Chapter 9Information and Knowledge Needs of Nurses in the 21st

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.uni-erlangen.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?