by Amelia Chauvette, RN, BScN, MScN
& Pauline Paul, RN PhD
The emergence of information and communication technologies (ICT) has significantly influenced nursing practice. This paper begins with the evolution of nursing informatics, the definition of nursing informatics and related historical, social, and political influences in Canada. In particular, the impact of Canadian health care policies and nursing organization emphasis on the need for nurses to be competent in the area of nursing informatics are discussed. As a result, the recognition that nurses must acquire computer and information literacy skills to work in this technological rich environment in all four nursing domains is critical. Finally, a brief examination of the impact of technology on nursing education is presented.
Keywords: nursing informatics, history, Canadian, competencies
Canadian healthcare systems have undergone tremendous change as a result of technology and communication influences that has consequently impacted nursing and nursing education. From these influences a new field of nursing, called Nursing Informatics (NI), has emerged. As it is a new field, NI does not have an extensive past. However, to understand the current status of NI in Canada, it is important to examine the historical roots of NI, as well as the social, technological and political forces which have contributed to its development. The purpose of this paper is to provide a historical overview of major factors that have influenced the development of NI in Canada, as well as to provide an overview of the definition of NI, the social and political influences on NI, and the importance of NI in current nurse education.
Revolutions usually occur as a result of innovations and technological advancements. There have been two major revolutions brought about by technology; the Industrial Revolution and the Information Revolution. The Industrial Revolution began in Britain in the late 18th century and continued into the 19th century (History.com staff), then spread to other parts of the world. For the first time, machines were used in the manufacturing sector to increase productivity, the steam engine and automobile were developed to improve transportation and the telegraph was used to quicken communication.
By the mid-19th century, a rudimentary computer developed by Charles Babbage appeared (Thede, 2003). From here, further advancements in information, technology and communication led us to the Information Revolution, which began in the 1950’s. Computer systems such as Hospital Information Systems (HIS) were developed and used in healthcare for administrative and accounting purposes (Saba, 2015). During the 1960’s, studies were conducted analyzing the applicability of computers in nursing practice. Nurses began using electronic tools as monitoring devices to assess patient status (Saba, 2015). By the 1970’s, HIS were being used for processing physician order entries as well as for results reporting. In addition, computer applications in nursing were beginning to appear in the literature (Ozbolt & Saba, 2008). In the 1980’s, the first cellular phones and personal computers were introduced. The mid-1990’s saw the development of the Internet which in turn made communication and information available to anyone at any time. Computers are now an essential part of healthcare, as they streamline nurses’ work, improve efficiencies, and enhance the delivery and safety of the care delivered.
In the 2000’s, information was digitalized into music, books, and video. Personal computers and mobile communications have become standard tools. Nurses are expected to use electronic medication records (EMR) to assist in administering medications, electronic health records (EHR) to document, implement and evaluate care, and use mobile devices and the Internet to access point-of-care data and relevant information. Some nurses are also using telehealth to provide nursing care to patients in rural and remote areas (McIntyre & McDonald, 2014). This is in stark contrast to 1874, when the first Canadian hospital-based nursing school, the St. Catherine General and Marine Hospital in Ontario (Kirkwood, 2005), was established. Here, nursing education was based on an apprenticeship model where nursing students learned to nurse by providing care to the patients on the unit in exchange for room and board, thus providing cheap labour to staff hospitals (Kirkwood, 2005). Information was not readily available then, and the training a nurse received was dependent on the knowledge of a few supervisors.
Florence Nightingale has been described in the literature as a forerunner of NI specialists. She gathered, organized, processed and analyzed data and then wrote reports on the health of British soldiers in Crimea (Ozbolt, & Saba, 2008). In Canada, the role of the NI began in the mid-1980’s as many nurses assisted in the design and application of HIS in health care and nurses were appointed to be the “clinical-technical bridge” (Hebert, 1999 p. 10). Nurses were instrumental in implementing this system with their clinical knowledge.
Informatics, defined as the science of information, evolved from German, French and Russian origins. In 1957, Karl Steinbach, a German pioneer in computer science, first coined the term “informatics” originating from “informatik,” meaning computer science (P, 2013) which concerns itself with the “application of computers to store and process information” (Fourman, p.1, 2002). While another author (Saba, 2001) states that it was first coined by the French computer scientist, Dreyfus in 1962 as “ informatique” .Walter Bauer translated the French term into English as “informatics” (Pramilaa, 2013). In 1966, Mikhailov advocated for the Russian term” informatika”, and the English term “informatics”, as the term for the study of the use of information technology in various communities (Fourman, 2002).
Many disciplines began to incorporate the term informatics to indicate a specialty within the specific field of study such as, ‘medical informatics’ or ‘nursing informatics.’ While reviewing the literature, there is no widely accepted definition of nursing informatics as it is continually evolving as new information, technology and communication emerges, and also because nurses interpret, analyze and evaluate data in various ways. It is important, however, to have a consensus definition as it can guide nursing practice, education, administration and research and also help to establish competencies. It also is fundamental in shaping a speciality (Stagger, & Thompson, 2002).
First coined by Dr. Marion Ball (Hannah & Kennedy, 2010) and first described in 1980, by Scholes and Barber as:
“the application of computer technology to all fields of nursing-nursing services, nurse education, and nursing research” (as cited in Thede, 2012, p.73).
This definition highlights the use of computer in all domain of nursing practice.
Hannah (as cited in Stagger, & Thompson, 2002), the first Canadian nurse informatician, defined NI based on a definition of medical informatics as:
“the use of information technology in relation to any of the functions which are within the purview of nursing and which are carried out by nurses. Hence, any use of information technology by nurses in relation to the care of patients, or the educational preparation of individuals to practice in the discipline is considered nursing informatics” (p. 256).
Again, this definition is limited and focuses only on the use of computers in nursing. Graves and Corcoran’s (1986) commonly cited and seminal definition, studied the phenomenon of NI, and defined NI as:
“a combination of computer science, information science and nursing science designed to assist in the management and procession of nursing data, formation and knowledge to support nursing practice and the delivery of nursing care” (p.227).
This definition integrates three bodies of knowledge: nursing, computer science and information science. The definition implies that nurses require some basic computer skills to find, analyze and effectively use information. Hebert’s (1999) definition from the Canadian Initiative of National Nursing Informatics Project defined NI as:
“the application of computer science and information science to nursing. NI promotes the generation, management and processing of relevant data in order to use information and develop knowledge that supports nursing and applies it in all domains.” (p. 4).
This definition is very similar to the former definition of NI. Finally, the Canadian Association of Schools of Nursing (CASN), Canada’s national organization which accredits undergraduate nursing programs, and the Canadian Nursing Informatics Association (CNIA) adopted the International Medical Informatics Association (2009) definition:
“the 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”.
This definition emphasizes the practice of applying NI in nursing.
De Gagne, Bisanar, Makowski, and Neumann (2011) indicated the term Health Informatics should be used in nursing as nurses are not the only health care professionals utilizing informatics and because they work as part of an inter-professional health care team. However, nurses interpret, analyze and evaluate the data based on nursing knowledge prior to communicating the information to other health care professionals.
As evidenced by the multiple definitions, NI is continuously evolving and nurses are now incorporating information, technology and communication into their domain of practice. However, these definitions highlight the fact that NI is a specialized body of knowledge within nursing dedicated to the improvement of patient care through information, technology and communication.
The American Nurses Association recognized NI as a specialty in 1992 with its own body of knowledge (Saba, 2001). In Canada, NI has not yet been recognized as a specialty, however it is represented at the national and provincial levels through numerous associations such as the Canadian Nursing Informatics Association (CNIA).
In 2001, founded by Dr. Lynn Nagle, a new nursing association emerged dedicated to NI, called the Canadian Nursing Informatics Association (CNIA). The CNIA is a special interest group representing the voice for Nursing Informatics in Canada. The CNIA is designated as a full associate group of the CNA. CNIA is also a member group of the International Medical Informatics Association- Special Interest Group in Nursing Informatics, which has a role in furthering and expanding informatics in healthcare through international collaboration. Canada is one of twenty-eight countries participating in this association. In 1983, the association held its first conference in nursing informatics in Amsterdam. This is where Dr. Marion Ball first coined the term NI (Petrucka, 2014).
In 2006, a peer- reviewed journal, The Canadian Journal of Nursing Informatics, was launched. It gives nurses a platform to disseminate Canadian research relating to nursing informatics. It also includes presentations, reviews and other publishable knowledge.
Some nursing programs have incorporated NI into their undergraduate curriculum such as Kwantlen Polytechnic University (Kaminski, 1999). Partnering with the department of Science in Health Informatics, the University of Victoria offered the first graduate double degree program in NI in 2009. However, formal education in NI remains minimal. The Canadian Survey of Health Informatics Programs and Health (Covvey & Fenton, 2014) conducted in 2013-14 indicated that several Canadian universities offer health informatics programs at the undergraduate and graduate levels, but there was only one program specific to nursing.
This past year, the CNIA, issued a Canadian Informatics pin. The pin illustrates Florence Nightingale rose diagram representing her statistical work during the war and affirming she was a pioneer of NI.
Numerous reports have emphasized the importance of incorporating informatics into nursing practice. We are encouraged by policy makers at the provincial and national levels to change the direction of health care. At the provincial level, The Fyke Report (2001), Caring for Medicare: Sustaining a Quality System, commissioned by the Saskatchewan government under Romonov, identified challenges and outlined solutions for sustaining Medicare. One of those solutions was the recommendation to develop EMRs, stating that they are the “cornerstone of an efficient and responsive health care delivery system and quality improvement and accountability” (p 74). That same year, the Mazankowski report (2001) was also released; mandated to review the Alberta heath care system at the time by the Premier. The recommendation focused on new technologies such as EMRs, and a debit-style electronic health card to make the health system more efficient and cost-effective.
At the federal level, The Kirby report (2002) entitled The Health of Canadians: The Federal Role advocated again for the use of EMRs to help gather comprehensive information but also to make informed decisions. The report was also instrumental in developing Canada Health Infoway, a federal organization tasked with establishing EMRs across Canada by the year 2015. It addition, it encouraged the use of digital health such as e-prescribing, telehealth and remote patient monitoring to improve the health of Canadians. Reporting the same year as the Kirby Report, Commissioner Roy Romanow, presented the report Building on Values: The Future of Health Care in Canada (2002) also referred to as the ‘Romanow Report.’ It also advocated for Canada Health Infoway to take the initiative in establishing EMRs across Canada and encouraged the use of information technology to provide safe, quality patient care and patient access to health information to improve their health. As a result of these two reports, the Prime Minster and Premiers agreed that all governments should take measures to “improve the quality, accessibility and sustainability of our public healthcare system” through the Frist Ministers Accord (2003, p.1). The Accord addressed several significant issues in healthcare by improving information technology through the use of EHRs and telehealth, and by providing support to Canada Health Infoway in order to provide safe, quality and sustainable health care (First Ministers of Canada, 2003).
Internationally, in 2004, The World Health Organization launched a patient safety programme identifying that patient safety is a serious global public health issue. It acknowledged implementing technology to ensure patient safety as one of its thirteen action areas to improve patient safety.
All of these Reports have one theme in common: to provide safe quality health care through the use of technology. As nurses, we have more contact with patients than any other health care professional – therefore it is imperative for nurses to incorporate technology into their daily practice to ensure safe patient care. In addition, federal and provincial mandates have contributed to the impetus of information, technology and communications (ICT) in nursing.
In addition to federal and provincial mandates, nursing professional organizations were also a driving force for the incorporation of technology in all domains of nursing. In 1998 a national initiative lead by the Canadian Nurses Association (CNA), called the National Nursing Project Informatics (Hebert, 1999), was launched in order to promote the development of nursing informatics education in Canada. The aim of the project was to begin developing a national consensus on the definition of NI, and to propose competencies, educational strategies and priorities. Following this national initiative, the CNA released several documents highlighting the importance of nursing informatics. This included the publication What is nursing informatics and why it is so important? (2001), which emphasized the importance of incorporating NI into nursing practice. In addition, it informed nurses on how informatics can be used in all nursing domains and how it will affect their practice (CNA, 2001). In 2006, the CNA (2006a) released a position statement on nursing informatics entitled, Nursing Information and Knowledge Management. The document stressed that nurses must possess competent skills in information management and communication technology in order to work in health care and to promote patient safety. This position statement is currently under revision.
The CNA recognized that ICT are important strategies to support in nursing practice. In 2006, the national nursing association released their E-Nursing Strategy for Canada to develop and incorporate information, technology and communications into all domains of nursing with the goal of improving practice and patient outcomes through three strategic directions. The three strategies included access, competencies and participation. Nurses must be able to access ICT in order to support nursing care, and nursing programs must establish competencies and nurse participation in the development of ICT knowledge, and also to help transfer that knowledge to other health care professionals (CNA, 2006b). Furthermore, a key component of the E-Nursing Strategy is the Canadian Nurses Portal Project, also referred to as NurseONE – an Internet portal that provides nurses with evidence-based resources to support them in their practice, tutorials in computer skills, and practice and continuing competency support (CNA, 2006c).
Looking to the future, the CNA Strategic plan 2015-2019 (CNA now: CNA Strategic Plan 2015-2019, 2015) focuses on Primary Health Care. One of the five key principles of Primary Health Care identified in Alma Alta Declaration by the World Health Organization (WHO, 1978) is innovation and technology. This principle is reiterated in the CNA strategic plan identifying that nurses must become computer and information literate in order to become responsive and to be able to integrate technology in their practice.
Positions statements, national reports and initiatives all have overwhelming support and encourage the use of NI. Nurses need to increase their knowledge and develop skills in computer and information literacy to support them in all domains of nursing; thus competencies are imperative for nurses.
It was recognized as a national as well as an international priority that all nurses need to possess ICT skills and knowledge to enable them to provide safe quality nursing care in the twenty-first century health care system. As such, it is essential that entry-level nurses possess foundational knowledge, skills and attributes or competencies in ICT.
Several authors have identified NI competencies in the literature. The most commonly cited ones are the competencies proposed by Staggers, Gassert and Curran (2001). The authors’ well-recognized work also researched the evolution of the definition of nursing informatics, and defined NI competencies as:
“the integration of knowledge, skills and attitudes in the performance of various nursing informatics activities within prescribed levels of nursing practice.” (p. 306).
Staggers, et al. (2001) also established a framework and identified competencies for beginner, experienced, specialist and expert level nurses. The Canadian initiative, the National Nursing Informatics Project (Hebert, 1999) also developed a framework that identified NI competencies. In the United States, the Technology Informatics Guiding Reform, (TIGER, 2009) in another initiative that also created a framework enabling educators to incorporate competencies in their curricula.
Inspired in part by the work of Staggers et al. (2001) and the TIGER initiative (2009), in 2012, the Canadian Association of Schools of Nursing (CASN) released a key document entitled Nursing Informatics Entry-to-Practice Competencies for Registered Nurses. This was the first national consensus on nursing informatics core competencies. CASN outlined essential informatics knowledge, skills, judgment and attributes that a graduating nurse must possess. The document is also intended to guide curriculum development in ICT competencies. CASN (2012a) has identified three over-arching competencies: information and knowledge management, professional and regulatory accountability, and use of ICTs and has supplemented each with criteria indicators. Each of these competencies was inspired by one overreaching competency: “Use information and communication technologies to support information synthesis in accordance with professional and regulatory standards in the delivery of patient care” (p. 5). Each of these competencies needs to be integrated into Canadian nursing curricula with the anticipation that the knowledge will spill over into nursing practice thus enabling nurses to work in an evolving complex healthcare environment.
CASN addressed the importance of informatics in nursing education by developing achievable competencies. It is expected that nursing education programs will provide opportunities for students to apply the entry-level competencies through their learning experiences. Aimed to serve as a motivator in accelerating informatics in education and practice, these competencies were encouraged and prioritized to improved ICT for the entire profession, as it is recognized that ICT can make health care safer, of higher quality and more efficient. As such, ICT must be blended in nursing practice as well as in education.
Building on the National Nursing Informatics Project (Hebert, 1999), the CNIA (2002) conducted a national study describing the current state of undergraduate nursing informatics education in Canada, entitled Educating Tomorrows Nurses: Where is Nursing Informatics? Its primary goal was to promote the development of nursing informatics. The report concluded that there is little comprehension of nursing informatics in undergraduate education programs.
In 2012, CASN released supporting documentation as a number of gaps were identified in incorporating competencies within nursing curricula. First, CASN’s Nursing Informatics Inventory of Existing Teaching and Learning Resources (2012b) provided nurses at any level with an array of resource-appropriate ICT tools to increase the capacity to teach nursing informatics. Secondly, the Nursing Informatics Teaching Toolkit (2013) was created to guide nursing faculty in teaching students about nursing informatics competencies. As nurse educators, we are responsible to ensure the CASN competencies are being met upon graduation. Faculty members must be role models. Little research has been reported as to whether or not the competencies are being integrated into nursing curriculums across Canada to date.
As in healthcare, the Information Revolution has dramatically influenced the educational environment and how educators teach, as well as how students learn. In the past, students learned in a classroom through the traditional lecture method of instruction. Educators used blackboards and textbooks to augment teaching. Students memorized information and recorded data on paper as passive recipients in learning.
Today, ICT is part of our everyday professional activities. Technologies that exist today have revolutionized nursing education. Pedagogical approaches have also changed. Educators have numerous teaching tools which have become more sophisticated, such as: mobile devices, human patient simulators, personal response systems and learning materials which can be accessed anywhere at any time through learning management systems. Classrooms can see no walls, as education can be provided through distance learning.
Currently, most nursing students are from the millennium generation. Their generational characteristics are such that students may have more experience in using technology than faculty members. They use technology at a higher rate than generations preceding them. They were raised with the Internet and most are comfortable using technology. They use digital communication and social media to connect with friends. Most students admitted into nursing program are very often computer literate (McIntryre & McDonald, 2014). Learner-centered approaches are emphasized. Students are active learners. Educators no longer hold all the answers but are viewed as facilitators, assisting in the learning process. Now, there is too much information that can be easily accessed, and students need the skills to decipher what is important information. They need to interpret and evaluate evidence-based information, and thus need to be information literate.
The use of technology in education has been described in the literature since the early 1970s (Found, 2012). However, much of the focus of ICT in nursing education has been in the tools and delivery of education for ICT-enhanced practice, and not on how computer or information literacy is integrated into curricula (McNeil, Elfrink, Pierce, Beyea, Bickford, & Averill, 2005).
Information and communication technologies have revolutionized health care and nursing education, and will continue to have profound effects as new technologies and innovations emerge in healthcare. Evolving applications in ICT have given rise to a new era of nursing and nursing informatics. Nursing informatics is the blending of ICT and nursing science to be used for nursing practice. This paper highlighted historical, social and political influences in the development of nursing informatics in Canada. It explored how ICT has influenced nursing curricula as educators have been challenged to incorporate CASN competency guidelines. New generations of students are technologically confident, but must also become information literate. Emerging technologies have and will continue to change pedagogy and the delivery of nursing education. Ongoing advances will continue to shape the nursing landscape in the twenty-first century.
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Amelia Chauvette has been a nurse educator for the past 15 years at Thompson Rivers University – Williams Lake campus. She also has over 20 years of national and international practice experience in a variety of settings. Born in Montreal, Quebec, Amelia graduated in 1997 from the University of Ottawa with a BScN, University of Montreal in 2001 with a MScN and is presently completing a PhD in Nursing at University of Alberta with an interest in nursing informatics and education.
Dr. Pauline Paul, PhD RN is a Professor and the Associate Dean Graduate Studies, Faculty of Nursing University of Alberta.