice of nursing
informatics can occur in any area where nurses practice, this model is appli- cable in all practice settings (Lange, 1997). It is therefore a realistic model for standardizing nursing informatics education methodology.
Summary
Informatics knowledge, in this age of information, is necessary for growth of the nursing profession. The number of available nursing informatics graduate-level programs is increasing, but the informatics expertise of fac- ulty members to teach in those programs is critical if the nursing profession is to meet the challenges presented by integration of this rapidly advancing technology into healthcare. Therefore the graduate-level nursing informatics educational environment must continue to strive to become a forum where educator and student meet in an expanded capacity made possible by an in- crease in the integration of computer competence in the nursing informatics curricula.
This practice does not undermine the importance of noncomputerized systems in the field of nursing informatics but responds to the challenge of keeping pace with the changing regimen. By creating a pilot nursing in- formatics program utilizing the suggested adaptations of Riley and Saba’s NIEM, increased computer and information literacy and competence can be achieved in a graduate-level nursing informatics program. Therefore it is suggested that research be conducted to determine the effectiveness of such a program to (1) measure the effectiveness of the proposed program in relation to improving computer literacy and therefore increasing compe- tence; (2) determine the feasibility of developing an actual program; and (3) add to the current knowledge base about nursing education curriculum requirements for nursing informatics graduate-level programs.
Once validated through research, this proposed model can serve as a guideline for schools of nursing that are in the process of considering, planning, developing, or implementing graduate-level nursing informatics curricula.
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