by Sherrie-Ann Camilli RN, BScN
MHS Graduate Student, Athabasca University
Canadian healthcare is undergoing constant change with subsequent evolution in practices and business processes. Much of this change is a result of technological influence and the introduction of electronic tools. With technology advancing at remarkable rates, the pace of change in nursing practice needs to occur in parallel. The emergence of nursing informatics as a specialty may be a result of the need for appropriate levels of competency in the management of information and communication technology. Best practice guidelines are being introduced in the literature and clinical settings in order to promote competency or refresh knowledge with updated applications.
Technology has undoubtedly offered benefits to patient care and education; however, challenges still exist that need to be addressed. Of particular importance is the consideration of incorporation of informatics concepts in undergraduate nursing curriculum. It is hypothesized that the best strategy for ensuring that nursing graduates are optimally prepared to apply technology to nursing knowledge upon entry to practice is to establish a foundational skillset during undergraduate study. Continuous professional development is recognized by scholars as an integral part of professional nursing culture and the inclusion of informatics is no exception.
Keywords: nursing, healthcare, technology, informatics, entry-level competencies, undergraduate education, professional development, continuing education, best practice
There is little doubt in the minds of patients, practitioners, clinical educators, policy makers, medical researchers, and healthcare administrators that the culture and status of Canadian healthcare is one of constant evolution. Significant changes can be observed in the way that communication, documentation, and inquiry are currently being conducted; these shifts have been influenced dramatically by the introduction of electronic tools. It can be expected that technology will continue to advance at unimaginable speeds toward higher levels of sophistication and innovation (Dagiene & Jevsikova, 2012); therefore, healthcare practice, research, and education strategies must continue to grow and reform at rapid speeds as well.
With the advancement of technology in healthcare, comes great successes in the form of reliability, productivity, service enhancements, and operational efficiencies. However, the improvements and benefits are not without a variety of anticipated and unanticipated challenges. In the nursing profession, difficulty with technological proficiency may present itself as early as during the undergraduate curriculum (Jones & Donelle, 2011), potentially leading to challenges and competency issues upon entry into the workforce. Nursing informatics is still a relatively new specialty in healthcare and there is increasing awareness that a need exists for minimum competencies to be established (COACH, 2013). National nursing governing bodies are recognizing the need for nursing students to attain a level of proficiency upon entry to practice (Nagle, 2013) and best practices guiding the use of technology in nursing are beginning to appear in the literature (Giuse, Williams, & Giuse, 2010; Myers & Shannon, 2012). With nursing students and practicing nurses moving further into remote and rural settings, the need for the availability of reliable electronic tools as well as competency with independent use of them is further reinforced (Charania, Cowan, & Tsuji, 2013; Kuziemsky et al., 2012; Lustria et al., 2010).
The intention of this article is to highlight some of the contributions of technology in modern Canadian healthcare and the ways in which they have enhanced the quality of patient care. However, there are also known challenges that require further exploration and discussion. This paper offers a broad historical literature review of the role of healthcare informatics in Canadian nursing practice and undergraduate nursing education. The literature will also serve as an overview of benefits and drawbacks; highlighting technological progress and challenges that may have already been overcome, as well as projecting anticipated challenges facing the future of informatics in nursing. While this paper is written from a nursing perspective, the information and discussion may be beneficial to other healthcare professionals, educators, administrators, leaders, and researchers who wish to explore the expanding role of informatics in healthcare and the challenges that are present in education, practice, and beyond.
It is assumed by this author that the development and implementation of best practices and business processes surrounding the uses of electronic communication tools in various healthcare environments will enhance the benefits of technological applications and ultimately, improve patient care outcomes. However, in order to optimize the enhancements offered by sophisticated electronic tools, the seeds of technological proficiency must be planted early in undergraduate nursing education and reinforced throughout all aspects of practice.
In the late 1960s, hospitals were equipped with their first computer systems which over the next 40 years, would eventually replace much of the paper that would be used in nursing units (Murphy, 2010). Since the 1970s, nurses have contributed to the purchase, design, and implementation of technology in the clinical setting and inevitably, the definition of nursing informatics has been in a state of constant reform ever since (Murphy, 2010). Presently, nursing informatics (NI) is defined by the International Medical Informatics Association (IMIA) as the integration of nursing science, knowledge, practice, and management with information and communication technologies to promote global health of individuals, families, and communities (Murphy, 2010; Nicoll & Crawford, 2013). This definition is an adaptation of the National Nursing Informatics Project (NNIP) definition where NI is the application of computer and information sciences to nursing, promoting the generation, management, and processing of relevant data in order to use information and develop knowledge that supports nursing in all domains of practice (Nicoll & Crawford, 2013). While the definition has been modified by various authors over the past 20 years, the IMIA definition has been generally accepted in many Canadian nursing contexts (Nicoll & Crawford, 2013).
In 2009, IMIA’s definition was officially adopted by the Canadian Nursing Informatics Association (CNIA) which is an organization that represents the national development of the NI specialty and serves as an international networking and advisory group (CNIA, 2012). In addition to the CNIA, the Canadian Nurses Association (CNA), Canadian Association of Schools of Nursing (CASN), Academy of Canadian Executive Nurses (ACEN), and the Canadian Organization for Advancement of Computers in Health (COACH) are some of the national organizations who have either sponsored or published initiatives that promote the skills of computing in nursing. While the term informatics refers to the translation of data into meaningful information (Hebda & Czar, 2013), nursing informatics is specific to the component of informatics that is relevant to the nursing profession (Nicoll & Crawford, 2013). Overall, the specialty of NI is receiving increased attention from scholars as the scope expands into multiple aspects of the nursing profession. In fact, the literature databases are abundant with studies that reflect upon the incorporation of technology into nursing practice and educational settings, as well as the benefits and challenges that are bundled within.
The pace of change in nursing practice settings is remarkable and many authors could argue that nothing contributes more to changes in practice than the introduction of new and innovative technology (Huston, 2013; Jones & Donelle, 2011; Kaminski, 2014). Information and communication technologies (ICTs) can be easily recognized as standard components of the nursing process and daily nursing practice, appearing as electronic assessments (i.e., minimum data set or MDSs), electronic health records (EHRs), and telemedicine, to name only a few.
Nursing assessment comprises a significant aspect of total patient care and the process for collecting and recording assessment data has been enhanced by the introduction of an international standardized minimum data set (MDS) instrument. The Resident Assessment Instrument (RAI) is a type of MDS and has been implemented in Canada for more than 15 years and has the ability to provide reliable information that can be used to support case mix based payment systems, quality monitoring, outcome measurement, and service planning (Hirdes et al., 2013). One significant limitation of the MDS is that the documentation recorded within it captures information that is relevant only at the point of assessment and does not capture care planning, implementation, or follow up evaluation.
The EHR is a digital record of a patient’s history; an aggregate that serves as a multi-disciplinary compilation across many locations or sources (i.e., hospitals, labs, clinics, pharmacies, diagnostic imaging, and public health agencies) and is available 24 hours a day, 7 days per week (Giuse, Williams, & Giuse, 2010; Huston, 2013; Jones & Donelle, 2011). EHRs offer improved documentation legibility, and rapid communication (Stevenson & Nilsson, 2011) as well as enabling direct access to a full spectrum of patient data that would be equivalent to attending clinical rounds (Giuse, Williams, & Giuse, 2010). Canada Health Infoway (CHI) has been mandated by Health Canada to implement a baseline EHR for all Canadians by 2015 (CHI, 2009). With tools such as EHRs and MDSs becoming more common in the clinical setting, it is becoming easier to recognize the influence of national governance and mandates that contribute even further momentum to the pace and directions of growth in the nursing profession.
Treatment options are going online as well. For example, the emergence of telemedicine offers a variety of health services using telecommunications (i.e., phone and video) in order to provide improved instant access to care as well as more timely follow up for compliance and monitoring. As nursing practices and processes continue to evolve in assessment, intervention, and evaluation, levels of competency need to be continuously refined and enhanced in order to maintain proficiency with the new and constantly updated ICTs that are being implemented in practice settings. Some workplaces have mandatory training opportunities available for site-specific applications while optional continuing education opportunities may be offered in local community colleges or universities, clinical settings, online, or at professional development conferences.
Educational delivery is being carried out in innovative and convenient ways, including the use of simulation, virtual classrooms, distance education, podcasts, web conferencing, and online assessments. Similar to practice settings, technology in nursing education augments rapid accessibility to information, supports communication and collaboration, provides a wider variety of learning opportunities to a broader population of students, and generates an enormous electronic data set that can be analyzed and evaluated for improvements. For example, reports that are prepared for accreditation bodies may be generated from a data source that has accumulated through electronic instructional and assessment methods.
The introduction of nursing informatics (NI) in the undergraduate curriculum is a topic that can be seen throughout the literature as the need for competency with ICTs becomes clearer. Nursing students are gaining increasing exposure to technologies during undergraduate studies which includes but is not limited to: increasing volumes of electronic health records, digital diagnostic tools, health monitoring, and reporting equipment, barcode scanning, as well as mobile and hand-held documentation devices (De Gagne, Bisanar, Makowski, & Neumann, 2012). If nursing students do not receive adequate preparation to be able to competently manage electronic tools during undergraduate education, there is a strong possibility that there will be adverse effects upon the manner in which new graduates relate to care and practice (Kleib, Zimka, & Olson, 2013). However, national governing bodies are beginning to mandate the inclusion of a nursing informatics skillset as a component of entry-level competencies.
The introduction of proficiency in technology as an entry level requirement was not an arbitrary decision made by healthcare organizations and educational institutions. In fact, it has been greatly influenced and mandated by organizations such as CASN to the extent that a nationally endorsed set of entry-to-practice competencies for nursing informatics was introduced in 2012 (CASN, 2012). Three nursing informatics competencies have been set out by CASN (2012) which include the ability of nurses to manage information and knowledge; maintain accountability with respect to regulation and professional standards; and utilize ICTs skillfully. The competencies are reflective of the need to expect a core set of skills and applicable knowledge from nursing students upon completion of the undergraduate nursing program (Nagle, 2013).
According to CASN (2012) these three competencies will lead to the achievement of an overarching competency: “Uses information and communication technologies to support information synthesis in accordance with professional and regulatory standards in the delivery of patient care” (p. 5). This overall competency will translate professional judgment that is guided by standards of practice and evidence-informed care into safe and appropriate application of ICTs in delivery of patient care (Hirdes, 2013; Nagle, 2013). Informatics competency is crucial to managing care of clients in all healthcare settings, including nursing (Stephens-Lee, Lu & Wilson, 2013). Without establishment and achievement of a minimum competency set in NI, there is a presumable risk of negative outcomes for patients; perhaps in terms of nonstandardized documentation practice, security compromisation, or data interpretation error.
Safe practice is a primary focus of nursing and the need for vigilance with patient care is emphasized given the current health complexities of populations. This diligence equates to quality documentation practices, careful monitoring of patient statuses, and early recognition of deterioration combined with timely management of adverse events (Stevenson & Nilsson, 2011). Technology has lent support as well as challenges to nursing practice and as a result, there are transformations occurring within the profession in order to prepare nurses to effectively and appropriately utilize ICTs (Nagle, 2013). However, it is plausible that the best prepared nurses could be subject to making errors if the electronic applications being used are poorly designed or implemented. Organizations wishing to successfully implement ICTs would be wise to approach an implementation plan with multiple stakeholder involvement, systematic scrutiny over the choices of application, in combination with a meticulously designed roll-out, training, and evaluation schedule (Myers & Shannon, 2012).
Unfortunately, even the most comprehensively crafted plans are vulnerable to error. Data entry issues with respect to reliability, completeness, validity, and adherence to coding principles contributes to poor quality of data integrity and potentially, incorrect outputs and interpretations by the software or users. In fact, some authors argue that the only way to verify reliability of information is to systematically evaluate the psychometric properties of the data. The risks posed to quality by poor training, lack of staff buy-in (opposition or resistance), selection bias, short-staffing, high staff turnover, inadequate coding policies, and lack of feedback to end users are always possible in workplace settings (Hirdes et al., 2013). The sheer magnitude of the volume of information captured in ICTs may be enough to overwhelm a user and lead to errors (Myers & Shannon, 2012). Perhaps one of the most effective ways of ensuring that data integrity is preserved is by providing adequate availability of ongoing training opportunities and refresher sessions once an application is introduced into the workplace. These opportunities would ideally include reinforcement of best practice in documentation as well as measures that can be taken in order to protect stored information.
Privacy and information security are essential considerations when collecting and storing sensitive patient information. Security and confidentiality may be breached if users do not log out of electronic records when they finished their session and subsequently, unauthorized users are able to gain access to, or possibly even modify patient information (Henriksen, Burkow, Johnsen, & Vognild, 2013; Jones & Donelle, 2011). Therefore, policies and processes need to be reinforced in order to protect patient confidentiality and reduce the risk of breaches.
In remote communities, barriers such as accessibility, transportation, knowledge deficits, follow up for compliance, and financial constraints are some of the many contributors to disparities in health services (Lustria et al., 2010). Rural informatics supports the application of ICTs in remote or underserviced communities. In fact, the use of technology in rural and remote settings may provide increased access to clinical service and specializations, allow for more timely and convenient follow up, as well as provide opportunities for health screening, teaching, and promotion. However, lack of qualified staff, management, infrastructure, and public funding may pose significant challenges to the introduction and sustainability of sophisticated technologies in remote areas (Kuziemsky et al., 2012).
Despite the planned implementation of a nationwide EHR system, few Canadian nursing schools have incorporated this technology into the curriculum and some of the barriers identified include significant costs, a lack of infrastructure to support NI training as well as a lack of faculty expertise in NI (Jones & Donelle, 2011). Due to the broad scope of NI, educators are having difficulty in knowing which concepts must be included in the undergraduate curriculum in order to achieve expected levels of competency (Stephens-Lee, Lu, & Wilson, 2013). Jones and Donelle (2011) examined the use of electronic documentation in undergraduate nursing education and found that the students’ lack of knowledge regarding patient assessment and history also affected their ability to use the tool to its full potential. Therefore, a need exists for more research to develop frameworks that will effectively introduce leveled NI concepts into the undergraduate curriculum, given the limited applicable knowledge base that nursing students have yet to fully develop.
Some students are moving into remote communities to carry out practical learning experiences and still require the ability to stay connected to their studies and Faculty Advisors while off campus. However, learning at a distance may pose challenges when connectivity is inconsistent due to poor infrastructure, low bandwidth, and lack of readily available general information technology support. Measures intended for improving connectivity and student comfort with a variety of software clients (such as web conferencing, Blackboard, and mobile applications) would be beneficial to implement collaboratively on the part of sending institutions and the receiving communities (Charania, Cowan, & Tsuji, 2013; Kuziemsky et al., 2012).
In the process of performing day-to-day nursing care with the routine use of ICTs, a significant amount of data is generated and accumulated. Secondary use of health data is not uncommon in epidemiological research, in fact, some health records may be of great benefit to public health studies due to the volume of data that is available. It is clear that research evidence offers valuable insight and information that informs nursing practice. Not only will research support best practice in the profession of nursing, but it will also support higher education as it will inform the curriculum development teams of ways that technology can be introduced in undergraduate studies and how entry level competencies can be assessed. However, there are considerations that are necessary for the ethical use of health information and processes for obtaining informed consent to release that information.
While the attainment or maintenance of technological proficiency may not be mandatory in all clinical settings, it may become compulsory in light of the attention being given to minimum competencies by national accreditation bodies such as CASN. Jones and Donelle (2011) argue that the provision of additional instruction in the use of ICTs offers support to novice as well as seasoned nurses so that they may be able to manage patient care effectively in technology enhanced health care settings. However, there are factors to consider such as costs, development, organization, implementation, and ongoing evaluation of learning activities for staff.
Some authors predict that the recognition of ICTs as essential tools in quality nursing care combined with an influx of technologically-competent nursing graduates sets the stage for successful adoption of ICTs. However, continued success rests heavily upon commitments to education, training, evaluation, and skilled leadership with establishment of clear workflow processes (Jones & Donelle, 2011; Myers & Shannon, 2012).
In secondary schools, authors have recommended that the key concepts of informatics such as the basic ideas that underlie modern computers, networks, and information be introduced in the curriculum (Dagiene & Jevsikova, 2012). This would further support a baseline competency that has already been established upon entry to nursing school and students would be better equipped to begin application of those concepts through the lens of a healthcare professional. Stephens-Lee, Lu, and Wilson (2013) recommend a process of developing an integrated approach for assisting educators to enhance the curriculum so that nursing students are able to improve their capacity to use NI science to guide and inform their practice. For example, concepts such as basic computer skills, information literacy, and information management need to be reinforced at both faculty and student levels in order to integrate NI comprehensively. From the nursing student’s perspective, the use of electronic tools in undergraduate education allows for hands-on learning and application of theory to praxis when used in scenarios. With repetitious practice and reinforcement, comfort levels increase and proficiency is fostered (Jones & Donelle, 2011).
There are limitations in this paper that need to be acknowledged. There are more examples of ICTs in nursing practice and education besides the few that have been highlighted. Also, the challenges that have been outlined are not inclusive and deserve a more comprehensive exploration of the root causes of the issues and strategies in mitigating them.
The future of nursing practice holds promise of even more technological breakthroughs and innovations. For example, less invasive and more accurate tools for diagnostics and treatments are being designed, as well as applications using robotics and 3D imaging (Huston, 2013). Overall, the future of nursing practice will likely be influenced by additional research on best practices in proper use of communication technologies and management of information in order to achieve optimal health outcomes for patient populations. Additional research is required to test the application of specific educational strategies that will elicit entry-level competencies in the use of ICTs and application of NI (Jones & Donelle, 2011). As a foundational starting point, Stephens-Lee, Lu, and Wilson (2013) offer a framework for curriculum design that addresses the three core competencies and overarching competency as defined and endorsed by CASN (2012)
The practice of caring for patient populations is evolving as the nursing profession continues its pursuit of quality, efficient, safe, and ethical care. Technology has certainly evolved as well; offering the first web browsers on large monitors in the early 1990s, eventually giving way to an electronic omnipresence that we have come to depend upon in our everyday lives (Murphy, 2010). The use of ICTs in clinical and educational settings, including rural and remote areas, have offered significant benefits such as convenience and efficiency. However, challenges still remain with respect to ensuring that resources, infrastructure, staffing, training, and business process are managed and allocated appropriately. It is widely understood that the advancement of technology contributes to the pace of advancement in the nursing profession. In order for the two to grow in tandem, nursing students and practicing nurses will be required to attain and maintain high levels of proficiency with ICTs that are commonly used in the clinical setting. Overall, many of the issues that have been identified in this paper can be linked with educational opportunities either in preparation of students entering the nursing profession or in maintenance or improvement of levels of competency in active practice. Going forward, the starting point of introducing NI competency will logically point to learning design at the undergraduate level.
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Sherrie-Ann Camilli is a registered nurse, presently working in an administrative role in undergraduate medical education. A part-time graduate student, Sherrie-Ann anticipates completion of the Masters, Health Studies program at Athabasca University in April, 2014. Looking forward, Sherrie-Ann is interested in research and publication on best practice in healthcare informatics.