Chapter 9
Information and Knowledge
st
Needs of Nurses in the 21
Century
Objectives
• Define nursing informatics.
• Describe the goal of nursing informatics.
• Describe how clinical information technologies
are and will impact nursing practice.
• Explore how nurses can create and derive
clinical knowledge from information systems.
• Speculate on the future of nursing in the
context of health informatics.
Information Production and Access
• The information and knowledge informing 21st
century of healthcare delivery has been
growing at an unprecedented pace in recent
years.
• Extended and expanded access to clinical
research findings and decision support tools
has been significantly influenced by the
advent of computerization and the internet.
Need for Quality Information
• Working in environments of increasingly
complex clinical care and contending with the
management of large volumes of information,
nurses need to avail themselves of the
technological tools that can support quality
practice that is optimally safe, informed and
knowledge-based.
Global Definition of Nursing
Informatics
• Nursing informatics science and practice
integrates nursing, its information and
knowledge and their management with
information and communication technologies
to promote the health of people, families and
communities world wide.
IMIA-NI definition, adopted July 2009, Helsinki, Finland www.ssk.med.unierlangen.de
Informatics Nursing Roles
Nurses in identified informatics roles typically focus
their efforts on:
• articulating meaningful clinical nursing data and
information structures that can be codified and
processed
• identifying the information processes associated with
nurses’ work
• 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.
Informatics Needs
• 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
charged with assuring that healthcare delivery is:
•
•
•
•
•
safer
knowledge-based
cost-effective
seamless
timely
Informatics to engage consumers
• With the evolving emphasis on issues such as
chronic disease management and aging at
home informatics can encompass the use of
technologies to empower citizens to more
effectively manage their own health and
wellness.
Informatics and Nursing Resources
• 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.
Nurse as Knowledge Worker
• 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).
Nurse as Knowledge Worker
• 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.
Creating Clinical Knowledge
• 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).
Creating Clinical Knowledge
• 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.
Creating Clinical Knowledge
• 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.
Creating Clinical Knowledge
• 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.
Creating Clinical Knowledge
• Ethics – access to standards of ethical practice,
but also access to experts in the field of moral
reasoning to guide interaction.
• In each and every instance of interacting with
the CIS, a nurse will add further to these
repositories of knowledge on the basis of their
daily clinical challenges and queries.
Using Clinical Knowledge
• 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.
Using Clinical Knowledge
• 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.
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.
CDS Tools
• Computerized alerts and reminders (e.g., medication
due, patient has an allergy, potassium level abnormal);
• Clinical guidelines (e.g., best practice for prevention of
skin breakdown);
• Online information retrieval (e.g., CINAHL, drug
information);
• Clinical order sets and protocols; and
• Online access to organizational policies and procedures.
In the future, these tools will be possibly expanded to
include applications with embedded case-based
reasoning.
CIS Data Input Devices
• Biometrics (facial recognition, security)
• Voice and video recordings (client interviews and
observations, diagnostic procedures, ultrasounds)
• Voice-to-text files (voice recognition for documentation)
• Medical devices (infusion pumps, ventilators,
hemodynamic monitors)
• Bar-code technologies (for medication administration)
• Telehomecare monitoring (for use in diabetes and other
chronic disease management)
Leadership Challenge
• 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).
Strategies for Leadership
• Identify the informatics education needs of
nurse leaders.
• Develop mentorship programs for the
acquisition of informatics leadership skills.
• Assure enrollment of nurse leaders as
sponsors for electronic health records
initiatives.
Clinical Practice Challenge
• 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.
Clinical Practice Challenges, Con’t.
• 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.
• 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.
Strategies for Clinical Practice
Challenges
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.
Challenges for Education
• 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”.
Education Challenges, con’t.
• 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.
Education Challenges, con’t.
• 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.
Strategies for Education
• Need to share prototypes of informatics
integration among schools of nursing.
• Consider interprofessional education
opportunities in addressing informatics
concepts and competencies.
• Nursing faculty need to be obligated and
supported in the attainment of basic
informatics competencies.
Strategies for Education, cont.
• Seek and allocate funding for the
development of innovative curricular models
and associated technological support.
• Incorporate accreditation criteria that
necessitate an integration of informatics core
concepts and competencies in all basic nursing
programs (See current NLN AC and CCNE
standards)
A View of the Future
• 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.
A View of the Future
With the availability of rich data 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.
A View of the Future
• 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.
Thought Provoking Questions
• What are the possibilities to accelerate the
generation and uptake of new nursing
knowledge?
• What should be the areas of priority for the
advancement of informatics in nursing?